Appendix II.

Integrating Gender-Based Violence Initiatives into Health Facilities:
Selected Resources

Zambia’s response to the HIV epidemic, and especially the roll-out of HIV treatment programs, can benefit substantially from integrating initiatives that detect and address gender-based violence and other abuses as part of an overall strategy to address gender-based abuses.  Over the last few years, a number of international and regional agencies have stressed the key role of health facilities in detecting and responding to gender-based violence, and have devised program guides on ways to establish and run such programs.  These agencies include USAID, UNFPA, and the Pan American Health Organization (PAHO), among others.  Literature and guidelines produced by these agencies266 can inform planning, implementation, and monitoring of initiatives to address gender-based violence in Zambia’s HIV sector.

UNFPA devised a program guide that proposes three models for screening for and addressing gender-based violence in health facilities, especially those providing reproductive and sexual health services.  UNFPA’s recommended interventions range from displaying information on gender-based violence in waiting rooms and rest rooms to having personnel within the facility specifically trained to screen for gender-based violence and to make appropriate referrals or give legal and other advice.  The guide provides clear steps that could inform changes in the healthcare system in Zambia.

The guide seems to influence UNFPA’s work in Zambia, although the agency focuses more on the health of adolescent girls in the area of HIV/AIDS, rather than adult women.  In August 2004, UNFPA launched a Zambia-specific training manual on gender-based violence and HIV/AIDS for use by local organizations.  The manual provides guidelines on planning, conducting, and evaluating workshops on HIV/AIDS and gender-based violence.  It also provides a step-by-step explanation of gender, socialization, society’s perceptions of males and females, and power relations between men and women.  It then introduces gender-based violence, and addresses its nature, extent, causes, and consequences.  It provides information on Zambian organizations and institutions to which service providers can refer survivors of gender-based violence, and finally addresses HIV/AIDS and its gender dimensions.267

Another important resource is USAID’s Addressing Gender-based Violence through USAID’s Health Programs.  Developed to help USAID program officers integrate responses to gender-based violence into their health sector portfolio during project design, implementation, and evaluation, this guide draws upon promising approaches that address gender-based violence in health settings, and focuses on intimate partner violence and on sexual violence by any perpetrator.  The guide establishes principles for programs aiming to address gender-based violence in health settings.  These include ensuring survivors’ safety and autonomy, devising interventions that are appropriate to local settings, employing both a public health and human rights perspective, encouraging multi-sectoral interventions, and investing in evaluation to assess the success of programs.268

USAID’s guidelines suggest three different approaches to prevent and respond to gender-based violence:  service delivery programs, community mobilization interventions, and communication for social and behavior change.  According to the document, community mobilization programs can prevent gender-based violence through changing the dominant gender norms269 that sanction gender-based violence.  This includes challenging beliefs held by healthcare providers—such as considering domestic violence a private matter—that might influence their response to gender-based violence. The document provides guidelines on what community mobilization programs should and should not do.  The second approach suggested by USAID is the establishment of “communication for social and behavioral change programs” (CSBC) to raise awareness.  CSBC can support initiatives that challenge the acceptability of gender-based violence at individual, community, and national levels; improve community response to gender-based violence; and increase media awareness of the link between HIV/AIDS and gender-based violence.

Most relevant to the findings of this report is USAID’s third approach, which focuses on healthcare service delivery programs—particularly those working in the field of sexual and reproductive health—in addressing gender-based violence.  The guide lists steps through which healthcare delivery programs can address gender-based violence, starting with institutional commitment to address gender-based violence, followed by introducing changes that fully integrate gender-based violence throughout healthcare facilities, a strategy called a “systems approach.”270 The importance of this strategy is that it recognizes the implications of deciding to tackle gender-based violence on different aspects of healthcare services, including the physical infrastructure of clinics (whether counseling rooms ensure privacy), the professional culture of the facility, patient flow, training and supervision of staff, and the existence of referral networks.271 Using a systems approach, according to USAID, is particularly important in resource-poor settings where legal systems are weak and referral systems are inadequate.

In integrating a concern with gender-based violence in the work of health facilities, USAID recommends ongoing training and sensitization of healthcare workers on gender-based violence, “routine screening” for gender-based violence only when programs have functioning protections to safeguard women’s emotional and physical safety, and the participation of healthcare facilities in “broader prevention efforts, referral networks, and advocacy campaigns.”272  Finally, the guide recommends that healthcare facilities and programs seek economic sustainability before launching specialized services addressing gender-based violence, and not duplicate existing community initiatives.  The guide identifies a number of interventions that are feasible in resource-poor settings.  These include support groups for survivors of gender-based violence (instead of individual psychotherapy) and finding alternative informal safe havens with friends or family instead of shelters.   

