Respondents and health facilities
The study team conducted 11 KIIs with agency staff. Five of 15 health facilities run by national and international organizations and militaries were visited in Zaatri Camp. Study sites included three health clinics, one camp hospital, one maternity hospital and the MOH Mafraq referral hospital located outside of Zaatri camp in Mafraq. Six health facilities were visited in Irbid City, two health centers, two clinics, and two hospitals. The team conducted 14 FGDs among refugee women, in Zaatri Camp there were 101 women and in Irbid City there were 58 women, respectively.
MISP awareness and knowledge
All but one of eleven key informants (KIs) was aware of the MISP, and nearly half knew all five MISP objectives. However, approximately two-thirds of KIs were not aware of the additional priorities of the MISP.
Coordination of the MISP
Nine KIs reported that UNFPA hosted RH coordination meetings weekly in Zaatri Camp and monthly in Amman. Participants reported that coordination mechanisms, health indicator collection issues (although there was greater emphasis on Zaatri Camp indicators) and MISP implementation was discussed. A KI also said that non-governmental organizations that are not funded are missing from coordination meetings. In addition, several respondents said that RH coordination for urban areas was lagging behind camp coordination because the coordination meetings in Amman tended to focus on the more visible daily refugee influx and refugees concentrated in the camp setting in Zaatri whereas refugees in urban areas, disbursed within host communities were less visible.
The majority of KIs reported that MOH and/or World Health Organization protocols were available to support MISP implementation and funds were available for a MISP response. Three quarters of respondents reported that RH Medical Kits were available and adequate for this response. In both settings, all groups reported that clean home delivery kits were not distributed. One KI explained that given facility-based deliveries were available in Zaatri camp and the urban setting, and the norm among the populations in Jordan and Syria, there was a concern that the distribution of clean delivery kits could encourage home deliveries.
All facilities in Zaatri Camp were open and convenient for adolescent females, but none of the facilities had an appropriate entrance for clients with disabilities. None of the five facilities visited provided RH outreach services. In the FGDs, the majority of women in the Zaatri groups agreed that agencies had not communicated directly with the refugees about the emergency response. Across the groups in Irbid City, most women reported that they were not contacted by agencies and learned about services through their community.
Prevent and manage the consequences of sexual violence
Seven key informants reported knowledge about measures to prevent sexual violence and treat survivors. However, measures to prevent sexual violence were insufficient and only one site had the human resource capacity and supplies to provide clinical care for rape survivors.
In Zaatri Camp, women expressed concerns about the lack of lighting and their fears of using the toilets at night. In Irbid City, women reported feeling unsafe sending their daughters to school on public buses. Women said that they were fearful of telling their families of sexual violence due to fears of honor killing, or being disowned by family. The women discussed what they perceived as more cases of domestic violence in the camp than what they observed while living in Syria but were fearful of negative consequences if they reported experiencing violence. The women voiced a desire mostly for psychosocial services, in addition to prevention and medical care but were unaware of service availability. Nearly all women across the groups in Irbid City agreed that they would not feel comfortable attending health services for reasons including no benefits from receiving health care and family stigmatization. Additionally, all groups with young women said that they would not tell anyone if they experienced violence. Regarding incidents of sexual violence that are usually reported to UNHCR protection, the Moroccan Field Hospital had not received any sexual violence survivors, although Mafraq Hospital had received one. Treatment and forensic evidence collection was available at Prince Hamza or Mafraq hospitals but they did not have standard protocols. Jordan Health Aid Society (JHAS) clinic was the only facility visited that has a protocol to manage sexual violence survivors in the camp. In Irbid City, there was a formal referral protocol for sexual violence survivors from the health centers to the Family Protection Unit including a standard incident reporting form. Partners stated the MOH was developing a national protocol for clinical management of rape survivors.
Reduce HIV transmission
Three of nine key informants had essential knowledge on how to reduce HIV transmission. When asked about HIV transmission, all FGDs from Zaatri Camp and five groups in Irbid City stated that they knew about HIV and acquired immunodeficiency syndrome (AIDS). Also, refugee women did not trust the blood supply and had a greater fear of contracting HIV through blood than sexual contact.
Safe blood was available for transfusion in both Zaatri Camp and in Irbid City from a blood bank. Most facilities enforced standard precautions, including use of disposable needles and syringes and sharps disposal boxes. In an event of a health worker’s occupational exposure to HIV, limited occupational post-exposure treatment was available in Amman.
Eight of ten key informants reported that condoms were available through clinics and in women’s safe places. In Zaatri Camp, male condoms were in stock, but female condoms were unavailable. In Irbid City health facilities, most clinics did not supply condoms to non-married women. Men could buy condoms from pharmacies. FGD participants showed very limited knowledge of where they could obtain condoms in Zaatri Camp but participants in Irbid City understood that condoms were available through pharmacies.
Prevent excess maternal and newborn morbidity and mortality
Approximately half of the key informants could identify all of the priority activities within the objective to prevent maternal and newborn morbidity and mortality. In Zaatri Camp, normal deliveries, basic emergency obstetric care and newborn care functions were conducted at the Gynécologie Sans Frontières maternity clinic. Obstetric emergencies requiring comprehensive emergency obstetric care including post-abortion care and management of newborn complications were referred to the Moroccan Field Hospital. A few women in Zaatri Camp described deterioration in the quality of services over time, including a lack of physical examinations and drugs and unqualified health providers. The deterioration in services may be linked to the large influx of refugees that had been experienced in the months prior to and during the evaluation.
