This descriptive qualitative study involving key informant interviews sought to identify activities that were carried out by SPRINT partners, including IPPF member associations (RFHAF and TFHA), other non-government organisation (NGO) and community-based organisations, and the Ministries of Health in Fiji and Tonga to foster workforce, organisational and community capacity development before Cyclone Winston (2016) and Cyclone Gita (2018). In addition, interview questions explored how these activities influenced the type, scope, and timeline of SRHR response to these cyclones and mitigated challenges to delivering the MISP. We used the reporting guide outlined by O’Brien et. al  to present our findings.
In this paper, we define capacity development as efforts to improve the knowledge and skills of those providing SRH care, information, and services, building support and infrastructure for organizations, and developing partnerships with communities . The research was informed by a framework designed to assess public health emergency response capacity  across various levels (systems, organizational, and individual) and the phases of the disaster management cycle (preparedness, response, recovery, mitigation) (see Fig 1). This study was, however, only concerned with the preparedness and response phases.
Fiji and Tonga were selected as case studies to explore preparedness and response to SRH. Both countries have a shared experience of tropical cyclones but have different cultural and demographic contexts. Fiji is a Melanesian country with a population of 897,295 (across approximately 100 inhabited islands), while Tonga is a Polynesian country with a population of 105,845 (across 36 inhabited islands) [14, 15]. While both are upper-middle-income countries  and have youthful populations, Tonga is more densely populated (49/km² compared with 147/km² in Fiji). SRH indicators also differ across the nations. Fiji has a contraceptive prevalence rate (CPR) of 30 percent, while Tonga's CPR is 17%. Adolescent fertility rates are similar in both in Fiji and Tonga (49 vs. 30 births per 1,000 women 15-19 years) , while the percentage of women subjected to physical and sexual interpersonal violence in their lifetime (2000–2015) differs (64% vs. 40%) respectively .
The Fiji National Disaster Management Office (NDMO) is the coordinating Fiji government's coordinating body for natural disasters. While the Ministry of Health and Medical Services has identified maternal, newborn and adolescent care and gender-based violence amongst the top health priorities in a reproductive health response , SRH in emergencies (SRHiE) is absent from the Fiji Ministry of Health Reproductive Health Policy  and the Fiji National Disaster Management Plan  that was current at the time of Cyclone Winston. The emergency management and response structure in Tonga are led by the National Disaster Council (NDC) and directed by a national plan that does not include SRH . Disaster management is noted in a generic manner in the National Health Strategic plan . SRHiE is identified in a government SRHR needs assessment  published before Cyclone Gita. Both countries have adopted a National Cluster System based on the UN model. The key clusters involved any SRHiE response are the Health and Nutrition/Health, Nutrition and Water, Sanitation and Hygiene cluster (led by the national Ministry of Health and co-led by WHO and UNICEF) and the Safety and Protection cluster (led by the national Ministry of Women and co-led by UN women). At the time of cyclone Winston and Gita, the 2010 version of the MISP for SRH (see Fig 1) was the standard applied in both responses.
Study informants were recruited purposively to include individuals from key organisations and included staff who were directly involved in the preparedness and response efforts to cyclones Gita and Winston. We sought a diversity of perspectives, including government and NGO workers, across both countries' health and disaster response sectors. Information about the study was sent to key individuals with an invitation to participate in an interview.
The findings of the desk review informed the development of questions for the interviews and helped identify possible participants. A stakeholder reference group were invited to provide input into the interview questions, and these were piloted in January 2020. Due to the COVID-19 pandemic, Australia closed its international borders in March 2020, prohibiting travel to Tonga and Fiji. As a result, interview data were collected via telephone, Zoom, Skype, and email. During the recruitment and data-gathering processes, several communication challenges were experienced due to the interviewers' remoteness, which made it difficult to establish contact with respondents and develop rapport. These were overcome by multiple contacts and discussions with individuals over six months in 2019. These multiple contacts enabled saturation to be reached through concurrent analysis that identified that no new patterns were emerging. Due to the small number of informants and unique context, respondents have been de-identified as much as possible to ensure confidentiality. To maintain anonymity, direct quotes included in this report are not attributed to individuals.
