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Tough Choices in Implementing Multisectoral Reponses to Gender-Based Violence Prevention and Response Sarah Eckhoff, Technical Advisor for Gender

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SESSION OVERVIEW Introduction to the session Overview of key terms associated with multisectoral approaches to GBV prevention and response Review of three case studies within which multisectoral approaches to GBV prevention and response have been employed: Kenya and Mozambique Group brainstorm and discussion Wrap-up

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GENDER-BASED VIOLENCE Gender-based violence (GBV) is defined as an umbrella term for any act that is perpetrated against a persons will, and that is based on socially ascribed (gender) differences between males and females. 1 Acts constituting GBV include intimate partner, sexual, and emotional violence, as well as harmful traditional practices, including female genital cutting and early marriage. GBV is correlated with myriad adverse health outcomes including: unintended pregnancy; depression; substance abuse; sexually transmitted infections (STIs), including HIV; and maternal and child mortality 2 1 UN Inter-agency Standing Committee, Guidelines for Gender-based Violence Interventions in Humanitarian Settings: Focusing on Prevention of and Response to Sexual Violence in Emergencies (2005). 2 Population Reference Bureau, Gender-based Violence: Impediment to Reproductive Health (USAID/Interagency Gender Working Group, 2010).

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WHAT ARE PRIMARY AND SECONDARY PREVENTION OF GBV? Primary prevention: Efforts to enhance the protective factors that prevent GBV Secondary prevention: Interventions that aim to moderate the immediate effects of GBV

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PRIMARY PREVENTION OF GBV Efforts to enhance the protective factors that prevent GBV: Deconstructing harmful gender norms Education Promotion of gender equality Promotion of non-violent conflict resolution Interventions may include: School-based programs to foster greater gender equality Community-based activities to foster collective reflection and dialogue around gender norms through the lens of power and access

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SECONDARY PREVENTION OF GBV Efforts that aim to moderate the immediate effects of GBV: A package of clinical services (e.g., provision of PEP for HIV and STI prevention and provision of emergency contraception, treatment of injuries, forensic evidence collection, Hepatitis vaccination, abortion) Psychosocial, legal, and police support Temporary shelter Secondary prevention modalities: One-stop center: where clinical services are co-located with police, legal, and psychosocial support services; and, Integrated services model where clinical services are integrated into existing health services, and connected through referrals to appropriate police, psychosocial, shelter, and legal aid support.

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EXPERIENCES OF GBV IN KENYA AND MOZAMBIQUE *Data not collected in Mozambique DHS on women aged 15-49 whose first sexual intercourse was forced against their will.

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TANZANIA: TUTUNZANE II Pathfinder supported MOH to develop 5 separate GBV clinical management training curricula for health providers Developed through multisectoral collaboration Master training of national trainers conducted in Dar es Salaam: cascade training in 4 regions Facilitation of local planning within Dar es Salaam to respond to gaps in GBV services Galvanizing community-led responses to GBV and VAC Integration of GBV and VAC referral into HIV counseling and testing

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KENYA Government-led multisectoral prevention and response model that operated at facility and community levels Implementation began with the WJEI pilot in Kibera and Kenyatta National Hospital from 2009-2011 and continued with APHIAplus Key interventions : Community-based interventions to increase knowledge of intersections between HIV/AIDS and GBV and galvanize community responses to GBV Capacity building of health providers Integrated package of services at health facilities OSCs Strengthening of multisectoral coordination Male engagement through male champions network

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MOZAMBIQUE Multisectoral approaches to primary and secondary prevention of GBV within 2 projects and 2 provinces UNTF-funded project in Gaza Province Norwegian Ministry of Foreign Affairs in Inhambane Province Gender norm transformation interventions: School-based activities Community-based activities + male involvement Bolstering community responses to GBV Building the capacity of multisectoral providers engaged in GBV response Establishment of services for survivors Integrated package of services with multisectoral referrals One-stop-centers Increasing multisectoral coordination Strengthening multisectoral referrals

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MOZAMBIQUE

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OVERARCHING LESSONS LEARNED Greater investment must be made in measuring the effects of primary prevention interventions Government and community buy-in and participation are key in implementing sustainable multisectoral approaches to secondary prevention of GBV Need to go beyond provider training to ensure that services are integrated and of quality Human resources must be sufficient to staff stand-alone OSCs Uptake of services at health facilities is not consistent across contexts A participatory development process is key in fostering multisectoral coordination at all levels Indicator consistency will facilitate greater cross-program and cross- context learning

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RECOMMENDATIONS FOR FUTURE CONSIDERATION Many OSCs are often well-marked and located in larger provincial hospitals; this can pose a significant access barrier for survivors The maturity and strength of the health system must be considered when selecting a secondary prevention modality In contexts where uptake of services at health facilities is more limited among GBV survivors policy barriers must be overcome to increase access to EC and PEP (e.g., via police) Multisectoral referral linkages must be strengthened to ensure that survivors are reaching essential services The unique needs of male survivors of GBV must be considered in project design

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COUNTRY X BRAINSTORM GBV is pervasive throughout this country; among even the highly educated physical violence is acceptable while GBV refers mostly to cases of sexual violence Post-conflict state where there is little faith in the justice system including police Many actors in GBV prevention and response efforts; although provider turnover challenges capacity building One comprehensive one-stop-center (rural) and one center for GBV survivors excluding police services (urban) EC and ARVs are available at lower level facilities; providers are apprehensive to provide ARVs for PEP to GBV survivors Medical certificate must be signed by government doctor (provincial hospitals) in order for legal redress to be pursued Understood that many GBV survivors do not seek services

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GROUP BRAINSTORMING Based on the lessons-learned put forward as well as any of your experiences, what recommendations would you make to employing these multisectoral approaches to primary and secondary prevention of GBV? Is there one secondary prevention modality that seems most feasible in certain contexts or health systems? What are the limiting factors in terms of one secondary prevention modality over the other? When we think about primary prevention and the behavior and norm change necessary, what are the strategic choices that we face as implementers when scaling-up?

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