Transcription
Gender-Based Violence (GBV) Rapid Assessment and Service Mapping Reportfor MCSP-supported Facilities in Kogi and Ebonyi States, NigeriaAbridged VersionNOVEMBER 2017Written by:Chioma Oduenyi, Gender Advisor, MCSP NigeriaEXECUTIVE SUMMARYGender-based violence has severe impacts on health and well-being, particularly for pregnant women andtheir children. As part of efforts to strengthen the Nigerian health system’s response to gender-basedviolence (GBV) and to mitigate its impacts on reproductive, maternal, neonatal, child and adolescenthealth (RMNCAH), the USAID Maternal and Child Survival Program (MCSP) carried out a rapid assessmentto determine the availability of GBV prevention and response services; and perceptions and knowledgeof GBV among health workers. A service mapping to assess the availability of GBV referral services wasalso conducted in both states.MCSP carried out field assessments over a period of 10 days in 30 MCSP-supported facilities in Ebonyi andKogi states, based on client load and senatorial geographical spread. Key informant interviews wereconducted with the following stakeholders: State Ministry of Women Affairs and Social Development (SMOWASD),
State Ministry of Health (SMOH)Local Government Areas (LGAs),Heads of Community Based Organizations (CBOs),Faith Based Organizations (FBOs),Gender officers at legal and law-enforcement agencies,Officers-in- charge of health facilities,Community LeadersSummary of Findings:This rapid assessment and service mapping provides strong evidence on the total absence of systematicstrategies or a coordinated strategy for GBV prevention and response in both Ebonyi and Kogi States’health systems: Stakeholders were generally aware of GBV issues, including widespread GBV occurrence, existence ofnational and state laws on GBV, but with limited understanding on GBV prevention and responsestrategies;Women in Kogi and Ebonyi states do experience high rates of GBV, particularly rape and IPV, but thereis a low level of reporting of GBV cases both for healthcare and law-enforcement;There are huge gaps in the existing knowledge base and infrastructure for prevention and responseof GBV in both states. Health providers were found to generally lack the capacity to provide basic firstline support to GBV survivors (defined as counseling, safety planning and referrals) as very few serviceproviders were aware of, or ever referred GBV survivors to referral services. Most health workershave never received any form of training on gender-based violence, and limited their care to treatingphysical injuries only. Essential services required to effectively provide post-GBV care at health facilities areconspicuously non-existent, for example a private room for safe counseling, post-exposureprophylaxis for HIV prevention within 72 hours of an assault, etc. GBV prevention and response responsibilities are shared by the state and local governments,police, and community-based organizations. However, there is a lack of coordination,knowledge, funding, communication and collective action.INTRODUCTIONMCSP Nigeria works to improve the quality and utilization of maternal, newborn, child and adolescenthealth interventions including post-partum family planning and addresses gender-related barriers thataffect service uptake within healthcare facilities in Kogi and Ebonyi states. One of MCSP’s targetedinterventions includes strengthening post-GBV care services at selected MCSP-supported health facilities.Beyond commonly-cited barriers that hinder the uptake of available health services, the lack of routinepost-GBV care poses a great risk in the delivery of quality healthcare to women and children in Ebonyi andKogi States.In Nigeria, acts of violence against women cut across religion, social class and ethnic groups. IPV is said tobe the most common and pervasive form of GBV in Nigeria1. Though several small-scale research has beencarried out in different regions, there is a paucity of data to determine state-specific prevalence of IPV.Female genital mutilation is widely practiced in southern Nigeria with Ebonyi state having the secondhighest number of females circumcised (74%) while Kogi has one of the lowest around 1%1. The mostaffected survivors usually are of low socio-economic status. They can hardly afford transport money toaccess referral services in the cities.1
