1. Gender and Health Unit Pan-American Health Organization Regional Office of the World Health Organization Violence against Women: The Health Sector Responds

2. Published May 2003 Result of 10 years of work Collaborative effort between PAHO, PATH, CDC and WHO Funding from SIDA and NORAD Violence against Women: The Health Sector Responds

3. Background GBV is one of the most widespread human rights abuses and public health problems in the world today GBV is devastating, affecting women and girls’ long- term physical and mental well-being The ripple effects of GBV compromise the well-being of families, communities and societies A strategy to address the problem is needed - for health workers, decision-makers and communities

4. The Health Sector Responds to GBV Over the last decade, GBV has been widely recognized as a public health and human rights problem Over the last decade, GBV has been widely recognized as a public health and human rights problem Several conventions and declarations (CEDAW, DEVAW, Belem do Para) have established international/governmental commitment to addressing and eliminating GBV Several conventions and declarations (CEDAW, DEVAW, Belem do Para) have established international/governmental commitment to addressing and eliminating GBV GHU has played a pivotal role in these developments within the Americas GHU has played a pivotal role in these developments within the Americas Our primary emphasis has been on the involvement, not only of the health sector, but of women themselves, their families and communities Our primary emphasis has been on the involvement, not only of the health sector, but of women themselves, their families and communities

5. The Health Sector Responds to GBV VAW is “…any act of gender based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women…” Chapter I - Gender-Based Violence: A Public Health and Human Rights Problem…. SOCIETYCOMMUNITYRELATIONSHIP INDIVIDUALPERPETRATOR - Being male - Witnessing marital violence as a child - Absent or rejecting father - Being abused as a child - Alcohol use - Marital conflict - Male control of wealth and decision-making in the family - Poverty, low socioeconomic status, unemployment - Associating with delinquent peers - Isolation of women and family - Norms granting men control over female behaviour - Acceptance of violence as a way to resolve conflict - Notion of masculinity linked to dominance, honour or aggression - Rigid gender roles ECOLOGICAL MODEL OF FACTORS ASSOCIATED WITH INTIMATE PARTNER VIOLENCE

6. The Health Sector Responds to GBV Chapter I - Gender-Based Violence: A Public Health and Human Rights Problem…. 10-50% of women have been victims of intimate-partner violence 10-50% of women have been victims of intimate-partner violence Women are at greatest risk of violence from men they already know Women are at greatest risk of violence from men they already know Violence is a complex problem - cannot be attributed to one cause Violence is a complex problem - cannot be attributed to one cause Nature and Extent Consequences Increased risk of physical/reproductive and mental health problems Increased risk of physical/reproductive and mental health problems Increased exposure to STIs and HIV Increased exposure to STIs and HIV Increase in negative health behaviours (drug-use/sexual risk-taking) Increase in negative health behaviours (drug-use/sexual risk-taking) Homicide, suicide, maternal mortality, miscarriage Homicide, suicide, maternal mortality, miscarriage

7. The Health Sector Responds to GBV In response to this reality, PAHO’s Gender and Health Unit... Chapter II - The “Critical Path”: From Research to Action…. Developed and implemented the “Critical Path that Women Follow when Affected by Family Violence” in 16 communities of 10 countriesDeveloped and implemented the “Critical Path that Women Follow when Affected by Family Violence” in 16 communities of 10 countries RESPONSE FACTORS - Availability/Quality of services - Social representations of service providers - Obtained results MOTIVATING FACTORS - Information/Knowledge - Perceptions/Attitudes - Previous experiences - Support from close people DECISIONS AND ACTIONS TAKEN

8. The Health Sector Responds to VAW The study found that... Chapter II - The “Critical Path”: From Research to Action…. All women interviewed were victims of physical and/or psychological, sexual and economic violenceAll women interviewed were victims of physical and/or psychological, sexual and economic violence Women were generally unaware of their rightsWomen were generally unaware of their rights Even when they took steps to resolving their situation, the women met with frustrating resultsEven when they took steps to resolving their situation, the women met with frustrating results For the majority of women, violence started following co- habitation or marriage, and was exacerbated by pregnancyFor the majority of women, violence started following co- habitation or marriage, and was exacerbated by pregnancy Women tolerated abuse out of fear, social pressure or lack of financial resourcesWomen tolerated abuse out of fear, social pressure or lack of financial resources Women identified the negative attitudes of service providers as primary obstaclesWomen identified the negative attitudes of service providers as primary obstacles