Data were analysed using a template as per the procedure described by King . The data were coded according to key categories of interest-based upon the aims of the study using the qualitative software management system QSR Nvivo 12. This list of codes formed the initial template that represented the themes in the textual data. These themes were modified over time, as new data revealed additional themes. A framework of factors influencing SRHiE Response, together with a broad understanding of capacity and capacity development programming (see Fig. 1), informed the template that was employed for the data analysis. This template allowed for the consideration of a wide range of factors that may enhance or threaten the effectiveness of SPRINT-supported preparedness capacity development efforts and the response.
This study was granted ethical approval by the Human Ethics Research Committee of the University of Technology, Fiji National Health Research Ethics Committee, and the Tonga National Health Ethics and Research Committee.
Eight key informants were interviewed for this study. We outline the findings according to the preparedness and response phases.
Preparedness: Before Cyclones Winston and Gita
Before Tropical Cyclone Winston in Fiji, key informants reported that few capacity development activities had taken place to support the delivery of the MISP. Only one respondent received training with no-follow-up, and some SROP staff were familiar with the MISP, but had not received formal training. Of those involved in response to Winston from the sub-regional office (SROP) and the Member Association RFHAF, only one responder had received training on the MISP. This training had been provided during the second phase of the SPRINT Initiative. A significant amount of time had passed since the completion of this training, no follow-up refresher training or opportunity for the individual to apply their new knowledge or skills. Staff from the SROP were familiar with the MISP due to their involvement in reporting and supporting regional humanitarian work. However, they had not received a formal orientation to the package.
At the onset of the cyclone, two surge capacity staff members from IPPF were sent to Fiji to conduct a 'crash course' for RFHAF staff on the basics of the MISP and coordination skills needed to support the response in Fiji. These staff members had been involved in implementing SRH services during crises in different contexts. A key informant stated:
…the crash course in Fiji it was really focused on coordination. And how to handle yourself and your staff in crisis situations. How to be more tolerant, more strategic, and how to react quickly, to how fast things are the way things change. So it was really preparing them psychologically and emotionally on what would happen. Because family planning, HIV, maternal health, SGBV, they’ve been doing this for how many years in their work as RFHAF. They know this stuff. What they do not know and what they will be faced with is how stubborn a government official can be, how chaotic a response can be, how uncoordinated it can be, how to manage to work around the interests of some people.
Participants appreciated the practical nature of this training, with one explaining that “when we did the crash course, they focused on what we would be doing” (Respondent). Further capacity development strategies were deployed to ensure involved nursing staff and volunteers were familiar with where their tasks fit within the MISP implementation, to clarify roles, and to explain each medical mission's processes and procedures. In addition to these formal training sessions, these two experienced IPPF staff-members remained with the in-country and SROP-supported response teams for ten days to advise, guide, debrief and build daily on lessons learnt.
In Tonga, key informants reported that training had been conducted well before the onset of cyclone Gita. This training had been conducted alongside other preparedness activities, including a national stakeholder meeting on the MISP, training on long-acting reversible contraceptives (LARC), Orientation to Sexual and Gender based violence in emergencies (SGBViE), and attendance at cluster meetings and interagency coordination with stakeholders.
In 2017, the TFHA hosted a national stakeholder meeting to orient participants on the MISP. This meeting was followed by a more detailed MISP training conducted by the IPPF Pacific Humanitarian hub in partnership with TFHA and supported by the SPRINT program. Twenty-four volunteers/ first responders participated in this MISP orientation session in the capital, Nukualofa. In addition to MISP orientation sessions, TFHA ran LARC training to incorporate this into future service provision and orientation to SGBV. This training was delivered alongside regular preparedness activities and participation in national stakeholder meetings with the National Emergency Management Office, MoH, Ministry of Internal Affairs, Emergency Services (including Police), and local NGOs working in women’s rights, disability, and lesbian, gay, bisexual, transgender, queer, intersex (LGBTQI) areas.
Training also continued during the response when gaps in the provision of psychosocial support for SGBV survivors were identified, especially on the island of 'Eua. A half-day orientation on SGBV in emergencies was conducted in 2018 for field responders, facilitated by UNFPA and supported by SPRINT response funding in collaboration with TFHA, IPPF Pacific Humanitarian Hub, and the MoH. A total of 42 Tongatapu-based clinical staff nurses and midwives were trained in basic concepts and fundamental guiding principles in dealing with a range of SGBV issues. Gita, therefore, provided the opportunity to upskill clinical staff building competence and networks, and relationships.
