1. Global best practices addressing Gender-based violence (GBV) in reproductive health (RH) programs Sarah Bott, Consultant to the Futures Group

2. Why Should RH Programs Address GBV Prevention: Can reframe GBV as a public health problem Can apply public health approaches to prevention Response: Can identify women in danger before violence escalates Increase access to comprehensive survivor services Reduce negative health outcomes of GBV Assist survivors to access help / services/ legal protections Improve SRH outcomes: Improve t he effectiveness of HIV prevention Improve sexual/ reproductive health programs for youth Provider better quality, integrated health care for women

3. What Do We Mean By Best Practices? Growing number of initiatives Limited evidence of effectiveness Lack of investment in rigorous evaluation Methodological challenges, e.g.: -Hard to define / measure indicators of success -Results often require long term follow-up -changing violence levels hard to measure/interpret -Unclear whether attitudes proxy for behavior

4. At Least 4 Different Levels Laws and public policies Institutional reform: health services Mobilizing communities Communication for behavior change / changing gender norms

5. Health Services: Common Problems Health professionals not trained to recognize GBV as a public health issue Providers share negative attitudes about women and GBV common in society Health care orgs not equipped with infrastructure policies, training, supplies, referral networks Legal protections and social services for survivors often lacking in low-income countries

6. The Systems Approach Institutional commitment Sexual harassment policies Infrastructure that allows privacy Policies to protect confidentiality Staff training and support Referral networks to community services Care Protocols for survivors Supplies such as EC and STI prophylaxis Data collection systems

7. Bottom Line: GBV Issues are Integral to Womens Health Attention to GBV needs to be incorporated into: –University training of health professionals –Efforts to improve SRH quality of care –SRH care protocols, including HIV/AIDS and SRH programs for adolescents –Tools for monitoring and evaluating quality of womens health care

8. Routine Screening / Enquiry Issue consumes much of the literature Worldwide controversy on risks / benefits Definitive evidence of net benefit probably unrealistic (example of mammograms) Two clear lessons: a)Institutional reforms should come first b)All RH programs should be prepared to respond to GBV, not just those that screen

9. Role of SRH Programs in Improving Laws and Public Policies SRH programs can reframe GBV as public health Educate / train policy makers, law enforcement Advocate to improve policies specific to SRH: –Survivors access to EC, forensic exams, STI/HIV prophylaxis; –Sensible reporting laws for providers; –Coordinate law enforcement and medical services –Improve the medico-legal system

10. SRH Policy Reform: Medico- Legal System, South Africa Researchers documented dysfunctional system Advocates lobbied for legal and policy reform The government changed laws and regulations Government implemented forensic nursing system and other reforms Evaluation of impact is pending...

11. Community Mobilization Has been shown effective for prevention Appears to be essential for improving the service response for survivors Best if takes a multi-sectoral approach Best known / well documented here today So what is role of RH programs? –Some documented successes used PLA in SRH framework (Reprosalud, Stepping Stones) –RH programs can frame GBV as public health

12. Promising Examples of Communication for Social Change Education-entertainment (Soul City, South Africa/ Sexto Sentido, Nicaragua) Life skills education for youth (New Visions, Egypt) HIV/AIDS prevention programs that address gender- norms (Program H, Latin America)) Unfortunately, many youth SRH / HIV prevention programs for youth assume that sexual activity is a voluntary decision; fail to address sexual coercion

13. Lessons re: Communication for Social Change Easiest to change norms and behavior among youth HIV/AIDS prevention more effective if address GBVe.g. sexual coercion Essential to target boys and men as well as girls and women Prevention focused solely on potential victims generally fails

14. Evaluation Challenges: Prevention Hard to separate contribution of multiple strategies Changing violence levels hard to measure and interpret Attitudes easier to measure than behavior, but may not be adequate proxy for perpetration Individual outcomes easier to measure than community-level changes