9. The Health Sector Responds to VAW Out of the “Critical Path” study grew the Integrated Model for Addressing GBV... Chapter III - Joining Forces to Address GBV…. NATIONAL COALITIONS SECTORS COMMUNITIES Advocate for improved policies and legislation Build capacity, develop instruments and systems Form networks, organize campaigns and self-help and support groups GENDER EQUITYGENDER EQUITY PARTICIPATIONPARTICIPATION PARTERSHIPSPARTERSHIPS CROSS-CUTTING VALUES OPERATIONAL LEVELS INTERVENTIONS OF THE INTEGRATED MODEL DETECTION First step towards breaking the cycle of violence ATTENTION AND CARE Imperative that providers have the necessary policies, materials, protocols and procedures PROMOTION AND PREVENTION Raising awareness about GBV is key to preventing it

10. The Health Sector Responds to VAW At the regional level...  Symposium 2001: Gender-Based Violence, Health and Rights in the Americas  Technical exchanges between Central American and Caribbean countries  Political commitment to address GBV Chapter III - Joining Forces to Address VAW…. What has the Integrated Model achieved? At the national level...  Inter-sectoral coalitions formed in 10 countries  GBV legislation passed in 10 countries  “Critical Path” results published in 10 countries  GBV prevention campiagns in 10 countries  GBV detection, prevention and care incorporated in health-sector reform policies in 5 countries At the sector level...  Instruments and systems developed and implemented  Norms and protocols in 10 countries  Surveillance systems in 5 countries  Training modules in 10 countries At the community level...  Formation of more than 150 community networks  Support groups for men and women formed in 5 countries  Self-help groups formed in 8 countries  Zero tolerance campaigns and other non-violence activities promoted in numerous communities

11. Lessons Learned from Central America July/August 2001 - Participatory evaluation of the Integrated model project to determine... July/August 2001 - Participatory evaluation of the Integrated model project to determine...  A review of project and country documents  Interviews with informants (PAHO consultants, MOH staff, etc…) carried out in each country  Focus group discussions with stakeholders  Whether health providers changed the way they thought about and addressed violence  Whether women’s “Critical Path” had become less complicated  What lessons were learned through the implmentation of the project Components...

12. Lessons Learned from Central America Increasing international and national recognition of GBV as a public health and human rights problem Increasing international and national recognition of GBV as a public health and human rights problem Chapter IV - Policy and Legal Reforms….  Creation of National Plans on preventing violence against women in several countries (for e.g. PLANOVI in Costa Rica, Mesa Nacional in Peru)  Legislative reform throughout Central America - for example:  Establishment of protective measures  Expanding the concept of injury  Establishing family ties as an aggravating circumstance  Changing the status of sex crimes/spousal violence to public offenses

13. Lessons Learned from Central America Chapter IV - Policy and Legal Reforms…. Putting the laws into effect...  Interpretation of laws may be biased by culture or other factors  Little coordination between family and criminal justice courts  Contradictions between family law and domestic violence law  Allowing offenders “curative treatment” instead of prison time  Mediation is neither forgiveness nor reconciliation  Mandatory reporting dicourages providers from asking questions  Legal proof may be required fron forensic physicians (very few)

14. Lessons Learned from Central America Why is GBV invisible in the health sector? Chapter V - Building an integrated approach….  “There’s simply no time to talk or perform special exams for women reporting violence”  “I thought that there were just a few people living like this and that it was something shameful…”  “Women do not speak for fear that the husband will be put in jail and then no money will come into the household”  “People think that our indigenous costumes make us stupid…In the health centre we have to wait longer”  “When someone isn’t sensitized he can get annoyed and think…`Now how am I going to get rid of her?’”  “I wanted to get things off my chest but I felt rejected by the other health workers”  “Health workers - doctors, nurses, health inspectors - are men first before they are health workers. ” Statements from health workers

