Family and Sexual Violence in : a medical emergency

The Australian Government Inquiry into the human rights issues confronting women and girls in the Indian Ocean – Asia Pacific region Submission by Médecins Sans Frontières (MSF)

Family and sexual violence (FSV) is widespread across Papua New Guinea (PNG) both within and outside the family. Women and children are particularly vulnerable. And despite the alarmingly high statistics we see in the few studies that exist and in Médecins Sans Frontières’ (MSF) own clinical data, this is thought to be only the tip of the iceberg. The full magnitude of the problem of FSV in PNG is not understood due to the lack of disaggregated data available and the challenges survivors face in coming forward.

Family and sexual violence is a medical emergency and must be treated as such. FSV survivors can suffer both acute and long-lasting medical and psychological consequences. If they do not receive adequate and timely care, there can be grave ramifications for the individual and potentially also the community.

Médecins Sans Frontières has been working with FSV survivors in PNG since 2007 and promotes the provision of ‘5 essential services1’ to all FSV survivors in one session as a minimum level of care. While the national and provincial governments have made improvements in the medical care of FSV survivors, there is still a very long way to go. Currently, due to the scarcity of Family Support Centres (FSCs) across the country, access of FSV survivors to all of the essential services in a timely manner is not assured. This can lead to unnecessary further suffering, illness and even death. All of which is preventable.

This paper looks at the medical and psychological needs of FSV survivors, what the PNG government and other actors are currently doing to address these and the priority actions that must be taken in order for more FSV survivors to receive needed care.

Finally, MSF identifies six steps the Australian government could take to best support the provision of much-needed medical and psychological support to FSV survivors across PNG. These recommendations are in line with, and thus complementary to, the Australian government’s current and planned activities. We believe they would not necessarily require a great amount of additional financial resources or personnel, yet could have significant benefits for FSV survivors. We urge the Australian government to leverage its influence, knowledge and experience from its decades of support in PNG to provide even greater help to FSV survivors.

1 As discussed in section 3.

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1. Médecins Sans Frontières (MSF) in Papua New Guinea

Médecins Sans Frontières (MSF) is an international, independent, medical humanitarian organisation that delivers emergency aid to people affected by armed conflict, epidemics, healthcare exclusion and natural or man-made disasters. In PNG MSF aims to improve access to integrated basic health care and mental health services for survivors of Family and Sexual Violence (FSV), and to improve access to emergency medical and surgical care to survivors of both FSV and general violence where necessary. MSF nurses and doctors began treating PNG survivors of FSV in December 2007. Since then, our medical teams have done close to 19,000 consultations to provide emergency medical and psychological care in Lae2, Tari, Maprik and . These are women, children and men who have been raped, beaten and otherwise physically or sexually assaulted by family members, spouses or intimate partners and unknown assailants.

In addition to treating patients directly, MSF staff working at ’s Angau Memorial Hospital trained staff from more than 28 provincial and district hospitals and health centres around the country between 2010 and 2012.

MSF also works in partnership with PNG’s Family and Sexual Violence Action Committee (FSVAC) supporting them to ensure the National and Provincial governments move forward with agreed strategies for planning and implementing FSCs throughout the country.

2. Family and sexual violence (FSV) in PNG

Family and sexual violence (FSV) is a global problem, with 35% of women worldwide experiencing some form of sexual violence (SV) or intimate partner violence (IPV) at some time in her life3.

But in Papua New Guinea, the rates of FSV are significantly higher. Early government- commissioned nationwide studies from the 1980s found that 66% of husbands interviewed in PNG said they beat their wives, while 67% of women interviewed in PNG said they had been beaten4. A 2008 study of sexual violence documented rates of reported rape at 44%5 across PNG. Cultural practices of polygamy, early marriage, customary justice, as well as high levels of criminality mean that women and girls (and to a lesser but unknown extent men and boys) can expect to experience sexual violence at some time in their lives. In a landmark study in the Lancet of male experience of sexual violence in ten countries in South East Asia, one in four men admitted to committing rape and nearly half to committing some form of violence against their partner. In Bougainville, Papua New Guinea, the figures were particularly concerning, with around 80% of men admitting to committing some form of violence against their partner6. The study found that in Bougainville one in five women’s first experience of sex was rape.

