PRB

The link between crisis and self-care should be clear. In crisis settings—such as natural disasters and war—health systems rapidly become overwhelmed. Self-care can bridge service gaps by helping displaced, marginalized, and underserved individuals self-manage, self-test, and self-treat certain conditions. The concept of self-care is key to strengthening the resilience of health systems and their capacity to absorb, mitigate, and prevent vulnerability to shocks and stresses.¹

PRB interviewed more than a dozen staff at humanitarian organizations in West and Central Africa to understand how they use self-care approaches (for a list of who we spoke with, see Interviews, below). We came away with an important realization: Self-care advocates have more work to do to clarify the utility of self-care and the importance of self-care approaches in conflict settings.

Pandemic Highlights Self-Care Knowledge Gaps

The last three years of the global COVID-19 pandemic have highlighted the need for sustainable solutions to alleviate overwhelmed health services and mitigate the life-threatening consequences of crises. COVID-19 was an eye-opener on self-care; the 2022 World Health Organization (WHO) guidelines on self-care describe COVID-19 as an illustrative global threat that led to the increased need for humanitarian assistance despite the major shortage of health workers.² In West and Central Africa, where several countries are facing internal conflict, the pandemic has overburdened already weak systems.³ To cite one example, essential services, such as sexual and reproductive health care, were disrupted or suspended in many countries, putting the health and well-being of countless individuals in jeopardy.⁴

The UN General Assembly (UNGA) is planning a high-level meeting on pandemic prevention and response in September 2023 in coordination with WHO; self-care will be extremely relevant in the forthcoming UNGA discussions.⁵ Yet, findings from our interviews revealed that self-care was not a term largely used by humanitarian organizations and was not often referred to in their policies. Some spokespeople cited field activities that are considered self-care (for example, self-diagnosis and testing for HIV and malaria, the mid-upper arm circumference (MUAC) bracelet for malnutrition), but overall, organizations were not aware of nor involved in global or regional self-care discussions, with two exceptions (Doctors Without Borders/Médecins Sans Frontières and the International Rescue Committee). And while most of the organizations interviewed, especially those with field missions, were unaware of the WHO self-care guidelines, they were keenly interested in learning how to apply them.

Community Health Workers Are Gateway to Self-Care

The enabling environment, including laws and policies that ensure stable public services, as well as health systems, is critical to integrating self-care approaches. And local actors, interviewees said, are key to successful implementation, especially in humanitarian settings. Self-care approaches in the field must begin with official national policies and guidelines, such as have been adopted by Nigeria, Senegal, and Uganda.

In particular, community health workers (CHWs) are the gateway to self-care because they are close to hard-to-reach populations and can act as relays to share information.⁶ CHWs are trusted members of the community; their presence is often preferred since they communicate in a language that is understood, with a face that is familiar.⁷ According to the International Rescue Committee, CHWs can be a bulwark when the health system collapses; thus, humanitarian organizations often seek to strengthen CHW capacities.⁸ “Relying on the CHWs is necessary for organizations as ours to fill the gaps in the health system in crisis, and to guarantee a minimum of treatment for vulnerable people,” said Papys Lame of the Alliance for Medical Action (ALIMA) in Dakar, Senegal. ⁹

Private local actors can also play crucial roles: When providers are shut down, or hospitals are overwhelmed, pharmacists, for instance, can be good alternatives to find solutions to support patients facing shortages.¹⁰

Reproductive Health Approaches Are Critical in Conflict

Self-care interventions related to sexual and reproductive health (SRH), such as self-injectable contraceptives and medication abortion are among the more feasible in times of emergency. Addressing the SRH conditions in a country in crisis might also help prevent worsening of the crisis. One useful model is the Minimum Initial Service Package (MISP), a set of critical and life-saving activities required to meet the SRH needs of affected populations at the onset of a humanitarian crisis.¹¹ The MISP was developed by the Inter-Agency Working Group on Reproductive Health in Crisis (IAWG), including the United Nations Population Fund (UNFPA) and partners.

Moreover, because 61% of maternal deaths happen in fragile countries in crisis, SRH constitutes one of the main priorities for preventing death and ill health among women of childbearing age.¹² Supervised by the UNFPA and aligned with guidance from the United Nations Central Emergency Response Fund (CERF), the objectives of the MISP and self-care align. Promoting self-injectables and making emergency contraception accessible can help prevent unintended pregnancies and reduce the risks of gender-based violence .

