Women Deliver’s 4th Global Conference, taking place on May 16–19, 2016, will be the largest gathering to discuss girls’ and women’s health and rights in the last decade and one of the first major international meetings to follow the launch of the Sustainable Development Goals (SDGs). Front and center in the SDGs and the Women Deliver’s agenda is the goal to eliminate all forms of violence against women and girls. Jhpiego is hosting a reception on May 17 at the Women Deliver conference on this topic and other issues related to women’s empowerment.
Jhpiego’s gender experts Myra Betron, Joya Banerjee and Shamsi Kazimbaya took time out from a workshop in Rwanda to discuss the impact of gender-based violence (GBV) on the health of women and girls.
Q: What opportunity does Women Deliver offer for advocacy around GBV?
Myra Betron (MB): A goal for us at Jhpiego is to bring to light GBV as it affects maternal health. We are working on this issue in eight countries now: Ghana, Guinea, Haiti, Madagascar, Mozambique, Nepal, Rwanda and Tanzania.
Over the past decade, the issue of GBV has come to be recognized as a public health concern. While GBV has been integrated into HIV/AIDS services and prevention, the maternal health field has lagged behind in recognizing the links between GBV and maternal health and, thus, has invested little in addressing GBV.
As a health system strengthening organization, Jhpiego has an important role to help demonstrate what the health sector can do to prevent and respond to GBV. There is now a lot of evidence on what can be done to prevent GBV beyond the health sector. For example, here in Rwanda, we will use community mobilization and education to change attitudes and behaviors that support GBV, an approach that has been proven effective in similar places, like Uganda.
However, the health arena offers key opportunities to address GBV. A health care provider should be able to recognize the common signs and symptoms of GBV, sensitively inquire about it and conduct some basic empowerment counseling, so the survivor knows she has rights and services she can access, whether in the community or at a nearby hospital. A health care provider should be able to provide some basic safety planning, so if a woman is in any immediate danger, she can get to a safe place and has the resources to care for her children.
Joya Banerjee (JB): Beyond educating health care providers on GBV care, health facilities should have a private room for counseling and a safe room for recuperation; they should advertise the services to the community and educate women and families on the elements of GBV and their rights.
Q: What is the impact of GBV on access to health services?
JB: GBV predominantly affects women and girls and includes physical, sexual, psychological and economic violence. When a woman is experiencing GBV, she is also encountering controlling behavior, reduced access to financial resources and limited mobility outside of the home. That means women experiencing GBV are less likely to access health facilities, and that can have a range of impacts. When women don’t have access to family planning, they can’t space their pregnancies over a period of time to support the health of the mother and baby. Lack of access to prenatal care, for example, may lead to premature birth. Direct health impacts from GBV range from miscarriage and stillbirth to depression and disability to suicide and death, and the list goes on.
MB: In addition, depriving or controlling a woman’s access to household income and resources is considered a form of GBV. If a woman doesn’t have money, she may not be able to pay for transport to a health facility or for health services if she gets there.
Shamsi Kazimbaya (SK): In some communities, traditional or cultural norms preclude a woman from talking about or sharing experiences with GBV. She keeps this to herself and never seeks out help or services. We still have the challenge of women who are victims of violence being unable to access this right because of traditional environments and social norms.
Q: Can you share an example from your work?
SK: I am reminded of a woman I met at a health facility in Rwanda who was a victim of GBV. Her story exemplifies the economic and cultural barriers to accessing care. The woman had two children who were sick, and she didn’t have the financial means to take them to the health facility. She had been asking her husband to pay for health insurance, but he refused, saying that he never got sick himself and wouldn’t waste his money on it. The children were sick with malaria, but the woman didn’t know it at the time—and the husband wouldn’t give her money to take their children to the health facility.
Upset and worried for her children, the woman borrowed money from friends in the village—less than $2—and she bought painkillers for the children. A few days later, one of the children became sicker. The mother went to her husband again; he was with friends, drinking in the village. The husband’s friends teased him, saying, “What kind of wife do you have who comes and bothers you here?” The woman ended up borrowing more money from friends so she could take her sick child to the health center. But by the time the health care providers began to treat the child, he was so sick that he died. She had to rely on a man at the health facility to help her carry her dead son back to her house. A second child, a daughter, died the same night.
Suspecting the entire family might be sick from malaria, health care providers pressed the village chief to help bring the woman’s other three children to the health facility for treatment. When I arrived in the village, the health care providers urged me to visit this couple. The children were doing much better. The woman tried to leave her husband, but her family insisted she return to him.
This is a tragic example of the impact GBV can have on a woman and her family. We are beginning work to educate the community on GBV through the U.S. Agency for International Development’s flagship Maternal and Child Survival Program (MCSP), which is led by Jhpiego. We will be partnering with a local organization that will host community dialogues and mobilizations on gender-related themes and discuss the prevention of GBV and importance for a woman and her family to access health services.
Q: What role do governments have in addressing GBV?
MB: The government of Rwanda has demonstrated a strong commitment to addressing GBV. In 2009, the government passed a national law against GBV and, in 2011, a very comprehensive national plan to address GBV. Their leadership has been instrumental in the establishment of GBV services and prevention campaigns.
JB: MCSP is working with the government to help revise their standards and training curricula for GBV care. We will be working to give health care providers the kinds of tools they need to identify the type of clinical care to offer. We are also integrating GBV screening into antenatal care in district health centers so that women who come for services can discuss these issues in a health care setting. It is a good entry point to screen, counsel and refer women undergoing GBV.
SK: Rwanda also has a system of one-stop centers at the hospital level where GBV officers practice. The centers have a name in the local language—Isange, which means to feel at home—as a way to discourage stigma and make victims feel comfortable when they come to seek services. The first Isange One-Stop Center was established in July 2009 in Kigali, at the Kacyiru Police Hospital. Currently, 25 of these centers are operating in Rwanda. Their objective is to provide a holistic or comprehensive range of services to the victim, including psychosocial, medical, legal and police services, as well as helping to reintegrate into the community adults and child survivors of GBV and child abuse.
Q: And the woman whose children died of malaria, have things improved for her?
SK: The good news today is that the advocacy I did at the local administration helped to renovate that family’s house and give them some food provisions to continue helping the children recover. Local authorities have started to follow up more closely with this family and are helping them improve their relationship. They now have health insurance; the husband became more sensible and decided to pay for it. The woman is happy that she can easily seek out health services whenever they are needed, and she has even said that since we met, the husband has become less violent; she is hopeful that things will improve even more.