The Minimum Initial Service Package (MISP) in Humanitarian Settings

EXECUTIVE SUMMARY

The Minimum Initial Service Package (MISP) for Reproductive Health is the global standard for what must be done in the first hours and days of a humanitarian emergency to prevent the most immediately preventable reproductive health deaths and harms. It defines five priority objectives — coordination, sexual violence response, HIV transmission reduction, maternal and newborn death prevention, and planning for comprehensive care — that together constitute the minimum below which no humanitarian response should fall. The MISP was developed in the 1990s following documentation that women were dying preventable deaths in refugee camps and displacement settings because reproductive health received no dedicated emergency attention. Its existence represents one of the genuinely transformative achievements of UNFPA's normative leadership: it institutionalised the expectation that reproductive health is an emergency priority from Day 1.

UNFPA leads MISP coordination in most humanitarian settings through its role as global lead for the GBV Area of Responsibility and as co-leader of reproductive health within the Health Cluster. In practice, this means UNFPA's country office confirms the reproductive health coordination lead at the onset of an emergency, deploys Inter-Agency Reproductive Health (IARH) kits from pre-positioned stocks, and facilitates the multi-agency coordination group that ensures all five objectives are being implemented across the full humanitarian system. UNFPA is the coordinator, not the sole implementer — in most settings, NGOs (IRC, CARE, MSF, IMC) are the primary service providers, and WHO and UNHCR play parallel technical and protection leadership roles.

Two fundamental realities shape MISP implementation on the ground. The first is the gap between the standard and actual delivery: independent assessments and after-action reviews consistently find that the MISP is not fully implemented at the onset of most emergencies. The most common failures are late coordination (taking days rather than hours), absence of clinical management of rape (CMR) services within the 72-hour window, stockouts or misdistribution of RH kits, and failure to reach the community level with clean delivery support. These are not isolated failures — they are the norm rather than the exception, and they are documented across diverse crisis types and geographies. The second reality is the protracted crisis problem: the MISP was designed for acute onset emergencies, but the majority of people living in humanitarian crisis today are in protracted situations (Syria, DRC, South Sudan, Afghanistan, Yemen) where the acute/recovery distinction collapses and neither MISP-level nor comprehensive-level programming is consistently delivered.

For practitioners, understanding the MISP's five objectives operationally — what each requires, what resources it depends on, and what the most common failure modes are — is the essential foundation for reproductive health emergency response. For decision-makers and funders, understanding that the MISP standard is consistently not met in practice, and that the gaps are primarily due to underfunding, inadequate pre-positioning, and insufficient surge capacity, is the key strategic insight: this is a resource and system problem, not a knowledge problem.

KEY FACTS

MISP definition: The Minimum Initial Service Package defines the priority reproductive health actions to be implemented from the onset of a humanitarian emergency. It is defined by the Inter-Agency Working Group on Reproductive Health in Crises (IAWG) in the Field Manual (most recent comprehensive edition: 2018; ongoing online updates).
The MISP is not a kit: The MISP is a set of priority actions. The Inter-Agency Reproductive Health (IARH) Kits are the supply mechanism that supports implementation — they are distinct from the MISP itself. Having kits in a warehouse does not equal MISP implementation.
Five MISP objectives: (1) Coordinate reproductive health; (2) Prevent and respond to sexual violence; (3) Reduce HIV transmission; (4) Prevent excess maternal and newborn morbidity and mortality; (5) Plan for comprehensive reproductive health services.
UNFPA's role: Global lead for GBV Area of Responsibility; co-lead of reproductive health in the Health Cluster; primary procurer and deployer of IARH kits; technical lead for MISP coordination standards.
Reproductive health crises scale: An estimated 600 million people globally are currently living in humanitarian settings (OCHA, 2023 estimates), of whom an estimated 26 million are women of reproductive age. Every major emergency creates immediate reproductive health needs — pregnancies, deliveries, sexual violence — regardless of whether programmes are prepared for them.
CMR 72-hour window: Post-exposure prophylaxis (PEP) for HIV prevention following sexual assault must be initiated within 72 hours of exposure to be effective. This is the hardest operational constraint of MISP Objective 2 and the most commonly missed.
Maternal deaths in emergencies: An estimated 60% of preventable maternal deaths now occur in conflict-affected and fragile states (WHO/UNICEF, 2022). Emergencies disrupt facilities, displace health workers, break supply chains, and force deliveries in unsafe settings — each factor increasing maternal risk.
RH kit deployment: UNFPA pre-positions IARH kits globally for deployment within 48–72 hours of an emergency onset. Kits include sub-kits for CMR, clean delivery (community and facility levels), newborn care, emergency contraception, condoms, STI treatment, and blood transfusion.
MISP training gap: Studies of humanitarian surge staff consistently find that fewer than 50% of international responders deployed to new emergencies have received MISP training (IAWG surveys, 2015–2020). This is identified as one of the most persistent systemic gaps.
Protracted crisis proportion: More than 80% of the people in humanitarian need globally are in protracted crises lasting more than 3 years (UNHCR, 2022). The MISP's acute-onset framing is therefore inapplicable to the majority of the current humanitarian caseload.
EmONC standard in emergencies: WHO/UNFPA standards require at minimum 5 basic EmONC and 1 comprehensive EmONC facility per 500,000 population. In acute emergency settings, the immediate standard is more modest — at minimum, identifying existing facilities that can serve this function and establishing referral pathways to them.
GBV in every emergency: Evidence across crisis types (conflict, natural disaster, displacement) confirms that GBV — particularly sexual violence — increases in every humanitarian emergency. This is not an assumption — it is a consistent empirical finding across hundreds of emergency settings over 30 years. See UNFPA-W-05 for detail.
Adolescent-specific MISP: The 2018 MISP Field Manual update strengthened guidance on adolescent-specific reproductive health within the MISP, including safe spaces, non-discriminatory CMR for adolescent survivors, and ASRH information access. Implementation of adolescent-specific elements is even less consistent than the general MISP.
Disability inclusion: The 2018 update also strengthened disability inclusion guidance — ensuring that women and girls with disabilities can access MISP services, receive accessible information, and are included in GBV response. Implementation of this guidance is very limited in current practice.