The 2016 WHO Global Plan for Action to strengthen the role of the health system within a national multisectoral response to address interpersonal violence, in particular against women and girls, and againstchildren, advocates for and encourages member states to strengthen the role of the health system inorder to effectively respond to violence against women and children. The Government of Nigeria hascommitted to numerous international and national goals to reduce the prevalence and impact of GBV,including the Sustainable Development Goals, requiring an elimination of all forms of violence againstwomen and girls, and passed the Violence against Persons Prohibition Act in 2015. Civil Society in Nigeriahas also increased social and legislative advocacy, established gender and family units in the police,advocated for male participation in violence prevention, and provided GBV support services. However,government efforts at the federal and state levels have failed to keep pace, particularly in terms of healthservices, linkages between the health and justice sectors, and social/ mental health support services forsurvivors.At the most basic level, if a survivor of GBV discloses experiencing violence to a health provider, or displaysobvious signs and symptoms of experiencing GBV, the provider and health system must be equipped toprovide basic care in a private, compassionate, and evidence-informed manner. Treatment of acute injuries;Provision of HIV post-exposure prophylaxis (PEP) within 72 hours of a sexual assault;Provision of emergency contraceptives within 120 hours of a sexual assault;Empathetic counseling and safety planning;Referrals to support services (police, emergency shelter, mental health, economic empowerment,etc.)However, facilities and the health systems in Ebonyi and Kogi states are under-equipped and providersare insufficiently trained to offer this care. The lack of services, combined with survivors’ concerns abouttheir safety and avoiding stigma, have resulted into very few survivors currently seeking services. In otherMCSP countries such as Rwanda, once the quality and coverage of GBV services has improved andcommunities are made aware of them, the caseload of GBV survivors has dramatically increased, givingthem the opportunity to mitigate the harms perpetrated by GBV on their health, well-being andlivelihoods.OBJECTIVESThe overall objectives of the assessment were;1) To understand the GBV situation in Kogi and Ebonyi states, including knowledge and attitudes,prevention and response strategies, and barriers to accessing services;2) To map the availability of GBV services and develop a referral directory for selected 30 MSCPsupported health facilities.METHODSMCSP used a purposive sampling procedure to select respondents by convenience, and conducted a rapidassessment of GBV using qualitative and quantitative methods. This activity lasted from 3rd-25th July, 2017.A team of three consultants and the MCSP Nigeria Gender Advisor held planning meetings from 3rd-5thJuly and presented a detailed plan for field work to the MCSP technical team on 7th July at Jhpiego office,Abuja. The 10-day field visits were held from 10th-21st July in both Kogi and Ebonyi States.2
RESPONDENTSMCSP interviewed a total of 63 respondents (25 female/ 38 males) in Kogi State and 78 (54 females/ 24males) in Ebonyi State. The respondents include key informants at the SMOWASD, SMOH and LGAcouncils; Service providers at MCSP-supported health facilities; Contact persons at identified governmentagencies and NGOs with GBV-related functions; and Community leaders.ASSESSMENT TOOLSMCSP developed and used semi-structured questionnaires for key informant interviews for selected stateand local government officers, health facility heads and heads of organizations performing GBV servicesor referrals. The tools for assessing health facility staff were pre-tested prior to the field visit at theNational Hospital, Abuja, and findings were incorporated.SITE SELECTIONMCSP visited 30 health facilities in Ebonyi, and 27 in Kogi.Type of health facilities visitedFACILITY TYPEKOGI (n 27)EBONYI (n 30)PRIMARY1019SECONDARY141031TERTIARYDATA COLLECTIONMCSP conducted face-to-face interviews with providers to collect quantitative and qualitative data aboutGBV knowledge and perceptions, the existence of GBV services in their facilities, and what the providerswould need to improve (or begin delivering) basic GBV care. MCSP also gathered contextual informationfrom community leaders who provided detailed information on GBV situation within their communities.DATA ANALYSISMCSP transcribed responses from recordings and field notes, and coded responses across differentcategories of respondents, groups, and the two states using bivariate analysis and simple frequencies forcomparisons between the two states.LIMITATIONS Difficulty in meeting with government officials due to non-payment of staff salaries in Kogi, assome offices had to be visited up to 3 times before interviews could be conducted.Difficulty in accessing some communities delayed the process and telephone interviews weredone where face to face visits were impossible.MAJOR FINDINGSGBV Health Services:3
