United Nations Secretary-General António Guterres recently visited Rohingya refugee settlements in Cox’s Bazar, Bangladesh. He reflected that nothing could have prepared him for the “bone-chilling accounts” of ethnic cleansing, including of girls and women who were “gang-raped while family members were tortured and killed.” The Myanmar military has long used sexual violence as a weapon of war, and the recent violence that drove nearly 700,000 Rohingya to flee to Bangladesh was no exception.
In refugee and other crisis contexts, women and girls are disproportionately affected by limited access to essential services, including health care. According to the UNFPA’s June situation report, there are 316,000 Rohingya women of reproductive age, 63,700 pregnant women, and a grave risk and reality of gender-based violence. Women who deliver children born of rape often experience another trauma of being shamed and ostracized, and those who contract HIV and other sexually transmitted infections face social marginalization. There is a clear need for provision and access to consistent, reliable, and effective sexual and reproductive health (SRH) services, which save lives and promote resilience in humanitarian contexts. The Minimum Initial Service Package (MISP) identifies crucial actions at the onset of crisis to ensure its implementation in order to prevent and manage the consequences of sexual violence, reduce HIV transmission, prevent maternal and newborn death and illness, and plan for comprehensive sexual and reproductive health care.
Here are some questions that the government of Bangladesh and international partners should consider when looking to expand access to quality SRH services for Rohingya refugees and host communities:
What are key gaps in SRH services in Rohingya settlements?
In February, the Inter-Agency Working Group on Reproductive Health in Crisis (IAWG) issued a report summarizing recommendations for steps that the Bangladesh government, implementing agencies, and donors should take to strengthen SRH services provided to Rohingya refugees. One month later, the Joint Response Plan (JRP) was released for the Rohingya humanitarian crisis, outlining plans for a coordinated response to meet the needs of refugees and host communities. Both reports express concern about the many challenges voiced by implementing partners, including high home birth rates and the lack of 24/7 availability to health clinics, access to voluntary contraception, HIV/STI treatment, and comprehensive post-rape care (including access to safe abortion care). Actors on the ground are working to scale up provision of the MISP, but this alone will not ensure that women and girls are able to access services. Access is limited by a number of factors, including restrictions on mobility, low community awareness of services, cultural barriers, and opposition by husbands. The challenges of both provision of and access to SRH services is intensifying with the onset of monsoon season.
One of us (Huang) went to Cox’s Bazar in May and heard about the need to rapidly ramp up support for the implementation of global standards. Huang heard of male staff being allowed to enter women and girls’ safe spaces. Allowing men into safe spaces directly counteracts the primary value that they provide to vulnerable women, as well as UNFPA’s standards and guidance for the implementation of effective spaces during crises. For Rohingya women, safe spaces enable discussion, activities, and individual and group counseling to take place in a safe and secure environment. Failing to maintain these as women-only spaces hinders SRH efforts, including related to preventing and responding to gender-based violence (GBV) and sharing information on how to access reproductive health, psychosocial, and other services. This is just one example of the need for greater capacity and resources to meet SRH needs.
Where does Bangladesh fall when it comes to SRH services?
UNFPA considers Bangladesh to be generally progressive in its laws and policies affecting women. The government is striving to make progress in the health sector and made significant commitments to SRH in its 2016-2020 five-year plan, including: reducing maternal mortality; increasing the number of births attended by “skilled health staff”; and increasing the contraceptive prevalence rate. Bangladesh has achieved progress in these areas, with an over 50 percent decrease in maternal mortality since 2000 and ranking in the top 10 percent of countries for contraceptive prevalence. (In other areas, accelerated effort is needed; for example, Bangladesh is in the bottom 10 percent for antenatal visits.) This progress has likely been slower to reach Cox’s Bazar, an officially designated “lagging district” in Chittagong Division, as its residents are more vulnerable than the overall population: 33 percent of Cox’s Bazar residents live below the poverty line versus 24.3 percent nationwide, and the primary school completion rate is 54 percent versus 80 percent nationally. In recognition of significant challenges in Chittagong Division, Bangladesh included a focus on the area among its concrete and ambitious Family Planning (FP) 2020 commitments. Notably, these FP2020 commitments also include mainstreaming the MISP into Bangladesh’s emergency responses.
How do SRH baselines compare for Bangladeshi and Rohingya women? How do priorities align?
Despite the laudable targets in Bangladesh’s plans and its achievements to date, urgent progress on the ground is still needed. As of 2016, 62 percent of women gave birth at home (Bangladesh remains in the bottom 10 percent of countries for facility-based deliveries), GBV affected 87 percent of ever-married women, and the rate of adolescent pregnancy (113 births per 1,000 women aged 15-19 years) is the highest in South Asia. Yet, the government allocated only 4.1 percent of its budget to health ($32 per capita in 2015). Spending on SRH services was only a fraction of this already low amount. Bangladesh’s National Health Accounts (NHA) show that the government spends 7.5 percent of its total health expenditure on maternal health and 7 percent on reproductive health. The rough statistics that are available indicate that Rohingya women and girls in Cox’s Bazar are facing similar challenges, but to greater degrees. Reports from Cox’s Bazar consistently highlight high home birthing rates (only 22 percent of women give birth outside their shelters), reports of significant GBV (16,503 incidents reported between August and May), and significant funding gaps for health (only 12.3 percent funded of the $113.1 million requested through the JRP).
What is needed as the crisis becomes protracted?
The current focus is rightly on immediate humanitarian needs, including scaling up provision and access to the MISP. Yet historical experience (with refugees having been displaced for an average of 10 years) and Myanmar’s posture (including failure to provide conditions for safe and voluntary return) suggest that significant levels of return are not possible in the foreseeable future. With 316,000 Rohingya women of reproductive age and 360,000 girls under the age of 18, and the continued needs of women and girls in host communities, SRH requires priority attention. It is critical to begin longer-term planning for comprehensive SRH services (as called for in the MISP) that strengthens local health infrastructure and services for refugees and host communities alike. Given the small amount of per capita health spending by the Bangladesh government and limited donor funds, there is a need to develop evidence-based and sustainable approaches. With high out-of-pocket expenditures on health in Bangladesh, this should include consideration of schemes (e.g., subsidies and cash transfers) that enable refugees and vulnerable populations in host communities to access services in the longer-term.
Just before his joint trip to Bangladesh with Guterres, World Bank President Jim Yong Kim announced $480 million of grant-based support for the Rohingya crisis, including a $50 million additional grant to an existing health sector support project. This is notable because less than a year into the crisis, development actors are making financing available to support host country systems in the refugee response. The health grant includes contributions from the Canadian government, a global leader on gender equality and addressing GBV, which will hopefully translate into a prioritization of quality SRH services. In October, Sweden announced a grant to increase the integration of midwives into the Bangladesh’s health system to reduce maternal and newborn mortality and morbidity, including a focus on vulnerable populations in Cox’s Bazar. Additional financing that seeks to expand and improve SRH service delivery to refugees and hosts, while strengthening local systems, is much needed.
As the crisis becomes protracted, the needs of refugees should be included in national development planning across sectors, including health, while keeping in mind refugees’ need for tailored psychosocial and other support. With support from its partners, Bangladesh should set ambitious, yet realistic targets for expanding access to quality SRH services to refugees and hosts. To advance progress toward these targets, international partners should prioritize SRH services in policy dialogue and their financial and technical support, maintaining focus even when the crisis fades from the headlines.
Many thanks to the International Rescue Committee’s Rita Nehme and CGD’s Roxanne Oroxom for their thoughtful and constructive input. All errors remain our own.