BACKGROUND AND CONTEXT

Why the MISP Exists

Before the MISP's development in the mid-1990s, reproductive health received no systematic attention in humanitarian response. The sector-cluster system that governs humanitarian coordination had no dedicated reproductive health component. Pregnant women gave birth without skilled attendance in refugee camps, postpartum haemorrhage was not managed, sexual violence survivors had no access to post-exposure prophylaxis or emergency contraception, and antiretroviral continuity for HIV-positive displaced people was not ensured. Women died from preventable causes because the humanitarian system had no framework for prioritising their care.

The catalyst for the MISP was a combination of the 1994 Rwandan genocide (which generated a massive refugee crisis with documented reproductive health neglect), the growing evidence on GBV in conflict settings from Bosnia and Somalia, and the ICPD 1994 Programme of Action's recognition of reproductive health as a right. A group of reproductive health specialists, working through the newly formed IAWG on Reproductive Health in Crises, developed the MISP framework between 1994 and 1999. The first published MISP manual appeared in 1999.

The MISP represented two conceptual breakthroughs: first, that reproductive health could and should be prioritised from Day 1 of an emergency (challenging the prevailing assumption that it was a recovery-phase concern); and second, that a minimum, achievable package — rather than a comprehensive service standard — was both more realistic and more protective than demanding full services immediately.

The Evolving Humanitarian Context

The humanitarian landscape has changed significantly since the MISP was designed:

Protracted crises dominate: The acute-onset emergency (earthquake, sudden flood, rapid conflict escalation) represents a minority of the humanitarian caseload. Most humanitarian need is now in multi-year, multi-actor situations where the MISP's "emergency phase" framing does not apply cleanly.
Scale and complexity: The largest humanitarian operations (Syria, Yemen, DRC, Afghanistan, South Sudan) involve millions of beneficiaries, dozens of UN agencies and NGOs, and political complexity that constrains coordination in ways the MISP framework did not anticipate.
Climate-induced crises: Cyclones, floods, droughts, and displacement linked to climate change are increasing. These are often rapid-onset but recurrent — the same country may experience multiple MISP-requiring events in a single year.
Digital and connectivity: Mobile phones, GPS, and digital health tools have changed what is logistically possible in emergency response, creating new opportunities for MISP implementation (remote counselling, digital case management, drone supply delivery) that the framework is only beginning to incorporate.

WHAT UNFPA DOES: PROGRAMME DETAIL

UNFPA's Coordination Role

UNFPA does not implement all five MISP objectives alone — it coordinates implementation across the humanitarian system. This distinction matters operationally and for accountability.

Confirming the coordination lead: At the onset of any humanitarian emergency, one of the first actions required by MISP Objective 1 is formal confirmation that a lead organisation for reproductive health coordination exists and is functioning. UNFPA country office staff are expected to take this role immediately upon emergency onset. In practice, this requires:

Contacting WHO, UNHCR, and health cluster leads within the first 24–48 hours
Convening the first reproductive health coordination meeting within the first week
Creating a shared service mapping document (what RH services exist or are being established, where, by whom)
Establishing communication channels for regular updates across agencies

RH sub-working group management: The reproductive health sub-working group (SWG) within the Health Cluster typically includes UNFPA, WHO, UNHCR, UNICEF, major international NGOs, and sometimes national NGOs and government health ministry representation. UNFPA facilitates these meetings, maintains the gap analysis, and leads reporting to the inter-cluster level. In protracted settings, this mechanism may be a standing monthly meeting rather than an emergency activation.

Information management: UNFPA leads collection and dissemination of 4Ws (Who is doing What, Where, and When) data on reproductive health services in emergency settings. This is essential for identifying gaps and avoiding duplication.

