Minimum initial service package (MISP) for sexual and reproductive health for women in a displacement setting: a narrative review on the Syrian refugee crisis in Lebanon

Abstract

Background Women and girls are disproportionately affected in times of conflict and forced displacement, with disturbance in access to healthcare services leading to poor sexual and reproductive health outcomes. The minimal initial service package (MISP) was created to mitigate the consequences of conflict and prevent poor sexual and reproductive health (SRH) outcomes, especially among women and girls. The aim of this narrative review was to explore the SRH response for Syrian refugee women and girls in Lebanon, with a focus on MISP implementation. Methodology A comprehensive literature search was conducted for peer-reviewed articles in 8 electronic databases and multiple grey literature sites for articles published from March 2011 to May 2019. The target population was Syrian refugee women in Lebanon displaced from Syria as a result of the conflict that erupted in March 2011. The selected articles addressed MISP, SRH needs and services, and barriers to service access. A narrative synthesis was conducted, guided by the six main objectives of the MISP. Results A total of 254 documents were retrieved, from which 12 peer-reviewed articles and 12 reports were included in the review. All identified articles were descriptive in nature and no studies evaluating MISP or other interventions or programs were found. The articles described the wide range of SRH services delivered in Lebanon to Syrian refugee women. However, access to and quality of these services remain a challenge. Multiple sources reported a lack of coordination, leading to fragmented service provision and duplication of effort. Studies reported a high level of sexual and gender-based violence, pregnancy complications and poor antenatal care compliance, and limited use of contraceptive methods. Very few studies reported on the prevalence of HIV and other STIs, reporting low levels of infection. Multiple barriers to healthcare access were identified, which included system-level, financial, informational and cultural factors, healthcare workers. Conclusion This study highlights the main SRH services provided, their use and access by Syrian refugee women in Lebanon. Despite the multitude of services provided, the humanitarian response remains decentralized with limited coordination and multiple barriers that limit the utilization of these services. A clear gap remains, with limited evaluation of SRH services that are pertinent to achieve the MISP objectives and the ability to transition into comprehensive services. Improving the coordination of services through a lead agency can address many of the identified barriers and allow the transition into comprehensive services.

Perceived facilitators and barriers to the provision of sexual and reproductive health services in response to the Syrian refugee crisis in Lebanon

“…This finding is surprising given the fact that more than half of respondents indicated to have participated in SRH-related training. These results could be attributed to the fact that MISP is not widely recognized as a concept/package in Lebanon, 21 and consequently, the different SRH services provided under the MISP, even when related, were not referred to or framed as MISP. Indeed, when the respondents were first approached, none of them were aware of the MISP and its objectives.…”

“…23 This is thought to be attributed to the absence of a lead coordinator within their organization, who is responsible for proper communication and coordination among pertinent institutions, which was also evident in a similar review in Lebanon. 21 Several factors were reported to have facilitated the delivery of SRH response for Syrian refugees, these included the availability of a Leading Reproductive Health Agency-about the MoPH, as one the most important enablers. MoPH is heavily engaged in the provision of a multitude of services to Syrian refugees in this regard, including reproductive health care, family planning services, and basic medications.…”

“…According to a recent narrative review assessing MISP for Syrian refugee women in Lebanon, limited data and assessments exist in Lebanon that critique the SRH response to Syrian refugees in the country. 21 Our assessment is the first to highlight and analyze the extent of MISP readiness and response to the Syrian refugee crisis in Lebanon, using a globally standardized assessment tool and informed by comprehensive sample selection criteria that allow for the identification and selection of the most relevant SRH stakeholders working in this field.…”

“… 23 This is thought to be attributed to the absence of a lead coordinator within their organization, who is responsible for proper communication and coordination among pertinent institutions, which was also evident in a similar review in Lebanon. 21 …”

“… 20 Although MISP was developed roughly 20 years ago, a limited number of studies have evaluated its implementation and effectiveness to date. 21 , 22 Among the available studies, results reflect varying degrees of success and limited implementation. 7 , 22 In principle, the challenges about the implementation of MISP revolve around its practicality, integration, communication, coordination, availability, quality of referral systems, and most importantly, the lack of national strategies.…”