Minimum Initial Service Package (MISP) in Crisis and Emergency Settings

The Minimum Initial Service Package (MISP) for Sexual and Reproductive Health (SRH) is a coordinated set of priority, life-saving activities implemented at the onset of every humanitarian crisis. It applies to conflict, displacement, epidemics, natural disasters, outbreaks, refugee settings and other emergencies. “Minimum” means the essential starting point—not the only care affected people deserve. The response should expand into comprehensive SRH services as soon as possible. The MISP has six linked objectives: coordination, sexual-violence prevention and care, HIV/STI prevention, maternal/newborn survival, prevention of unintended pregnancy, and transition to comprehensive SRH integrated into primary health care. Current inter-agency guidance also emphasises safe abortion care to the full extent of applicable law.

Learning objectives

• Explain why SRH needs continue and often increase during crises.
• State the six MISP objectives and the priority actions under each.
• Organise a safe MISP response from first coordination meeting to integrated recovery services.
• Provide emergency clinical care for sexual-violence survivors, pregnant women, newborns and people needing contraception or HIV/STI services.
• Identify supplies, staff, referral, safeguarding, data and quality requirements.

1. Why MISP is needed immediately

Crises disrupt health facilities, supply chains, transport, privacy, communication, skilled attendance and family support. Women may give birth without assistance; survivors of rape may lose access to post-exposure prophylaxis; people living with HIV may run out of ART; contraceptive users may face unintended pregnancy; and newborns may die from preventable hypothermia, sepsis or birth asphyxia. Increased risk does not wait for a formal needs assessment.

2. The six MISP objectives at a glance

1. Coordinate implementation: identify a lead SRH organisation/person within the health sector/cluster.
2. Prevent sexual violence and respond to survivors: protection, confidential clinical care, psychosocial support and referral.
3. Prevent HIV/STIs: condoms, blood safety, PEP, ART continuity, PMTCT and syndromic/STI services.
4. Prevent excess maternal and newborn morbidity/mortality: 24/7 referral, clean delivery, EmONC and essential newborn care.
5. Prevent unintended pregnancies: voluntary contraception, emergency contraception and continuation of existing methods.
6. Plan comprehensive SRH integration: expand beyond the initial package and strengthen health-system building blocks.

3. Objective 1—Coordination and leadership

First coordination actions

• Appoint a named MISP/SRH coordinator with authority, deputy cover and clear reporting line to the health sector/cluster and district/national authorities.
• Map all affected and host populations, health facilities, mobile teams, referral hospitals, transport routes, safe spaces, laboratories, blood services and partner organisations.
• Identify what is functioning, what is unsafe, what is inaccessible and where gaps are greatest—without delaying lifesaving implementation for a lengthy baseline survey.
• Include women’s, adolescent, disability, refugee and community representatives in decisions; do not plan only from the perspective of agencies.
• Coordinate clinical protocols, referral forms, confidentiality, data definitions, stock reporting, infection prevention, security and staff supervision.

Minimum coordination outputs

4. Objective 2—Prevent sexual violence and care for survivors

Protection and prevention

• Work with protection, security, camp-management and community groups to improve lighting, safe toilets/water points, safe distribution queues, shelter privacy and safe routes to clinics.
• Train all staff to recognise risk, challenge stigma and never demand proof before providing care.
• Provide information discreetly about where to seek help; ensure services are accessible to adolescents, people with disabilities, men/boys and LGBTQ+ people where relevant and safe.

Survivor-centred first contact

1. Ensure immediate safety; separate the survivor from the alleged perpetrator and avoid repeated retelling.
2. Obtain informed consent for each examination, test, treatment, evidence collection and referral. A caregiver’s consent must not erase an adolescent’s voice or best interests.
3. Use a trained interpreter, not a child or accompanying person with a possible conflict of interest.
4. Provide privacy, non-judgemental listening and choice. Do not pressure reporting to police before urgent care.
5. Assess injuries, pregnancy risk, bleeding, strangulation, head injury, suicidal thoughts and urgent medical needs.