IARH Kit Procurement and Deployment

The IARH kits are the most tangible UNFPA contribution to MISP implementation. UNFPA manages the global kit system — from specifications through pre-positioning to emergency deployment.

Kit sub-components (as of IAWG 2018 specifications):

Kit 0A — Condom supply: Male condoms; sized for 10,000 users for 3 months (approximately 24 condoms/user/month)
Kit 0B — Clinical management of rape: Complete CMR supplies for 100 rape survivors including EC, PEP starter packs, STI prophylaxis, examination supplies, documentation forms
Kit 1 — Clean delivery kit (individual): For community-level deliveries — soap, cord clamp, plastic sheet, blade, gloves; for approximately 10 deliveries
Kit 2 — Clinical clean delivery: Facility-level delivery supplies for approximately 125 deliveries; includes manual vacuum aspiration (MVA) supplies for management of incomplete abortion
Kit 3 — Newborn care: Supplies for neonatal resuscitation and basic newborn care
Kit 4 — Blood transfusion: Blood collection and transfusion supplies
Kit 5 — Emergency obstetric surgery: Surgical supplies for caesarean section
Kit 6 — Oral contraceptives: 12-month supply for 500 users
Kit 7 — Injectable contraceptives: Supply for 500 users
Kit 8 — STI management: Standard STI treatment protocols for 200 patients
Kit 9 — IUD for emergency contraception: 50 copper IUDs with insertion supplies
Kit 10 — Implants: Contraceptive implants for 50 users
Kit 11 — Surgical instruments supplement: Additional gynaecological instruments

Deployment logistics: UNFPA pre-positions kits in regional hubs (global pre-positioning warehouses in Dubai, Copenhagen, and in regional locations including Nairobi and Panama City). Standard deployment time from pre-positioned stock to in-country is 48–72 hours for most major emergency settings. In some protracted settings, UNFPA country offices maintain their own in-country pre-positioned stocks that can be activated immediately.

Kit quantity calculation: The number of kits required is calculated based on the estimated affected population using SPHERE standards and demographic assumptions (proportion of women, proportion pregnant, incidence of sexual violence). In practice, accurate population estimates are unavailable at emergency onset, and kit quantities are initially estimated conservatively then replenished.

Objective-Level Operational Detail

Objective 1: Coordinate

The minimum standard: A designated lead organisation for reproductive health coordination is confirmed and operating within the first week of an emergency. Ideally, UNFPA staff are on the ground or remotely coordinating from Day 1.

Real-world constraint: UNFPA country offices are present in approximately 150 countries, but staffing levels vary enormously. In small offices in countries with rare large-scale crises, the reproductive health programme officer is also covering multiple other portfolios; surge staffing from UNFPA's emergency roster must be deployed. The quality and speed of surge staffing is a significant variable in MISP Objective 1 implementation.

Objective 2: Prevent and Respond to Sexual Violence

The minimum standard: Clinical management of rape (CMR) services functionally available within the 72-hour window. This does not require a purpose-built facility — it requires a trained health provider with the right supplies in a location that survivors can reach and feel safe accessing.

Operational requirements checklist:

Identify existing health facility closest to the affected population
Confirm that a trained provider is available 24/7 (not just during day hours)
Confirm that Kit 0B supplies are present and staff can access them
Confirm that PEP starter packs are in stock and not expired
Establish a referral pathway to a facility with PEP if the primary facility cannot provide it
Establish a safe, confidential space for examination
Brief community information points (community leaders, community health workers, women's groups) on where survivors can go

Common failures at this objective (documented across after-action reviews):

Provider present but untrained in CMR protocol
Kit 0B supplies in warehouse, not distributed to facility
PEP starter packs expired or out of stock
No night-time or weekend coverage — survivors who cannot access care within business hours miss the 72-hour window
No referral pathway established or known to community members
Fear of stigma, retribution, or re-traumatisation prevents survivor disclosure, so even functional services go unused

Objective 3: Reduce HIV Transmission

The minimum standard: Condom supply and distribution; PEP availability for sexual assault survivors (overlapping with Objective 2); antiretroviral therapy (ART) continuity for displaced PLHIV.

ART continuity: In high HIV-prevalence settings (sub-Saharan Africa particularly), large-scale displacement can disrupt ART supply chains. People living with HIV who miss ART doses face viral rebound and increased HIV transmission risk. UNFPA coordinates with WHO, UNHCR, and national AIDS programmes to map displaced PLHIV and ensure ART resupply.

Practical constraint: ART continuity requires knowing who was on treatment before displacement — which requires functioning health records that are frequently unavailable after conflict or disaster. Clinical assessment and restart protocols are the fallback; standard WHO treatment guidelines provide these.

Condom distribution: Condom distribution in the early phase of an emergency is straightforward logistically (Kit 0A) but faces social and gender dynamics that complicate uptake. Distribution through health facilities reaches those accessing care; community-level distribution through trusted intermediaries (community health workers, women's groups) is necessary to reach the broader affected population.