2 This project was handed over to the National Department of Health in mid 2013. 3 World Health Organisation (WHO), Violence Against Women. http://www.who.int/mediacentre/factsheets/fs239/en/ 4 Toft, S & Bonnel, S. (1985), “Marriage and Domestic Violence in Rural Papua New Guinea,” issue 18 of Occasional Paper, Law Reform Commission of Papua New Guinea. 5 Lewis. I., Maruia, B. & Walker, S. (2008), “Violence against women in Papua New Guinea,” Journal of Family Studies, 14(3),183 - 197. 6 The Lancet Global Health. (2013) “First multi-country study of rape and partner violence finds that nearly a quarter of men report having committed at least one rape” September 10th 2013.

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MSF’s experience of treating patients in PNG and its data confirm that there is a high level of need for medical care for FSV survivors. Close to 19,000 FSV consultations have been provided in MSF-supported clinics since 2007. Between the three current projects in Tari, Maprik and Port Moresby, MSF treats an average of 130 cases of family and sexual violence per month, 57 of which are for rape.

These studies, combined with MSF’s experience, highlight the alarmingly high levels of FSV in PNG. However, the true extent of FSV across the country is not understood due to the serious lack of FSV-specific statistical information and data collection tools. This is a major problem that hinders any attempts to support FSV survivors, and will be discussed later in this paper.

Although data is limited, MSF’s experience suggests that an alarmingly large number of SV survivors are children. The rate of children below 18 years seen by MSF in the Regional Treatment and Training (RTT) supported facilities in the National District Capital was 53% of all rape survivors in February 2014 and 65% of all rape survivors in March. Patient testimonies show that the perpetrator is generally a relative or known person. According to MSF psychologist Cindy Scott: “this often means that it is not a one-time traumatic event, but goes on for years, chipping away at the basic core of the developing child’s ability to trust, learn, regulate emotions and solve problems. Additionally, in many cases, parents may be reluctant to come forward because this may create conflict in the family or community”. MSF trains the FSC nurses to provide child friendly, appropriate medical care and psychological first aid, and engages the guardians in understanding the impact that the abuse has had on the child and how to support the child’s recovery. There is still a long way to go for all Family Support Centres to have child-friendly services available, with active links to effective social welfare, child protection and police services, to ensure that child survivors are not returned to a situation in which they are assaulted again.

3. Family and sexual violence: a health emergency

“29% of women had been forced into sex when pregnant and 17% had been beaten, with the result that one in five had lost their pregnancy. Two thirds of women who experienced physical violence had been injured, usually on multiple occasions. Depression, suicide and post-traumatic stress disorder were much more common among women who experienced partner violence than other women. They were also much more likely to have a miscarriage, a sexually transmitted infection and to have been prevented from using contraception than women who had not experienced violence.”7

Family and sexual violence survivors may have both acute and long-lasting medical and psychological needs. They require immediate medical and psychological care to treat what are often serious injuries and to treat or prevent diseases and other medical and psychological conditions. This care is time critical. If a woman does not get the medical attention she needs immediately after rape, her chances of contracting a disease, in particular HIV, increase substantially. And, as we have seen in many international contexts, HIV prevalence can, and does, destroy the social and productive fabric of a country and its workforce.

7 Rachel Jewkes, Emma Fulu Yandisa Sikweyiya, (September 2013) “Family Health and Safety Study, Bougainville, Papua New Guinea.”

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Treating FSV as a medical emergency ensures not only that the survivor is cared for immediately, but also that the longer term health and economic consequences of family and sexual violence on the broader society is mitigated.

Médecins Sans Frontières defines five essential services that should be available immediately following any incident of FSV. These services are ideally offered in one single session and represent the minimum level of care required. The five essential services include: medical first aid; psychological first aid; prevention of HIV and other STIs8; vaccination against hepatitis B8 and tetanus, and emergency contraception to prevent unwanted pregnancies that are the result of rape8.

