Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

The RESPOND Project/Burundi

October 2012

2012 EngenderHealth (The RESPOND Project)

The RESPOND Project c/o EngenderHealth 440 Ninth Avenue New York, NY 10001 U.S.A. Telephone: 212-561-8000 Fax: 212-561-8067 e-mail: [email protected] www.respondproject.org

This publication is made possible by the generous support of the American People through the U.S. Agency for International Development (USAID), under the terms of cooperative agreement GPO-A-000-08-00007-00. The contents are the responsibility of the RESPOND Project/EngenderHealth and do not necessarily reflect the views of USAID or the United States Government.

This work is licensed under the Creative Commons Attribution-Noncommercial- Share Alike 3.0 Unported License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/3.0/.

Suggested citation: The RESPOND Project. 2012. Services for sexual violence survivors in Kayanza and Muyinga provinces, Burundi. New York: EngenderHealth.

CONTENTS

CONTENTS ...... iii ACKNOWLEDGMENTS ...... v ACRONYMS AND ABBREVIATIONS ...... vii EXECUTIVE SUMMARY ...... ix INTRODUCTION ...... 1 METHODOLOGY ...... 3 FINDINGS ...... 5 RECOMMENDATIONS ...... 15 REFERENCES ...... 21 APPENDIX A. Health Facility Manager Questionnaire ...... 23 APPENDIX B. Health Provider Questionnaire ...... 33 APPENDIX C. Key Informant Interview Guide ...... 41 APPENDIX D. List of Key Informants ...... 45 APPENDIX E. Focus Group Discussion Guide ...... 47

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi iii

ACKNOWLEDGMENTS

This study was conducted with the generous financing of the Burundi Mission of the United States Agency for International Development (USAID).

The study was led by Marie-Christine Ntagwirumugara, a consultant for The RESPOND Project/Burundi, and by Mahamadi Cissé, the project manager for RESPOND/Burkina Faso. The study was conducted through close collaboration among RESPOND, the Ministry of National Solidarity, Human Rights and Gender (MSNDPHG), the Ministry of Public Health and the Fight against AIDS (MSPLS), and administrative authorities in Kayanza and Muyinga provinces. Marie- Christine Ntagwirumugara served as the lead author and Ashley Jackson from RESPOND served as the lead technical editor. The report was also reviewed by Esther Braud, Maureen Clyde, Santiago Plata, Hannah Searing, Fabio Verani, and Jane Wickstrom from EngenderHealth/RESPOND. The report was copyedited by Michael Klitsch and was formatted by Elkin Konuk. Thanks are due to each of these collaborators.

RESPOND also extends its gratitude to the health facility managers, health providers, Family Development Center teams, community members, and all others who participated in this study.

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi v

ACRONYMS AND ABBREVIATIONS

ABUBEF Burundian Association for Family Well-Being ADDF Association pour la Défense des Droits des Femmes AMAVES Association of the Compassionate for the Assistance of Those Affected by HIV/AIDS APRODH Association for the Protection of Human Rights and Detained Persons ARV antiretroviral (drug) BCC behavior change communication CDF Family Development Center COP Country Operational Plan FGD focus group discussion GBV gender-based violence ICRW International Center for Research on Women MAP Men As Partners® MSNDPHG Ministry of National Solidarity, Human Rights and Gender MSPLS Ministry of Public Health and the Fight against AIDS NGO nongovernmental organization PEP postexposure prophylaxis PEPFAR U.S. President’s Emergency Plan for AIDS Relief SEED Supply–Enabling Environment–Demand SOP standard operating procedure SRH sexual and reproductive health STI sexually transmitted infection SV sexual violence SWAA Society for Women and AIDS in Africa TMAP Technical Support to Map Gender-Based Violence Services in Tanzania UNICEF United Nations Children’s Fund USAID U.S. Agency for International Development

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi vii

EXECUTIVE SUMMARY

Addressing sexual violence (SV) is a priority of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) initiative in Burundi. With the support of PEPFAR and the partnership of the Ministry of National Solidarity, Human Rights and Gender (MSNDPHG) and the Ministry of Public Health and the Fight against AIDS (MSPLS), the RESPOND Project aims to improve efforts to prevent SV and to respond to SV survivors in two provinces—Kayanza and Muyinga—through the following results: 1. Strengthen the health sector response for SV survivors 2. Promote gender-equitable norms to prevent SV and to support survivors 3. Increase the capacity of communities and civil society to prevent SV

Building upon the results of a national SV assessment led by RESPOND in August 2011, this study aimed to:  Assess the health services available to SV survivors in the two provinces  Identify other, nonmedical services available to SV survivors in the two provinces  Explore the factors that allow SV to take place and prevent survivors from seeking help  Develop recommendations for PEPFAR and the relevant ministries in Burundi  Guide the strategy and activities of the RESPOND Project in Burundi

Data were collected in a total of four townships in Kayanza and Muyinga. RESPOND audited 17 health centers and two hospitals, interviewing the 19 facility managers and an additional 30 providers. Key informant interviews were conducted with 24 administrative authorities, community leaders, and representatives of organizations that work in SV services. Focus group discussions (FGDs) were held with single-sex groups of 9–11 community members each. A total of 158 community members participated in 16 FGDs.

Facility audits showed that health centers lack the trained staff and equipment necessary to respond to SV and that many providers hold attitudes that are unsupportive of SV survivors. Since they are unprepared to care for SV survivors, providers at health centers typically refer cases to hospitals after providing very few services, such as treating wounds and providing antibiotics for treatment of sexually transmitted infections (STIs). Given significant barriers to pursuing these referrals, it is likely that many survivors do not receive adequate medical care for SV, even after seeking it at health centers.

Outside the health system, services for survivors are similarly limited. In both provinces, some legal and psychosocial services exist, although they are not well-known by communities. The study found no economic reintegration services or safe houses currently available to SV survivors in the two provinces. The Family Development Centers (CDFs), which are charged with coordinating SV services, have insufficient staff and funding to fulfill their mandate. While woman volunteers called “baremeshakiyago” (peer educators) and “imboneza” (community relays) raise community awareness about health and social issues, which in theory include SV, there appear to be no structures with which to engage men in SV prevention.

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi ix

Factors that allow SV to happen and that prevent survivors from receiving help include power imbalances between men and women, the acceptability of marital rape, fears of retaliation by the perpetrator, taboos around discussing SV, the blaming of SV survivors, corruption in the court system, and cost and transportation barriers.

Key recommendations include the following:  Prepare health centers to offer survivors at least a minimum package of SV services, including counseling and referrals. Providers who work at first-line and referral facilities should be trained. It is very important for training to address attitudes around SV. Existing job aids for infection prevention and the care of SV survivors need to be adapted and disseminated to health facilities. Key commodities, supplies, and services, such as drugs for postexposure prophylaxis (PEP), tetanus and hepatitis B vaccines, STI tests, pregnancy tests, and emergency contraception need to be provided.  Provide CDFs with adequate resources to oversee the multisectoral coordination of partners in the care of SV survivors and offer the services in their mandate, including psychosocial support and the facilitation of medical and legal services for survivors. CDFs should involve stakeholders in selecting and evaluating SV services.  Develop a national behavior change communication (BCC) strategy that includes a detailed road map for the MSNDPHG’s BCC activities, target audiences, and messages to prevent SV. A plan to monitor and evaluate the implementation of the BCC strategy also needs to be established.  Engage male champions in the fight against SV. Male as well as female community volunteers should be trained to model equitable gender norms, speak out against SV, and address barriers to seeking care. Groups of male champions could be recruited from mining companies, since miners were identified by communities as commonly perpetrating SV.

x Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

INTRODUCTION

Burundi is emerging from a long period of civil war in which sexual violence (SV) was used as a weapon of war. While available data are inadequate to estimate the prevalence of SV in postconflict Burundi, they suggest that SV remains widespread (ACAT Burundi & OMCT, 2008). The perpetrators now tend to be relatives, teachers, and others who are known to the survivor, rather than members of armed groups (Zicherman, 2007). A 2009 survey by the United Nations Children’s Fund (UNICEF) found that 19% of adolescents had their sexual debut before age 10, 35% between the ages of 10 and 14, and 35% between 15 and 19. One in five (19%) reported that SV had occurred in their school (UNICEF, 2009).

Addressing SV is a priority of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) initiative in Burundi. Not only is SV a concern as a human rights issue, it is also associated with HIV infection and other adverse health outcomes (Ellsberg & Betron, 2001). Burundi faces a generalized HIV epidemic, with an adult HIV prevalence of 1.4% according to the 2010 Demographic and Health Survey (ISTEEBU, MSPLS & ICF International, 2012).

With $488,000 in PEPFAR funding for Country Operational Plan (COP) 12 and the partnership of the Ministry of National Solidarity, Human Rights and Gender (MSNDPHG) and the Ministry of Public Health and the Fight against AIDS (MSPLS), the RESPOND Project aims to improve efforts to prevent SV and to respond to SV survivors in two provinces of Burundi—Kayanza and Muyinga. The provinces were selected to allow the project to build upon the achievements of the maternal and child health program that PEPFAR operates in these provinces. Within these provinces, RESPOND will work in four townships: Kabarore and Muruta townships in Kayanza Province, and Butihinda and Giteranyi townships in Muyinga Province. Townships in Kayanza were selected because the Regional Outreach Addressing AIDS through Development Strategies (ROADS) Project ROADS, led by FHI 360, is already established in other townships (Kayanza, Matongo, Gahombo, and Butaganzwa) in the province and it is preferable to avoid duplications. In Muyinga, the mining townships of Giteranyi and Butihinda were chosen because of the high risk of SV in these communities.

The design of the intervention is informed by EngenderHealth’s Supply–Enabling Environment– Demand (SEED) Programming Model™, a holistic programming framework based on the principle that sexual and reproductive health (SRH) programs will be more successful and sustainable if they comprehensively address the multifaceted determinants of health and if they include synergistic interventions within the mutually reinforcing areas of supply, enabling environment, and demand. Specifically, RESPOND seeks to attain the following results: 1. Strengthen the health sector response for SV survivors 2. Promote gender-equitable norms to prevent SV and to support SV survivors 3. Increase the capacity of communities and civil society to prevent SV

A national SV needs assessment led by RESPOND in August 2011 highlighted, among other findings, the following challenges:  A lack of systematic training in SV response for medical personnel  A lack of referrals and coordination between organizations and service providers across different sectors  Underreporting of SV due to stigma, normalization of SV, and the impunity of perpetrators

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 1

RESPOND conducted the present formative study to deepen its understanding of certain needs uncovered by the assessment, collect baseline data in the target provinces, and develop recommendations.

Study Objectives The present study aimed to:  Assess the health services available to SV survivors in the two provinces  Identify other, nonmedical services available to SV survivors in the two provinces  Explore the factors that allow SV to take place and prevent survivors from seeking help in the two provinces  Develop recommendations for PEPFAR and the relevant ministries in Burundi  Guide RESPOND’s strategy and activities in Burundi

2 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

METHODOLOGY

In April 2012, RESPOND collected data on services for SV survivors in the intervention provinces and townships through audits of health care facilities, focus group discussions (FGDs), and key informant interviews.

Health Facility Audits Audits of health facilities allowed the evaluation of services offered to SV survivors, the quality of services offered, the availability of necessary equipment and supplies, knowledge and attitudes of medical care providers toward survivors, standard operating procedures (SOPs), confidentiality and record-keeping practices, referral practices, and infection prevention practices. The data collection tools were designed by RESPOND and were tested in Guinea and Côte d’Ivoire prior to this study. The facility manager questionnaire is included as Appendix A and the provider questionnaire is included as Appendix B. English versions of these tools will be available soon.

Health facility audits were done through individual interviews with facility managers as well as with available providers. Nineteen health facilities in the intervention provinces were audited (nine in Kayanza and 10 in Muyinga). These 19 were selected to include the most accessible health centers in the four target townships and the one hospital in each province. The two hospitals have catchment populations of between about 100,000 and 238,000, while the 17 health centers each serve approximately 10,500 to 36,000 people. The 19 facility managers and an additional 30 providers were interviewed.

Key Informant Interviews Semi-structured interviews were held with administrative authorities, community leaders, and representatives of organizations that work in SV services. Interviews identified the role and structure of institutions with regard to SV services, other SV services in the townships, links between actors, and challenges that survivors face when seeking help. With permission, the data collection tool was adapted by the RESPOND Project from a tool designed by the International Center for Research on Women (ICRW) for the Technical Support to Map Gender-Based Violence Services in Tanzania (TMAP) Project. The English version of this tool is included as Appendix C.

A total of 24 interviews were held in addition to the informal interviews that took place during the preparation of the study. The list of key informants is included as Appendix D.

Focus Group Discussions FGDs were conducted with members of the communities around the health centers to understand social norms and attitudes regarding SV, barriers that prevent SV survivors from accessing services, and strategies to improve service delivery. With permission, the data collection tool was adapted by RESPOND from a tool designed by ICRW for the TMAP Project. The English version of this tool is included as Appendix E.

A total of 16 FGDs were held with single-sex groups of 9–11 community members each. In each of the four townships, RESPOND conducted four FGDs with the following target groups: women aged 18–24, women ages 25 and older, men aged 18–24, and men ages 25 and older. The study did not

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 3 include participants under age 18, due to the sensitivity of the topic. Community leaders assisted RESPOND to recruit participants on the basis of the following criteria: a. Participants should meet the age and sex guidelines for their FGD category. b. Participants should not be selected based on a history of surviving or perpetrating SV. c. Participants should be generally knowledgeable about the community.

The sample was not intended to be statistically representative of the broader community. Table 1 presents the number of participants by sex and age across the 16 FGDs.

