1. Ana Flávia Pires Lucas d´Oliveira Associate professor Preventive Medicine Department Faculty of Medicine University of São Paulo November 2005 Primary Health Care Programs Brazil´s response to Gender Based Violence

2. Research and social action oriented Group Violence, gender and health Multidisciplinary team since 1994 Research Training Advisory to Municipality and State Health Departments Partnerships

3. Contents Violence and health in Brazil Hospitals – first step Health Center Care – a model for assistance Women and their experience of being cared Network of services – Service´s Guide Remaining Challenges

4. Sexual Violence Care Brazil: Legal abortion only in cases of rape or mother´s life risk Law from 1940 1989: First public hospital doing legal abortion- SP 2005: more than 50 public hospitals doing legal abortion

5. Sexual Violence Guideline Ministry of Health Prophylaxis of unwanted pregnancy, Sexually Transmitted Disease and AIDS Legal Abortion Psycho-social support

6. But... Most of the cases are rape perpetrated by strangers Marital rape invisible within health sector Hospital based programs Programs concentrated in few big cities

7. Primary Health Care and VAW Easier and more frequent access for women Community based care Access along all the life – time Opportunity to make domestic violence visible Targeted to common health problems highly associated to domestic violence

8. Establishing a local network West region of São Paulo - 400.000 inhabitants Partnership Municipality-University 1 hospital (sexual violence) and 1 health centre (domestic violence) as reference Monitoring and supervision 2000-2004

9. Medical School Health Center Attending domestic violence since 2000 - integral health care 1. Make VAW visible to all professionals 2. Promote listening of women in a non judgemental way 3. Offer a specific activity: the Severe Family Conflict (CONFAD)

10. If the woman accepts About 1 hour activity 1 to 4 sessions Any female health professional can run the activity, since she is properly trained

11. At CONFAD Identify risk of life Identify support women already have Discuss gender base of domestic violence Share information on the network to assist domestic violence Share making decisions on womens life project Refer to services she chooses Monitoring womens path ( folowing-up)

12. The CONFAD statistics 2000 - 41 2001- 57 2002- 98 2003- 153 2004- 122 Around 3000 women seen every year at the unit 26,4% miss the appointment - very similar to medical appointments 83,6% Interpersonal Partner Violence

13. One day I came here to bring my son. I guess it was God that put these people on my way ! The nurse asked me how I was and I said: Everything is all right... But... I was hit, had a deep cut in my eye and my husband is threatening to kill me! I said just like that, I don´t know why, I think I was so crazy that I did it... And she wanted to know everything in details... She said they have a program on violence against women, asking me if I didn´t want to attend. She booked an appointment to me. It was very good (...) It was my salvation, they gave me strength, helped me very much (Maria) Quotes: Discovering CONFAD

14. Quotes: being listened and talking

15. Quotes: linking violence with illness

16. Quotes: evaluating and referring other women Every time I see someone with a problem, I say: go to the health centre, it is very good, it was good for me it will be to you too. I refer because it was a very good place to me, I had support, I like it very much (Maria) It was worthwhile, I feel like another person, because I felt as I was nobody, I felt like actual garbage. Nowadays I feel I am someone, I will not say I feel I am more than anybody: I feel I am a regular person and that is good.

17. Service´s Guide on violence against women 1996 - 40 services 2002 - 91 services 2005 - 123 services Published and distributed to all services

18. Services of the guide Police - Women´s police station Justice Psycho-social assistance Health Shelters Basic Orientations

19. Gender based program in a health care centre Support women Guarantee rights Awareness of connections violence-health Change the approach of symptoms and their solutions Less medicines, less exams, more womens rights Reference - Limits of health sector to deal with the problem/connections and referral are fundamental

20. Challenges Continuous monitoring and supervision Working with men Developing the Network among services from different sectors Evaluation - what is the gold standard