Women’s Protection and Empowerment and Reproductive Health Rapid Assessment Report LGA: Monguno Ward: Central Ward Date: September 5, 2016 Prepared by: ERT-WPE Manager and ERT-RH Coordinator

Date 1. Introduction Since 2009, and with more recent escalation since 2012, the Boko Haram insurgency has crippled northeastern Nigeria. More than 20,000 civilians have lost their lives and thousands of women and girls have been abducted and forced into sexual slavery.1 Borno State has been particularly affected, with widespread displacement and all 27 local government areas (LGAs) in Boko Haram control at one point. Of the 7 million people in need across northeastern Nigeria, 3 million remained trapped in inaccessible areas. However, in recent months, advances by the Nigerian Army and the Multinational Joint Task Force have led to improved access to some LGAs in Borno, revealing significant humanitarian needs. Most internally displaced persons (IDPs) have fled to nearby towns/centers that are protected by the Nigerian military, either staying in camps or taking refuge in abandoned schools, housing estates, hospitals, and other government institutions. Although ongoing violence and limited accessibility make data difficult to come by, there are an estimated 100,000 people in need in the Monguno Local Government Area (LGA)2, 63,000 of whom are IDPs residing in camps.3 As the Nigerian military pushes further north, additional IDPs arrive each day. Agencies including Refugee International, Amnesty International, Human Rights Watch, UNICEF and others have noted the specific targeting of women and girls, the violence they experience under Boko Haram, and the dire need for specialized services for them. Yet, as International Alert reports in “Bad Blood,” there has been minimal effort to identify and address women and girls’ needs, much less target them as priority beneficiaries for any programming.” The IRC carried out a rapid assessment in three camps4 within Monguno’s Central Ward: Government Girls Secondary School, Central Primary School, and Government Secretariat School, all of which are in Monguno town. The IRC also visited the MSF clinic, and Monguno Central Hospital. The IRC did not find any gender-based violence (GBV) response and prevention actors or activities in the areas assessed; all of the areas lacked basic reproductive health (RH) and maternal health facilities, equipment, and staff. Based on findings outlined within this report, the IRC team suggests the following recommendations: The IRC will ensure direct RH and WPE services for women and girls by taking the following actions:  Establish a one-stop safe space for women and girls which will provide holistic RH and WPE services in Primary School and Government Girls Secondary School. This combined approach – with RH and GBV services targeting the population of women and girls broadly – will help promote health-seeking behavior, promote confidentiality, offer a safe space for women and girls to convene, and reduce stigma for GBV survivors seeking care. Services should include but not be limited to: GBV case management, psychosocial support for women and girls, clinical care for sexual assault survivors (CCSAS), and RH information sessions.  Ensure RH providers have timely access to medication and working equipment.

1 https://www.hrw.org/news/2015/05/26/nigeria-new-president-should-address-abuses 2 OCHA, June 29, 2016. 3 Number cited in a conversation with Col. Emere of the Nigerian Army 8th Division in Konduga on August 2, 2016. 4 Due to time limitations on the ground, the IRC was unable to visit additional camps as part of this rapid assessment.

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 Train available nurses on Minimum Initial Standards for RH, which includes CCSAS, family planning, post abortion care.  Identify and train Traditional Birth Attendants (TBAs) and WPE response volunteers in the community.  Work with Community Health Workers (CHWs) in the community to support trained midwives. Humanitarian actors should reduce risks to women and girls by taking the following actions:  Sensitize medical staff on GBV guiding principles, basic RH, and the needs of women and girls in the current crisis.  Establish and make accessible the GBV referral pathway in medical centers, which will include nutrition centers, and other community spaces such as camp coordination areas.  Promote use of sector-specific sections from the 2015 GBV Guidelines by other humanitarian actors.  Sensitize communities on the consequences of GBV and referral pathways  Distribute 12,600 dignity kits to IDP women and girls of reproductive age.5  Reduce the need for firewood consumption by providing alternative fuels or acceptable cooking methods.  Advocate for increased joint patrols to assist women with firewood collection.  Apply the 2015 GBV Guidelines minimum, sector-specific actions to ensure best practice and risk reduction for women and girls.

2. Assessment Overview and Findings

Assessment Objectives  To assess the availability of GBV prevention and response services and reproductive health services  To identify GBV response and RH service delivery gaps  To propose interventions to improve the level of access to these services for women and girls

Assessment Methodology The IRC visited three IDP sites in Monguno: Government Girls Secondary School, Central Primary School, and Government Secretariat School. In addition, the team went to MSF malnutrition clinic and the main referral hospital, Monguno Central Hospital. The team held one focus group discussion with 11 women and collected information on health-seeking behaviour and available services from key informants working in medical centers and directly from women through the focus group discussion. The IRC was not able to hold additional focus group discussions due to lack of time on the ground.