Preparation and Upstream Policies Are Vital for Success

While the benefits are clear, training for to support self-care approaches is not yet a priority in the acute phase of a humanitarian response.¹³ Self-care should be seen as a viable solution when resources are scarce—but it is not a replacement for the primary health care services that governments should provide.¹⁴

The people we interviewed frequently stressed the importance of enacting supportive policies for self-care in a stable environment before a crisis; the same sentiment has been echoed by Dr. Asis K. Das, Senior Public Health Officer for the UN High Commissioner for Refugees West and Central Africa region. To gain government support, pilot projects that demonstrate the benefits of self-care approaches should be conducted, our interviewees said.

Self-Care Approaches Are Key for Humanitarian Settings

These interviews highlight the relevance of self-care in emergency situations, where health services are under pressure. The increasing number of crises and the trend toward protracted conflict warrant consideration of effective solutions for affected populations. The agency that self-care approaches offer, especially in the case of self-injectable contraceptives, empowers women to make choices about their own health. To governments, organizations, and advocates looking to improve health outcomes, the time to prioritize self-care approaches is now.

Interviews

The list below represents the organizations and position titles of the 11 interviews conducted between August and December 2022. 

• Alliance for Medical Action (ALIMA), Medical Service Manager.
• FHI 360, Research for Scalable Solutions, Behavioral Scientist, Maternal, Newborn, and Child Health Division; Associate Director, Research Utilization (two people interviewed).
• International Labour Organization (ILO), Regional Specialist on HIV and AIDS for Africa.
• International Rescue Committee (IRC) in Burkina Faso, Health and Nutrition Coordinator.
• Joint United Nations Programme on HIV/AIDS (UNAIDS), Senior Adviser, Community Support West and Central Africa.
• Médecins Sans Frontières (MSF), Regional Director West and Central Africa.
• Norwegian Refugee Council (NRC), Burkina Faso, Manager Burkina Faso Teams.
• Terre des Hommes, Burkina Faso, Medical Coordinator and Health Cluster Co-Coordinator.
• United Nations High Commissioner for Refugees (UNHCR) West and Central Africa, Senior Public Health Officer.
• United Nations World Food Program (WFP), Regional HIV Officer.
• Youth Alliance for Reproductive Health (YARH), Co-Founder and Team Leader; Program Manager; Project Manager (three people interviewed).

References

[1] Align MNH, “Self-Care in Humanitarian and Fragile Settings: Overcoming Challenges, Embracing Opportunities, and Advancing a New Advocacy Agenda,” July 14, 2022. Webinar.

[2] “Aide des pairs : Faire avancer l’auto-soin au Sénégal et au Nigeria.” Webinar.

[3] United Nations Office for the Coordination of Humanitarian Affairs (OCHA), Humanitarian Action. “Analyzing Needs and Response: Section 2 Response Plans: West and Central Africa.” The seven countries include Burkina Faso, Cameroon, Central African Republic, Democratic Republic of the Congo, Mali, Niger, and Nigeria.

[4] World Health Organization, Pulse Survey on Continuity of Essential Health Services During the COVID-19 Pandemic, August 27, 2020.

[5] John Heilprin, “UN Approves High-Level Pandemic Summit,” Health Policy Watch, February 9, 2022.

[6] Justin Matheson-Turner, “Community Health Workers: The True Heroes of HIV Self-Testing,” PSI Impact blog, July 6, 2016.

[7]World Health Organization, “Self Care During COVID-19,” June 12, 2020.

[8]Interview with the International Rescue Committee, August 16, 2022.

[9] Interview with Papy Lamb, ALIMA, conducted by Elsa LeDuc, PRB intern, 2022.

[10]Luna El Bizri et al., “The Role of Community Pharmacists in Increasing Access and Use of Self-Care Interventions for Sexual and Reproductive Health in the Eastern Mediterranean Region,” Health Research Policy and Systems 19, supplement 1 (2021).

[11] United Nations Population Fund, Minimum Initial Service Package (MISP) for SRH in Crisis Situations, 2020.

[12]Nguyen Toan Tran et al. “Sexual and Reproductive Health Self-Care in Humanitarian and Fragile Settings: Where Should We Start?” Conflict and Health 15, no. 22 (2021).

[13]Sylvia Kehlenbrink et al., The Burden of Diabetes and Use of Diabetes Care in Humanitarian Crises in Low- and Middle-Income Countries (draft only), 2019.

[14]Toan Tran et al. “Sexual and Reproductive Health Self-Care in Humanitarian and Fragile Settings: Where Should We Start?“