Findings from stakeholders’ mapping and analysis indicated that the 58 KIs interviewed were affiliated with a total of 15 different entities/agencies. The average years of the KI’s field experience was 10.5±8.3 years. Most (91%) of the KIs had a direct working experience with Syrian refugees in Jordan. Ministry of Health, UNFPA, and Jordan Health Aid Society (JHAS) Clinic were reported by 50% of the KIs as the key agencies responsible for coordinating SRH services provision to Syrian refugees (see Table 2 for more details). 71% of KIs (n=41) stated having a list of the different agencies implementing RH response to Syrian refugees within their organization and provided that list to the research team; while, almost one third (n=12) did not have or provide a copy of the list.
Table 2
Organizations reported as responsible for coordinating SRH services for Syrian refugees (N=58)
Organization | Frequency | Percentage% |
Ministry of Health | 12 | 20.7% |
UNFPA | 10 | 17.2% |
Jordan Health Aid Society (JHAS) Clinic | 8 | 13.8% |
Nour Al Hussein Foundation- NHF | 7 | 12.1% |
UNHCR | 5 | 8.6% |
Medecins Sans Frontieres (MSF) | 3 | 5.2% |
WHO | 3 | 5.2% |
Rawabi Al Balqa | 2 | 3.4% |
Others | 8 | 13.8% |
Total | 58 | 100.0 |
About 45% of KIs (n=26) had varying degrees of knowledge about MISP its associated objectives and activities. As for receiving training on MISP, 88.5% (n=23) indicated that they themselves received training on the MISP. However, of these, 56.5% (n=13) either did not remember or indicated that the last training they received was before 2017. The median number of participants that attended the last training on MISP (as indicated by them) was 25 participants. Only 59.3% (n=16) confirmed the commitment of their organizations in providing MISP training for their health professionals.
Similarly, 88.5% (n=23) confirmed that they ever engaged in providing some MISP-related RH services. The highest number of respondents who were engaged in the provision of some MISP-related services was indicated to be early on during the crisis i.e. in 2011 and 2012. 91.7% KIs (n=22 out of 24) explained that their roles were centred around providing: direct patients care, followed by planning for RH in emergency policy plans, introducing Disaster Risk Reduction (DRR) program within the organization, and MISP monitoring and evaluation.
Only 15 KIs (25.9%) responded on the number of health personnel assigned to the implementation or provision of MISP within their organizations, which ranged from 2 personnel to as high as 100 staff members with a highly skewed distribution (median=4 staff members).
Results on knowledge of the different MISP objectives and priorities indicated similarly inadequate understanding and comprehension of the respondents. Many of the KIs were not able to identify the different MISP objectives correctly and were rather reliant only on the transferred knowledge gained from expertise and daily routine practices. Only 26 out of the 58 KIs (44.8%) answered this section. Of which, 20-24 KIs were aware of some (but not all) of the MISP objectives, and two did not know any of them. “Preventing excess maternal and newborn morbidity and mortality” was the most commonly recognized MISP objective by 92.3% KIs (n=24), while “reducing HIV transmission” and “ensuring the health sector/cluster identifies an organization to lead the implementation of the MISP” were the least recognized objectives. Sources of information and knowledge about MISP was through training that was offered on MISP within the respondents’ current organization followed by attending special dedicated courses (See Table 3). As for the six MISP priorities, 16-22 KIs were able to indicate all of them, and 4 KIs were able to recognize any of them. “Ensuring availability of contraceptives in order to meet demand” was the most-reported priority, followed by “availability of STIs treatment” and “distribution of culturally appropriate menstrual protection material”. “Ensuring availability of antiretrovirals (ARVs)” was the least reported.
Table 3
Sources of information about MISP and knowledge about the objectives
Objectives | How did you hear about MISP | Total (out of 58) |
1* | 2* | 3* | 4* | 5* |
Prevent excess maternal and newborn morbidity and mortality | n | 18 | 3 | 3 | 5 | 4 | 24 (41.4%) |
% | 75% | 12.5% | 12.5% | 20.8% | 16.6% |
Plan for comprehensive SRH services, integrated into primary health care as the situation permits | n | 17 | 3 | 3 | 5 | 4 | 23 (39.7%) |
% | 73.9% | 13% | 13% | 21.7% | 17.3% |
Prevent and manage the consequences of sexual violence | n | 15 | 4 | 3 | 5 | 3 | 22 (37.9%) |
% | 68.1 | 18.18% | 13.63% | 22.7% | 13.6% |
Ensure the health sector/cluster identifies an organization to lead the implementation of the MISP | n | 14 | 3 | 3 | 5 | 3 | 20 (34.5%) |
% | 70% | 15% | 15% | 25% | 15% |
Reduce HIV transmission | n | 14 | 3 | 3 | 5 | 3 | 20 (34.5%) |
% | 70% | 15% | 15% | 25% | 15% |
1*= Through my current organization/centre/institute/agency |
2*= MISP Distance Learning Module online course |
3*= MISP course at a university |
4*= Experience in the field |
5*= Reading the Inter-Agency Field Manual on RH in Humanitarian Setting |
On the roles of organizations in engagement in MISP implementation, most agencies hosted/ facilitating regular meetings on MISP implementation (n=18) followed by sharing information, and periodically participating in the meetings upon invitation.