Key informants also noted that the TFHA staff had attended several cluster meetings as key stakeholder. These included meetings with the Health, Nutrition, Water, Sanitation and Hygiene (HNWASH) cluster and the Safety and Protection cluster involving the MoH, UN agencies and NGOs.
Responding to Sexual and Reproductive Health needs after Cyclones Winston and Gita
An SRH response was launched in the aftermath of both Tropical Cyclones Winston and Gita. The scope of these responses differed, and Table 1 summarises these against the objectives of the MISP (2010). Key differences are seen in preventing and responding to sexual violence and planning for comprehensive RH services, integrated into primary care. Safe and rational blood transfusion in place was not reported in either setting.
The training at the onset of the cyclone response led trainees, with the assistance of regional staff, to initiate a Family Health Sub-cluster to facilitate a collaborative SRH response with the MoH and Medical services teams. According to one key informant, this was essential “otherwise reproductive health would have been lost in the health cluster because they had so many other concerns”.
Before the guidance that was provided during this training, staff had found this a challenging time.
we had to learn which cluster meetings to go to. We had to see where we fit into the security one and the health clusters. Even in the health clusters, we had to fight even to have a reproductive health cluster within the health cluster which wasn’t there before…That’s why we were so disadvantaged, there was a lot to handle”.
Links with the MoH had not been formalised. One informant said:
there was collaboration, there was an existing memorandum of understanding with the Ministry of Health but it dipped a bit and that relationship sort of was estranged… During TC Winston, there would have been, there was a relationship, but it wasn’t an active, engaged relationship shall we say during TC Winston”.
One informant stated: “we had to make extra efforts to be brought in” due to the lack of an active relationship with government despite an existing memorandum of understanding. These 'extra efforts' in the form of advocacy by IPPF SROP and MA representatives and guided by surge capacity staff led to the establishment of the sub-cluster and the delegation of responsibility to RFHAF- achievements regarded as impressive by several respondents. They also strengthened the relationship with government, an outcome explained by one respondent as:
crucial because these are the things that will really hinder you, will make it very difficult for one humanitarian team to operate if you do not have the support from your own leadership and if the government doesn’t trust you.
While informants noted confusion regarding what cluster meetings to attend and weak relationships, they were also aware of general confusion at the time of the response "at that time, it was not really coordinated by the government, there were so many organisations that came in with different agendas and they wanted to be the first in." Despite this, all agreed that coordination had improved in the recovery phase of the disaster, stating that the situation is:
[better] coordinated, not like before when we were looking and finding ways with the existing system of the government, but now we know after the MISP, after the set-up of the humanitarian arm here, it’s more coordinated and it’s quicker.
Medical missions were launched the day after the brief training in Fiji. The RFHAF/IPPF SPRINT team delivered family planning counselling and referred pregnant women in their third trimester to birthing units. They distributed clean delivery kits, contraceptives, and dignity kits (containing sarongs, undergarments, thongs, whistles, soap, and sanitary pads). The team also provided safe spaces for displaced women and girls and community awareness on GBV. One responder reflected
the first intervention…was really disorganised, but after that when we came to the second one we were able to take a lot of lessons and even recommendations from the community about how we could do it best and we even incorporated that intervention when we went to the west.
Skills weaknesses were noted especially in relation to GBV that may also have affected the response:
we were just at that point strengthening the objective two components of MISP and so I think at that time we couldn’t even consider ourselves a player at that point because we were not involved in the GBV or the protection work in Fiji as we should have been...
The collation of supplies and logistics also delayed the medical response as no action had been taken for securing these during the preparedness phase. One informant said: “what delayed our trip was we had to buy the stuff and get our dignity kits.” Another stated:
at that time we were trying to rent vehicles and they were all out… And that was a drawback because we were a bit late in our response… There was no coordination and we should have booked the car but we had all these competing agendas.
Roles were not always clear to responders who reported taking on many:
So, I was everywhere. I don’t really understand what was my role at that time because I seemed to be doing everything! I coordinated, I went to the village headmen, I went to the Ministry of Health for meetings, then I wore my nursing cap when I gave the injection and I was also the driver
In addition to MISP work staff were engaged in activities that were not related to SRH:
The chief of the village we visited was sick. And because it was so far away up the mountains and there was no transport, we had to get the chief man, because he had something that needed medical attention and because we were there, we had to drive him down to the main hospital. But we had to do it. And after a hurricane it’s not that easy to drive the Fiji roads where you have bridges washed away and big potholes. So that was something besides the MISP that we did during our response.