Objective 4: Prevent Excess Maternal and Newborn Mortality

The minimum standard: Clean delivery kits at community level; referral pathways to EmONC-capable facilities; basic neonatal resuscitation capacity at delivery points.

The pregnancy count: In a displaced population, the number of women who will give birth in the first month can be estimated from population size and demographic assumptions (approximately 1–2% of the total population will give birth in any given month). This figure is the basis for kit sizing and staffing planning.

Clean delivery kit (Kit 1): Enables any person — including untrained community members — to facilitate delivery with minimum hygienic standards. The kit's contents (sterile blade, clean plastic sheet, cord clamp, soap, gloves) are designed to prevent the most common causes of neonatal infection (tetanus from unclean cord care, puerperal sepsis from unclean delivery environment). Distribution of Kit 1 to community leaders, traditional birth attendants (as community agents, not skilled providers), and displaced community health workers is the immediate action.

Referral pathway establishment: The highest-impact single action for preventing maternal death in an emergency is often not a clinical intervention but a logistical one — establishing and communicating a referral pathway so that obstetric emergencies can reach EmONC. This requires: identifying the nearest functioning EmONC facility, establishing transport (vehicle, motorcycle ambulance, or community carry mechanism), and ensuring that facility has been alerted and will accept referrals. In conflict settings, safety of referral routes is an additional consideration.

Skilled birth attendant deployment: Where possible, UNFPA and partners deploy midwives or skilled birth attendants to the emergency setting — either from national SBA rosters or through international NGOs. This is a slower action than kit distribution (takes days to weeks) but is the most protective for deliveries.

Objective 5: Plan for Comprehensive RH Services

The minimum standard: A defined plan for transitioning from MISP to comprehensive reproductive health services, with named actors, timelines, and resource requirements.

What comprehensive services include: Full antenatal care; skilled delivery services; postnatal care; family planning (including full method mix); comprehensive GBV case management; STI screening and treatment; safe abortion where legal; adolescent SRH services.

Why this must start at Day 1: Comprehensive services take time to establish — training staff, setting up facilities, procuring supplies, establishing protocols. If planning begins after the acute phase, there is a gap of weeks to months where neither MISP nor comprehensive services are available. Starting planning immediately shortens this gap.

The protracted crisis trap: In settings like South Sudan, DRC, Yemen, and Syria, emergency funding cycles have funded MISP-level services for 5–10 years without transition to comprehensive services. The perpetual MISP situation — where the emergency is never declared over, funding remains short-term humanitarian funding, and comprehensive services are never established — is the most common failure of MISP Objective 5 in practice.

THE EVIDENCE BASE

MISP Effectiveness — Evidence Quality: Moderate (for implementation) / Strong (for underlying clinical interventions)

The MISP is a package of priority actions, not a single intervention. Its overall effectiveness cannot be evaluated with a single trial. Evidence must be assessed component by component:

Clinical interventions within MISP: Strong evidence

Oxytocin/misoprostol for PPH prevention: See UNFPA-W-01. Near-definitive evidence from Cochrane reviews.
Neonatal resuscitation: WHO/ILCOR systematic reviews confirm that basic neonatal resuscitation training reduces early neonatal death rates. Evidence quality: strong.
PEP for HIV prevention after sexual assault: Systematic review evidence and biological mechanism strongly support 72-hour initiation as effective. The absence of RCT evidence is due to ethical constraints, not evidential weakness.
Emergency contraception (levonorgestrel): Cochrane review (Cheng et al., 2017) confirms effectiveness in preventing pregnancy when taken within 72 hours of unprotected sex (85% reduction in expected pregnancies when taken within 24 hours, declining with time).

MISP implementation and coordination: Moderate evidence

No RCT of MISP vs. non-MISP emergency response has been conducted or is feasible
Retrospective comparative analyses by the IAWG show that emergency settings with systematic MISP implementation have fewer reported maternal deaths and higher proportions of sexual violence survivors receiving CMR than settings without — but confounding (more organised responses are more organised generally) limits causal inference
Post-implementation reviews and after-action reports document what was implemented, what was not, and why — these are the primary evidence base for understanding implementation gaps

Evidence on implementation gaps: Strong (consistently documented)

Multiple IAWG survey studies (2010, 2015, 2019) have found that full MISP implementation is achieved in fewer than 30% of assessed emergency settings in the acute phase
CMR service availability within 72 hours is the most commonly missed standard — available in fewer than 50% of assessed settings at Day 3 of an emergency
These findings are consistent across crisis types (natural disaster, conflict, refugee emergency) and geographic regions

Humanitarian RH Evidence Base: Weak Relative to Development Settings

A consistent finding in the reproductive health in humanitarian settings literature is the weakness of the evidence base relative to development settings. Key reasons:

Research ethics challenges: conducting controlled studies in emergency settings is extremely difficult
Access limitations: conflict settings are often inaccessible to researchers
Data systems disruption: vital registration and health information systems collapse in emergencies
Short programming cycles: few programmes run long enough to generate outcome data

The result is that most humanitarian RH programming is based on extrapolated development-setting evidence, clinical consensus, and best practice from retrospective reviews — rather than direct humanitarian-setting trials.