USAID’s resource would be a useful tool in integrating gender-based violence in health facilities disseminating ART in Zambia, particularly in terms of introducing these initiatives in facilities supported by PEPFAR.  Although USAID has a strong presence in the country, as of August 2007 they “have not introduced these guidelines to [USAID’s] grantees …although [they] are in the process of doing so.”273 

An important resource that shares best practices in terms of health sectors’ responses to gender-based violence in the Americas region is the Pan American Health Organization’s Violence against Women: The Health Sector Responds.274 The resource is a step-by-step description of PAHO’s interventions to address gender-based violence in Central America, including via the health sector and in clinics. PAHO’s strategy, which emphasizes flexibility and respect for local experience, started with analyzing women’s experiences of gender-based violence, the ways women respond to it, and the availability of community, legal, and health sector resources in ten countries in Latin America. 

Steps applied by PAHO in Latin America include: the development of national policies that recognize gender-based violence as a public health issue; outlining basic principles and guidelines for caring for survivors of gender-based violence using a gender and human rights perspective; drafting protocols on appropriate care for patients affected by gender-based violence; developing training plans for personnel on the use of norms and protocols; creating support groups for survivors of gender-based violence; promoting male involvement in such programs; developing a system that is able to report on gender-based violence cases throughout the health system; and establishing or strengthening community networks so as to coordinate the response to gender-based violence.275

At the regional level, the Southern African AIDS Trust has devised counseling guidelines on domestic violence that are specific to Southern Africa.276  Informed by experiences of professional HIV counselors, people living with HIV/AIDS, and members of HIV/AIDS organizations, the guidelines target both male and female patients seeking counseling, and address myths and misconceptions associated with gender-based violence, the link between domestic violence and the transmission of HIV/AIDS, the need for effective counseling, the signs and symptoms of domestic violence, and how to identify them.  One of the important points that this resource covers is how fear of domestic violence can affect women’s ability to disclose HIV status or other sexually transmitted infections.  It cautions counselors that many women who have followed the advice of healthcare staff and discussed their HIV status with their husbands have suffered greatly.277  It also provides guidelines on counseling women living with HIV/AIDS who are survivors of violence and on support to counselors.   The guidelines mainly target volunteer counselors, non-professional counselors, and professional counselors who do not have extensive experience in counseling people living with HIV/AIDS.  It does not discuss the impact of gender-based abuses on HIV treatment.

These resources are useful tools in reforming the healthcare system and equipping it to respond to the two epidemics of HIV/AIDS and gender-based violence in Zambia. 

266 USAID, Addressing Gender-based Violence through USAID’s Health Programs; Pan American Health Organization (PAHO), Violence Against Women: The Health Sector response (Washington, DC: PAHO, 2003); and UNFPA, Practical Approach to Gender-based Violence: A Programme Guide for Health Care Providers and Managers  (New York: UNFPA, 2002), (accessed April 17, 2007).  Also see UNFPA, Programming to Address Violence Against Women: 10 Case Studies. (New York: UNFPA, 2007), chapters 1, 5 and 8; and A. Guedes, “Addressing Gender-Based Violence from the Reproductive Health/HIV Sector: A Literature Review and Analysis.”

267 UNFPA, “Gender Based Violence and HIV and AIDS: A Training Manual,” 2004. In Zambia UNFPA’s activities in the area of gender and HIV/AIDS currently focus on adolescent girls’ attitudes to sex, dating, and HIV.  The agency also places United Nations Volunteers who cover gender and AIDS generally. Human Rights Watch interview with Mekia Mohamed Redi, gender and HIV/AIDS officer, UNFPA, Lusaka, February 14, 2007.

268 USAID, Addressing Gender-based Violence through USAID’s Health Programs, pp. 11-12.

269 Gender norms are the “learned and evolving beliefs and customs in a society that define what is ‘socially acceptable’ in terms of roles, behaviors, and status for both men and women.  In the context of HIV/AIDS, these gender norms strongly influence both men’s and women’s risk-taking behavior…as well as HIV treatment.”  UNAIDS, “Summary Presentation of Findings of HIV and Gender Assessments of National HIV Responses and Draft Policy Guidelines to Address Gender Equality and Equity,” 20th Meeting of the UNAIDS Program Coordinating Board, Geneva, Switzerland, June 25-27, 2007, p. 3.

270 Ibid., p. 22.

271 Ibid., p. 22.

272 Ibid., p. 24.

273 Human Rights Watch email correspondence from Ngaitila Phiri, USAID, Lusaka, August 3, 2007.

274 PAHO, Violence against Women: The Health Sector Responds.

275 Ibid., pp.43-46.

276 Southern Africa AIDS Trust (SAT) - Harare, “Counseling Guidelines on Domestic Violence,” 2004, (accessed May 20, 2007).

277 Ibid., p. 6.