It is important to minimise any further burden and stress on FSV survivors. Referring survivors back and forth to different services, asking them to explain again and again what happened and why they need care, adds to the suffering and creates unnecessary barriers that some patients simply cannot face overcoming. That is why MSF believes it is so important that these five essential services are provided by one health care provider, in one single session, in one location.

Medical first aid

Family and sexual violence may result in physical injuries. This can be so severe that it leads to fistula and/or incontinence. The resulting hygiene problems often result in isolation from the family and/or community and further stigmatisation. It is important to treat all injuries immediately to prevent infection or further complications.

Psychological first aid

The deepest wounds for a FSV survivor are often the ones that are invisible, with the trauma having long lasting effects on a person’s ability to function and carry on with their lives. The short term effects can be acute, when patients are in a state of shock, and in the longer term, they can develop severe mental health disorders. FSV survivors will commonly experience sleep disorders, nightmares, eating disorders, severe anxiety and flashbacks. Psychological effects of rape can also have negative implications for future sexual and reproductive health.

Psychological first aid can assist individuals and families after a traumatic experience, such as FSV. It helps to reduce the impact on both the family and the wider community of such traumatic events and reduce the impact that violent relationships have on a woman’s future reproductive health.

Psychological first aid consists of: Assurance of basic needs and safety; Restoration of control and emotional stabilization (utilising basic counselling skills); Empowerment of social networks; Reinforcement of self, healthy coping mechanisms, and stimulation of new ones to improve resilience; Plans for restoration of daily life activities.

There is little knowledge in PNG about the need for and benefits of psychological first aid. Despite this, MSF has found increasing interest amongst FSV survivors in accessing these services. In 2010 MSF held 953 individual mental health consultations at the FSC in Tari. In 2013 this had more than doubled to 2,232 consultations that year.

8 Applicable in SV cases

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A 2012 evaluation of the Lae FSC, which was run by MSF at the time, found that most patients who received two or more counselling sessions reported improvement in their presenting complaint (81%) and in their functionality (75%), and the proportion that showed improvement was slightly higher with the higher the number of counselling sessions received. This was the case even for those who only received two sessions of counselling, and was also the case for both IPV and SV survivors.9

Prevention of HIV and other STIs

Rape, due to its violent nature, is likely to involve a higher risk of HIV than consensual sex due to possible genital injuries. The risk of infection with other sexually transmitted diseases also exists. The risk is further increased in the case of gang rape.

Post exposure prophylaxis with an antiretroviral treatment can prevent HIV infection if started within 72 hours after the sexual assault and rigorously continued for 28 days. Timely care is a key challenge: the sooner treatment starts, the more likely it is to be effective.

The most common STIs, if not treated, create both considerable discomfort and can develop over time into a variety of pathologies, including pelvic inflammatory disease, neurological and cardiac diseases, infertility and complications in future pregnancies.

Therefore MSF provides all patients with systematic prophylactic treatment for sexually transmitted infections (chlamydia, gonorrhea, syphilis, cancroids and trichomoniasis). Even when medical care is sought after a longer period, full prophylactic treatment for STIs is provided.

MSF has seen an increasing awareness regarding the need to seek immediate help after rape in order to prevent HIV and unwanted pregnancy. We believe MSF and other organisation’s outreach and education efforts have made a significant contribution to this more timely health seeking behaviour. In Tari, for example 71% of FSV survivors seeking help at the FSC in the first three months of 2014 presented in under 72 hours of the incident. This is up from 60.3% in 2013 and 55% in 2012. However, follow-up to ensure completion of the 28 day PEP course remains a major challenge due to a number of factors that are discussed later in this report.

Vaccination against hepatitis B and tetanus

More contagious than HIV, hepatitis B is another virus that can be acquired as a consequence of rape. The vaccination is very effective in preventing transmission if given within 24 hours of the incident. MSF offers vaccination against hepatitis B as part of the systematic care offered to all survivors of rape. A first dose of hepatitis B vaccine is given at the initial medical consultation. This is repeated at day seven and day 28 in order to provide protection lasting up to one year. As with other treatments, compliance and follow-up medical visits are a challenge in PNG.