Table 1. FGD participants, by sex and age

Sex Age No. of FGDs Total no. of participants Men 18–24 4 40 >25 4 40 Women 18–24 4 39 >25 4 39 Total 16 158

4 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

FINDINGS

Assessment of the Health Sector Response to SV In general, health facilities—especially health centers—are not equipped or staffed to respond to SV. The great majority of health care providers lack training in the care of SV survivors. Since they are unprepared to care for SV survivors, providers at health centers typically refer them to hospitals after providing very few services, such as treatment of wounds and provision of antibiotics for STIs. Given significant barriers to pursuing referrals, it is likely that many survivors do not receive adequate medical care for SV, even after seeking such care at health centers.

Human resources  Across the 19 health facilities, the largest cadre of providers was nurses. Nurses made up 80% of the personnel (214 of 266 providers). Another 9% were auxiliary nurses. Of the 30 providers interviewed—the providers most likely to treat SV—22 (73%) were nurses and 7 (23%) were auxiliary nurses. Among those interviewed, the numbers of male and female providers were equal (15 men, 15 women).  The average health center in the sample had six providers, including four nurses. In contrast, Kayanza Hospital had 72 nurses, seven doctors, and one midwife, while Muyinga Hospital had 73 nurses, six doctors, and two midwives.  Health centers lack the laboratory skills needed to provide survivors with essential tests (e.g., for HIV and other STIs). Across the nine health facilities serving several hundred thousand people in Kayanza Province, there were only three lab technicians, all of whom were based at Kayanza Hospital. (Muyinga Hospital did not report the number of lab technicians.)  Few medical specialists are available to provide higher-level care for SV survivors. Only the two hospitals had any doctors on staff. While Kayanza had seven doctors and Muyinga had six, none were specialists in the disciplines most relevant to SV: gynecology, urology, or surgery.

Provider training  Of the 30 providers interviewed, only six (20%) had received SV training. The six trainings reported took place between 2004 and 2012 and ranged in length from two to 15 days. They were led by the MSPLS, CARE, the Society for Women and AIDS in Africa (SWAA)-Burundi, and Pathfinder (for three providers). Most of the previous trainings covered the definition of gender- based violence (GBV), its causes and consequences, psychosocial and medical care of survivors, certificates of forensic evidence, confidentiality, informed consent, and special considerations for child survivors.  Only four of 19 facility managers (21%) felt that their providers have the knowledge and skills needed to provide holistic care for SV.  Interviewers asked the providers to list the steps they would take if a survivor of rape presented at their facility. Interviewers listened without prompting and checked off the steps named by the provider against a checklist of critical steps in the care of SV survivors. When answering this question, almost all providers skipped many steps. For example, only six (20%) said that they would discuss confidentiality, four (13%) would give a pregnancy test, and four (13%) would offer postexposure prophylaxis (PEP). None of the 30 providers said they would test for STIs other

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 5

than HIV, administer hepatitis B or tetanus vaccines, evaluate the survivors’ suicide risk, or discuss the survivors’ safety. None of the providers would establish a medical certificate of forensic evidence, in part because only doctors are authorized to do so and only higher-level facilities (hospitals) have doctors on staff. Table 2 below presents the numbers and percentages of providers who would take each step.

Table 2. Number (and percentage) of providers reporting various steps that they would take when responding to SV No. (%) Step (n=30) Provide psychosocial support/comfort to the client 10 (33%) Assure the client of confidentiality 6 (20%) Inform the client of his/her right to accept or decline any of the services offered 0 (0%) Refer the client to another provider in the same facility 3 (10%) Ask the client to describe what happened, any symptoms, and relevant medical history 22 (73%) (e.g., HIV status) Perform a physical examination 20 (67%) Treat any wounds 9 (30%) Test for pregnancy 4 (13%) Offer emergency contraception 16 (53%) Test for HIV 11 (37%) Offer PEP 4 (13%) Test for other STIs 0 (0%) Treat STIs 7 (23%) Administer vaccines (e.g., tetanus, hepatitis B) 0 (0%) Inform the client of his/her right to press charges against the perpetrator(s) 1 (3%) Establish a medical certificate documenting evidence of rape, according to the wishes 0 (0%) of the client Discuss the client’s security (e.g., if there is a risk of continued SV) 0 (0%) In cases of domestic violence, ask if children in the home are exposed to the risk of 0 (0%) violence Evaluate the client’s risk of depression or suicide 0 (0%) Refer the client for other services 20 (67%) Other 3 (10%)

Provider attitudes  Many providers reported holding attitudes that are unsupportive of survivors. o Four providers (13%) agreed with the statement “If a survivor says she was raped but she doesn’t want to go to the police, it’s probably because she wasn’t really raped.” o Twenty-two providers (73%) agreed with the statement “Survivors of rape are too traumatized to make good decisions about their medical treatment.” o Eleven providers (37%) agreed with the statement “Rape is sometimes the fault of the victim (e.g., if she was wearing a short skirt, if she went to a night club).” Such attitudes pose an obstacle for care-seeking and for provision of high-quality care.  In 13 of 16 FGDs, participants brought up provider attitudes as a barrier to care-seeking: They reported that some survivors do not seek health care because they fear that they will be unwelcome at health facilities. In addition, all but one key informant cited inhospitable providers

6 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

and staff as a challenge in health facilities and other services. Several described how SV survivors are received at facilities as “deplorable.”

Forensic evidence  Providers at health centers do not collect forensic evidence or establish medico-legal certificates documenting evidence of SV. The MSPLS mandates that only doctors are authorized to complete medico-legal certificates. Furthermore, the health facilities in the sample did not have all of the materials necessary for the collection of forensic evidence.

SV services  In both provinces, providers at health centers typically refer SV survivors to the hospital after providing very few services. Given significant barriers that may prevent survivors from pursuing these referrals, it is likely that many do not receive adequate medical care for SV, even after seeking it at a health center. This is a significant missed opportunity.  SV services are not well-integrated into the policies and programs of the MSPLS. The national health plan for 2011–2015 gives little attention to SV.

Referrals  While providers at health centers refer clients to hospitals, they do not typically refer them for services in other sectors (police, legal aid, psychosocial support, etc.). Lists of referral services within the catchment area are not available at health centers.  When health centers refer survivors to hospitals, the survivor and relatives often do not know the referral hospital. In the event that the survivor knows the referral hospital, she often lacks the means to cover the cost of transportation, food, and lodging to travel there. Health centers have no funds or ambulances to assist survivors in reaching the hospital.

SOPs for SV services  SOPs are written instructions on how to carry out a specific function in order to assure quality. None of the 19 facilities have SOPs or other protocols for the care of SV survivors. The national- level SV needs assessment conducted by the RESPOND Project in 2011 showed that such SOPs are not available at the national level either (RESPOND, 2011).

Data collection  Confidentiality is not adequately protected. Only one facility (Muyinga Hospital) uses identification (ID) codes for SV survivors. Only five facilities (26%) keep client data in locked filing cabinets, and only two (11%) require providers to sign a Code of Conduct that addresses confidentiality.  Collection of data on SV is not systematic. Only six facilities (32%) report the number of SV cases to the national SV data collection system.

Medical products, equipment, instruments, and expendable supplies  Facilities lacked many of the essential products, equipment, instruments, and supplies for the care of SV survivors. Only hospitals, not health centers, had laboratories in which to conduct STI testing. At the time of the audit, fewer than half of the facilities in both provinces were equipped to offer tetanus and hepatitis B vaccinations, which are part of the package of essential services for

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 7

SV survivors. Not all facilities had the supplies for offering pregnancy tests or emergency contraception (Table 3).

Table 3. Number (and percentage) of facilities with various products, equipment, instruments, and supplies in stock at the time of the audit, as reported by facility managers

No. (and %) Product, equipment, instrument, or supply (n=19) Gloves 16 (84%) Sheet to cover survivor during examination 15 (79%) HIV test 6 (32%) STI test materials 2 (11%) Antibiotics to treat STIs 18 (95%) Emergency contraception (pills or IUD) 15 (79%) Pregnancy test 15 (79%) Tetanus and/or hepatitis B vaccination 6 (37%)

 Six facilities (32%)—the two hospitals and four health centers—offered antiretroviral drugs (ARVs). However, PEP coverage is restricted because, until recently, only doctors were authorized to prescribe ARVs. A decree from the MSPLS now allows nurses to prescribe ARVs and thereby offer PEP if they have completed training on ARV provision. This training has not yet been rolled out to nurses in the intervention townships. Therefore, health centers in the four townships currently only stock ARVs that are assigned to resupply patients living with HIV.  Stock-outs of PEP and emergency contraception were common at the sites that carried them.  All of the facilities had private consultation rooms, with the exception of one facility that is under reconstruction after a fire.

Infection prevention  Standards for waste management were met in some but not all facilities. Most facilities (84%) disposed of sharp objects separately. Two-thirds threw medical waste away far from the community, in closed containers. One in five facilities (21%) had a formal plan for waste management.  Fewer than half of the facilities had posted job aids on infection prevention.  Fewer than half of the facilities had at least one provider who received training in infection prevention or waste management in the past year.  While some providers had been vaccinated against tetanus, very few had been vaccinated against hepatitis B.

Identification of Services for SV Survivors in Other Sectors In both provinces, services exist for legal aid and psychosocial care of survivors; however, not all of these services are well-known in the community. Psychosocial support is typically given informally by those who know the survivor rather than by mental health professionals. Financial support and protection services are almost nonexistent. The study found no associations that offer survivors economic reintegration services or safe houses.

8 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

Tables 4 and 5 present the services available at facilities in Kayanza and Muyinga provinces, respectively. It should also be noted that a draft law on GBV exists at the national level, but it had not been adopted by the time this report was written.

Table 4. Multisectoral services available for SV survivors in Kayanza Province

Type of Organization or assistance agency Description Multiple Family Development CDFs are the decentralized structures of the MSNDPG that are Center (CDF) charged with fighting SV. The CDF in Kayanza has a mandate to offer the following services, although in reality many services are unavailable due to funding constraints:

1. Psychosocial services  Individual counseling  Family counseling and mediation  Referrals to mental health specialists  Follow-up with survivors

2. Medical services (since January 2012, through UN Women, the United Nations Entity for Gender Equality and the Empowerment of Women)  Accompaniment of survivors to medical services  Transportation of survivors to reach health services  Payment of the cost of health care

3. Legal services  Information about rights and legal procedures  Referral to prosecutors and judicial police  Accompaniment of survivors to prosecutors and judicial police  Payment of survivors’ lawyers  Follow-up on survivors’ cases  Assistance with drafting complaints  Transportation of survivors and witnesses  Payment of costs related to the court proceedings

In reality, financial and human resource constraints prevent the CDF from offering many of these services. The CDF in Kayanza has only one staff member. The CDF has centers in six of nine townships in Kayanza. Among the three townships without centers are Muruta and Kabarore, the two Kayanza townships where this assessment took place.

CDFs keep statistics on the number of SV cases received, although data quality is low due to insufficient data collection tools and financial constraints. Pathfinder International Pathfinder works in the townships of Kabarore, Butaganzw, and Kabarore in Kayanza province. It trains health providers and assures post-training follow-up. Pathfinder has also worked on engagement of men in family planning. In addition, the organization has trained community networks to help survivors of sexual violence. MUREKERISONI This network of SV survivors refers and accompanies new victims to Network Kayanza Hospital, the police, and prosecutors.

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 9

Medical Kayanza Hospital and 8 See findings on “Health sector response to SV” above. health centers SWAA-Burundi, SWAA-Burundi works in HIV prevention through peer educators and Kayanza Branch treatment of persons living with HIV. The organization provides services to SV survivors to reduce the impacts linked to HIV and AIDS. The branch in Kayanza offers HIV testing, emergency contraception, STI treatment, psychosocial counseling, and referral to Kayanza Hospital for PEP.

The organization also makes referrals to the CDF, to Care International’s UMWIZERO project for child survivors of SV, and to the Association for the Protection of Human Rights and Detained Persons, as well as for other legal services. Legal Association pour la ADDF engages in the promotion and protection of the rights of women. Défense des Droits des The organization addresses SV through awareness-raising on the rights Femmes (ADDF) of women, laws against SV, the penal code, and family law. ADDF advocates for policy changes in favor of equality between the sexes. It also offers women services to improve their status, including literacy courses and income-generating activities. Furthermore, ADDF offers legal counseling and follow-up for SV survivors and accompaniment of survivors to court.

In addition to referrals to prosecutors and the police, ADDF makes referrals to Kayanza Hospital for treatment and prophylaxis. Association for the APRODH provides SV survivors with legal counseling, identification of Protection of Human SV cases, referral and legal aid, and advocacy for policy changes. Rights and Detained Persons (APRODH)— APRODH makes referrals to Kayanza Hospital, other legal services, the Kayanza Branch CDF, the Association of the Compassionate for the Assistance of Those Affected by HIV/AIDS (AMAVES), and the MUREKERISONI Network. Public prosecutor’s The prosecutor conducts the investigation and prosecution of criminal office—Kayanza cases, including cases of SV. In general, the prosecutor serves as the lawyer for the survivor. Certain focal points in the prosecutor’s office have training in sexual and gender-based violence. The CDF provides some financial support for the prosecutor to visit the scene of the crime.

The prosecutor’s office does not require the survivor to pay any fees to introduce her case. However, during the proceedings, the survivor must typically bear certain costs, such as travel and support of witnesses and the acquisition of a medical certificate following examination by an expert. The survivor must also cover the cost of documentation when she accepts civil action.

The prosecutor’s office makes referrals to Kayanza Hospital, the CDF, and SWAA-Burundi. High Court of Kayanza The High Court judges SV cases. Some judges of the Court have been trained in the handling of SV cases. Currently, the CDF bears the cost of supporting witnesses, purchasing copies of the judgment, and other costs.

The Court refers cases to Kayanza Hospital, the prosecutor, and the CDF. Safe house None Currently, there is no safe house for SV survivors in Kayanza. However, or shelter the project PAIVA-B is constructing a safe house for the Kayanza CDF.