IMPLEMENTATION REALITIES

Common Failure Modes: A Systematic Account

Independent assessments across multiple emergency settings have documented the following recurring failure patterns:

1. Late coordination establishment (Objective 1) In most emergency settings, formal RH coordination is established 3–14 days after an emergency onset — well after the 72-hour window for CMR has passed for early survivors. Causes: UNFPA staff are not pre-deployed; travel restrictions and logistics slow initial response; inter-agency coordination itself takes time to establish. Mitigation: UNFPA surge roster staff with MISP training who can be on the ground within 24–48 hours; pre-crisis coordination agreements with key NGO partners.

2. CMR services absent at onset (Objective 2) This is the single most commonly documented failure across all MISP assessment studies. Causes: trained providers are not present at health facilities serving the affected population in the first days; Kit 0B is pre-positioned but not distributed; there is no safe space for CMR at available facilities; and in many settings, the expectation of violence at onset is not operationalised into contingency plans. Mitigation: pre-emergency CMR training for national staff; facility protocols for CMR activation; known CMR site identified in emergency preparedness plans.

3. Kit misdistribution and stockouts Kits arrive in-country but accumulate in central warehouses while facilities serving affected communities are unstocked. Distribution logistics (last-mile delivery, customs clearance, in-country transport) are the bottleneck. A documented example: the 2010 Haiti earthquake response, in which large quantities of reproductive health supplies remained in Port-au-Prince warehouses for days while tent cities delivering babies had nothing.

4. Community-level kits not reaching target Kit 1 (clean delivery) is designed for community distribution, but distribution networks at community level are typically weaker than facility-level distribution. Community health workers, traditional birth attendants, and community leaders who should receive kits are often not known to the international response in the first days, and community-level distribution is de-prioritised against facility-level supply.

5. Referral system absent Women in emergency settings who develop obstetric complications cannot access EmONC because no referral pathway has been established. This may be because: no functioning EmONC facility has been identified; transport arrangements have not been made; or the referral pathway exists on paper but is not communicated to communities. This kills women even when kits are in place.

6. Surge staff lack MISP training International humanitarian responders deployed to emergency settings commonly lack MISP training. IAWG surveys found that in 2019, approximately 45% of international surge staff reported having received MISP training in the previous 3 years. This is a training system problem — MISP training is not systematically integrated into the pre-deployment requirements of most humanitarian organisations' staff pipelines.

7. Protracted crisis funding mismatch In settings like South Sudan, DRC, and Syria, humanitarian funding is provided in 1-year cycles through humanitarian response plans. Reproductive health services — both MISP-level and comprehensive — require multi-year planning, investment in health worker capacity, and facility infrastructure. Annual funding cycles prevent this. The result: MISP activities are refunded annually but comprehensive services never become established because there is no funding for the infrastructure investment they require.

Geography of Current Humanitarian RH Programming

Syria/displacement crisis: The Syrian civil war (from 2011) created one of the largest humanitarian reproductive health challenges in recent decades. UNFPA Syria has maintained a substantial programme including mobile clinics, midwife training, and reproductive health kit distribution across opposition-held, government-held, and cross-border areas. A 2019 assessment found that approximately 60% of Syrian women of reproductive age in non-government-controlled areas had access to some form of reproductive health services — a significant achievement given the operational environment, but still a 40% coverage gap.

DRC: The longest-running active conflict on the continent. UNFPA DRC maintains one of UNFPA's largest emergency reproductive health programmes, with a focus on sexual violence response and reproductive health service delivery in conflict-affected areas of the east. The DRC programme has been evaluated by the IEO (2019) as effective in maintaining MISP-level services but constrained by access limitations, security risks to health workers, and chronic underfunding.

Yemen: The conflict from 2015 has reduced Yemen's health system to near-collapse. UNFPA Yemen supports reproductive health services through a combination of direct facility support, mobile teams, and midwife deployment. The combination of active conflict, health worker displacement, and infrastructure destruction makes full MISP implementation extremely challenging. Maternal mortality in Yemen is estimated to have worsened significantly since 2015.

Rohingya crisis (Cox's Bazar, Bangladesh): The 2017 influx of approximately 700,000 Rohingya refugees into Cox's Bazar created one of the largest and most densely settled refugee situations in the world. UNFPA's reproductive health response — including MISP implementation, midwife deployment, and GBV response — has been relatively well funded and coordinated compared to most emergency settings. Programme evaluations have found high coverage of CMR and maternal health services relative to MISP standards, though access barriers for the most vulnerable women persist.