Assessment Findings The following actors are providing services in the IDP camp and host community:  The Aliiance for International Medical Action (ALIMA) (Health and Nutrition)  United Nations Children’s Fund (UNICEF) (WASH and Health)  International Committee of the Red Cross (ICRC) (Health)

5 Number is based on reproductive health guidelines that at least 20% of a female population is of reproductive age.

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 United Nations Population Fund (UNFPA6) (PSS)  Médecins Sans Frontiers (MSF) (Health) The assessment identified several unmet needs for women and girls, including GBV response and health gaps. The lack of basic response services and absence of actors providing GBV and RH services is alarming in the midst of a crisis that is known for violence directly targeting women and girls. Humanitarian actors are appropriately focused on the critical need to address malnutrition rates; however, women and girls’ needs in terms of GBV response and RH services are being largely neglected.

1. Lack of Service Provision for women and girls

1.1 Reproductive Health All of the camps had health actors. However, they lacked services for women of reproductive age, as well as services for pregnant and lactating women. Health actors had access to clean delivery kits (though they lacked a wrapper for the child); however, there was no uniform distribution or service beyond a clean delivery kit. Antenatal Care was unavailable; even as some health providers indicated they wanted to care for pregnant women, the materials were unavailable. In the Primary School Camp, a woman who delivered recently, conducted her own delivery. In Secretariat Camp, there was a midwife available but there was no available private space and limited or dilapidated equipment. Besides maternal care, there was no mention by health actors of accessibility to post abortion care or family planning. All the medical tents lacked privacy should consultation be sought by women or girls. In general, there was a clear lack of consultation of women and girls of reproductive age on their needs. 1.2 GBV No GBV response or prevention services were visible in the three camps. Women and girls the IRC spoke with were not aware that GBV services existed or how to access them. There is a false perception among NGO, UN and Ministerial actors that GBV needs to be reported before providing a response7. In part as a result, and due also to societal norms and fear of being shunned by their families and communities, women expressed strong reluctance to report violence for fear of being identified as a GBV survivor. NGO and UN actors were unable to provide information on services for survivors of GBV or what follow up happen or be needed if GBV is reported. No actors interviewed were aware of existing GBV response services including: GBV case management, PSS for women and girls, CCSAS, or regular consultations with women and girls on access to services. In addition, actors did not express an understanding of GBV in humanitarian contexts and the need for response services. Beyond direct GBV response, women who spoke with the IRC were visibly distressed and held their heads low when they speaking about the area outside the perimeter of the camp. They said that water and latrines were accessible; however, women still must venture outside the camp for firewood. The women stated that most violence occurred outside the camp.8 One female NGO staff member who brought up the lack of privacy in the

6 UNFPA indicated they are working in Girls College and Science College IDP camps. They have 6 workers providing PSS. However, no GBV case management, GBV risk reduction, or reproductive health staff were operational. UNFPA stated the 6 staff were being trained on PSS during the day of the assessment. 7 2015 IASC Guidelines for Integrating Gender-Based Violence in Humanitarian Settings: “all humanitarian personnel ought to assume GBV is occurring and threatening affected populations; treat it as a serious and life-threatening problem; and take actions based on sector recommendations in these Guidelines, regardless of the presence or absence of concrete ‘evidence’.” 8 The IRC did not delve further into this during this initial focus group discussion since no response referrals were available to inform the women of if they self-disclosed. This is in line with WHO ethical guidelines.

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clinics for women and girls also expressed that the “bush is not safe,” and that it is difficult for women and girls to discuss safety concerns. In addition to safety issues, women and girls brought up the need for material support. They expressed the need for clothing and cloth, possibly linked to the need for menstrual hygiene items.

2 Access and referrals to health services Clinics in the IDP sites indicated they refer severe health cases to the main referral hospital, Monguno Central Hospital. However, there was a clear disconnect between expected services at the hospital, actual services, and accessibility. The doctor at the referral hospital commented, “Very few women come here. They have a TBA.” Overall, the IRC heard from service providers and other key informants and prevalent view that if women are not accessing services it means their needs are adequately met. This is contrasted with what the IRC heard from women themselves, who explained not being able to access the hospital due to transportation fees and the presence of soldiers in the area. International guidelines and the IRC’s own experience in delivering GBV services also illustrates that in the absence of safe, confidential and tailored services, women and girls are not likely to come forward to seek care. The MCH doctor also noted that in the previous month, there were 2-3 deaths related to delivery. He was unable to explain further why the deaths occurred.

3 Lack of knowledge on GBV by medical staff There was a stark lack of knowledge on GBV by healthcare providers. Some health workers were dismayed at the lack of response and privacy but were unsure how to promote proper services in relation to both GBV and RH. When medical staff at the referral hospital were asked how they would treat a case of rape or sexual violence, a doctor responded that you must: “look for trauma and sperm deposit.” The doctor was questioned further to explore if medication9 should be provided, but he was unable to provide an answer and indicated no medication would be necessary. Also concerning was the emphasis from medical personnel that survivors “cannot just come on their own [to the hospital]” since they should be accompanied by a police officer. Other than direct service provision, there is also significant concern around GBV messaging to survivors who may consider seeking services. When one NGO staff member providing healthcare was asked what information she would provide a survivor of rape, she stated, “I will advise them, not to repeat again.” Lack of adequate medical response protocols, lack of training, and resulting attitudes that place blame for sexual assault on the survivors, are all obstacles to women and girls accessing lifesaving healthcare.

9 For treatment of rape, emergency contraception, post-exposure prophylaxis of HIV, and STIs should be provided.

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