As for the three MISP activities to prevent and manage the consequences of sexual violence (ensure community awareness about the benefits and availability of clinical services, make clinical care available to the survivors of rape, and put in place measures in place to protect women and girls from sexual violence), 18 to 21 KIs had some knowledge. Regarding knowledge about the three MISP activities to reduce HIV transmission (ensures safe blood transfusion practice, makes free condoms available, and facilitates and enforces respect for standard precautions), 19 to 20 KIs were aware. As for knowledge about the five MISP activities to prevent excess maternal and newborn morbidity and mortality, 18 to 22 KIs were aware of at least one of the five activities. “Ensuring the availability of both skilled birth attendants and supplies for normal births” and “Emergency Obstetric Comprehensive and newborn care services at referral hospitals” were the most recognised activities (recognized by 22 and 21 participants), while “distributing clean delivery kits to visibly pregnant women” was the least recognized activity (recognized by 18 participants). Finally, 24 KIs had some knowledge pertaining to how the organization should transition towards the implementation of comprehensive SRH services as the situation permits. Examples included: coordinating ordering SRH equipment and supplies according to the demand, followed by collecting existing background data” and “assessing staff capacity, and identifying suitable sites for future service delivery. However, in each of these activities, the relevant knowledge/ awareness of the KIs was limited, where by, 4 to 8 KIs did not know any of MISP activities pertaining to MISP objectives.
About half of the 58 respondents (31 KIs) confirmed the presence of a national Disaster Risk Reduction (DRR) agency or department, while only 17 KIs were able to provide a specific name. Similarly, 24 KIs reported that there is no DRR health policies or strategies at their organizations, while only 28 KIs acknowledged that DRR policies and strategies targeted SRH and vulnerable populations in Jordan (see Figure 1). Only 9 KIs indicated that it was either 2016, 2017, or 2018 when latest health risk assessment was conducted. Upon exploring the perceived SRH risks and potential barriers impeding a comprehensive SRH service provision for Syrian refugees, only 9 KIs shared their thoughts. Of these, the following risks were indicated: maternal and neonatal deaths and inaccessibility and unaffordability to use SRH services, followed by increased domestic sexual violence, and lack of adequate antenatal care. Similarly, only 22 KIs responded to the section on the different community engagement approaches in early warning systems. The most commonly reported engagement approaches by these KIs included: partnership/ collaboration with local society/appropriate agencies (9 KIs), sharing community responsibility and accountability for policies and protocols, promoting family planning use (5 KIs) and engagement in awareness programs/health education (4 KIs).
With regards to the extent of national preparedness to implement SRH interventions during the early onset of Syrian crisis, 15 to 40 KIs, out of 47 respondents, (31.9-85.1%) confirmed that their organization made prior preparations to launch at least one of the ten SRH programs in response to the Syrian humanitarian crisis. Out of the 10 SRH programs implemented, the most commonly implanted ones include: maternal health (mentioned by 40 KIs), family planning (40 KIs) and condoms distribution (mentioned by 38 KIs), while the least implemented ones were provision of ARVs and access to safe blood (mentioned by 15 KIs) (See Table 4). International NGOs played a fundamental role in setting up the implementation of most of these SRH programs as compared to governmental organizations (MOH). 44 out of 58 KIs (75.9%) confirmed the organization of training workshops for their health workers (nurses, doctors, midwives, etc.) in Jordan to prepare for a humanitarian crisis. Data collection of SRH indicators for monitoring and evaluation of services was the most-reported activities, as it aimed at ensuring effective coordination and implementation of the different MISP objectives, while mapping, vetting and support of health facilities was the least recognized activity for the same purpose. Findings also indicated that only 20.7 to 22.4% of the needed supplies and kits were procured and pre-positioned prior to the crisis. Further, only 15 KIs (25.9%) confirmed the presence of a logistics and commodities system to support the emergency distribution of health supplies, including SRH related supplies, while most of the KIs (>45%) were unmindful of any actions that have been undertaken for the same purpose.