15. Lessons Learned from Central America Chapter V - Building an integrated approach…. PAHO’s Integrated Approach emphasizes….  Development of national policies recognizing violence as a public health problem  Drafting of norms and protocols that define the kind of care that should be offered to victims of violence  A training plan for health personnel on use of the norms  Creation of support groups for violence survivors  Promotion of male involvement in violence prevention  Development of an information system to track reports of GBV through the health sector  Development of community-level public awareness  Establishment of community networks

16. Lessons Learned from Central America Chapter V - Building an integrated approach…. Lessons learned from the Integrated Approach….  Establishment of a specific health sector policy outlining the role of health providers in addressing violence is a key step towards institutionalizing violence programs and raising awareness among personnel  The placement of program coordination for care for GBV or family violence in the areas of women’s health and reproductive health services facilitates lateral integration into other programs and services  Inter-programmatic coordination is essential for enabling violence programs to become integrated laterally into key health programs and for ensuring the sustainability of the violence program  Having oficially approved norms and protocols helps to ensure the quality of care and also facilitates the scaling up of pilot experiences  It is important to train all health personnel on the identification of and basic care for women suffering violence. This creates a favourable environment so that individuals may be identified and referred for care.  Surveillance systems for violence should consider collecting as a minimum, information identifying the type of violence (physical, sexual, psychological), the sex and age of the victim, as well as the age and relationship of the perpetrator to the victim.  Information systems are only valid if the data are used to improve services. Not only is it a waste of resources, but it is also unethical to collect information or carry out active screening for violence with the sole purpose of information- gathering, if no services are offered in return

17. Lessons Learned from Central America Chapter VI - What Happens at the Clinic? How can health workers support women living with abuse? Assess for immediate danger Provide appropriate care Document the woman’s condition Develop a safety plan Inform the woman of her rights Refer the woman to other community resources

18. Lessons Learned from Central America Chapter VI - What Happens at the Clinic? Lessons learned from the Integrated Approach….  It is not enough to simply wait for women to disclose violence on their own. Experience has shown that many women are willing to talk about violence, but it isw usually necessary for health personnel to take the initiative and open the discussion  Encouraging health personnel to screen women for violence in their regular practice can be an excellent exercise for raising general awareness and helping personnel to become more confident in treating cases of violence. Ideally the screening tool should include questions on physical, emotional and sexual violence, as well as violence during pregnancy  It is not necessary to have specialized personnel in mental health to provide quality care for victims. What is essential is to motivate and train staff and to organize services so that women that need support receive treatment with a human quality and in a timely manner  Emotional support is essential for health providers who care for survivors of violence. Activities to ensure support for personnel should be included in norms and implemented at the local level

19. Lessons Learned from Central America Chapter VII - Beyond the Clinic….  Community healh leaders have a crucial role to play in violence prevention, through the promotion of nonviolent relationships, and by informing the community about their legal and social rights - and providing information and appropriate referrals to abused women. Lessons learned from the Integrated Approach….  The establishmet of community networks can greatly help in coordinating services form victims of violence and in developing joint programs for violence prevention  Abusers’ treatment groups should not be confused with men’s refelction groups. The purpose of the reflection groups is to encourage men to challenge prevailing cultural views on masculinity and to become more sensitive to gender-equitable norms. Men’s groups can be an effective way to involve both adults and young men in violence prevention activities  Support groups can be a very effective technique for helping violence survivors. Nevertheless, health providers do need training and ongoing support to be effective facilitators

20. Lessons Learned from Central America Chapter VIII - Global Implications of the Integrated Approach…. Expanding the model beyond Central America….  The approach is flexible and non-prescriptive  The approach calls for action at several levels  A multi-sectoral approach achieves the best results  Partnerships and networks provide the necessary underpinning  The health sector has a fundamental role to play in violence-prevention and caring for victims of violence  Training is critical to developing and sustaining the health sector’s role in violence prevention and care  The health sector should be pro-active in raising community awareness about GBV

21. Lessons Learned from Central America Chapter VIII - Global Implications of the Integrated Approach…. The most important lesson we have learned is that... “Violence can be prevented…In our own countries and around the world we have shining examples of how violence has been countered. Governments, communities and individuals can make a difference” Nelson Mandela