However, informants stated that such activities were necessary to build rapport with community members. Some of them challenged the need for SRH response when they believed that they needed shelter and food.
It’s actually about convincing the masses why it is important. It was not an easy job but we were able to tell them, during a disaster and after…women won’t stop having babies during a disaster…The communities came to appreciate that and that was quite a good feeling
IPPF surge staff remained with the in-country and SROP-supported response teams in Fiji for ten days to advise, guide, and debrief. One informant recalled:
The good thing about it is after every village we went to, no matter how late it was we would sit together as a team…and go through the day…We built on our lessons learnt every day and we had [the two support persons] there and they were really observers when we provided the service except the doctors and counselling. But they would attend the information sessions and go in and see how we would demarcate the areas and the signs and they would help explain properly and they would feedback to us in the evening.
Key informants were optimistic about the response to Gita, “overall, the response was good and the TFHA team felt they were in control”. Staff were described as highly motivated, with one informant declaring: "it was new for us and became very exciting for us to provide the MISP, and we were able to get DFAT, who is the donor, to join us on one of our visits and they were happy with what we showed”. Comparisons were made with the response in Fiji and one key informant stated:
Tonga [the population] is much smaller [than Fiji] and the [TFHA] members as well have a very strong relationship with the Ministry of Health. I think those two things, there were a few things to their advantage. For example, one of the National Disaster Management Office coordinators actually sits on the Tonga Family Health board and also a Ministry of Health officer.
In addition, relationships and networks developed with the MoH, NGOs and communities during preparedness activities were easily activated in response to Gita. When the MoH made an official request to the TFHA to facilitate SRH services and education to communities affected by tropical cyclone Gita on 19th February 2018, the TFHA formed a “core team” with the MoH and NGOs to undertake these activities in coordination with the HNWASH and Safety and Protection Clusters.
One individual stated that the TFHA had “a very good relationship with the Australian DFAT post in Tonga, maybe because they’re just down the road. There’s that active engagement even during normal times”. However, there was “a rapid learning curve” when it came to moving from the training room to disaster implementation. The assistance provided by the IPPF humanitarian hub including the training and development of a response plan and proposal for funding was regarded as a “big advantage“ by a key informant.
Staff roles were expanded when the TFHA team agreed with the MoH to include cervical cancer, diabetes and high blood pressure screening in the response “given the high burden of non-communicable disease in the Tongan community“. As in Fiji, it was identified that staff lacked capacity to address objective 2 of the MISP, responding to sexual violence. They instituted a brief training intervention to increase the capability of nurses to counsel and refer identified cases.
Despite informants expressing satisfaction with the response, some pointed to necessary improvements including the need to better think through transport to outer islands as staff had to rely on fishing boats and tailoring dignity kits to suit the local context. Plans to improve preparedness were in train including undertaking MISP readiness assessment, the integration of the MISP into the national reproductive health policy, and lobbying to include the MISP in the Tongan Government’s goal to respond within the first 72-hours of an emergency.
Key informants agreed on several issues, including that preparation is key for any response and that this must include hands on skill development and building and maintaining strategic relationships and community links. As explained by one participant:
80% of your response lies in how prepared you are. And being prepared doesn’t just mean that you have clinicians trained, or the resources prepositioned, it’s about being part of a national support network… we need to have those linkages to national level. We need to have those policies in place, we need to have the buy in from the key ministries…and I think we need to have partnerships- these play a great deal in the preparedness needs. And definitely capacity building at the MA level not just for the clinical or program staff but for youths engaged, at the board level for governance and so people are clear about what their role is and how that contributes to the bigger, broader picture of meeting people’s SRH needs.
Respondents from both Tonga and Fiji noted a lack of systemic data collection on the status of vulnerable and marginalised groups during the response. This lack of data was seen as a barrier to mobilising an effective SRHiE response and planning future responses. In Tonga, this need for reliable data was reported to extend beyond particular groups to a general shortage of demographic and health-related data at a country level. One informant called for “standards for reporting and country appropriate indicators to allow the comparison of responses.” While UNFPA provided commodities for distribution, they did not assume an implementing function during the cyclone responses. It was suggested, however, that UNFPA involvement in monitoring and evaluation would have benefited the response in both countries.