Health service providers interviewed in both states had a fair knowledge of GBV (57% in Ebonyi and 44%in Kogi), and knowledge seemed to increase with facility type as primary health facilities had the leastknowledge, followed by the secondary and tertiary facilities. Provider’s knowledge of GBV were measuredby asking whether they had been involved in a GBV sensitization/training course, directly managed anyGBV cases, or if they were aware of any GBV-related programs in their communities. However, there waslimited knowledge on effective strategies to prevent GBV and to care for survivors.GBV knowledge among service providers: Comparing Kogi and Ebonyi statesGBV KNOWLEDGE AMONGEBONYIKOGISERVICE PROVIDERSVERY GOOD1 (3%)2 (8%)6 (20%)11 (41%)FAIR17 (57%)12 (44%)POOR6 (20%)2 (8%)GOODThe medical director at GH, Idah remarked, “it is not culturally acceptable here for a doctor [man] to aska woman if her husband beat her” GBV cases, especially IPV, are perceived as ‘family matters’ and notrequiring unnecessary intrusion from outsiders. Respondents in both states also cited religious beliefs andinability of some men to cater for their families due to recent economic conditions as pre-disposing factorsexacerbating GBV prevalence. From the chats with community leaders and CBOs, culture is identified asan important factor affecting GBV. Male dominance especially in mutual relationships, seems to beaccepted as a norm.“Most times women are the source oftheir violence, some women are lazyand have subjected themselves to themercies of men”- Women Leader, Afikpo South, EbonyiCommon forms of GBVFindings showed “rape” to be the most common form of GBV in the communities according to 44% ofclinic respondents in Kogi and 42% in Ebonyi, with the second most common type, as Intimate PartnerViolence (IPV). Service providers in secondary and tertiary health facilities reported more rape thanproviders in primary health facilities. GBV affects mostly female minors in Ebonyi and adult females inKogi. Female genital mutilation (FGM) is a cultural practice in some places in Ebonyi State and it is a grossviolation of human rights and results in numerous adverse health consequences, but stakeholdersreported that it is on the decline.4
Common types of GBV occurring in the communityCommon type of GBV in community50%45%40%35%30%25%20%15%10%5%0%Kogi (n 27)Ebonyi (n 30)GBV Policies and lawsEbonyi has a legislation against GBV called Ebonyi State Protection against Domestic Violence Law, 2005.Kogi state on the other hand, is still in the process of domesticating the Violence against PersonsProhibition (VAPP, 2015) Act. At the State ministries and LGA offices, there was a general knowledge ofthe existence of national and state laws/policies pertaining to GBV, though none of these policydocuments were available to be sighted. Among the non-governmental organizations, almost all wereaware of GBV laws/policies, but application of any of the policies was higher in Kogi (70%) than Ebonyi(13%) where more NGOs confirmed having utilized the national GBV guidelines and referral standard.Application of GBV PolicyAPPLICATION OF GBV POLICY100%0%KOGIEBONYIYESNOPost-GBV care provided at the health facilitiesGBV Survivors usually seek care when they sustain physical injuries and need medical attention as a resultof GBV. When rape cases are presented at the primary health facilities, they are usually referred to higher-Even when survivors present at the clinic with obvious symptoms of GBV, they rarelyopened up to the service provider5
level facilities (secondary or tertiary). Facility staff interviewed in both states admitted that the rate ofseeking health care among survivors is very low.“I remember when one of our staff was beaten up by the husband, she told us she hit her head on thewall”- Nurse, Kogi StatePost-GBV care given at the health facilitiesPost-GBV Care at Health bonyiNo service provider interviewed had ever referred a GBV case to the social welfaredepartment for long term psychosocial supportThough GBV has serious health consequences including death, disability, miscarriage, fistula, stillbirth,etc., service providers do not feel they have a role in the management of survivors besides treatingphysical injuries. Doctors at secondary health facilities usually encounter GBV survivors amidst very tightclinic schedules, and social welfare officers are unavailable in the secondary facilities to counsel them,rather the social welfare officers are situated at the local government headquarters. Some serviceproviders expressed concern adding ‘extra work load’ to their already strained manpower, if they haveto look out for GBV survivors.Current GBV programs and servicesIn Ebonyi, the State Ministry of Women Affairs and Social Development (SMOWASD) and Ebonyi StateCommunity and Social Development Project performed GBV-related activities such as providing seedgrants for women to start businesses, community mobilization and skills acquisition while in Kogi State,most GBV-related activities in the SMOWASD were on hold due to lack of funds. The SMOH andSMOWASD are responsible for GBV activities such as community mobilization or seed grants even thoughthere was a lack of funds for some activities, however, the gender focal persons in the ministries in bothstates had few GBV responsibilities as their Directors provided most of the information gathered duringthe assessment. One of the deficits for post-GBV response identified in both states was lack of a stateowned emergency shelter for GBV survivors, though a couple of organizations run safe houses. The socialwelfare units of the LGAs (situated in the LG councils) in both states are poorly funded and ill-equipped tocarry out GBV-supportive functions and difficult to access by far away communities.6