Table 4
Preparedness for SRH programs during the early onset of Syrian crisis according to the type of organization (N=47)
SRH program | Type of Organization | YES n (%) | NO n (%) |
Governmental | Local NGO | International NGO |
Maternal health | n | 6 | 14 | 20 | 40 (85.1%) | 7 (14.9%) |
% | 15% | 35% | 50% |
Family planning | n | 7 | 14 | 19 | 40 (85.1%) | 7 (14.9%) |
% | 17.5% | 35% | 47.5% |
Condoms distribution | n | 7 | 13 | 18 | 38 (80.9%) | 9 (19.1%) |
% | 18.4% | 34.2% | 47.3% |
Neonatal health | n | 6 | 11 | 18 | 35 (74.5%) | 12 (25.5%) |
% | 17.1% | 31.4% | 51.4% |
Sexual Transmitted Illnesses (STIs) | n | 4 | 8 | 14 | 26 (55.3%) | 21 (44.7%) |
% | 15.3% | 30.7% | 53.8% |
Response to sexual violence | n | 5 | 6 | 13 | 24 (51.1%) | 23 (48.9%) |
% | 20.8% | 25% | 54.1% |
Standard precaution | n | 5 | 6 | 12 | 23 (48.9%) | 24 (51.1%) |
% | 21.7% | 26% | 52.1% |
Prevention of sexual violence | n | 5 | 5 | 13 | 23 (48.9%) | 24 (51.1%) |
% | 21.7% | 21.7% | 56.5% |
Access to safe blood | n | 4 | 5 | 9 | 18 (38.3%) | 29 (61.7%) |
% | 22.2% | 27.7% | 50% |
ARVs for continuing users | n | 2 | 2 | 11 | 15 (31.9%) | 32 (68.1%) |
% | 13.3% | 13.3% | 73.3% |
With respect to the onset of the SRH response, 28 KIs (48.3%) indicated that the initiation of SRH services (in the context of the MISP) commenced within one to two weeks of the influx of the crisis, while 8 KIs (13.8%) reported that it commenced within three weeks or more, and more than one-third (20 KIs) did not know the exact date of when the SRH response was initiated. The extent of response of the 10 SRH programs were consistent with the extent of extent of preparedness for those programs (See Figure 2). Similar to SRH preparedness, the international NGOs played the main role in implementing the early SRH response programs during the Syrian crisis compared to governmental organizations (MOH). Only 14 KIs (14 KIs; 24.1%) confirmed having a list of dedicated SRH staff in their agencies for any emergency response (with doctors, nurses, and midwives as the most common healthcare workers included in the list), while the rest did not know or mentioned not maintaining such list. Similarly, only 40% of the stakeholders (23 KIs) confirmed having dedicated funding for SRH response during the Syrian crisis, of these 20 could not specify the exact amount of funding either allocated or received. UNFPA and the UNHCR were indicated to be the main funding agencies, followed by MOH and WHO. Almost 45% (26 KIs) indicated limited availability of SRH kits. The most available kits were ‘condoms’ and the least available ones were ‘vacuum extraction during delivery’ and ‘blood transfusion’. As for the availability and distribution of clean delivery packages, 23 KIs (39.7%) emphasized that the packages were available and distributed to Syrian refugee women. Further, 12 KIs (46.2%) indicated that they did not perceive that the availability of SRH kits was adequately responsive to the needs of this crisis. The main reasons attributed to the shortages in SRH kits were financial challenges, inadequate administrative and logistics preparations, transportation challenges, inadequate implementation guidelines, and lack of equipped operating rooms. Coordination among the various humanitarian NGOs was variable, 6 KIs (10.3%) indicated no coordination among while 9 KIs (15.5%) reporting to have adequate degrees of coordination by participating in weekly RH meetings with other organizations. Almost half of the organizations (27 KIs) confirmed that they provided direct community access to information about the available SRH/MISP services, the benefits of seeking MISP services and where/how to locate them. This access was mainly facilitated by community health care workers and the distribution of IEC materials.
Having clear protocols to inform and guide the implementation of the MISP objectives coupled with setting up a lead SRH agency were perceived to be the two most important facilitators during the implementation of the SRH services, whereas inadequate funding, workforce, and supplies for response were the three main barriers reported (See Figure 3). Further, adequate monitoring and evaluation, strengthening the capacities of the workforce to ensure adequate quality of SRH service delivery and care, regular and periodic capacity building activities, a holistic approach for responsive and coordinated SRH response, keeping accountability standards at the core center for evaluating and coordinating response, and strengthening in the areas of community engagement, community awareness, partnership and mobilization were perceived to be especially lacking and required immediate prioritization.