10 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

Table 5. Multisectoral services available for SV survivors in Muyinga Province

Type of Organization or assistance agency Description Multiple Family Development The CDF in Muyinga Province is tasked with offering the same list of Center (CDF) services as the CDF in Kayanza Province. However, like the CDF in Kayanza, financial and human resource constraints prevent it from offering many of these services. CARE International— In Muyinga, CARE offers community care of SV survivors in terms of Muyinga Branch family planning and reproductive health services, legal aid, psychosocial support, and economic capacity-building.

CARE refers survivors to the Muyinga Hospital and to legal services. Pathfinder International Pathfinder works in the townships of Giteranyi, Buhinyuza, Muyinga and Gasorwe in Muyinga province. It trains health providers and assures post-training follow-up. Pathfinder has also worked on engagement of men in family planning. In addition, the organization has trained community networks to help survivors of sexual violence. Medical Muyinga Hospital and See the findings on “Health sector response to SV” (page 5). nine health centers Muyinga has a provincial hospital that was not included in the sample of health facilities. SWAA-Burundi— SWAA-Burundi works in HIV prevention through peer educators Muyinga Branch and treatment of persons living with HIV. The organization provides services to SV survivors to reduce the impact of HIV. The branch in Muyinga offers HIV testing, emergency contraception, STI treatment, psychosocial counseling, and referral to Muyinga Hospital for PEP.

The organization also makes referrals to the CDF and the Diocese of Muyinga for counseling. Burundian Association ABUBEF offers SV survivors some medical services and makes for Family Well-Being referrals to Muyinga Hospital. They have partnerships with SWAA- (ABUBEF) Burundi (for HIV testing), the CDF, and Pathfinder International. Legal APRODH—Muyinga APRODH provides SV survivors with legal counseling, identification Branch of SV cases, referral and legal aid, and advocacy for policy changes. APRODH makes referrals to Muyinga Hospital, to other legal services, and to the CDF. Iteka League The Iteka League counsels SV survivors, refers them to the hospitals and for legal aid, and follows their legal cases. Provincial Police The commissioner hears about and investigates cases of SV and Commissioner refers survivors to the hospital and the CDF. Public prosecutor’s The prosecutor conducts the investigation and prosecution of office—Muyinga criminal cases, including cases of SV. In general, the prosecutor serves as the lawyer for the survivor. Certain focal points in the prosecutor’s office have training in sexual and gender‐based violence. The CDF provides some financial support for the prosecutor to visit the scene of the crime.

The prosecutor’s office does not require the survivor to pay any fees to introduce her case. However, during the proceedings, the survivor must typically bear certain costs, such as travel and support

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 11

of witnesses and the acquisition of a medical certificate following examination by an expert. The survivor must also cover the cost of documentation when she accepts civil action.

The prosecutor’s office makes referrals to Muyinga Hospital, the CDF, and SWAA‐Burundi. High Court of Muyinga The High Court judges SV cases. Some judges of the Court have been trained in the handling of SV cases. Currently, the CDF bears the cost of supporting witnesses, purchasing copies of the judgment, and other costs.

The Court refers cases to Muyinga Hospital, the prosecutor, and the CDF. Psychosocial The Conference of Through the project “Listening to and Healing Memories,” the counseling Bishops of the Catholic Catholic Church in Muyinga offers psychosocial counseling for SV Churches of Burundi survivors. Services also include group therapy and community awareness-raising through theater and community mobilization.

The project refers survivors to health structures and to APRODH for legal aid. Other Dushirehamwe In Muyinga, volunteers for the national nongovernmental organization (NGO) Dushirehamwe raise awareness about SV and refer survivors to the hospital and legal services. However, the organization has a limited presence and has only volunteers, not staff, in Muyinga Province.

Currently, the gold standard of a well-coordinated referral system remains unmet. Referrals of SV survivors are most commonly made to the CDFs and to hospitals. Representatives of SV organizations reported few links between organizations that serve survivors. At periodic health coordination meetings, partners sometimes meet others working in SV services. Attempts at coordination are being piloted by CDFs, the decentralized structures of the MSNDPG that are charged with fighting SV. Partners expressed an interest in coordination meetings, saying they would increase synergy between services.

Women in the community volunteer to serve as “baremeshakiyago” and “imboneza.” The mission of these networks of volunteers is to raise community awareness of health and social issues, including SV. However, members of these networks do not have pedagogical tools, and it is unclear what their messages are. Currently, the baremeshakiyago fulfill several different functions, including advocating for children’s rights, promoting family planning, and fighting SV. Some represent up to five or six NGOs at the same time. The demands of serving multiple initiatives overburden many baremeshakiyago. A major limitation of the effectiveness of baremeshakiyago and imboneza in preventing SV is that they are exclusively women.

Factors Impeding Help-Seeking and Enabling SV In FGDs, community members reported that the most common and accepted forms of SV in their communities are:  Rape of adolescent girls, especially by schoolteachers and motorcycle taxi drivers  Marital rape

12 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

 Prevention of one’s spouse from using family planning  Forced sexual relations between a woman and her father-in-law (as in the traditional practices of gutera intobo and gukazanura)  Forced marriage and/or sexual relations between a woman and her brother-in-law (as in the traditional practice of gucura) Participants cited a number of other forms of SV in their communities, including:  Early marriage, including forcing a young woman to marry the man who impregnated her, even if it was through rape  Forced abortion for pregnancies outside of marriage  Rape of domestic servants by their employers  Rape of children  Incest  Sexual harassment  Forced prostitution  Other traditional practices, such as forced sex with a pregnant woman during labor (kubangura) or just after she has given birth (gukanda)

All 16 groups of community members said that the form of SV considered the most serious is the rape of children. According to them, child survivors are the most likely survivors to receive help, such as medical treatment, after rape.

FGDs revealed a number of factors that allow SV to happen and that prevent survivors from receiving help.  Marital rape is widely considered acceptable. Participants in 15 of 16 FGDs reported that marital rape is common, and participants in six of 16 FGDs said it is considered acceptable. They explained that a married woman is expected to be sexually available to her husband at all times; her consent is considered unnecessary. Survivors of marital rape rarely disclose what they have experienced, because of the fear of being rejected by their husbands and the stigma associated with revealing the secrets of the household. If a survivor were to report marital rape, she would be called an “ikimenabanga,” a pejorative Kirundi word for someone who reveals a secret.  SV survivors fear retaliation by the perpetrator. Among the most common forms of SV are unwanted sexual advances and rape by men in positions of power, including fathers-in-law, schoolteachers, and the employers of domestic workers. Motorcycle taxi drivers, too, have power over those who depend upon them for transportation. When asked what types of SV occur in their communities, every FGD brought up examples in which perpetrators had power over survivors beyond physical strength. Given these imbalanced power dynamics, it is not surprising that participants in 15 of 16 FGDs said survivors often fear what the perpetrator and those who are close to him would do if the survivor were to disclose the incident.  The topic of SV is taboo. Since discussion of SV is rare, survivors feel uncomfortable and ashamed to tell others about what happened to them. All FGDs described shame as a barrier to seeking services.  Survivors are blamed for SV. A major barrier to seeking help is that survivors fear that others will not believe them or will blame them for the incident. Married women and adolescent girls are

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 13

particularly likely to be blamed. By reporting SV, a survivor risks harming not only her own reputation, but also the reputation of her parents, children, and spouse. This issue emerged as a theme in all FGDs.  Survivors are stigmatized. All FGDs raised the concern that if others learn that a woman or girl experienced SV, she may be stigmatized and cast aside. Unmarried young women typically remain silent for fear of damaging their chances of finding a husband.  Pursuing justice through the court system is seen as difficult and futile. Participants in all FGDs named a number of barriers to bringing legal cases against SV perpetrators. First, court procedures are very long, meaning that they incur significant opportunity costs as well as financial costs. Survivors view the court system as corrupt and worry that their efforts will be in vain if the perpetrator bribes the judge. Furthermore, survivors often feel that they lack adequate proof to win their case. Survivors often hide what happened to them at first, and adolescent girls typically reveal SV incidents only after they realize that they are pregnant. At that point, evidence generally cannot be reconstructed.  Not all survivors can afford SV services. Across sectors, all of the key informants interviewed said survivors typically face financial barriers to accessing care. Most commonly, participants reported that survivors cannot afford: o Transportation to the referral hospital, which is far from where many live o The cost of medical services, especially PEP o The fee for establishing a medical certificate documenting evidence of SV

Two key informants elaborated that in Burundi women generally lack control over their families’ financial resources and must ask their husbands for money to seek care. Therefore, it is difficult to seek care without the husband’s knowledge. Participants in 11 of 16 FGDs cited cost as a barrier to seeking a medical certificate of forensic evidence.

14 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

RECOMMENDATIONS

Health Sector Response to SV To allow survivors to receive at least a minimum package of SV services at health centers, provider training is needed, as well as commodities and supplies such as drugs for PEP, tetanus and hepatitis B vaccines, STI tests, pregnancy tests, and emergency contraception. Provider training should directly address how providers can assist SV survivors even when their facility is not equipped to offer the full package of services.

SV services We found that many health centers offer very few services before referring survivors to the hospital for care. This is a significant missed opportunity. We recommend that the MSPLS and partners conduct SV training for providers, including providers at first-line health centers. Such training should emphasize the barriers to care-seeking and use a participatory approach to show how local health providers can offer survivors as many services as possible before referring them for higher-level care.

In addition, SV services are not well-integrated into the policies of the MSPLS. It is important for the next national health plan to address SV.

SOPs None of the 19 facilities had SOPs or other protocols for the care of SV survivors. We strongly suggest that the MSPLS adopt a clear protocol or set of SOPs, including diagrams, checklists, or other job aids, for the care of SV survivors. SOPs should address confidentiality and informed consent as well as the steps of care and referral. It is important for SOPs to build upon existing materials, such as the international template for SV SOPs (IASC, 2005). The MSPLS and its partners should train providers to use such tools to treat SV cases in an appropriate and sensitive manner. After receiving training, providers could train others at their facilities to follow the SOPs.

Human resources We have seen that health centers lack personnel with the laboratory skills needed to conduct essential tests. Only hospitals have personnel with these skills. The MSPLS should consider training health center staff in the laboratory techniques required for SV services. In addition, if they do so, health centers will need the necessary equipment to support lab work.

Provider training The study findings indicate that very few providers have the training, knowledge, and skills to effectively serve SV survivors. This shortcoming can be addressed in several ways:  Trainings in the care of SV survivors should include nurses, since they are far more numerous than any other provider cadre in the provinces.  As the MSPLS develops guidelines, SOPs, and/or job aids for the care of SV survivors, we recommend ensuring that the materials address confidentiality and informed consent as well as the steps of care and referrals. The MSPLS should also consider developing client materials that would facilitate high-quality counseling. We suggest training providers to use these tools to treat SV cases in an appropriate and sensitive manner.

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 15

 Provider training should specifically address steps that providers can take even if their facility is not able to offer the full package of services for SV survivors.  It is important to evaluate provider trainings and use this information to improve training tools.  We recommend that the MSPLS include SV in preservice curricula for doctors, nurses, midwives, and other providers.

Provider attitudes Our research has demonstrated that many providers hold unsupportive attitudes and do not treat SV survivors with respect. Provider training should use participatory activities to address attitudes around SV. These activities should engage participants in confronting harmful stereotypes and reflecting upon the challenges faced by SV survivors.

Forensic evidence Providers at health centers do not collect forensic evidence and establish certificates documenting SV; currently, only doctors at hospitals are authorized to complete medical certificates documenting evidence of SV. We recommend that the MSPLS authorize nurses at the health center level to collect forensic evidence. If this policy change takes place, it will be necessary to train nurses in this specific skill.

Referrals Referrals between available services currently lack coordination. This could be remedied in several ways:  At the provincial level, we suggest that CDFs maintain lists of multisectoral services for SV survivors. To encourage referrals and help-seeking, CDFs could share these lists with service providers and community members who attend awareness-raising sessions. We recommend that they update the lists on a regular basis and disseminate the updated lists.  The MSPLS and its partners should also develop a checklist for the care of SV survivors and train health providers to use it. Such a checklist should include steps for offering referrals for different types of services. It could also be one component of a national protocol or set of SOPs.  In addition, we recommend that the MSPLS and its partners harmonize referral forms that conform to international standards for the protection of survivors’ confidentiality. It is important for the provider training to include a module on referrals. The module should cover why and how to offer referrals, including the use of the harmonized referral forms.

Another problem is that due to transportation costs and a lack of information about where to go, survivors often do not make it to the hospital after being referred.  Provider training on referrals could address how to help the survivor overcome barriers to pursuing a referral.  Also, the MSPLS and its partners should seek ways to subsidize the cost of transportation from health centers to hospitals. However, community and clinic staff would need to be involved in a process to agree that this is a priority and the best way to move the program forward

Data collection A particular challenge in this area is that confidentiality is not well-protected. Provider training is needed on the steps to follow to protect survivors’ confidentiality. After training in SV, providers

16 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

could debrief their facility managers on ways in which the facility can improve its confidentiality practices. Additionally, the MSPLS could develop a Code of Conduct that addresses confidentiality. If possible and appropriate, facilities could require providers to read and sign it.

Data collection on SV in Burundi is also not systematic. Partners should provide technical assistance to reinforce the SV surveillance system.

Products, equipment, instruments, and supplies Many of the facilities in this study lacked essential medical products, equipment, instruments, and supplies for PEP, tetanus and hepatitis B vaccinations, STI testing, pregnancy testing, and emergency contraception. The MSPLS and its partners need to take steps to improve the availability of essential commodities, supplies, and equipment needed for the care of SV survivors and for the collection of forensic evidence. The MSPLS and PEPFAR could distribute emergency rape kits, which would remind providers of the care needed by survivors and would conveniently gather the necessary commodities and supplies in one place. In addition, given the lack of laboratories to test for STIs at the health center level, provider training should address syndromic management of STIs.