Victims of FSV may also be at risk of contracting tetanus, most commonly from the wounds inflicted during the attack. MSF verifies whether the person has been vaccinated, and offers immunization when necessary. Vaccination coverage is long (10 years) and presents a considerable health benefit, not least during childbirth and for the newborn.

Emergency contraception to prevent unwanted pregnancies as a result of rape

If a rape survivor seeks medical care as soon as possible within 120 hours following the incident, it is possible to prevent an unwanted pregnancy with emergency contraception.

9 Kamalini Lokuge (September 2012). “Evaluation of the MSF Sexual and Family Violence Project, Lae, Papua New Guinea”.

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4. The challenges to providing medical support to FSV survivors in PNG

a) Human resources

There is a dire shortage of healthcare workers throughout PNG, especially in rural areas where the majority of people live. For a population nearing 7 million, PNG has less than 400 doctors of which only 51 work outside Port Moresby, despite 87 percent of people living in rural areas. That’s one doctor per 17,068 people, compared to one per 302 in . There’s also a critical shortage of health workers – just 0.58 per 1,000 people, compared to WHO’s standards which specify 2.5:1,000 simply to maintain primary care. Within this overall context, there is a specific shortage of healthcare workers trained in working with FSV survivors.

Hiring and retaining healthcare providers with experience and knowledge of working with survivors of FSV is one of the greatest challenges to providing much-needed care for survivors across the country. Despite the widespread nature of sexual violence across PNG, medical and counseling staff do not currently receive specific training on working with survivors of FSV.

MSF sees the difficulties this creates in all of the centres where we work. Turnover of staff is a challenge, as much of the training and experience gets lost when an FSC staff member leaves the facility.

Working with survivors of FSV can obviously have a psychological impact on staff, especially if they themselves have suffered sexual or intimate partner violence in some form, as is often the case. Thus staff need to not only have specific medical training, but also training in how to cope in this work environment.

In order to ensure sensitive and appropriate treatment and care for survivors of FSV across the country, all hospitals should have some staff who have received specific training. Several modules on working with FSV survivors are being drafted and the proposal is for them to become part of the training curriculum of all staff involved in FSV care. This would mean that no matter at which point FSV survivors seek help, they should be able to be seen by specially trained staff who can either treat them or know where to refer them to. However this process has just begun, as the draft modules still need to be finalized by a working group which is yet to hold its first working session. This work is expected to take a year before a final draft can be submitted for approval to an “Advisory Committee” whose composition is yet to be defined and finally for adoption by the relevant government bodies.

b) Lack of awareness of medical services available

In MSF’s experience, most FSV survivors are not aware of the level of medical care available, especially regarding prevention of HIV and other STIs, emergency contraception and psychological support. Quite often they come just expecting to receive the medical report in order to receive compensation. But once they know the full support available to them they make full use of it.

At the end of the day, if you are providing quality, much-needed medical care, the patients themselves become your greatest advocates, which is what MSF has witnessed in the clinics we work in.

c) Stigmatisation of FSV survivors

Gossip and stigma are one of the most significant concerns facing FSV survivors and thus one of the greatest barriers to them accessing services. Sadly, many survivors of sexual

6 violence fear reprisal from their husbands if they find out and thus they don’t seek help. One example of this is a patient who returned to MSF’s clinic in Lae on numerous occasions. She was gang raped by strangers in front of her daughter and originally came to seek help after this situation. But after her husband found out he blamed her and repeatedly raped and beat her. Unfortunately, this link between sexual violence and IPV seems all too common. Teenagers may also not seek help as they fear being blamed by their family and forced to marry their assailant.

d) Distance and follow up

While one visit is obviously better than none, much of the support for FSV survivors requires follow up. For example, post exposure prophylaxis to help prevent HIV is a 28 day treatment and ideally there should be a follow up appointment after the treatment is concluded. Hepatitis B vaccine requires three separate doses. Survivors can also gain a greater benefit from subsequent mental health appointments. However, the distance survivors have to travel, stigma, competing priorities, lack of support from partners, side effects and lack of awareness of the importance of taking the full treatment, are among some of the barriers that can cause treatment interruption. Proximity to the perpetrator and ongoing abuse also frequently limit the survivor’s ability to complete treatment.