FUNDING, SCALE AND RESOURCES

Humanitarian Reproductive Health Funding Gap

Reproductive health is chronically underfunded in humanitarian response relative to need. Key data points:

Reproductive health has historically received approximately 1–3% of total humanitarian funding, despite affecting a large proportion of the affected population and being explicitly required under the MISP standard
The UNFPA annual appeal for humanitarian response is typically USD 400–600 million; actual contributions fund approximately 50–70% of the appeal
GBV programming receives less than 1% of total humanitarian funding (see UNFPA-W-05 for detail)
Emergency reproductive health kits (IARH) cost approximately USD 50–300 per kit for commodity costs; full programme support is significantly more expensive
UNFPA estimates that fully implementing the MISP in a rapid-onset crisis affecting 100,000 people requires approximately USD 1.5–3 million in the first 3 months — for commodities, surge staffing, and coordination; comprehensive services require significantly more

UNFPA's Emergency Preparedness Investment

UNFPA invests in emergency preparedness — pre-positioning of kits, surge roster development, country-level contingency planning — as a budget line within its humanitarian programme. Specific figures are not disaggregated in public reporting, but estimates from programme documentation suggest:

Global pre-positioning: approximately USD 10–20 million annually in kit stocks
Surge staff roster maintenance and training: approximately USD 5–10 million annually
Country-level contingency planning support: embedded in country programme budgets

The most significant cost-effectiveness argument for preparedness investment is the "golden hour" logic: a well-prepared response that activates within 24–48 hours prevents deaths that a delayed response cannot prevent. PEP started on Day 4 rather than Day 1 has lower efficacy; a woman who dies in labour on Day 2 because there was no referral pathway cannot be helped by services established on Day 5.

KEY DEBATES AND CONTESTED QUESTIONS

1. Is the MISP Standard Achievable in Acute Emergencies?

Some humanitarian practitioners argue that the MISP standard — particularly the 72-hour CMR window — is operationally unrealistic for most sudden-onset emergencies and creates a false accountability baseline. The counter-argument is that even if full MISP implementation is rare, the standard provides a target that drives improvement: without it, even less would be done. The evidence that the standard is regularly missed is clear; whether it should be revised downward (to reduce accountability failures) or invested in more heavily (to achieve it more consistently) is a genuine debate within the IAWG community.

2. MISP in Protracted Crises vs. Development Settings

The MISP was designed for acute-onset emergencies; most humanitarian need is now protracted. Some practitioners argue that in protracted settings, the MISP framework is a barrier to comprehensive services — it provides a low minimum standard that allows funders to argue the minimum is being met. Others argue the MISP remains useful as a check that basics are in place before more complex services are attempted. The IAWG has not fully resolved this tension operationally; its guidance on protracted settings has grown in the 2018 manual but the operational distinction remains ambiguous.

3. Safe Abortion in the MISP

The 2018 MISP Field Manual update strengthened language on safe abortion: where national law permits, access to safe abortion is a component of comprehensive reproductive health services and should be planned from the onset of an emergency. This is consistent with WHO clinical guidelines. However, UNFPA's position is constrained by donor conditions (the US Global Gag Rule restricts partners from providing abortion services even where legal; similar restrictions apply to some other donors) and by political context in many programme countries. The result is that safe abortion is often not available in humanitarian settings even where legally permitted, creating a situation where the MISP standard and operational reality diverge on this specific issue.

4. Surge Staffing vs. National Staff Capacity

The humanitarian system's traditional model of deploying international surge staff to acute emergencies has been critiqued as less effective than investing in national and local staff capacity before crises occur. National staff know local context, speak local languages, and are already present when an emergency begins. Evidence on surge staffing effectiveness vs. national capacity is limited but suggests that rapid response from national staff produces faster, more contextually appropriate responses than international surge deployment (localisation agenda, WHS 2016 commitments). UNFPA has invested in national surge rosters in some country programmes but the global system remains heavily dependent on international deployment.

5. GBV Data in MISP: The Under-Reporting Problem

MISP Objective 2 requires that CMR services be available and that survivors can access them. But most sexual violence in humanitarian settings is not reported to services — estimates suggest fewer than 10% of cases are reported (GBVIMS, 2018; academic literature). This means that absence of CMR demand at a facility does not indicate absence of sexual violence; it indicates absence of reporting. Programme managers must not interpret low CMR caseloads as evidence that violence is low — they should investigate whether survivors can access services and whether they feel safe doing so. This distinction is important for programme design and for donor reporting.

IMPLICATIONS BY AUDIENCE

For Frontline Staff and Practitioners

At emergency onset — your first 72 hours:

Confirm coordination: Within the first 24 hours, contact WHO health cluster lead and UNHCR protection lead to confirm UNFPA's role as reproductive health coordination lead. Request a first coordination meeting within 48 hours. Do not wait for others to call the meeting — call it yourself.
Establish CMR: Identify the nearest functioning health facility to the affected population. Confirm: trained CMR provider available? Kit 0B accessible? Safe examination space available? PEP in stock and not expired? If any of these are absent, this is your first action.
- If no trained CMR provider exists at the identified facility, rapidly train the most available skilled provider in the minimum CMR protocol (WHO emergency training materials exist for 2–4 hour abbreviated training) while sourcing trained CMR staff through the coordination group.
- Ensure community-level information about CMR access reaches women and girls within 24–48 hours of service establishment.
Deploy clean delivery kits: Kit 1 to community level. Identify existing community distribution networks — community health workers, women's group leaders, traditional birth attendants — and distribute. Do not wait for a comprehensive distribution plan; get kits to any community-level contact points immediately.
Establish the referral pathway for obstetric emergencies: Identify the nearest EmONC facility, confirm it is functional, arrange transport, and communicate the pathway to all health providers and community agents.
Condom distribution: Kit 0A to all distribution points and to community distribution agents. No gatekeeping — make condoms available without requiring interaction with a health provider.