Only doctors in hospitals have received the training to offer PEP. As part of their programs to fight HIV, the MSPLS and PEPFAR could train nurses to prescribe ARVs and make PEP available for SV survivors at the health center level. This is possible, now that the MSPLS has decreed that nurses with appropriate training can prescribe ARVs.

Stock-outs of essential supplies are common in Burundi. We recommend that the MSPLS and partners undertake problem identification exercises to uncover the reasons for stock-outs of PEP, emergency contraception, and other reproductive health products. The results of these exercises could inform activities to reinforce the supply chain.

Infection prevention This study has shown that standards for waste management are not met at all facilities. We suggest that the MSPLS require facilities to put in place and follow formal plans for waste management. Waste management practices could be monitored during supervision visits.

Fewer than half of the facilities had posted job aids on infection prevention. The MSPLS and partners should distribute IP job aids to all facilities and require these to post them. Additionally, fewer than half of facilities have a provider who received training in infection prevention or waste management in the past year. It would be helpful for providers to receive refresher training in infection prevention.

Finally, while some providers have been vaccinated against tetanus, very few have been vaccinated against hepatitis B. The MSPLS should offer hepatitis B and tetanus vaccination to all providers, especially those who handle waste.

Multisectoral Services for SV Survivors We recommend that the relevant ministries and partners fill the service gaps identified in this study. To provide holistic care, partners should seek to replicate the Seruka Center, an integrated center in Bujumbura for the care of SV survivors, in other provinces of Burundi.

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 17

CDFs need adequate human and financial resources to establish and lead provincial-level committees composed of actors across sectors to oversee multisectoral coordination of partners in the care of SV survivors. Members of these committees could include the MSPLS, the Ministry of Justice, the Ministry of Public Security, and the NGOs and structures listed in this report. We suggest that the CDFs, national-level MSNDPG, and partners maintain lists of multisectoral services for SV survivors. The lists could build upon those in this report, adding directions to the service provision sites and telephone numbers of contact people. Contact information for the organizations listed in Appendix D is available upon request. To encourage referrals, lists could be given to health providers during training. We suggest that providers review the lists with survivors who come into their facilities and who wish to access other types of services. Furthermore, the MSNDPG could distribute the lists to other types of service providers, to establish a system of referrals in multiple directions.

In addition, we recommend that administrative authorities invite the representatives of different SV services to local meetings to discuss the improvement of SV services. At the meetings, these representatives could describe their organizations’ mission, activities, and services. Such meetings would encourage providers of different services to connect, share information, and feel comfortable about referring survivors to each other. In addition, administrative authorities should consider including plans to address SV in their community development plans.

We recommend that the MSNDPG develop a national behavior change communication (BCC) strategy that includes a detailed road map and timeline for the Ministry’s and partners’ activities, target audiences, and messages addressing SV. The objective of the strategy would be to prevent SV and facilitate SV survivors’ access to available services. Partners’ messages and materials would be documented in the strategy. Such a strategy should include a monitoring and evaluation plan. Different BCC messages and approaches should be adapted to the local context and pilot-tested before they are scaled up.

To transform deeply-held views on gender and SV, we recommend that the BCC strategy engage men as well as women. The engagement of men is needed to prevent SV and reduce barriers to care- seeking. Male and female community volunteers could be trained as volunteer champions to speak out convincingly against SV, encourage survivors to seek help, and model equitable gender norms through their behavior. Groups of champions could develop and implement action plans, facilitate community- level discussions in public places, and serve as resource people to connect survivors with services. Groups of male champions could be recruited from mining companies, since miners were identified by communities as common perpetrators of SV. Partners could provide the MSNDPG with technical assistance to train and supervise champions.

Factors That Impede Help-Seeking and Enable SV Providers reported that survivors hide their experience of SV and rarely seek care. We recommend that the BCC strategy discussed above address the contributing factors that were raised through interviews and FGDs. We also have several additional recommendations on ways to prevent SV and encourage SV survivors to see help.

A major challenge is that marital rape is widely considered acceptable by many in Burundi. We recommend that the MSNDPG’s BCC strategy address marital rape and the attitudes that allow it to take place. One key message of the BCC strategy could be that everyone has the right to refuse sexual relations, no matter the circumstances. Champions could identify ways in which to make this message

18 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

convincing to the audience, possibly by drawing upon religious texts, stories, and/or analogies. Activities in the champion training could also address couple dialogue and the role of the spouses in the family.

In addition, study participants felt that SV survivors often fear retaliation by the perpetrator. Across multisectoral services, providers could offer safety planning to help survivors think through what they can do if they should experience violence again or fear that violence might occur. Safe houses should be made available to survivors at the provincial level, replicating the model of the Seruka Center. We also recommend that the training of health providers, police, and other providers strongly emphasize confidentiality practices, to reduce the risk of retaliation by SV perpetrators. As suggested above, the MSPLS could require providers to sign a Code of Conduct that addresses confidentiality.

The taboo nature of SV inhibits discussion of the topic. The training of champions should aim to increase their comfort with discussing SV, and champions’ subsequent activities could do the same in the communities they address. It is critical that champions be respected opinion leaders, so that their communities will be willing to listen.

It is unfortunate that SV survivors often are blamed for SV. The BCC strategy should address the consequences of blaming survivors, and champions could inform their communities about high-quality services where survivors can receive assistance without judgment or blame.

Study participants noted that SV survivors may no longer be seen as desirable partners. In areas where health providers receive training to protect confidentiality, champions could raise awareness about new confidentiality practices at health facilities, as well as survivors’ rights to keep their information confidential.

Pursuing justice through the court system is seen as difficult and futile. We recommend that the Ministry of Justice and partners in legal reform identify and implement best practices to reduce corruption and improve the justice system. In addition, the BCC strategy could encourage survivors to go to a health center immediately after an incident of SV. This would help them to receive the prophylaxis and treatment they need and establish medical evidence of rape.

Finally, not all survivors can afford SV services. We recommend that SV services at health facilities be subsidized by the MSPLS and by donors. If the MSNDPG and its partners establish a network of male and female volunteers in the community as champions for SV prevention, these champions could also act as resource people for survivors. Then if survivors lack funds to seek care, champions could help them identify and pursue formal or informal sources of financial assistance. We also recommend that the MSNDPG establish a national hotline for confidential counseling and information about existing SV services and rights with respect to SV.

Given that so many barriers to help-seeking exist, we recommend that the MSPLS and partners strive to reduce the need for referrals from health centers to hospitals by training providers and equipping health centers to offer SV services. To the extent possible, the MSPLS should also integrate counseling and social services at health centers, lessening the burden on survivors to seek services at multiple locations.

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 19

Key Recommendations In summary, key recommendations to the MSPLS and MSNDPG are:  Prepare health centers to offer survivors at least a minimum package of SV services, including counseling and referrals. Train providers who work at first-line and referral facilities. It is very important for training to address attitudes around SV. Adapt existing job aids for infection prevention and the care of SV survivors and disseminate them to health facilities. Provide key commodities, supplies and services, such as: PEP, tetanus and hepatitis B vaccines, STI tests, pregnancy tests, and emergency contraception.  Provide CDFs with adequate resources to oversee multisectoral coordination of partners in the care of SV survivors and offer the services in their mandate, including psychosocial support and the facilitation of medical and legal services for survivors. CDFs should involve stakeholders in selecting and evaluating SV services.  Develop a national BCC strategy that includes a detailed road map for the MSNDPHG’s BCC activities, target audiences, and messages about prevention of SV. In addition, a plan to monitor and evaluate the implementation of the BCC strategy is needed.  Engage male champions in the fight against SV. Train male and female community volunteers to model equitable gender norms, speak out against SV, and address barriers to care-seeking. Groups of male champions could be recruited from mining companies, since miners were identified by communities as common perpetrators of SV.

20 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

REFERENCES

Action des Chretiens pour l'Abolition de la Torture (ACAT Burundi) and Organisation Mondiale Contre la Torture (OMCT). 2008. NGO report on violence against women in Burundi.

Comité permanent interorganisations (IASC). 2005. Directives en vue d'interventions contre la violence basée sur le sexe dans les situations de crise humanitaire. Centrage sur la prévention et la réponse à la violence sexuelle dans les situations d'urgence. Genève. Accessed at: www.humanitarianinfo.org/iasc/content/subsidi/tf_gender/VBG.asp.

Ellsberg, M., and Betron, M. 2001. Spotlight on Gender: Preventing gender-based violence and HIV: Lessons from the field. Arlington, VA: AIDSTAR-One.

Institut de Statistiques et d’Études Économiques du Burundi (ISTEEBU), Ministère de la Santé Publique et de la Lutte contre le Sida [Burundi] (MSPLS), et ICF International. 2012. Enquête Démographique et de Santé Burundi 2010. Bujumbura, Burundi : ISTEEBU, MSPLS, et ICF International.

The RESPOND Project. 2011. Sexual violence assessment in Burundi. New York: EngenderHealth.

UNICEF. 2009. Analyse de la situation de l’enfant et de la femme. Burundi. Bujumbura.

Zicherman, N. 2007. Addressing sexual violence in post-conflict Burundi. Forced Migration Review, 27:48–49.

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 21

APPENDIX A. Health Facility Manager Questionnaire

RESPOND/Burundi Evaluation de base de l’état de préparation des Structures Sanitaires à Répondre aux violences sexuelles et violences basées sur le genre (VSBG)

GUIDE D’ENTRETIEN DU RESPONSABLE DU STRUCTURE SANITAIRE

INFORMATIONS GENERALES

Structure Sanitaire (nom) : ______

Type de Structure : ___ Hôpital régional ___ Hôpital de district ___ Centre de santé ___ Centre de santé privé ___ Autre (à préciser): ______

Province : ______

District sanitaire : ______

Commune : ______

Date (jj/mm/aa) ___/___/___

Nom de l’Enquêteur : ______

INSTRUCTIONS À L’INTENTION DE L’ENQUÊTEUR: Les responsables des structures devront être interviewés individuellement et s’ils sont disponibles.

Lisez cette paragraphe à la personne interrogée et répondez les questions ci-dessous : Saluez la personne-Bonjour…..). Je m’appelle ...... ……. Je représente le Projet RESPOND mis en oeuvre par EngenderHealth, une ONG internationale qui œuvre dans la santé de la reproduction. Nous aidons le Ministère de la solidarité nationale, des droits de la personne humaine et du genre du Burundi en vue d’améliorer les services en faveur des victimes de la violence sexuelle. Nous sommes en train de réaliser une étude dans le cadre du présent travail qui consiste à réunir des informations sur la formation, les comportements et les pratiques des prestataires dans les structures sanitaires. Nous avons aussi quelques questions pour vous sur la façon dont la structure élimine les déchets et protège l’environnement.

Vous ne courez aucun risque en acceptant de participer à cette étude. Elle pourrait plutôt vous profiter en nous aidant à améliorer les services au Burundi. Toutes les informations que vous me communiquerez seront gardées confidentielles ; votre nom ne sera pas utilisé et vous ne serez identifié en aucune manière. Si vous convenez de participer, cette interview devrait prendre en tout une heure approximativement. Votre participation est strictement à titre volontaire et il n’y aura pas de sanction en refusant d’y prendre part. Vous êtes libre de poser toutes les questions ; vous pouvez refuser de participer à cette évaluation ; il vous est loisible de vous abstenir de répondre à une quelconque question inscrite dans l’interview ; et vous pouvez à tout moment mettre fin à l’entretien.

Toute plainte au sujet de la façon dont vous avez été traité pendant l’interview ou tout tort éventuel que vous pourriez subir sera traitée. Veuillez prendre contact avec ______.

Avez-vous d’autres questions? (Si oui, notez les questions et traitez celles auxquelles vous pouvez répondre). Oui ______Non ______

Etes-vous disposé à participer à l’étude ? Oui ______Non ______

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 23

 Si le prestataire accepte de continuer, commencez le questionnaire par Q 1.0

 Si le prestataire ne consent pas à poursuivre, encerclez “interview refusée” et, si possible, donnez la raison pour laquelle l’entretien a été refusé. Remerciez le/ la pour avoir accordé son temps et passez à l’interview suivante.

Interview achevée: 1 = oui, achevée 2 = non, inachevée 3= interview refusée

Si l’interview est refusée (donnez-en les raisons): ______

Veuillez revenir ICI à la fin de l’interview pour indiquer si l’enquête a été menée à son terme.

1. PERSONEL 1.0 Quelle est la taille de la population servie par cette structure ? 1.1a Combien de prestataires ayant les Auxilière Autre qualifications suivantes travaillent dans Médecin Infirmièr Infirmièr Sage Femme A spécifier: cette structure ?

1.1b Si des médecins travaillent dans cet GYNECO- Autre hôpital, combien sont spécialisés dans OBST. Chirurgien Urologue A spécifier: chacun des domaines suivants

Veuillez donner la définition suivante de la VSBG : La question qui suit se réfère à la « violence sexuelle ou la violence basée sur le genre » (VSBG). Quand j’utilise le terme « VSBG » dans cette interview, je me réfère à tout acte nuisible qui se produit entre des personnes et qui est la conséquence des rôles normatifs du genre et des rapports inégalitaires du pouvoir entre les sexes. Certains des exemples de VSBG incluent entre autres :  Violence sexuelle dont l’exploitation/ sévices sexuels et prostitution forcée;  Violence physique excercée par un partenaire intime ou un petit ami;  Sévices psychologiques dont les menaces ou l’intimidation;  Mariage forcé/ précoce;  Pratiques traditionnelles néfastes dont gucura, kubangura , gukanda umuvyeyi , guteka ibuye rigasha et autres. 1.2 Existe-t-il dans cette structure un programme de réponse à la VSBG ? 1.3a Y-a-t-il dans cette structure des pretataires spécialement NE SAIT Si c’est formés pour répondre à la VSBG ? OUI NON PAS NON ou 1 0 88 NE SAIT PAS passer à Q. 2.1a 1.3b Si oui, combien sont les prestataires dans cette structure qui ont reçu une formation sur la VSBG au cours des trois dernières années ? 1.3c Quels sont les titres (ex. médecin, infirmier) des prestataires qui ont été formés ?