Ensuring patients attend follow up visits and complete treatment protocol is something MSF struggles with in its centres. For example, in the FSC in Tari that MSF runs only 53% of patients who were provided the 28 day post exposure prophylaxis course to prevent HIV in 2013 were confirmed to have completed the full treatment course, while MSF has no information regarding those who did not come to their follow up appointment. Some of the strategies that MSF has tried in order to overcome these challenges include: follow-up reminder calls when this doesn’t put the security of the patient at risk; health education and outreach; transport reimbursement; extensive education and information provided about treatment; and a treatment calendar is provided to help the survivor keep track of the pills taken.

e) Limitations of the network of services available for survivors of FSV

As a medical organization, MSF’s main focus lies in the provision of the 5 essential medical and psychological services to survivors of FSV described above. However, as MSF staff is all too aware, the care they provide does not cover all the acute needs of their patients by far. Survivors of FSV need a full range of adequate protection services, as well as access to justice. In response to these immediate needs and the lack of services and referrals, MSF, in partnership with the FSVAC and the NDoH, last year co-organized a multi-sectoral “Conference for a Comprehensive Response to Family and Sexual Violence”, bringing together the main stakeholders involved in the Health, Protection and Law & Justice sectors. On this occasion, a set of recommendations10 were adopted for all three sectors. The relevant government bodies and civil society actors such as the FSVAC need urgent support to ensure their full implementation, so that survivors’ immediate and long term needs are covered, in particular with regard to those services which fall outside of MSF’s field of expertise.

10 See annex 1

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5. The PNG government’s response to the medical needs of FSV survivors

Since MSF and partners began working with FSV survivors in PNG, we have seen an increased recognition of the critical need for timely, confidential medical and psychological care for FSV survivors.

In 2013 the National Department of Health (NDoH) published the Guidelines for PHA/ Hospital Management establishing hospital based Family support Centres, developed in close collaboration with the World Health Organisation (WHO), FSVAC, MSF and other partners. This is an essential tool to guide all hospitals throughout the country in establishing an FSC that meets the needs of FSV survivors.

However, in order for it to translate into better services for FSV survivors the government now needs to implement a strategy to ensure these operational guidelines are disseminated, accompanied by training for relevant staff and support to set up FSCs in compliance with the guidelines. Without such a strategy, the mere existence of the FSC guidelines will not result in access to greater medical and psychological care for FSV survivors across PNG.

Furthermore, these operational guidelines also need to be accompanied by clinical guidelines. Unfortunately, their creation has been a lengthy process that is still ongoing. The workshop planned by the NDoH and FSVAC to validate the draft guidelines is yet to be organized.

Finally, for both the operational and clinical guidelines to be truly effective, the government needs to monitor and enforce compliance. To date, no national monitoring tool has been put in place to allow provincial health advisors, NDoH planners and other stakeholders to assess the status of establishment of hospital based FSCs across the country, let alone to what extent those FSCs are complying with the guidelines and providing all five essential services.

To the best of MSF’s knowledge, there are currently nine hospitals, clinics or health centres in six provinces11 that are offering fully integrated care comprising all five essential services described above (five of these structures being currently still managed or supported by MSF). Plans for the establishment of 4 FSCs have been reported to be underway in 3 more provinces12. In addition to these, FSVAC reports that there are 6 more FSCs operating in 4 provinces other than the ones mentioned above13, with what appear to be varying levels of functionality and effectiveness. However MSF is not responsible for monitoring these FSCs for the provision of the 5 essential services in an integrated way, so cannot attest to the level of care provided in these locations. As is made clear from the above, this information is incomplete, and a full mapping of all FSCs in the country, as is proposed in the Pacific Women Shaping Pacific Development initiative is needed.