Social services, which the SMoWASD promoted to be available widely in every LGA through the socialwelfare offices, were found to be erratic and skeletal. At the SMoWASD, designated gender officers didnot seem to be in the know of GBV activities in the state, and poor coordination between officers andtheir Directors was evident. The LGA social welfare unit may not be adequately functional to provide longterm psychosocial counselling as they are usually situated far away from the communities in the LGAcouncil; besides they have no offices within the health facilities.GBV Activities by other government agencies:The Nigerian Police Force and National Security and Civil Defense Corps (NSCDC) handle mostly IPV andrape of minors. The National Agency for the Prohibition of Trafficking in Persons (NAPTIP) cater fortrafficked persons by offering rehabilitation and re-integration. The officers interviewed had just fairknowledge of GBV and associated laws and policies as cases were handled by alternative disputeresolution or prosecution by law. Financial constraints, weak laws and stigmatization were mentioned asbarriers to performing their GBV functions and solicited that partnership with donor organizations wouldaugment their efforts.GBV Activities by non-governmental organizations (CSOs, CBOs and FBOs)There was high level of awareness of both national and state-level GBV-related laws among CSOs, CBOsand FBOs that handle women and child right issues, in both states. There was a higher rate of usage ofGBV policies and guidelines among the organizations in Kogi (70%) than Ebonyi (21%). Most organizationsvisited were found to be performing more than one GBV referral service but majorly focusing oncommunity mobilization and advocacy with a very minimal combination of other functions such aspsychosocial counselling, social integration, economic empowerment, legal and law enforcement servicesfor post-GBV survivors. However, where these services or functions exist, they are located in urban areas,which makes it very difficult for GBV survivors to access due to distance and transportation costs. It isworth noting that the few services available through some NGOs are mostly international donor-drivenand donor-dependent, portending huge funding gaps for post-GBV care.Summary of GBV referral services available in Ebonyi & KogiGBV REFERRAL SERVICELong-term psychosocialcounsellingEBONYI Available in some health facilities forsexual violence victims Services rarely offered for other typesof GBV Provided by social welfare unit situatedin LGALaw enforcement Police not adequately funded andtrained to respond to GBV Not linked with health facilitySafe house/emergency shelter No state-owned yet SMLAS, NSCDC have shelterKOGI Available in some healthfacilities for sexual violencevictims Services rarely offered forother types of GBV Provided by social welfare unitsituated in LGA Police not adequately fundedand trained to respond to GBV Not linked with health facility Require sensitization onworking with GBV survivors No state-owned DACA & DCI have shelter SMOWASD staff volunteer7
Economic empowermentSocial re-integrationCommunity mobilization &advocacyReferrals NAPTIP & Family law center staffvolunteer Seed grants through ‘Women wey getsense’ cooperative (State Govt. project) Some NGOs provide Skill acquisition projects at LGA are notsteady, depend on available funds Some NGOs provide with donor-fundedprojects SMOH, SMOWASD, LGA Councils,health facilities, all NGOs SMOWASD, most NGOs (see referralmatrix) No identified state projectcurrently Some NGOs provide withdonor-funded projects No state/LGA skill acquisitioncurrently functional Some NGOs provide withdonor-funded projects SMOH, SMOWASD, LGcouncils, health facilities, allNGOs KONGONET, AYON, ChildProtection NetworkCommittee, most NGOs (Seereferral matrix)Referral organizationsMCSP used inclusion and exclusion criteria to select referral organizations in the referral directory. Twenty(20) organizations were contacted in Kogi and 21 in Ebonyi based on identified organizations and nonewas found to handle purely GBV cases. All the organizations interviewed in both states performedcommunity sensitization and advocacy as a direct service, and usually referred GBV survivors for medical,legal and law enforcement services. Other services such as social and economic empowerment projectsand IEC sensitization were found to be donor-dependent.FUNDING: EBONYIFUNDING: TERNALLYGENERATEDDONORFUNDEDGOVTSource of funding for referral organizationsUsually GBV occurs at night or on the weekends, and timely care is essential, particularly to prevent HIVand pregnancy for sexual assault survivors. It is important to ensure 24 hour care is available in at leastone or two secondary or tertiary hospitals in each state but all organizations interviewed offered freeservices and typically operate between 8am to 4pm, Mondays to Saturdays. Collaboration amongstreferral organizations was common and most of them offered direct services and also referred whennecessary. However, most organizations, including CBOs, have their operational offices in the state capitalwith field officers that visit rural sites on scheduled visits. NGOs were found to identify survivors byoutreach to communities, referrals from the public, other organizations and volunteers from thecommunity, or by the survivors coming themselves. They reported challenges such as insufficient funds,8