24 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

2. PROCEDURES OPERATIONNELLES STANDARD (POS) ET CONFIDENTIALITE 2.1a Disposez-vous de POS écrites, de protocoles ou NE SAIT Si c’est d’organigrammes qui rappellent aux prestataires comment OUI NON PAS NON ou prendre en charge une victime de la VSBG ? 1 0 88 NE SAIT PAS passer à Q. 2.2a 2.1b Si oui, veuillez m’exhiber les POS, protocoles, organigrammes ENQUETEUR: COCHEZ LES ou autres documents similaires qui guident la prise en charge DOCUMENTS QUI VOUS ONT ETE des victimes de la violence sexuelle MONTRES POS OUI / NON Autres protocoles (ex : La Stratégie Nationale de Lutte contre les OUI / NON VSBG) Organigramme OUI / NON Autre (à spécifier): OUI / NON

2.2a Certaines structures utilisent des codes pour protéger la NE SAIT Si c’est confidentialité autour de la patiente. Le personnel de la OUI NON PAS NON ou structure affecte aux patientes un code d’identification 1 0 88 NE SAIT composé de lettres et/ ou des numéros à porter sur les PAS, dossiers médicaux et les fiches de référence, en lieu et place passer à des noms des patientes. Cette formation sanitaire a-t-elle mis Q. 2.3a en place un système de codage pour les victimes de VSBG ? 2.2b Si oui, veuillez décrire le système de codage (ex. comment plusieurs personnes ont-elles accès aux informations identifiant la patiente? 2.3a Les dossiers des patientes sont-ils enfermés à clé dans des NE SAIT Si c’est classeurs ? OUI NON PAS NON ou 1 0 88 NE SAIT PAS, passer à Q. 2.4 2.3b Si oui, combien de personnes ont-elles accès aux classeurs fermés à clé ? 2.4 La définition du « consentement éclairé » est la compréhension et NE SAIT l’accord de la victime sur les mesures que vous recommandez. Pour OUI NON PAS l’obtenir on pose des questions, en répond à leurs propres questions 1 0 88 et à leurs préoccupations, et en obtenant leur accord pour poursuivre. Les prestataires dans cette structure sont-ils tenus d’obtenir le consentement éclairé de la patiente avant la transmission de toute information la concernant à une autre structure au moment de son orientation ? 2.5 Les prestataires et autres personnels dans cette structure NE SAIT sont-ils tenus de signer un Code de Bonne Conduite qui traite OUI NON PAS de la confidentialité de la patiente ? 1 0 88 2.6a Est-ce que cette structure sanitaire enregistre et fait des NE SAIT Si c’est statistiques des victimes reçues ? OUI NON PAS NON ou 1 0 88 NE SAIT PAS, passer à Q. 3.0

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 25

2.6b Si oui, est-ce que les prestataires et autres personnels sont-ils NE SAIT tenus d’obtenir l’accord des victimes avant de rendre compte OUI NON PAS de ces statistiques ? 2.6c A qui cette structure communique-t-elle le nombre de ONG AUTRE patientes qui viennent pour cause de VSBG ? GVT/M A A NE SAIT SLS spécifier: spécifier: PAS 1 2 3 88

3. SERVICES OFFERTS 3.0 Est-ce que cette structure offre des services aux patientes qui NE SAIT se présentent et signalent : OUI NON PAS Viol conjugal ? 1 0 88 Viol non-conjugal (viol dehors du foyer) ? 2 0 88 Autres formes d’agression sexuelle (tentative de viol, sodomie 3 0 88 forcée) ? Agression physique basée sur le genre ? 4 0 88 Mariage forcé ? 5 0 88 Autre types de VSBG ? Lesquels ? 6 0 88 (à spécifier): 3.1 La structure dispose-t-elle de salles de consultation qui NE SAIT garantissent le caractère privé protégeant les patientes contre OUI NON PAS les regards et l’ouie à la fois ? 1 0 88 3.2a Les prestataires offrent-ils dans cette structure des NE SAIT Si c’est contraceptifs d’urgence aux patientes qui ont subi des viols ? OUI NON PAS NON ou 1 0 88 NE SAIT PAS, passer à Q. 3.3 3.2b Si oui, y a-t-il eu des ruptures de stock en contraceptifs NE SAIT d’urgence pendant les trois derniers mois ? OUI NON PAS 1 0 88 3.3 Cette structure est-elle systématiquement approvisionnée en NE SAIT matériel de test des IST? OUI NON PAS 1 0 88 3.4 Cette structure est-elle systématiquement approvisionnée en NE SAIT matériel d’échantillonnage pour les besoins médico-légaux ? OUI NON PAS 1 0 88 3.5a Les prestataires de cette structure offrent-ils des services de NE SAIT Si c’est prophylaxie aux patientes qui ont subi des viols pour se OUI NON PAS NON ou prémunir des risques ? 1 0 88 NE SAIT PAS, passer à Q. 3.6a 3.5 Si oui, y a-t-il eu des ruptures de stocks en produits NE SAIT prophylactiques suivants au cours des trois derniers mois, OUI NON PAS pour prévenir l’exposition à des risques postérieurs au viol ? 3.5b Prophylaxie VIH (PPE) 1 0 88 3.5c Les médicaments pour le traitement des IST 1 0 88 3.5d Pilules de contraception d'urgence et / ou DIU 1 0 88

26 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

3.6 Les prestataires dans cette structure disposent-ils de matériel/ équipement, des fournitures et infrastructures nécessaires pour offrir des soins médicaux adéquats aux victimes de VSBG aujourd’hui ? (Vérifiez que les matériels/équipement sont NE SAIT présents) OUI NON PAS 3.6a Spéculum 1 0 88 3.6b Ruban à mesurer pour mesurer la taille des contusions, des 1 0 88 lacérations, etc. 3.6c Les sacs en papier pour la collecte de preuves 1 0 88 3.6d Bande de papier pour fermer et étiqueter les conteneurs / 1 0 88 sacs 3.6 e Des tubes pour le sang, et des containers pour l’analyse 1 0 88 d’urine 3.6f La lame 1 0 88 3.6g Pincettes, ciseaux, peigne 1 0 88 3.6h Matériel de réanimation pour le choc anaphylactique 1 0 88 3.6i Instruments médicaux stériles (kits) pour réparer les 1 0 88 déchirures, et matériel de suture 3.6j Aiguilles, seringues 1 0 88 3.6k Tourniquet 1 0 88 3.6l Couverture (blouse, tissu, drap) pour couvrir la victime lors 1 0 88 de l'examen 3.6m Serviettes hygiéniques commerciales, serviettes hygiéniques 1 0 88 locales ou tampons 3.6n Les gants 1 0 88 3.6o Les matériels pour le test des ISTs, y compris le VIH 1 0 88 3.6p Test de grossesse 1 0 88 3.6q Prophylaxie VIH (PPE) 1 0 88 3.6r Les médicaments pour le traitement les IST 1 0 88 3.6s Pilules de contraception d'urgence et / ou DIU 1 0 88 3.6t La prophylaxie/vaccination contre le tétanos et l’hépatite 1 0 88 3.6u Les médicaments pour soulager la douleur (par exemple, le 1 0 88 paracétamol) 3.6v L'anesthésie locale pour les sutures 1 0 88 3.6w Antibiotiques pour le traitement des blessures 1 0 88 3.6x Une salle (privée, tranquille, accessible, avec accès 1 0 88 aux toilettes ou latrines) 3.6y Une salle d’examen (privée, tranquille, accessible, avec accès 1 0 88 aux toilettes ou latrines) 3.6z Une table d'examen 1 0 88 3.6aa Une lumière, de préférence fixe (une torche pourrait effrayer 1 0 88 les enfants) 3.6bb L’accès à un autoclave pour stériliser le matériel 1 0 88 3.6cc Des chaises pour la victime et pour les personnes qui 1 0 88 accompagnent la victime 3.6dd Bassin du lit 1 0 88 3.6ee Lit d’observation 1 0 88

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 27

3.7 Si cela est nécessaire et souhaité par les victimes, est-ce que la structure est disposée à entreprendre les types de référence ci-après ? OUI NON Référence pour une assistance juridique ? 1 0 Lieu à spécifier:

Référence à un abri ou une maison/ un lieu en sécurité ? 1 0 Lieu à spécifier:

Référence pour counseling psychosocial? 1 0 Lieu à spécifier:

Référence pour réintégration sociale ? 1 0 Lieu à spécifier:

Référence pour réintégration économique ou pour assistance en 1 0 moyens de subsistance Lieu à spécifier:

4. SUGGESTIONS 4.0a Estimez-vous que les prestataires dans cette structure NE SAIT Si c’est OUI possèdent les connaissances ou les compétences nécessaires OUI NON PAS passer à Q. pour une prise en charge adéquate des victimes de VSBG ? 1 0 88 4.1 4.0b Si c’est non, selon vous, quelles connaissances et compétences additionnelles les prestataires devraient avoir pour offrir des soins adéquats aux victimes de VBG?

4.1 Quels sont les défis auxquels cette structure est confrontée pour répondre à la VSBG ?

4.2 Avez-vous des suggestions finales pour l’amélioration de la réponse par la structure à la VSBG ?

28 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

Veuillez lire ce qui suit: A présent, je vais vous poser quelques questions sur la manière dont la structure élimine les déchets et protége l’environnement. Il n’y a plus de questions au sujet de la VBG.

Elimination des déchets et protection de Pour chaque élément listé ci-dessous, encercler la l’environnement réponse 5.1 - Le site possède-t-il un plan de gestion écrit 1. Le site indique qu’il possède un plan de gestion écrit et qui montre à l’observateur les déchets généraux que celui-ci est présenté à l’observateur, non dangereux, les déchets médicaux liquides et 2. Le site indique qu’il possède un plan de gestion mais les déchets médicaux solides ? que celui-ci n’est pas présenté à l’observateur 3. Aucun plan formel de gestion 5.2 - Nombre et types de personnels formés en 1. Au moins un clinicien ou un non-clinicien formé ; ET le PI/élimination des déchets médicaux au cours des site a clairement affecté du personnel qui couvre toutes 4 derniers trimestres: personnel clinique._____ et les étapes de la gestion des déchets, au moins une personnel non clinique______personne formée 2. Aucune personne formée 5.3 - Le site a t-il clairement réparti au personnel 1. oui des responsabilités couvrant toutes les étapes du 2. non processus de gestion des déchets 5.3a 1. l’Hépatite B? Les agents de santé affectés sont-ils généralement – Oui; tous; vaccinés contre : – Oui, certains; – Non,aucun 2. le Tétanos? – Oui; tous; – Oui, certains; – Non,aucun 5.4 - Est-ce que le site dispose de fournitures et 1. Le site a des provisions d'eau de Javel, un seau pour la équipements adéquats et appropriés pour la PI et décontamination et un stérilisateur / autoclave la gestion des déchets? (Réf. guide PI), notamment 2. Le site a soit de l’eau de Javel soit un seau pour la des produits de décontamination, conteneurs, décontamination ou un stérilisateur / autoclave mais vêtements de protection? pas tous ces éléments en même temps 3. La SO n’a pas d’eau de Javel ni de seau pour la décontamination ni de stérilisateur/autoclave 5.5 - Est-ce que le site possède et utilise des aides 1. Au moins un outil de travail de PI est affiché dans la SO de travail et des protocoles de gestion des et/ou le pavillon et/ou la salle des procédures/ d’écluse, déchets ou des programmes de l'USAID, et le site suit l'utilisation des protocoles de gestion des d’EngenderHealth ou de l'OMS etc. déchets 2. Outil de travail soit affiché dans la SO ou le pavillon, ou la salle des procédures/ d'écluse ; ou bien les protocoles de gestion des déchets sont utilisés 3. Aucun aide de travail affiché dans les aires de travail 5.6 - Triage : des règles internes pour la 1. Déchets triés par type immédiatement et la séparation séparation appropriée des déchets par type à est faite au point où les déchets sont générés et les l'endroit où ils sont générés (par exemple, les objets tranchants contaminés sont immédiatement aiguilles et les objets tranchants disposés dans des isolés dans des conteneurs temporaires sûrs conteneurs spéciaux pour objets tranchants, 2. Déchets triés par type immédiatement, ou bien la comme des boîtes en carton, des bouteilles en séparation est faite là où ils sont générés, ou bien ils plastique ou des boîtes en fer blanc recouverts, sont placés dans des conteneurs appropriés, étanches, non perforables) 3. Déchets non séparés par type immédiatement et la séparation n'est pas faite là où ils sont générés et ils ne sont pas placés dans des conteneurs appropriés,