Clinical care after rape

• Offer wound care, analgesia, tetanus assessment, STI prophylaxis/testing according to national protocol and HIV PEP as soon as possible—ideally immediately and within 72 hours when indicated, completing a 28-day course.
• Offer emergency contraception: levonorgestrel 1.5 mg orally as soon as possible (effective up to 120 hours, less effective with delay); ulipristal 30 mg or a copper IUD may be alternatives where legal, available and clinically appropriate. Check drug interactions and pregnancy status; emergency contraception does not terminate an established pregnancy.
• Offer pregnancy testing at presentation and follow-up; provide options counselling and referral for safe abortion care to the full extent permitted by Ugandan law and policy.
• Provide psychosocial first aid, mental-health referral, social/protection support and follow-up for HIV, STI, pregnancy, injuries and safety.
• Forensic evidence collection is optional, consent-based and only when safe, lawful and feasible. Clinical care must never be withheld because evidence collection is unavailable.

5. Objective 3—Prevent HIV and other STIs

• Maintain uninterrupted ART for people living with HIV; establish medication refills, multi-month dispensing where feasible and safe transfer between facilities.
• Make condoms and lubricants accessible without judgement, including female/internal condoms when available.
• Provide HIV testing with consent, confidentiality and a clear confirmatory algorithm; link positive results to ART and prevention services.
• Provide PEP after sexual exposure, occupational exposure or other significant contact according to current Uganda guidelines; start as soon as possible and no later than 72 hours when indicated, with a complete 28-day regimen and follow-up testing.
• Continue PMTCT/eMTCT: ART adherence, viral-load monitoring where available, safe delivery planning, infant prophylaxis and infant-feeding counselling.
• Use syndromic or laboratory STI management according to national protocol; ensure partner notification/testing is voluntary and safe.
• Maintain safe blood transfusion: donor screening, sterile injection practice, sharps safety and post-exposure management for staff.

6. Objective 4—Prevent excess maternal and newborn mortality

Maternal services that must function

• At least one accessible facility with skilled birth attendance and a 24-hour referral pathway for obstetric emergencies.
• Basic/emergency obstetric and newborn care: parenteral antibiotics, uterotonics, magnesium sulphate, anticonvulsant care, assisted birth/caesarean referral, blood access and newborn resuscitation.
• Clean delivery and cord-care supplies; infection prevention; respectful maternity care and privacy.
• ANC and postnatal contacts, iron/folate, malaria/HIV/syphilis services, contraception, danger-sign education and safe transport.
• Continuity for women with previous caesarean, hypertension, diabetes, HIV, anaemia, multiple pregnancy or other high-risk conditions.

Newborn actions

• Immediate drying, warmth, skin-to-skin, breathing assessment, delayed cord clamping when appropriate and early breastfeeding.
• Bag-mask ventilation for babies who do not breathe; oxygen/CPAP and neonatal referral where available.
• Identify prematurity, low birth weight, sepsis, hypoglycaemia, jaundice, congenital anomalies and feeding difficulty.
• Kangaroo mother care for stable preterm/low-birth-weight babies; clean cord care and essential immunisation/prophylaxis.

Maternal/newborn emergency referral

7. Objective 5—Prevent unintended pregnancies

• Offer voluntary, confidential counselling and a choice of short- and long-acting methods; do not impose a method because the population is displaced or poor.
• Ensure existing contraceptive users can continue pills, injectables, implants, IUDs, condoms and sterilisation follow-up where safe.
• Provide emergency contraception after rape or contraceptive failure and explain timing, expected bleeding and follow-up.
• Maintain supplies for postpartum and post-abortion contraception, including condoms and methods suitable for breastfeeding, according to Uganda guidelines.
• Include adolescent-friendly services, disability-accessible information and protection from coercion.

8. Safe abortion care and post-abortion care

Unintended pregnancy can increase rapidly in crises. Provide non-directive pregnancy-options counselling, accurate information, management of miscarriage and complications, post-abortion contraception and referral for safe abortion services to the full extent of Ugandan law and policy. In emergencies, treat haemorrhage, infection, shock and incomplete abortion immediately; do not delay stabilisation while debating legal or social issues. Document consent and clinical findings confidentially.

