Comprehensive Responses to Sexual Violence in East and Southern Africa: Lessons Learned from Implementation

This 8-page policy brief shares the experience and lessons learned by the Population Council and partners who are part of the Sexual and Gender-based Violence (SGBV) Network, in implementing programming to address SGBV. According to the brief, many countries in Africa have recognised that they must address SGBV if they are to make progress toward human development goals, including significant reductions in poverty, HIV incidence, and maternal and infant mortality by 2015. Yet, there has been very little evidence in the region on how to effectively address SGBV taking into account local resource, cultural, and political realities. Efforts by members of the SGBV Network have advanced understanding of SGBV in the region, identifying both effective programme strategies and gaps in response efforts. This brief shares insights from this programming.

Since 2006, the Population Council has provided technical assistance and conducted research to strengthen the evidence base on SGBV programming in sub-Saharan Africa. These activities have created an active network of partners from across sub-Saharan Africa, who are developing, implementing, and evaluating core elements of a comprehensive, multisectoral response model. This model incorporates the overlapping and complementary responsibilities of three core sectors: health, police and justice, and social service sectors. It also recognises that survivors require access to all services, but that it may not be feasible, appropriate, or cost-effective to deliver all services in one location.

The lessons summarised below are intended to serve as a resource for programme managers and policymakers throughout the region, and contribute to the emerging evidence base on such programme strategies.

• Most survivors of sexual violence seeking services are children. In all partner programmes, the majority of survivors who sought care were aged under 18 years. Despite the large number of children and youth who report for care, most programmes do not offer child-friendly services, largely due to the lack of providers trained in examining, documenting, managing, and referring cases of child sexual abuse. As a result, in many settings children receive inadequate care and support. Recent versions of national SGBV guidelines from Kenya and Zambia serve as examples of how countries can begin to meet these needs. The National Guidelines on the Management of Sexual Violence in Kenya (2009) include special provisions for history taking of children, genitoanal examination of girls and boys, and PEP regimens for children.
• Community-level barriers commonly undermine care-seeking.It is widely believed that only a small proportion of those who experience violence seek any type of institutional care. In Swaziland, only 7% of child sexual abuse survivors reported seeking counselling, police response or health care services. Another study in Uganda and Rwanda identified key barriers to accessing such care: a preference of survivors and their families for resolving the issue at home; fear of stigma; the family’s preference to seek compensation directly from the perpetrator rather than through the criminal justice system; a lack of awareness of where to go for services and the procedures involved; inability to pay for transportation and service fees; long distances to the nearest service point; and threats by the perpetrator.
• Guidelines are necessary, but do not ensure comprehensive service delivery.While national guidelines are essential in the provision of comprehensive care to survivors of SV, a multi-sectoral approach and the engagement of a wide range of relevant actors is equally important. To spur the development and implementation of national guidelines, governments and partners benefit tremendously from the efforts of "champions", individuals or agencies within and outside the government who actively follow-up to ensure that guidelines are implemented properly.
• A variety of approaches can be used to provide quality, comprehensive care. Comprehensive care can be provided in different settings outside of a "one-stop" shop approach, where all services are provided in one location. Partners have demonstrated that a range of sustainable, effective approaches to providing comprehensive care exist, and that these can be effectively organised in a variety of ways depending on the context and capacity of existing services. Some models build on existing infrastructure and require only minimal inputs in training and supplies; in others, new systems and infrastructure must be established.
• Ensuring adherence to HIV post-exposure prophylaxis remains a key challenge.While notable progress has been made in increasing access to PEP, efforts to ensure compliance with the full 28-day regimen remain more limited. Loss to follow-up is consistently identified as a key factor in undermining efforts to encourage and monitor PEP adherence. Across settings, barriers consistently included client reluctance to seek follow-up due to stigma, trauma, cost, and availability of transportation. Within the facilities, provider work-loads and inadequate case management systems make it difficult to monitor follow-up care.
• Provider capacity remains an important barrier to quality, comprehensive care.In many public facilities across the continent, there is an acute shortage of staff, creating long waiting times, and full waiting areas, particularly in emergency departments. These conditions are extremely daunting for an SV survivor and mean that providers cannot offer the quality of care they would like to, or that no trained personnel are available. Quality of care is also undermined by negative attitudes toward survivors of SV.
• Comprehensive care services must include functional linkages between health and police services.In many countries, SGBV survivors report first to the police and often do not seek further health or support services. Strong referral networks are therefore essential to ensure survivors receive the health care they need, including the prevention of pregnancy and HIV transmission within the 72-hour window period for emergency contraceptives (EC) and PEP. One strategy for improving such linkages was tested in Zambia, where the police provided the survivors with EC and referrals to health facilities for further management and collection of evidence.
• Psychosocial support to survivors is important, but often lacking.Psychosocial support for SGBV survivors should include counselling, provision of safe houses, and community efforts to reduce stigma. However, such care is lacking in most low-resource settings due limited provider capacity, time, and evidence of what approaches are most effective. Experiences of network members demonstrate that training in basic interpersonal and counselling skills can substantially improve a survivor’s experience. In South Africa, nurses at Tintswalo hospital were successfully trained to provide basic counselling and trauma debriefing skills, with 99% of survivors reporting that the counselling was helpful.

Based on these findings, the following actions are recommended to improve programmes and policies across the region:

• Special guidance, training, and services are needed to adequately respond to the needs of child survivors, who currently constitute the majority of those seeking care in most countries.
• Community-level interventions must be implemented to reduce barriers to care-seeking and create awareness of the services available to survivors.
• Governments should consider an inclusive, participatory, and multi-sectoral approach to guideline development and dissemination to encourage active implementation.
• Health facilities should actively integrate services in at least one unit equipped with adequately trained providers and necessary supplies, and ensure that services are available on a 24-hour basis.
• Training for health care workers, police, and other support personnel must explicitly address commonly held biases against SGBV survivors, basic counselling, and interpersonal skills.

National policies and practices should be reviewed to ensure that nurses and clinical officers can collect medico-legal evidence and provide testimony in court.

• More evidence on cost-effective, sustainable and culturally-appropriate approaches for providing psychosocial support in low-resource settings is needed.

The brief concludes that there is also a need to explore other dimensions of SGBV services. In general, intimate partners are the most commonly reported perpetrators of sexual violence against women and children; however, most response services have focused on addressing the acute needs of survivors without consideration of the specific issues and challenges of violence within a marriage, family, or other domestic relationship. Additional research is needed to identify appropriate strategies for ethically identifying and meeting the needs of this large, and often silent, population. Just as importantly, more documentation is needed on successful strategies for preventing all forms of SGBV before it occurs.