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 29

Elimination des déchets et protection de Pour chaque élément listé ci-dessous, encercler la l’environnement réponse 5.7 - Manutention: collecte et transport 1. Transport approprié des déchets et utilisation des appropriés des déchets médicaux dans vêtements de protection et bonne hygiène (y compris l'établissement (par exemple manipulation aussi le lavage régulier avec du savon et de l'eau) minimale que possible des déchets médicaux avant 2. Transport approprié des déchets ou utilisation de l'entreposage temporaire et l'élimination; vêtements de protection ou pratique d'une bonne enlèvement et le vidange des conteneurs de hygiène déchets des salles d’opération, de procédures et 3. Transport inapproprié et manque d'utilisation de d’écluse avant qu’ils ne soient complètement vêtements de protection et de pratique d’une bonne pleins, au moins une fois par jour. Bonne hygiène, hygiène vêtements de protection) 5.8 - Entreposage provisoire: stockage sûr 1. Surface de stockage et étiquetage convenables et approprié et temporaire, emballage et étiquetage toujours pour moins de 24 heures des déchets médicaux dans l’établissement (toujours 2. Surface de stockage ou étiquetage convenables, ou pour moins de 24 heures, avant d'être éliminés; stockage toujours pour moins de 24 heures stockés dans un endroit désigné fermé très peu 3. Surface de stockage et étiquetage des déchets accessible au personnel, aux visiteurs et aux aliments. inappropriés, stockage parfois pendant plus de 24 réaction correcte en cas de déversement, blessures, heures exposition) 5.9 - Élimination générale finale: élimination 1. Les déchets sont jetés loin de la communauté et appropriée des déchets solides médicaux, déchets jamais stockés dans des contenants ouverts ni jetés médicaux liquides, objets tranchants et déchets dans un tas ouvert chimiques dangereux en dehors de l'établissement 2. Les déchets sont jetés loin de la communauté ou ne de santé (par exemple, tous les déchets solides et sont jamais stockés dans un récipient ouvert ni jetés liquides et les déchets contaminés sont mis au dans un tas ouvert rebut loin de la communauté. Jamais stockés dans 3. Déchets jetés dans la communauté et parfois stockés un récipient ouvert, jamais jetés dans un tas dans des récipients ouverts et jetés dans des tas ouverts ouvert.) 4. Inventaire, recyclage et / ou élimination corrects des produits chimiques et pharmaceutiques se rapportant au programme (y compris les produits chimiques utilisés dans la prévention des infections, les antibiotiques et les fournitures de PF) 5.10 - Elimination finale des déchets solides: 1. Le site a un incinérateur fonctionnant de façon élimination correcte, par exemple, dans optimale ou des dispositions pour le transfert hors du l’établissement si possible, sous la surveillance du site personnel, qui comprend les risques. On peut 2. Le site a un incinérateur fonctionnant de façon non utiliser le feu ou l'enfouissement ou le transport optimale ou des dispositions pour le transfert hors du vers un lieu d'élimination en dehors du site. site 3. Le site ne dispose pas d'incinérateur, ni de disposition La combustion fonctionnelle dans un tambour ou pour le transfert hors du site un incinérateur en briques est la meilleure. Moins optimale: la combustion à ciel ouvert, dans une petite zone désignée loin des locaux. S’ils sont humides, les imbiber de kérosène avant de mettre le feu). 5.11 - Elimination finale des déchets solides par 1. Le site possède un lieu d'enfouissement de déchets enfouissement en toute sécurité (par exemple à un opérant de façon optimale ou des dispositions pour le espace désigné, clôturé ou emmuré bien en vue transfert hors du site de l'établissement, avec une fosse suffisamment 2. Le site possède un lieu d'enfouissement de déchets grande pour tous les déchets médicaux solides opérant de façon ou des dispositions pour le transfert générés sur le site pour prévenir les pilleurs de hors du site poubelles et les blessures accidentelles. Fosse avec 3. Le site n'a pas de lieu d'enfouissement de déchets ni de un revêtement imperméable en plastique ou en disposition pour le transfert hors du site

30 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

Elimination des déchets et protection de Pour chaque élément listé ci-dessous, encercler la l’environnement réponse argile. Fosse d’enfouissement doublure à 50 mètres au moins de toute source d'eau pour éviter la contamination. Site pourvu d’un bon drainage, situé en aval de tout puits, sans eau stagnante, dans un endroit qui n'est pas sujet aux inondations. Le fond de la fosse doit être à 2 mètres au-dessus de la nappe phréatique (consulter l'autorité locale/ l’ingénieur responsable de l'eau sur l'emplacement de la nappe phréatique. Maintenir les déchets recouverts de 10-30 cm de terre.) 5.12 - Élimination en dehors du site: des 1. Toutes les précautions sont prises pour s’assurer que précautions sont elles prises pour s assurer que les les déchets sont transportés en toute sécurité déchets sont transportés et éliminés en toute 2. Certaines précautions sont prises pour s’assurer que sécurité? les déchets sont transportés en toute sécurité 3. Aucune précaution n’est prise pour assurer la sécurité du transport 5.13 - Autres observations et commentaires sur la PI et le stockage / élimination des déchets

Merci beaucoup d’avoir répondu aux questions. Nous apprécions votre temps et votre honnêteté.

Note pour l’enquêteur: Veuillez ne pas oublier de retourner à la page 1, et d’indiquer si l’enquête a été menée à sont terme. Assurez-vous de signer l’enquête et de donner toutes les informations générales demandées à la page 1.

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 31

APPENDIX B. Health Provider Questionnaire

RESPOND/Burundi Evaluation de base de l’état de préparation des Structures Sanitaires à Répondre aux violences sexuelles et violences basées sur le genre (VSBG)

GUIDE D’ENTRETIEN DU PRESTATAIRE

INFORMATIONS GENERALES

Structure Sanitaire (nom) : ______

Type de Structure : ___ Hôpital régional ___ Hôpital de district ___ Centre de santé ___ Centre de santé privé ___ Autre (à préciser): ______

Province : ______

District sanitaire : ______

Commune : ______

Date (jj/mm/aa) ___/___/___

Nom de l’Enquêteur : ______

INSTRUCTIONS À L’INTENTION DE L’ENQUÊTEUR : Les prestataires devront être interviewés individuellement et en aparté si le prestataire peut être disponible.

Lisez cette paragraphe à la personne interrogée et répondez les questions ci-dessous : (Saluez la personne-Bonjour…..). Je m’appelle ...... ……. Je représente le Projet RESPOND mis en œuvre par EngenderHealth, une ONG internationale qui œuvre dans la santé de la reproduction. Nous aidons le Ministère de la solidarité nationale, des droits de la personne humaine et du genre du Burundi en vue d’améliorer les services en faveur des survivantes de la violence sexuelle. Nous sommes en train de réaliser une étude dans le cadre du présent travail qui consiste à réunir des informations sur la formation, les comportements et les pratiques des prestataires dans les structures sanitaires. Cet entretien fait partie de ce travail et j’aimerais vous poser quelques questions sur cette structure.

Vous ne courez aucun risque en acceptant de participer à cette étude. Elle pourrait plutôt vous profiter en nous aidant à améliorer les services au Burundi. Toutes les informations que vous me communiquerez seront gardées confidentielles ; votre nom ne sera pas utilisé et vous ne serez identifié en aucune manière. Si vous convenez de participer, cet entretien devrait prendre en tout 45 minutes approximativement. Votre participation est strictement à titre volontaire et il n’y aura pas de sanction en refusant d’y prendre part. Vous êtes libre de poser toutes les questions ; vous pouvez refuser de participer à cette évaluation ; il vous est loisible de vous abstenir de répondre à une quelconque question inscrite dans l’entretien ; et vous pouvez à tout moment mettre fin à l’entretien.

Toute plainte au sujet de la façon dont vous avez été traité pendant l’entretien ou tout tort éventuel que vous pourriez subir sera traitée. Veuillez prendre contact avec ______.

Avez-vous d’autres questions? (Si oui, notez les questions et traitez celles auxquelles vous pouvez répondre). Oui ______Non ______

Etes-vous disposé à participer à l’étude ? Oui ______Non ______

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 33

 Si le prestataire accepte de continuer, commencez le questionnaire par Q 1.0

 Si le prestataire ne consent pas à poursuivre, encerclez “entretien refusé” et, si possible, donnez la raison pour laquelle l’entretien a été refusé. Remerciez le/ la pour avoir accordé son temps et passez à l’entretien suivante.

Entretien achevé : 1 = oui, achevé 2 = non, inachevé 3= entretien refusé

Si l’entretien est refusé (donnez-en les raisons): ______

Veuillez revenir ICI à la fin de l’entretien pour indiquer si l’enquête a été menée à son terme.

1. RENSEIGNEMENT SUR LE PRESTATAIRE 1.0 De quel sexe êtes-vous? (Ou MASCULIN FEMININ AUTRE/ NE SAIT PAS observer pour savoir s’il s’agit d’un 1 2 88 homme ou d’une femme au lieu de poser la question). 1.1a Quel est le titre de votre poste/ SI LA qualifications Auxilière Sage Autre PERSONN Médecin Infirmièr Infirmièr Femme A spécifier: E N’EST 1 2 3 4 5 PAS MEDECIN à passer 1.2 1.1b Si vous êtes médecin, quelle est Urologu Autre votre spécialité ? GYNECO-OBST. Chirurgien e A spécifier: 1 2 3 5 1.2 En quelle année avez-vous commencé à travailler dans les services de santé ? 1.3 En quelle année avez-vous commencé à travailler dans cet établissement ?

2. CONNAISSANCES ET ATTITUDES DU PRESTATAIRE 2.0a Savez-vous ce que l’expression « la violence sexuelle et la NE SAIT SI C’EST violence basée sur le genre » (VSBG) signifie ? OUI NON PAS NON OU NE 1 0 88 SAIT PAS aller à l’explication de VSGV 2.0b Si oui, veuillez décrire ce que signifie VSBG

34 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

Quelles que soient les réponses de la personne interrogée aux Questions 2.0 a et 2.0 b, veuillez donner la définition suivante de la VSBG : Quand j’utilise le terme « VSBG » dans cet entretien, je me réfère à tout acte nuisible qui se produit entre des personnes et qui est la conséquence des rôles normatifs du genre et des rapports inégalitaires du pouvoir entre les sexes. Certains des exemples de VSBG incluent entre autres :  Violence sexuelle dont l’exploitation/ sévices sexuels et prostitution forcée;  Violence physique y compris la violence physique excercée par un partenaire intime ou un petit ami;  Sévices psychologiques dont les menaces ou l’intimidation;  Mariage forcé/ précoce;  Pratiques traditionnelles néfastes dont gucura, kubangura , gukanda umuvyeyi , guteka ibuye rigasha et autres. 2.1 Si une survivante dit qu’elle a été violée, mais elle ne veut PAS NE SAIT pas aller à la police, c’est probablement parce qu’elle n’a D’ACCORD D’ACCORD PAS pas vraiment été violée. 1 0 88 2.2 Les survivantes du viol sont trop traumatisées pour PAS NE SAIT prendre les bonnes décisions par rapport à leur D’ACCORD D’ACCORD PAS traitement médical. 1 0 88 2.3 Le viol c’est parfois la faute de la victime (si elle portait D’ACCORD PAS NE SAIT une jupe courte, si elle est allé en boite de nuit,…). D’ACCORD PAS 1 0 88 2.4a Combien de fois (s’il y en eu) avez-vous reçu de SI C’EST formation sur la fourniture de services à des victimes de NEANT OU violence basée sur le genre (VBG) NE SAIT PAS, passer à Q. 2.5 2.4b Quelle (s) est (sont) l’ (les) organisation (s) ou institution FNUAP MSHP AUTRE NE SAIT (s) qui a (ont) organisé/ conduit la (les) formations (s) ? À spécifier: PAS 1 2 3 88 2.4c En quelle année la (les) les formation (s) a-t-elle (ont- elles) eu lieu ? 2.4d Combien de jours a/ ont duré la (les) formations (s) ? 2.4e Les thématiques suivantes avaient-elles été couvertes par OUI NON NE SAIT la (les) formation (s) ? PAS Définition de la VBG 1 0 88 Causes de la VBG 2 0 88 Conséquences de la VBG 3 0 88 Normes internationales pour la prise en charge des 4 0 88 victimes de VBG Procédures Opérationnelles Standard Nationales (POS) 5 0 88 pour la prise en charge des survivantes de VBG Apporter l’appui/ réconfort psychosocial aux victimes de 6 0 88 VBG Prise en charge clinique du viol 7 0 88 Collecte et documentation de preuves cliniques du viol 8 0 88 Confidentialité 9 0 88 Consentement éclairé (accord de la survivante) 10 0 88 Conditions d’ordre juridique pour les prestataires 11 0 88 Considérations spéciales si les victimes de VBG sont des 12 0 88 enfants/ mineurs Autre (à spécifier): 13 0 88

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 35

2.5 Comment noteriez-vous vos connaissances des lois sur la TRES BIEN FAIBLES TRES VBG ? BIEN FAIBLES 1 2 3 4 2.6 Quelles sont les lois burundaises sur les VBG que vous connaissez ?