ignorance around GBV issues, weak enforcement of laws, low level of reporting cases due to stigma, fearsfor safety and fears of GBV-related poverty, poor collaboration etc.CSOs and CBOs are usually situated in the urban centersThe majority of the NGOs, though operational in the communities, have offices in the state capitals. Theseare difficult to access by survivors coming from far-away health facilities and none of the organizationsinterviewed offered pick-up or free transportation.“The cost of responding to GBV is higher than the cost of prevention so why not stop it from happeningin the first place” – Program Manager, Ebonyi Humanity Foundation7.0. Recommendations Engage and sensitize all relevant stakeholders through an expanded stakeholder advocacymeetings involving state officials, selected service providers, community heads, police, legalofficers, community leaders, CSOs, CBOs and FBOs, etc.Establish contact persons and phone number from the police divisions, buy-in of NGOs tosupport linking of referral services to clinics and increased GBV awareness.Carry out massive sensitization at state, local government and community levels.Design and develop information, education and communication materials on GBV.Build capacity of health staff to respond adequately to GBV and to make referrals to supportorganizations through capacity building, supportive supervision and mentoring.Map out a clear referral pathway and protocol to monitor clinic referrals and ensure survivorsaccess the required care.Advocate to the Govt of Nigeria to extend support to NGO support services, particularlyemergency shelter, to protect the safety of women and girls at risk, and to reduce dependencyon donor funds.Carry out further studies to understand the specific socio-cultural factors that affect GBV invarious communities in Nigeria.8.0. ConclusionThough most cases go unreported, GBV survivors do seek care in health facilities and have human right tohigh-quality, compassionate care. Health providers may feel they do not have the time or expertise torespond to GBV, but programs to build their capacity to offer 1st Line Support have demonstrated successand did not prove to be too much of a burden on strained health facilities. The lives saved and the medicalcosts averted by offering 1st line care well-outweigh the cost of the investments required to engageproviders in basic care.Referral organizations were found to be mostly international donor-funded and hence donor-dependent,with poorly linkages to health facilities. There is a need to link the few existing GBV referral services to thehealth facilities through engagement with service providers and non-governmental organizations, legaland law-enforcement agencies. The legal and law-enforcement agencies were limited in their responsedue to weak enforcement of GBV-related laws, financial constraints and an unwillingness or inability ofsurvivors to pursue legal action. The existing government structure for social services through theSMOWASD and LG social welfare departments is skeletal and not properly coordinated. Strong socio-9
cultural factors surrounding GBV make isolated medical care inadequate and therefore, there is a need tostrengthen capacity of service providers on GBV case management and massive sensitization of allstakeholders and multi-sectoral collaboration amongst GBV actors to ensure optimal health outcome ofGBV survivors. These sensitizations on GBV prevention should be carried out at all levels, including thecommunities, to ensure that citizens and providers are aware of what types of violence constitute GBV,that it violates human rights and is illegal, that there are serious health consequences from GBV, that menand boys have a role to play in preventing GBV and finding non-violent methods to resolve conflict, andthat there are services available. Finally, there is strong need to advocate to government for theestablishment of routine post-GBV care services at health facilities by establishing avenues or mechanismswhere GBV survivors can access services for healthcare and other social services beyond health on aroutine basis.10
Gender-Based Violence (GBV) Rapid Assessment and Service Mapping Report for MCSP-supported Facilities in Kogi and Ebonyi States, Nigeria Abridged Version NOVEMBER 2017 Written by: Chioma Oduenyi, Gender Advisor, MCSP Nigeria EXECUTIVE SUMMARY Gender-based violence has severe impacts on health