CMR clinical checklist (minimum actions for any CMR encounter):

Medical history (survivor-led; do not re-traumatise with unnecessary detail)
Examination only with explicit consent; forensic documentation if the survivor requests and it is safe
Emergency contraception within 120 hours; maximum effectiveness within 72 hours
PEP: initiate the 28-day regimen; provide counselling on adherence; arrange follow-up at 72 hours and 28 days
STI prophylaxis: azithromycin (chlamydia/gonorrhoea), cefixime (gonorrhoea), metronidazole (BV/trichomoniasis), benzathine penicillin (syphilis prophylaxis)
Psychosocial first aid — do not attempt specialist counselling unless you are trained in it
Safety planning: does the survivor face ongoing risk? What can be done immediately?
Referral to psychosocial support, legal services, and shelter if available

In protracted settings:

Conduct a MISP assessment every 6 months: are all five objectives still being met? What has changed in service availability, population composition, and access?
Plan for transition to comprehensive services: identify what comprehensive services are missing, which actor could provide them, and what funding or capacity would be required.

For Programme Managers and Decision-Makers

Invest in pre-positioning: The highest-leverage investment in MISP preparedness is in-country pre-positioning of IARH kits and trained staff. A kit in a regional warehouse takes 48–72 hours to arrive; a kit in a country office can reach an affected area in hours. The cost difference is modest; the operational difference is significant.
Integrate MISP training into all pre-deployment requirements: Make MISP training a mandatory pre-deployment qualification for all staff who might be deployed to emergency settings, not just reproductive health specialists. The IAWG online MISP training is accessible, free, and takes approximately 4 hours. Make it a condition of deployment.
Track CMR service availability, not just kit deployment: The programme indicator should be "CMR service available with trained provider, within 72 hours" — not "Kit 0B deployed." Kits in facilities are useless without trained staff to use them.
Establish country-level contingency plans before emergencies occur: Every country with significant emergency risk should have a standing emergency reproductive health contingency plan that names: who leads coordination, where kits are pre-positioned, which facilities will serve as CMR sites, what the referral pathway is. This should be developed collaboratively with health cluster partners before an emergency.
Fund for protracted crises, not just acute response: If your programme is in a setting that has been "in emergency" for more than 18 months, acknowledge that the MISP-level funding model is insufficient and that comprehensive services require different (more sustainable, multi-year) funding arrangements.

For Donors and Board Directors

Reproductive health is chronically underfunded in humanitarian appeals: In a typical major humanitarian appeal, reproductive health receives 1–3% of total funding despite affecting 25–30% of the population (women and girls of reproductive age). This is a structural underfunding problem. Earmarked contributions to humanitarian reproductive health have a high marginal impact because the baseline is so low.
Pre-positioned kit funding is high leverage: A USD 50,000 investment in pre-positioned IARH kits in a country with emergency risk can prevent deaths in the first hours of an emergency that no subsequent investment can prevent. Pre-positioning is predictable, verifiable, and directly causal.
The 72-hour CMR window is the critical quality standard: Ask any UNFPA country office operating in a humanitarian setting whether CMR was available within 72 hours of the last emergency onset in their context. If the answer is no, understand why and what would be needed to achieve it.
Multi-year humanitarian funding: One of the most impactful changes a donor can make is shifting from annual humanitarian grants to multi-year humanitarian funding for protracted crises. This allows programme managers to invest in staff capacity, facility infrastructure, and supply chain systems that are impossible to build within 1-year funding cycles.
Invest in MISP training at scale: The gap in MISP-trained surge staff is solvable with a relatively small investment in systematic training infrastructure. Funding the IAWG to develop, maintain, and promote mandatory MISP training has leverage across the entire humanitarian system.

For Researchers

Implementation science is the priority: The evidence base for MISP clinical interventions is adequate. The research gap is in implementation: what organisational, coordination, and contextual factors determine whether MISP objectives are met in the first 72 hours of an emergency? Comparative case studies with systematic data collection across multiple emergency settings would generate actionable findings.
Protracted crisis RH evidence: There is very limited evidence on effective reproductive health service delivery models in protracted crises. What service delivery approaches (mobile teams, community health workers, telemedicine, integrated PHC) produce the best RH outcomes in multi-year humanitarian settings? Quasi-experimental designs are feasible in protracted settings.
Data quality in humanitarian settings: Vital statistics, population estimates, and health facility data are all severely degraded in emergencies. Research on innovative population estimation methods (satellite imagery, mobile data, rapid survey tools) that can inform MISP response in the absence of reliable baseline data is a priority.
Longitudinal studies of maternal outcomes in emergencies: Prospective cohort data on maternal outcomes in specific emergency settings — tracking women through pregnancy in displacement — would provide far more reliable evidence on risks and protective factors than the cross-sectional and retrospective data that currently dominate the literature.
CMR coverage and barriers: What proportion of sexual violence survivors in specific humanitarian settings access CMR within 72 hours, and what are the primary barriers? This basic epidemiological question is unanswered in most settings because it requires both service-side and community-side data collection.