3. PROCEDURES OPERATIONNELLES STANDARD (POS) ET CONFIDENTIALITE 3.0a Y a-t-il dans cette structure des prestataires qui sont OUI NON NE SAIT SI C’EST NON assignés à répondre à la violence sexuelle et à d’autres PAS OU NE SAIT formes de VBG ? 1 0 88 PAS passer à Q. 3.1 3.0b Si oui, faites-vous partie de ceux-ci ? OUI NON NE SAIT SI C’EST NON PAS OU NE SAIT 1 0 88 PAS passer à Q. 3.4a 3.1 Savez/ comprenez-vous quelles sont les rôles et tâches que OUI NON NE SAIT SI C’EST NON vous devez exécuter quand une victime de violence PAS OU NE SAIT sexuelle se présente dans cette structure pour les soins 1 0 88 PAS passer à médicaux ? Q. 3.3a 3.2 Quelles ressources avez-vous pour vous informer ce que vous devez faire quand une victime de violence sexuelle se présente dans la structure à la recherche de soins médicaux ? Les POS écrites 1 ENQUETEUR : Une description écrite des tâches 2 Des explications verbales données par le Directeur ou une 3 NE PAS PROVOQUER LA autre personne de la structure REACTION

Sur la base de formation ou d’instructions apprises hors 4 PLUS D’UNE REPONSE EST site PERMISE J’ai appris par moi-même 5 Autre (à spécifier): 6

3.3a Avez-vous des POS écrites, des protocoles, organigrammes OUI NON NE SAIT SI C’EST NON ou autres documents qui vous rappellent comment PAS OU NE SAIT prendre en charge une victime de violence sexuelle ? 1 0 88 PAS passer à Q. 3.4a 3.3b Si oui, veuillez m’exhiber les POS, protocoles, ENQUETEUR: ENCERCLER OUI POUR organigrammes ou autres documents similaires qui guident LES DOCUMENTS A VOUS MONTRES la prise en charge des survivantes de violence sexuelle POS OUI / NON Autres protocoles (ex: Protocole MSLS de soins intégrés OUI / NON pour les victimes de VBG Organigramme OUI / NON Autre (à spécifier): OUI / NON

36 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

3.4a Certaines structures utilisent des codes pour protéger la OUI NON NE SAIT SI C’EST NON confidentialité autour de la patiente. Le personnel de la PAS OU NE SAIT structure affecte aux patientes un code d’identification 1 0 88 PAS passer à composé de lettres et/ ou des numéros à porter sur les Q. 3.5a dossiers médicaux et les fiches de référence, en lieu et place des noms des patientes. Cette formation sanitaire a- t-elle mis en place un système de codage pour les survivantes de VBG ? 3.4b Si oui, veuillez décrire le système de codage (ex. comment plusieurs personnes ont-elles accès aux informations identifiant la patiente?) 3.5a Les dossiers des patientes sont-ils enfermés à clé dans des OUI NON NE SAIT SI C’EST NON classeurs ? PAS OU NE SAIT 1 0 88 PAS passer à Q. 3.6 3.5b Si oui, combien de personnes ont-elles accès aux classeurs fermés à clé ? 3.6 La définition du « consentement éclairé » est la compréhension OUI NON NE SAIT et l’accord de la survivante sur les mesures que vous PAS recommandez. Pour l’obtenir on pose des questions, en répond 1 0 88 à leurs propres questions et à leurs préoccupations, et en obtenant leur accord pour poursuivre. Les prestataires dans cette structure sont-ils tenus d’obtenir le consentement éclairé de la patiente avant la transmission de toute information la concernant à une autre structure au moment de son orientation/ référence ? 3.7 Les prestataires et autres personnels dans cette structure OUI NON NE SAIT sont-ils tenus de signer un Code de Bonne Conduite qui PAS traite de la confidentialité de la patiente ? 1 0 88 3.8a Est-ce que cette structure sanitaire enregistre et fait des OUI NON NE SAIT SI C’EST NON statistiques des survivantes reçues ? PAS OU NE SAIT 1 0 88 PAS passer à Q. 3.9 3.8b Si oui, est-ce que les prestataires et autres personnels OUI NON NE SAIT sont-ils tenus d’obtenir l’accord des survivantes avant de PAS rendre compte de ces statistiques ? 1 0 88 3.9 Le choix est-il donné aux victimes de violence sexuelle de OUI NON NE SAIT se faire traiter par un prestataire qui est une femme ? PAS 1 0 88

4. SERVICES OFFERTS 4.0 Est-ce que cette structure offre des services aux patientes NE SAIT qui se présentent et signalent : OUI NON PAS Viol conjugal ? 1 0 88 Viol non-conjugal (viol dehors du foyer) ? 2 0 88 Autres formes d’agression sexuelle (tentative de viol, 3 0 88 sodomie forcée) ? Agression physique basée sur le genre ? 4 0 88 Mariage forcé ? 5 0 88 Autre types de VSBG ? Lesquels ? 6 0 88 (à spécifier):

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 37

4.1 Pourriez-vous décrire étape par étape ce que vous auriez fait si une patiente qui vient tout juste de se faire violer se présente dans cette structure ? Donner un appui/ réconfort psychologique à la patiente 1 ENQUETEUR : PLUS D’UNE (ex. en lui expliquant que le viol n’était pas sa faute) REPONSE EST AUTORISEE. NE Assurer la patiente de leur confidentialité 2 PAS LIRE LES REPONSES OU Informer la patienté de son droit d’accepter ou de refuser 3 ORIENTER. SI LE PARTICIPANT un quelconque service offert DONNE UNE REPONSE AMBIGUE OU NE DONNE PAS Orienter la patiente vers un autre prestataire de la même 4 LE NIVEAU DE DETAIL INDIQUE structure pour consultation et soins SUR CETTE LISTE, DEMANDEZ : Demander à la patiente de décrire ce qui est arrivé, les 5 « POUVEZ-VOUS ME DIRE symptômes et les antécédents médicaux pertinents (ex : DAVANTAGE SUR LE SUJET ?» statut sérologique du VIH) ET/ OU ‘’Y A-T-IL AUTRE CHOSE Procéder à une consultation physique 6 QUE VOUS POURRIEZ FAIRE ?’’ Traiter les plaies, s’il y a lieu 7 Test de grossesse, s’il y a lieu 8 Prescription de contraceptifs d’urgence, s’il y a lieu 9 Test de VIH, s’il y a lieu 10 Fournir une prophylaxie pour se prémunir de l’exposition 11 aux risques, s’il y a lieu Test pour autres IST, s’il y a lieu 12 Traiter les IST, s’il y a lieu 13 Administrer d’autres vaccins, s’il y a lieu (ex: tétanos, 14 Hépatite B) Informer la patiente de son droit légal de faire supporter 15 les charges par l’auteur, s’il y a lieu Etablir un certificat médical documentant le viol, selon les 16 desiderata de la patiente Discuter de la sécurité de la patiente (ex: s’il y a un danger 17 à poursuivre les discussions sur la VBG) Dans les cas de violence domestique, demander si les 18 enfants de la maisonnée sont exposés au risque de violence Evaluer s’il y a des risques pour la patiente de s’exposer à 19 la dépression ou au suicide Référer la patiente pour d’autres services selon ses besoins 20 et souhaits Autre (à spécifier): 21

4.2 La structure dispose-t-elle de salles de consultation qui NE SAIT garantissent le caractère privé protégeant les patientes OUI NON PAS contre les regards et l’ouie à la fois ? 1 0 88 4.3a Les prestataires offrent-ils dans cette structure des NE SAIT SI C’EST NON contraceptifs d’urgence aux patientes qui ont subi des OUI NON PAS OU NE SAIT viols ? 1 0 88 PAS passer à Q. 4.4 4.3b Si oui, y a-t-il eu des ruptures de stock en contraceptifs NE SAIT d’urgence pendant les trois derniers mois ? OUI NON PAS 1 0 88 4.4 Cette structure est-elle systématiquement approvisionnée NE SAIT en matériel de test des IST? OUI NON PAS 1 0 88

38 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

4.5 Cette structure est-elle systématiquement approvisionnée NE SAIT en matériel d’échantillonnage pour les besoins médico- OUI NON PAS légaux ? 1 0 88 4.6a Les prestataires de cette structure offrent-ils des services NE SAIT SI C’EST NON de prophylaxie aux patientes qui ont subi des viols pour se OUI NON PAS OU NE SAIT prémunir des risques ? 1 0 88 PAS passer à Q. 4.7a 4.6b Si oui, y a-t-il eu des ruptures de stocks en produits NE SAIT prophylactiques au cours des trois derniers mois, pour OUI NON PAS prévenir l’exposition à des risques postérieurs au viol ? 1 0 88 4.7 A votre avis, quels matériels/ équipement, fournitures et infrastructures additionnels sont-ils nécessaires pour une prise en charge adéquate des survivantes de VBG ? 4.8 Avez-vous jamais rempli un certificat médical à utiliser par NE SAIT SI C’EST OUI une patiente comme preuve qu’elle a été violée ? OUI NON PAS OU NE SAIT 1 0 88 PAS passer à Q. 4.9 4.8b Si non, pour quoi ?

4.9 Savez-vous vers où vous pouvez faire les types suivants de référence pour les victimes de VBG de nécessité et selon les désirs de la patiente ? OUI NON Référence pour assistance juridique ? 1 0 Lieu à spécifier:

Référence à un abri ou une maison/ un lieu en sécurité ? 1 0 Lieu à spécifier:

Référence pour counseling psychosocial? 1 0 Lieu à spécifier:

Référence pour réintégration sociale ? 1 0 Lieu à spécifier :

Référence pour réintégration économique ou pour 1 0 assistance en moyens de subsistance ? Lieu à spécifier:

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 39

5. SUGGESTIONS 5.0a Estimez-vous avoir les connaissances et compétences NE SAIT SI C’EST nécessaires pour une prise en charge adéquate des OUI NON PAS OUI passer à survivantes de VBG ? 1 0 88 Q. 5.1 5.0b Si c’est non, de quelles connaissances et compétences additionnelles estimez-vous avoir besoin pour offrir des soins adéquats aux survivantes de VBG ?

5.1 Quels sont les défis auxquels cette structure est confrontée pour répondre à la VBG ?

5.2 Avez-vous des suggestions finales pour l’amélioration de la réponse par la structure à la VBG ?

Merci beaucoup d’avoir répondu aux questions. Nous apprécions votre temps et votre honnêteté.

Note pour l’enquêteur: Veuillez ne pas oublier de retourner à la page 1, et d’indiquer si l’enquête a été menée à sont terme. Assurez-vous de signer l’enquête et de donner toutes les informations générales demandées à la page 1.

40 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

APPENDIX C. Key Informant Interview Guide

Consent form for other stakeholders (Community leaders, organizations, agencies, associations)

Key Informant Interview1

To be read aloud by the interviewer at the start of the interview. Interviewer must sign to indicate that verbal consent has been obtained from all participants before initiating the interview.

Introduction “My name is ______and I am from the RESPOND Project, which is implemented by EngenderHealth, an international NGO in the area of reproductive health. [Introduce notetaker]. We are working with the Ministry of National Solidarity, Human Rights, and Gender in Burundi.”

Why are we here? “We want to improve the services that are provided for people who experience sexual violence. Sexual violence is any type of sexual contact against a person’s will, such as rape or unwanted touching. We invited you to this interview because of your role as a [service provider, government official or local leader] in this community. We would like to ask you questions on the services offered to survivors of sexual violence in this community, and the barriers accessing these services. We would like to invite you to be a part of our study so we can learn from you. We are not here to address cases of sexual violence at the moment, and we ask you not to share personal stories of sexual violence during the interview.”

What will happen if you agree to take part in this study? “We will ask you questions about services that are available to survivors of sexual violence in your community, and the barriers to accessing those services. We request that you share your thoughts and opinions honestly and truthfully with us. We will take notes on what you say to make sure that we represent your opinions and thoughts accurately.”

Will the study cause any discomfort to you? “We may ask questions that you may feel shy to answer or you do not want to answer. If this happens, you can refuse to answer or you can end the interview.”

Will being in the study bring benefits to this community? “We will note what you tell us and share the information with people in Burundi and the United States who work in public health, including the donor PEPFAR. These people want to know how to help survivors of sexual violence so that they can strengthen services in Burundi.”

What if you have any questions? “If you have questions or concerns about the study you can ask me now or you can contact us later at any of the numbers below.

1 This consent form and interview guide were adapted from a research protocol developed by the Technical Support to Map Gender-Based Violence Services in Tanzania (TMAP) Project. Under TMAP project, the International Center for Research on Women (ICRW) will work with EngenderHealth and local research consultants from the University of Dar es Salaam to implement a mapping of existing services and an assessment of community needs and perceptions related to gender-based violence in three regions of Tanzania. Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 41

Who will know you participated in the study? “When the study is finished we will write a report that includes what we learned from you and the others we talked with, but we will not connect your name with your opinions. We would like to include the name of your organization and a contact person in the report so that we can strengthen the network of services.”

Do you have to be in the study? “If you decide that you do not want to join the study, for any reason, we will respect your decision. We will not ask you why you do not want to participate. No negative consequences will occur if you choose not to participate.”

“Do you have any questions for me?”

If participant has any questions, record questions and your response here: ______

“Do you agree to participate in the interview?” [ ] Participant gives verbal consent  Continue [ ] Participant does not consent  End interview

“Do you agree for us to include your name, contact information, and organization in the report and on a list of referral services for survivors?” [ ] Participant agrees  Continue [ ] Participant does not agree  Continue

Verification of verbal consent [to be signed by interviewer]

I, the undersigned, certify that I have read and discussed the consent procedures with the participant and continued only on his/her consent.

Name of interviewer: ______Date: ______

Signature of interviewer:

IMPORTANT: Sign both copies: 1) must be retained on file by the research supervisor in a folder marked with the unique identifier of the participant and 2) given to the participant

42 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

Guide for Key Informant Interviews with other stakeholders (Community leaders, organizations, agencies, associations)

Participant Identification Number: ______District: ______

Township (commune): ______Date: ______

Participant Summary: ______Female ______Male

Participant institution/structure (organization, agency, association): ______

Participant title/function: ______

Interviewer: ______

Informed Consent (10 minutes) Before proceeding, facilitator must read consent statement (attached) and sign to verify that verbal consent has been obtained from the interview participant.

Questions: (50 minutes) 1. Role of participant’s institution/structure: a. What is the mission of [participant’s organization/agency/association]? b. What does [same] do to help survivors of sexual violence? c. What geographic area is covered by these services? d. Where does the funding for this work come from? e. What are the costs to survivors to access these services? Are there free services for low-income clients? f. Do you keep statistics on the number of survivors of sexual violence served? If so, how many survivors do you serve in an average month? g. How does the community know about the services you offer to survivors? (Probe for advertisements, announcements, if other organizations refer survivors to them, etc.) 2. Other SV services in the township: a. What sources of support are there in this township for survivors of sexual violence? i. Are there sources of legal support? Where? (Probe for police, courts, community leaders, NGOs, CBOs, paralegals, etc.) ii. Are there medical services for survivors of sexual violence? Where? iii. Are there sources of psychosocial support to address the mental health consequences of sexual violence? Where? (Probe for NGOs, CBOs, faith-based groups, support groups, counselors, psychiatric care, family mediators, etc.) iv. Are there sources of economic reintegration support, such as microcredit, vocational training, or livelihoods assistance? Where? (Probe for government agencies, NGOs, CBOs, faith-based groups, etc.) v. Are there sources of protection, shelter, refuge, or a safe place? (Probe for formal and informal sources of protection.) vi. Are there other sources of help that we have not discussed? (Probe for formal and informal sources of help.)