11 Lae FSC in Morobe; Well Women Clinic FSC in Mt Hagen in the Western Highlands, Buka FSC and Buin Health Centre in Bougainville; Maprik FSC in East Sepik; Tari FSC in Hela; Port Moresby General Hospital FSC, Lawes Road Clinic and 9 Mile Clinic in the National Capital District (the 5 latter ones being currently managed or supported by MSF). 12 Provincial Hospital in the Eastern Highlands (with financial support from DFAT); Modilon Hospital in and General Hospital in the Southern Highlands (the two latter ones with technical support from Voluntary Service Overseas - VSO). 13 Minj Hospital in Jiwaka; General Hospital in Milne Bay; Kerowagi District Hospital and General Hospital in Simbu, Arawa District Health Centre in Bougainville and General Hospital in West Sepik.

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Tentative mapping of FSCs :

Provinces with FSCs providing comprehensive integrated care to the best of MSF’s knowledge (as of May 2014) Provinces where the establishment of FSCs is said to be planned according to NDoH/VSO (as of May 2014) Provinces with additional operational FSCs according to FSVAC information (as of 2013 update)

While this is a positive start, there is obviously much more work to be done to ensure there are fully operational FSCs in all provincial hospitals, not to mention rolling out care to the district and then local level. As it currently stands, FSV survivors in nearly all locations apart from those who can access the aforementioned centres, will have to wait at numerous departments and centres if they are to have any hope of receiving all five necessary elements. In reality, most will simply not receive all five and many will not receive any medical or psychological support. The PNG government must ensure Family Support Centres complying with the operational guidelines are established in all provincial-level hospitals.

Since most of the nation’s population lives well away from provincial-led hospitals, the next step is obviously to make the five essential services available at a district level. However, that is a second phase once all provincial hospitals have fully operational FSCs.

One of the biggest obstacles to creating effective, targeted policies to support FSV survivors is the lack of data available. At the moment family and sexual violence is not being specifically measured in national data reports; FSV cases can be captured as “accidents and emergencies”, just like injuries resulting from traffic accidents are, or simply as “STIs”. To truly determine and appropriately respond to FSV, the government of

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PNG must have accurate data on the number and distribution of cases of family and sexual violence throughout the country.

The National Department of Health is currently reviewing the possibility of integrating the data collection tool designed by MSF into their health information system, however, we have yet to see any movement on this critical issue. Simply put, the PNG government’s current inability to measure and thus understand FSV across the country represents a serious obstacle in adequately addressing it. Thus implementing data collection tools allowing national data reports to specifically capture FSV consultations must be a priority. All Family Support Centres and other FSV healthcare providers should be required to report data on patients treated each month to the provincial and national departments of health, following agreed data guidelines.

6. The Australian government’s role

The Australian government’s focus on reducing violence against women and expanding support services14 as a priority area of the Pacific Women Shaping Pacific Development Initiative is commendable. The initiative specifically focuses on expanding support services for women survivors of violence as an initial focus in PNG. The provision of medical care for survivors of FSV should obviously be a priority, as discussed in this submission.

The Initiative includes support for PNG’s Family and Sexual Violence Action Committee (FSVAC) to build their capacity and help the group better coordinate hospital-based FSCs and other FSV services. The inclusion in this work of a mapping project to assess current hospital based FSCs15 will provide a baseline of existing services against which monitoring and evaluation of the status of implementation of FSCs across the provinces can be measured. Equally, planned discussions by a DFAT-funded facilitator with the National and Provincial governments on their agreed strategies for planning and implementing FSCs through the health system will help provide additional oversight and support.

The Australian government’s planned Happy Families Survey on FSV across the country will also be invaluable in measuring the country wide prevalence, nature and effect of FSV in PNG. This is desperately needed in order for the government to develop targeted strategies and programs to respond to the real need. However, as well as this one-off survey, it is important that ongoing data segregation tools are put into place in order to maintain up-to- date information on, and thus understanding about, FSV across the country. As discussed earlier, this is something that is currently being discussed and considered by the NDoH, but they need greater support in order to implement changes in the way sexual violence is currently documented across the country.