9. Objective 6—Transition to comprehensive SRH

The MISP is the starting point. As soon as security and capacity allow, expand to:

• Full ANC, skilled delivery, postnatal/newborn and child services with quality improvement.
• Comprehensive contraception, infertility care, menstrual health and adolescent SRH.
• Comprehensive HIV/STI prevention, testing, treatment and eMTCT.
• Cervical-cancer prevention/screening where feasible, breast health and gender-based-violence case management.
• Safe abortion and post-abortion care within law, psychosocial services and disability-inclusive care.
• Supply-chain strengthening, trained staff, supervision, community participation, data systems, financing and integration into primary health care.

10. Other priority SRH needs during crises

• Menstrual hygiene supplies, water, privacy and safe disposal.
• Continuation of hormonal contraception, ART, epilepsy medicines and other essential chronic medicines.
• Management of infertility and sexual dysfunction when basic lifesaving services are stable.
• Care for adolescents, older people, people with disabilities, men/boys and sexual/gender minorities according to safety and local policy.
• Psychosocial support, protection from exploitation, trafficking and transactional sex, and referral for legal/social services.

11. Supplies and logistics

12. Human resources and competencies

• Train health workers in MISP objectives, survivor-centred care, consent, confidentiality, PEP, emergency contraception, maternal/newborn emergencies, resuscitation and referral.
• Use task-sharing within national scope; ensure supervision and competency assessment rather than sending untrained staff to perform invasive procedures.
• Provide staff safety, rotation, psychological support, rest, security briefings and protection from burnout.
• Include community health workers, protection actors, laboratory/pharmacy/logistics staff, interpreters, psychosocial workers and disability/adolescent representatives.

13. Data, monitoring and accountability

• Collect only necessary data, store securely and aggregate reports so survivors cannot be identified.
• Track service availability, births, maternal/newborn emergencies, sexual-violence clinical care, PEP initiation/completion, contraception, HIV/STI testing, stock-outs and referrals.
• Use denominators carefully in displaced populations; explain uncertainty and avoid comparing sites without context.
• Review deaths and near misses confidentially, identify preventable delays and act on findings.
• Establish feedback and complaint mechanisms that are safe, confidential and accessible to women, adolescents and people with disabilities.

14. Clinical algorithms for frontline students

Survivor presents within 72 hours

1. Ensure safety, privacy and consent; assess injuries and urgent medical needs.
2. Offer HIV PEP, emergency contraception, STI prophylaxis/testing, tetanus/wound care and pregnancy testing.
3. Provide psychosocial first aid, safety plan and confidential referral.
4. Arrange follow-up for PEP adherence, HIV/STI/pregnancy testing, mental health and protection.

Pregnant woman in a displaced settlement with bleeding

1. ABCDE, estimate blood loss, check shock, gestation, pain and fetal status.
2. Start emergency treatment, IV access/bloods, avoid unsafe vaginal examination, contact receiving facility and transfer with handover.
3. After stabilisation, update ANC, birth plan, contraception/postpartum plan and psychosocial support.

Emergency programme set-up in the first days

1. Name MISP lead and map functioning services.
2. Secure referral, staff, commodities, communication and safe spaces.
3. Start all six objectives in parallel; do not wait for a perfect assessment.
4. Monitor stock, access, quality, protection and outcomes daily at first, then transition to routine reporting.

Quick self-test

1. What does “minimum” mean in MISP?
2. List the six core MISP objectives.
3. What time window is critical for HIV PEP after sexual exposure?
4. Name four components of survivor-centred care.
5. What maternal/newborn services must be linked by a 24/7 referral pathway?
6. Why must comprehensive SRH planning start during the initial response?

Further study and source integration

• UNFPA: Minimum Initial Service Package for SRH in crisis situations
• IAWG: MISP resources and implementation tools
• IAWG quick MISP reference
• WHO Health Cluster: MISP for SRH
• UNFPA/IAWG MISP reference PDF