CURRENT STATUS AND FUTURE DIRECTIONS

The MISP Field Manual (2018) is the current normative standard. The IAWG conducts periodic updates through an online platform; the 2018 version significantly strengthened guidance on disability inclusion, safe abortion, and adolescent-specific services.

UNFPA's 2022–2025 Strategic Plan explicitly identifies humanitarian response as a strategic priority, reflecting both the growing scale of humanitarian need and the recognition that a substantial proportion of UNFPA's core mandate (maternal death, GBV, unmet FP need) is now concentrated in humanitarian settings.

Key developments expected over the next 3–5 years:

Localisation: The Grand Bargain (2016) commitments and subsequent humanitarian reform discussions have focused on strengthening local and national actor capacity in MISP implementation. UNFPA is investing in national surge rosters in high-risk countries. The degree to which this reduces dependence on international deployment is a key test of localisation's effectiveness in the RH sphere.

Digital tools: UNFPA and partners are piloting digital CMR documentation systems, mobile health tools for pregnant women in displacement, and telemedicine supervision of community midwives. The digital agenda requires significant investment in connectivity, devices, and data protection systems. Evidence of effectiveness is limited but growing.

Climate-humanitarian nexus: The increasing frequency of climate-induced emergencies (cyclones, floods, droughts) requires integration of MISP preparedness into climate adaptation frameworks. This is at an early stage both conceptually and operationally.

COVID-19 lessons: The COVID-19 pandemic demonstrated both the resilience and the fragility of humanitarian reproductive health services. UNFPA emergency response adaptations developed during COVID (telemedicine, community distribution, personal protective equipment for CMR) have been incorporated into updated guidance and remain relevant for future health emergency contexts.

SOURCES

IAWG on Reproductive Health in Crises: Minimum Initial Service Package for Reproductive Health in Crisis Situations — Field Manual, 2018 — The defining normative document for MISP implementation. Covers all five objectives with operational detail, tools, and indicators. All practitioners working in emergency reproductive health must be familiar with this document. [iawg.net]
IAWG: Inter-Agency Reproductive Health Kits — Guidance and Specifications, 2018 — Technical specifications for all IARH kit sub-components. Essential for logistics and procurement staff. [iawg.net]
WHO: Clinical Management of Rape and Intimate Partner Violence Survivors: Developing Protocols for Use in Humanitarian Settings, 2019 — Clinical guidance for CMR in emergency contexts. Covers medical history, examination, EC, PEP, STI prophylaxis, psychosocial first aid. The standard reference for CMR training. [who.int]
Sphere Standards: Humanitarian Charter and Minimum Standards in Humanitarian Response (2018 edition) — Sector-wide standards including health standards relevant to reproductive health in emergencies. The MISP must be read alongside Sphere standards. [spherestandards.org]
IAWG: Assessment of Reproductive Health in Refugee Situations (multiple years, 2010–2020) — Surveys of MISP implementation quality across multiple emergency settings; the primary evidence source for implementation gap statistics cited in this document. [iawg.net]
Cheng L et al., "Interventions for emergency contraception," Cochrane Database of Systematic Reviews, 2017 — Cochrane review confirming effectiveness of levonorgestrel EC. [cochrane.org]
Roberton T et al., "Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries," Lancet Global Health, 2020 — Modelling study documenting expected indirect mortality impacts; relevant for understanding pandemic effects on MISP-level services.
Kruk ME et al., "High-quality health systems in the SDG era," Lancet, 2018 — Quality of care framework; applicable to understanding why having services is insufficient if quality is poor. Applies to humanitarian as well as development settings.
UNFPA: Reproductive Health in Emergencies — Programme Documentation and Annual Reports — UNFPA's own documentation of emergency RH programming by country and globally. [unfpa.org]
WHO: Adolescent-Responsive Sexual and Reproductive Health in Humanitarian Settings, 2020 — Technical guidance on adolescent SRH components of MISP; useful for practitioners working with adolescent populations.
UNHCR/UNFPA/WHO: Joint Guidance on Reproductive Health in Refugee Situations — Specific operational guidance for the refugee context, which has distinct legal, coordination, and service delivery features from other humanitarian settings.
Maine D, Thaddeus S, "Too far to walk: maternal mortality in context," Social Science & Medicine, 1994 — The three delays framework; the conceptual basis for understanding the operational requirements of Objective 4. [sciencedirect.com]