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 43

b. Do you offer survivors referrals to any of these services? i. If so, which ones? ii. How do you make referrals? (Probe for whether they fill out a form, call the referral site by telephone, or accompany the survivor to the referral site.) iii. How often do you offer referrals? c. Are there partnerships between the different sectors that serve survivors? If yes, please describe. d. In your opinion, what are the gaps in services for survivors in this township? e. Of all the services you know about for people who have experienced gender-based violence, which do you think are of the best quality? Why? 3. Barriers to Help Seeking a. In your estimation, what percentage of people who experience sexual violence seek help? i. From formal sources of support? ii. From informal sources of support? b. What are the main reasons that more people don’t seek help? i. From formal sources of support? ii. From informal sources of support?

Probe for interpersonal and attitude barriers (fear of stigma, fear of a partner, fear of renewed violence, embarrassment, attitudes of service providers, etc.); financial or logistical barriers (transport issues, lack of service availability, cost of services, lack of childcare, etc.); quality concerns (reputation of service providers/sites, lack of confidentiality measures, belief that the available services will not make a difference, cases of sexual violence perpetrated by providers.)

44 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

APPENDIX D. List of Key Informants

Provinces Structures Fonction Province de CDF Coordonnatrice CDF Kayanza Kayanza ADDF-Kayanza Coordonnatrice Provinciale Kayanza SWAA Coordonnateur antenne Kayanza Parquet de la République de Kayanza Point focal VSBG Tribunal de Grande Instance de Président du TGI et Point focal VSBG Kayanza Parquet de la République de Kayanza Procureur de la République et Point focal des VSBG APRODH antenne Kayanza Observateur des droits humains et chef d’antenne responsable du projet Giriteka Administration communale de Muruta Administrateur communal Administration communale de Secrétaire communal Kabarore Réseau Murekerisoni Représentante Légale Réseau des femmes leader de Kayanza Présidente Province de ABUBEF Responsable du centre jeune à jeune ABUBEF Muyinga Muyinga SWAA-Burundi antenne Muyinga Coordonnatrice adjointe – Responsable du counseling

CDF-Muyinga Coordonnatrice Care International à Muyinga Coordonnateur provincial du projet UMWIZERO Dushirehamwe antenne Muyinga Vice présidente Dushirehamwe

Conférence des Evêques Catholiques Responsable diocésain du projet écoute et

du Burundi guérison des mémoires

APRODH antenne Muyinga Responsable du projet assistance judiciaire des dossiers relatif aux VSBG Parquet de Muyinga Procureur de la République à Muyinga Tribunal de Grande Instance à Point focal VSBG au TGI Muyinga Muyinga Ligue Iteka Chargé d’écoute et observateur provincial des droits de l’homme Commissariat provincial de Muyinga Point focal provincial de lutte contre les VSBG CDF Butihinda Responsable CDF Butihinda CDF Giteranyi Responsable CDF Giteranyi

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 45

APPENDIX E. Focus Group Discussion Guide

Consent form for community members Participatory Focus Group2

To be read aloud by the facilitator at the start of the PFG. Facilitator must sign to indicate that verbal consent has been obtained from all participants before initiating the discussion.

Introduction “My name is ______and I am from the RESPOND Project, which is implemented by EngenderHealth, an international NGO in the area of reproductive health. [Introduce notetaker]. We are working with the Ministry of National Solidarity, Human Rights, and Gender in Burundi.”

Why are we here? “We want to improve the services that are provided for people who sexual violence. Sexual violence is any type of sexual contact against a person’s will, such as rape or unwanted touching. We invited you to this discussion because you are a member of this community. We would like to ask your questions on the services offered to survivors of sexual violence in this community, and the barriers accessing these services. We would like to invite you to be a part of our study so we can learn from you. We are not here to address cases of sexual violence at the moment, and we ask you not to share personal stories of sexual violence during the discussion.”

What will happen if you agree to take part in this study? “We will we will ask you questions about the types of sexual violence in this community, services that are available to survivors of sexual violence, and the barriers to accessing those services. We request that you share your thoughts and opinions honestly and truthfully with us. While we may share some of the information that you give us, we will not write your name anywhere and we will keep your identity confidential at all times. You are free to use your name or make up a name. We request that all participants treat the discussion confidentially; however we cannot guarantee that they will. We will take notes on what you say to make sure that we represent your opinions and thoughts accurately.”

Will the study cause any discomfort to you? “We may ask questions that you may feel shy to answer or you do not want to answer. Some questions may make you feel sad. If this happens, you can refuse to answer or you can end the interview.”

Will being in the study bring benefits to this community? “We will note what you tell us and share the information with people in Burundi and the United States who work in public health, including the donor PEPFAR. These people want to know how to help survivors of sexual violence so that they can strengthen services in Burundi. Your name will not be used in any documents.”

What if you have any questions? “If you have questions or concerns about the study you can ask me now or you can contact us later at any of the numbers below.

2 This consent form and FGD guide were adapted from a research protocol developed by the Technical Support to Map Gender-Based Violence Services in Tanzania (TMAP) Project. Under TMAP project, the International Center for Research on Women (ICRW) will work with EngenderHealth and local research consultants from the University of Dar es Salaam to implement a mapping of existing services and an assessment of community needs and perceptions related to gender-based violence in three regions of Tanzania. Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 47

Who will know you participated in the study? “When the study is finished we will tell people what we learned from you and the others we talked with, but we will not tell them your name.”

Do you have to be in the study? “If you decide that you do not want to join the study, for any reason, we will respect your decision. We will not ask you why you do not want to participate. No negative consequences will occur if you choose not to participate. If you choose to participate, you may stop at any time or skip any of the questions.”

“Do any of you have any questions for me?”

If any participant has questions, record questions and your response here: ______

“Do all of you agree to participate in the interview?” [ ] All participants give verbal consent  Continue [ ] One or more participant does not consent  End discussion and allow anyone who does not agree to participate to leave the room. If fewer than five participants remain, postpone discussion until a new group can be recruited.

Verification of verbal consent [to be signed by facilitator]

I, the undersigned, certify that I have read and discussed the consent procedures with the group and continued only on consent by all participants.

Name of interviewer: ______Date: ______

Signature of interviewer:

IMPORTANT: Sign both copies: 1) must be retained on file by the research supervisor in a folder marked with the unique identifier of the PFG and 2) given to the participant

48 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

Participatory Focus Group and Activity Guide

Discussion ID Number: ______District: ______

Township (commune): ______Date: ______

Participant Summary: ______Women age 20-24 ______Women age 25+ ______Men age 20-24 ______Men age 25+

Facilitators:

Informed Consent (10 minutes) Before proceeding, facilitator must read consent statement (attached) and sign to verify that verbal consent has been obtained from all PFG participants.

Ground rules (5 minutes) Facilitator asks participants to suggest ground rules that will help them feel comfortable sharing their ideas during the group discussion. Facilitator compiles the list in a location visible to all (e.g., flipchart, blackboard. Add to their suggestions:  “All information shared during the discussion must be treated confidentially. However, we request that you do not name any survivors or perpetrators of violence during the discussion, because we cannot guarantee that all participants in the discussion will keep stories confidential after the discussion.”  Only one person should speak at a time; respect opinions that differ from your own; try not to dominate the discussion, encourage everyone to speak.  You can use your own name or make up a name. If you use your own name, please use your first name only.

Activity Guide 1. Community definitions of sexual and gender-based violence (30 minutes) Activity: Free listing, ranking, and discussion  Free listing: Facilitator seeks a list of types of violence from group members and compiles in a location visible to all (e.g., flipchart, blackboard):“As a group, list the different types of violence that women experience. What are the things other people do that can hurt women?”  If responses are slow, facilitator can probe about any of the types of violence from the prepared list (see box below) that were not previously mentioned.  Facilitator should ensure that some examples of sexual violence are mentioned, including forms of rape that do not involve physical force (e.g., if a man demands sex from his domestic servant).

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 49

Prepared list of types of violence (if needed):  Physical violence, including beating, throwing things, pushing or shoving, kicking, choking, etc.  Psychological violence, including yelling at or humiliating in public, insulting, threating to hurt, threatening to withdraw financial support, refusing to pay for household expenses, controlling your partners’ activities (work, visiting friends), breaking or destroying your partners’ things, etc.  Sexual violence, including demanding sex from your partner when she doesn’t want it, rape by a stranger, using power or authority to coerce someone to have sex, using the threat of violence to force someone to have sex, harmful traditional practices that involve forced sex (gucura, kubangura , gukanda umuvyeyi , guteka ibuye rigasha), forced oral or anal sex, unwanted touching, etc.

 Facilitator focuses the group on the forms of sexual violence: “Which of these types of violence relate to sexual intercourse or other sexual actions?”  Facilitator circles the types of sexual violence on the list. “I’m going to call those types of violence ‘sexual violence.’ Are there any other types of sexual violence you would add?”  Facilitator guides group through discussion and ranking of the types of sexual violence. “Let’s discuss the types of sexual violence listed here. o Which actions are common in this community, in terms of frequency? o Which actions does the community consider acceptable? Which are considered serious? o For which actions on this list would a woman likely seek help afterward? Would a woman seek help from family members? From professionals? From someone else?”

Output of activity 1: Free list of types of violence, categorized by all of the above topics of discussion: which are common, which are acceptable, which are serious, and which prompt help- seeking.

2. Help-seeking options and behaviors (45 minutes) Activity: Open-ended story, free listing, and discussion “Thank you very much all the information you’ve already shared with us. Your input is already very helpful. You have said that after experiencing certain actions, a survivor would be likely to seek help. We’re now going to discuss how the survivor seeks help and where she can go in your community.”

 Facilitator reads two open-ended stories:

“I’m going to tell you two fictional stories. The first is about a girl named Sabine. Sabine is 18 years old. She is a secondary school student. She tries very hard in school, but she has a problem. Her teacher often compliments her looks and invites her to spend time with him after school. Sabine always says no, but she smiles so that he will not be angry with her. One day, her teacher tells her that she must come to his house, or he will give her poor marks. She is afraid that if she receives poor marks, she won’t be able to continue her education. When Sabine arrives at her teacher’s house, he forces her to have sex with him.”

“The second story is about a woman named Anne. Anne is 30 years old and has been married to Joseph for 12 years. They have four children. Over the years, Joseph has begun behaving in ways that Anne dislikes: he wastes their meager household resources during drunken evenings, comes home very late at night, and beats her. He has sex with Anne even when she says that she doesn’t want to.”

 Free listing: Facilitator asks participants the questions below regarding resources and services for survivors. He/she compiles the list in a location visible to all (e.g., flipchart, blackboard).

50 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi

 Imagine that the student, Sabine, decides to seek help. Where will she go first? What do they say to her? What will she decide to do next?  Imagine that the married woman, Anne, decides to seek help. Where will she go first? What do they say to her? What will she decide to do next? Are her options different than Sabine’s?  If Sabine or Anne feels very sad, depressed, or scared about the experience, what will she do? Where can she go for help?  If Sabine or Anne fears that she has health consequences, what will she do? Where can she go for help? What type of health services might they need?  If Sabine or Anne wants to report what happened, where would she report it?  If Sabine’s parents abandon her because of what happened, what will she do? Where can she go for help?  If Anne leaves Joseph, what will she do? Where can she go?  If Sabine stops attending school because of what happened, what will she do? If Anne leaves Joseph and she needs money, what will she do? Where can she go for a job or money?  If Sabine or Anne does not feel safe at home anymore, what will she do? Where can she go for help?

Outputs of activity 2: List of services available in the community and the group’s responses by question.

3. Perceived barriers to accessing services (30 minutes) Activity: Discussion “You discussed various sources of support, information, and health care that Sabine and Anne could seek. Let’s talk some more about these services.”  How common is it in this community that a person like Sabine would seek out all of those sources of support? What about a person like Anne?  How common is it that a person like Sabine wouldn’t seek any services or help? Why? What about a person like Anne?  Why do people like Sabine and Anne seek help in some cases and not in others?  Would it make any difference if Sabine were age 13?  Would it make any difference if Anne were age 60?  Would it make a difference if the aggressor were a stranger?  How easy or difficult is it for a person like Sabine or Anne to find out where she can go for help? Does everyone in your community know about (name of service/resource/clinic/NGO/auntie) and how it can help them? How do people find out that it exists? Output of activity 3: Notes on barriers to seeking particular services, with responses organized by question.

4. How to improve service delivery (15 minutes) Activity: Discussion/Ranking “You’ve just told us about some problems that exist in your community and also how people can receive support if they experience these problems. Now let’s close our conversation by thinking of how this situation could be improved.”

 Free listing: Facilitator seeks a list of suggestions to improve services from group members and compiles in a location visible to all (e.g., flipchart, blackboard):“Tell us now, what could be done to improve the services available for survivors of violence? What could be done to help survivors access these services?”

Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi 51

 Ranking: Facilitator asks group members to prioritize the list of suggestions and numbers the top few: “This is a great list of options for improving services. Which do you think is the most important of these options? Can we identify the top two or three priorities for your community in this regard?”

Output of activity 4: Ranked list of the top options for improving services.

Closing (5 minutes) 1. Thank participants for their time and ideas, and express how helpful it has been for the facilitators. 2. Reemphasize need for confidentiality. 3. Ask the participants if they have any questions for the facilitators.

52 Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, Burundi