14 Key Result Area 6 of the Pacific Women Shaping Pacific Development Initiative. 15 The outcomes for this project include: 10 Family Support Centres based in provincial hospitals assessed and plans to reopen and offer quality services agreed with government and community stakeholders. http://www.pacificwomen.org/wp-content/uploads/PNG-Country-Plan-Summary.pdf

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7. Recommendations for the Australian government

MSF has identified six additional steps the Australian government could take to best support the provision of much-needed medical and psychological support to FSV survivors across PNG. These recommendations are very much in line with, and thus complementary to, the Australian government’s current and planned activities. We believe they would not necessarily require a great amount of additional financial resources or personnel, yet could have significant benefits for FSV survivors. These are additional steps the Australian government could take to leverage its influence, knowledge and experience from its decades of support in PNG. The recommendations are as follows: a) Support the National Department of Health (NDoH) to rapidly adopt the draft clinical guidelines specific to FSV care, to disseminate them and organize trainings on them.

The adoption of comprehensive clinical guidelines for the treatment of FSV survivors is the first and most essential step to ensure the provision of adequate FSV care in NDoH facilities. It also is a precondition to reach other important objectives, such as the creation of a training curriculum on FSV for relevant health care staff (see recommendation 7c). The Australian government is well placed to help move this process forward due to the close working relationship with NDoH officials. b) Provide technical support to help the NDoH implement the data tool MSF designed to disaggregate national data reports to specifically include FSV.

The Happy Families Survey will provide much-needed insight into the nature and extent of FSV across the country. However, it must be coupled with ongoing data collection about FSV. As discussed in this report, that currently doesn’t exist. The Australian government has the technical knowledge and relationship with NDoH to help them create and implement these guidelines and tools in a timely manner. c) Support the National Department of Health (NDoH) and the Ministry of Education to have the draft training modules on working with FSV survivors approved and incorporated into the training curriculum for relevant health care and counseling staff as soon as possible.

The Australian government and Australian-based training institutions have a long-history of involvement in health worker training in PNG and thus are perfectly placed to help move forward this recommendation in a timely manner and help overcome current delays. d) Support the NDoH to roll out training to all provincial hospitals in the country on the Guidelines for PHA/ Hospital Management establishing hospital based Family support Centres.

As detailed in this submission, the finalisation and publication of these operational guidelines was an important step, however without accompanying training and distribution throughout the country they will be of little use. Monitoring the roll-out of this training could be included as part of the mapping of FSCs across the country (see point 7e), which is already established in the work plan of the Pacific Women Shaping Pacific Development Initiative. e) Ensure the mapping of FSCs across the country as part of the Pacific Women Shaping Pacific Development Initiative includes an evaluation of their functionality and effectiveness, in line with the NDoH’s Guidelines for PHA/ Hospital Management establishing hospital based Family support Centres.

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This will help assess the services that FSV survivors can currently access and help clarify where each FSC needs support.

f) As stated in the Pacific Women Shaping Pacific Development Initiative, continue to support the FSVAC in working with National and Provincial governments to ensure they implement their agreed strategies for planning and establishing Family Support Centres in each province.

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We would encourage you to visit our mission in PNG to see first-hand the issues raised in this report. In PNG, please contact the MSF Head of Mission,

For further information or questions please contact MSF Australia Advocacy and Public Affairs Manager,

Annexes

Recommendations from the November 2013 Conference for a Comprehensive Response to Family and Sexual Violence:

Health recommendations:

Delivering guidelines Ensure implementation of the roll out to ALL provinces of FSCs that comply with the Guidelines through attaining CEO commitment to provide services to Survivors, supported by changing institutional thinking through training of hospital management, NDoH staff and other stakeholders in other relevant sectors. The existing Circular regarding fee-free services should be upgraded to Policy. It should be implemented by hospital CEOs and enforced, with penalties for non-compliance. Training Establish accredited mental health training in PNG (integrated into the nursing curriculum or as scholarship, delivered by NDoH supported by qualified partners. Identify and create a database of trained counselors in the country and build the counseling capacity for GBV. Training on FSV issues with all hospital staff to ensure sensitive & appropriate treatment & referral of survivors at any entry-point. Training of trainers for medical staff, including clinical guidelines to ensure that will be monitored by NDoH. Referral and Coordination Establish or strengthen provincial level FSVACs to coordinate clear referral pathways between sectors. Establish standardised referral pathway within the existing hospital structure until an FSC is in place. FSVAC to act as the central coordination point for all reporting on FSV activities and data collected by local, national & international stakeholders. Service delivery FSCs must be design and services provided in a child-friendly manner.