At two Irbid City referral hospitals services for normal deliveries, basic and comprehensive emergency obstetric care, comprehensive abortion care within the law, and post-abortion care were available. FGD participants stated that a UN registration card resulted in free services for pregnant women. Despite free services, women showed reluctance to use them as they were perceived to be “bad” quality due to the lack of privacy and female providers.
A referral system to facilitate transport and communication from the community to health facilities was available in the camp and in Irbid City, with ambulance transportation the most common mode of transport in both settings. Due to traffic congestion, referrals could take 30 minutes or more in the camp, while referrals in Irbid City took 10-45 minutes. In all of the health facilities in Zaatri Camp and Mafraq Hospital, qualified medical personnel were present 24 hours a day, seven days a week but staff complained about an increased case load and insufficient human resources since the onset of the crisis.
Plan to integrate comprehensive RH services into primary health care
Just over half of the key informants were aware of activities to plan for comprehensive RH services such as assessing and addressing staff capacity to provide comprehensive RH services. Seven of eight respondents reported informing the community of the health benefits to seeking RH services. The majority stated that this was undertaken through health education campaigns. In Zaatri Camp, most reproductive health indicators were collected, but the quality of the indicators was questioned. For example, one report showed a hospital occupancy rate of 120%. Facilities in Irbid City separately reported refugee and non-refugee indicators to the MOH. In terms of planning future sites for delivery of services, UNFPA had recently opened a new maternal and child health center in Zaatri Camp, while planning was also underway to establish more obstetric services for normal deliveries at Primary Health Clinics, at one per 5,000 persons. UNHCR pays health care costs for refugees referred to Mafraq hospital from Zaatri Camp. In Irbid City health facilities, registered refugees did not have to pay for clinical services as they are covered by the MOH. In most government clinics, unregistered refugees, unless they were referred by JHAS and UNHCR covered the cost, paid similar fees to uninsured Jordanians.
In the camp, there were many complaints from FGDs about lack of medications, while in Irbid City, complaints focused on the cost of medications. In Zaatri Camp, requests were made to increase services for special needs populations and vulnerable community members. In Irbid City, the main reasons for not seeking health care among refugees were the disrespect shown to the women by providers, limited or inappropriate medicine and long wait times for care. One KI said that inter-agency service guides on health and protection services had been developed for Syrian refugee-impacted governorates of Jordan. A KII reported that information and education was provided to new arrivals through service booklets, given to JHAS who subsequently distributed them to refugees, including unregistered refugees. In addition, a UNHCR help desk was available.
Additional priorities of the MISP
An array of family planning methods, including oral contraceptive pills, injectable contraceptives, and intrauterine devices were available. According to Jordanian guidelines emergency contraception can be provided through combined oral contraceptives although a dedicated emergency contraception product was only available for post rape care in one setting. There were provider barriers in access to family planning including emergency contraception. For example, one provider stocked contraceptives but reported that “women did not want them” while another provider reported they would not give emergency contraception to a rape survivor or an unmarried woman. There were cost barriers in the urban context. Although focus group participants expressed a strong need for family planning, half of the participants in Zaatri Camp and almost all in Irbid City were unaware of the locations for free family planning services. Most women in Zaatri Camp and Irbid City mentioned that they would try to self-abort through lifting heavy objects if they had an unwanted pregnancy.
Both providers and service users indicated uneven and inadequate availability of services and supplies related to STIs and HIV, as well as menstrual hygiene. Syndromic management of STIs was not mentioned by representatives of the facilities visited in Zaatri Camp. Most providers said that STI cases were rarely seen. In Irbid City settings providers were not familiar with standard protocols for syndomic management of STIs. None of the facilities at Zaatri Camp provided antiretroviral therapy, including the referral hospital in Mafraq. Those needing antiretroviral therapy were referred to facilities in Amman. It was reported in the FGDs that women in Zaatri Camp received a single distribution of hygiene products upon their arrival but staff at the distribution sites were rude to them. Half of the women had heard about distributions at registration but, when they returned for additional hygiene supplies, they were told that none were available.
Integration of reproductive health into disaster risk reduction and emergency preparedness
Just over half of KIs reported that there was a national disaster risk reduction agency in Jordan. Mixed responses were received in terms of whether a health risk assessment had been undertaken and whether disaster risk reduction health policies or strategies were in place.
In terms of agency preparedness, approximately two-thirds of respondents reported that their organization undertook preparedness for this crisis. Preparedness trainings included a national training on the MISP in June 2011; the MISP regional training of trainers in Cairo in December 2012; MISP training in Zaatri Camp; and gender-based violence training for police.
Regarding the prepositioning of supplies, while four out of nine KIs reported that RH supplies were procured and pre-positioned, a representative from the agency responsible for this process said that supplies were not pre-positioned.
In summary facilitating factors to MISP implementation are Jordan’s pre-existing health care infrastructure and willingness to address RH among Syrian refugees. Other factors included: the identification of a dedicated agency within the health sector to lead RH coordination; available funding for RH; relative concentration of people in Zaatri Camp; prior MISP training; and, highly skilled and dedicated work force. In contrast, reported barriers to MISP implementation included insufficient funding for the urban response; a lack of female staff; and the absence of a national protocol on clinical management of rape. Other perceived barriers included: limited supplies distribution despite availability; the crisis occurring before Jordan implemented its MISP contingency plan; and the large urban caseload.