Understanding Operational Barriers to Family Planning Services in Conflict-Affected Countries: Experiences from Sierra Leone

This February - May 2007 study highlights issues affecting provision of family planning (FP) in conflict-affected settings, using experiences in Sierra Leone as the focus from which to derive lessons on refugee/internally displaced persons (IDP) family planning needs; barriers to quality, accessible services; policy actions to overcome barriers; and capacity building of local groups to recognise and analyse barriers. According to the study, the adoption and implementation of appropriate "operational policies" can alleviate barriers to healthcare until international community guidelines and protocols on refugee/IDP health needs are met through national policy and guideline development.

The document notes that the range of complementary reproductive health (RH) services (e.g., safe motherhood, prevention of gender-based violence, HIV/sexually transmitted infection (STI) prevention) are essential and have been identified as part of the Minimum Initial Services Package (MISP) for reproductive health in crisis situations.

The three primary study sites in Sierra Leone included the camp and surrounding community near Bo town; the Largo camp and community in Kenema District; and Lungi community in Port Loko District. The study gathered information through focus group discussions, a "Journey of a Woman" exercise using drawing of pictures of participant stories of their families - before, during, and after the conflict (the 3 stages of study applied here), key informant and provider interviews, and the POLICY project Policy Environment Score (PES) to assess the degree to which the policy environment facilitates access to high-quality FP/RH services.

The report details women's and men's responses on FP at the three stages of study. Responses show increased availability of condoms with the presence of non-governmental organisations (NGOs) both during and after the conflict, and increased FP services after the conflict, though clinics were reportedly hampered by stockouts of medicines of up to one month. Reports varied on barriers such as price, and some women reported going to local markets for lower priced FP products such as injectable contraceptives. Barriers to FP included lack of availability in the immediate post conflict stage, limited knowledge of contraceptive use, particularly among IDP women, inability to travel to hospitals, and restrictions on FP access for single women, adolescents, and women with low parity. Some refugee women reported learning from programmes on sensitisation to the need for FP, provided by national and international organisations.

The document suggests the following barriers, in addition to costs and stockout problems: lack of community-based distribution; shortage of trained reproductive health specialists; inability/unwillingness of providers to recommend different contraceptive options if the client experiences side effects; long wait times and poor treatment at health facilities; condom promotion that is limited to HIV prevention; and greater attention needed for men’s reproductive health issues.

Recommendations for stakeholders include:

1. develop a strategy to implement the newly approved National Reproductive Health Policy;
2. prioritise areas for rolling out the new reproductive health policy that did not receive the FP attention that refugee camp areas received;
3. reform and reinforce logistics to improve availability of contraceptives;
4. Ministry of Health (MOH) and NGOs should collaborate to develop strategies for encouraging male involvement, addressing sexual violence, and increasing knowledge on the availability of emergency contraception;
5. provide in-service training for all health facility personnel on reproductive health;
6. replicate and scale-up Marie Stopes International's model of community-based distribution; and
7. rebuild and resupply health facilities.

Recommendations for the international community include:

1. advocate for the inclusion of family planning in repatriation plans with a focus on providing adequate supplies of commodities for women to be used during the transition back to their country of origin.
2. include FP in the initial package of services provided to refugees during the camp registration process.
3. systematically examine and strengthen the reproductive health knowledge of camp providers.
4. provide immediate access to comprehensive and compassionate care for sexual violence and torture survivors including emergency contraception.
5. establish a collaborative approach to importing commodities during a conflict.