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Create a dedicated psycho-social counselor position in every hospital. FSC to be closely located to A&E. Additional resources and a systematic approach to patient follow up are required. FSCs do not pose barriers to accessing services, including for men. Data collection should follow standard guidelines and be systematically reported. Community awareness & outreach Upskill remote and community-based HW/volunteers to reach population provide first response & awareness. Mobile clinics & community-based outreach to build awareness, gather data, provide basic healthcare. Stakeholder mechanisms & advocacy Provide more forums to facilitate more effective networking between partners to share experiences, lessons & skills. FSVAC & inter-departmental govt decision making working group to convene annually to review and advance the national level FSV policy response framework. Advocate through existing forums at the national and provincial level for necessary resources to deliver on the Guidelines such as: Gender Forum PMT and PCMC committees CIMC (FSVAC)

Law & Justice recommendations:

Family Protection ACT Speedy certification, development of regulations and implementation of the Family Protection Act Roll out a funded awareness program on the FP Act Ensure that there is adequate allocation of resources by Government to implement the FPA Accredited counselling services to be linked to Court for implementation of FPA Police Establish a FSVU in all targeted provinces Police to conduct community awareness on roles of the different units within the Police Increase the allocation of resources and personnel for investigations More sensitivity training on FSV for all police not just FSVU Introduce a ‘’No drop policy for FSV cases Courts Create specialized Courts to focus on FSV Empower authorities and seek other strategies to allow speedier issuing of IPO’s Court clerks to be trained on IPOs No fees to be charged for accessing the justice system – especially at local level More sensitivity training on FSV for judiciary and other court officials Develop alternative sentencing options for courts to protect families interests Child Protection Specialized services for children Coordination between CBC and Child Welfare Ensure child friendly spaces are provided at police and court level Medical Reports Training of legal officers to understand the MRs L&J to prosecute on their own set of evidences assessment and not only MRs Overarching Issues Compensation should not be allowed for FSV offenses Awareness on impact of compensations on survivors

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Confirm FSVAC role to coordinate different sectors. Para-legal training for service providers Volunteer Victim Support Services to be encouraged or established Awareness on FSV laws and policies, using different modes of communication – partnering with private sector

Protection Recommendations:

LPA Department Community Development to complete the review of the LPA and achieve its implementation by June In order to implement the LPA, the LPA Council must be established to take charge of training of service providers and gazetting them as Child Protection Officers. Child Welfare department civil society to develop campaigns that create Awareness and understanding by communities of the purpose of LPA and the attributions of a child protection /gazette officer to remove a child when necessary. Community Development Department to prioritizing child protection funding. Conduct mapping of multi-sectoral child protection services at provincial level. Safe-houses Finalise the guidelines and standards for safe-houses including: 1- Special measures for children including infra-structure. 2- Tool to assess that safe-houses comply with standards. 3- Attendance of one resident trained social worker or counselor. 4- Process of coordination between provincial FSVAC, NGO’s and partners when establishing safe-houses. Address the impact of land issues on restricting locations of safe-houses Minimum Standards for Safe Houses to be endorsed by the Department for Community Development (Welfare) with a clear monitoring role in place. Existing Safe Houses assessed by Office of the Director for Welfare to ensure they meet the Minimum Standards and licenses provided accordingly. Provision of a toll free number that provides information on safe-houses and FSV services in the callers area. Repatriation should be considered as an option for helping women to escape violence situations where appropriate and upon survivor’s request. Strategies need to be developed for overcoming challenges posed by bride price and other cultural practices which may be a barrier to this. Collaboration between the safe-houses and security providers to ensure the provision of discreet services and appropriate safety for survivors and staff. Update directory of existing safe-houses and submit to the Department of Welfare. Department of Welfare shall assess all existing establishments within a reasonable time-frame. (3 months) Referral Provincial FSVAC responsible for coordination of data and information of protection services. Referral pathway to be developed between all sectors.

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