TWUBAKANE Decentralization and Health Program in Rwanda STUDY ON THE READINESS OF THE POLITICAL, LEGAL, HEALTH AND COMMUNITY SYSTEMS TO RESPOND TO GENDER-BASED VIOLENCE IN THREE DISTRICTS OF THE CITY OF KIGALI Kigali, May 2008 TABLE OF CONTENTS Table of Contents ................................................................................................................................................. 2 List of tables ......................................................................................................................................................... 5 List of figures ........................................................................................................................................................ 6 Acknowledgement ............................................................................................................................................... 8 Acronyms and abbreviations ............................................................................................................................... 9 Summary ............................................................................................................................................................ 11 I. INTRODUCTION ....................................................................................................... 22 1.1. Context of the study, political and programmatic justification ................................................. 22 1.2. Defining GBV ........................................................................................................................... 23 1.3. Objectives ............................................................................................................................... 24 II. METHODOLOGY ..................................................................................................... 25 2.1. Research systems and techniques ........................................................................................... 25 2.2. Sampling strategies and selection of sites for the study ........................................................... 25 2.3. Interviewees’ characteristics ................................................................................................... 27 2.4. Selection and training of data‐collecting agents ...................................................................... 28 2.5. Pretest of data‐collecting tools ................................................................................................ 28 2.6. Data collection ........................................................................................................................ 29 2.6.1. Level 1: Assessing the readiness of the policy environment to respond to GBV ..................................... 29 2.6.2. Level 2: Assessing the readiness of the health system to respond to GBV .............................................. 29 2.6.3. Level 3: Assessment of the community support system .......................................................................... 30 2.6.4. Contact with local authorities .................................................................................................................. 31 2.6.5. Organization of on‐field team members and supervision ....................................................................... 31 2.7. Data analysis ........................................................................................................................... 31 2.8. Dissemination of results .......................................................................................................... 31 2.9. Limitations .............................................................................................................................. 31 III. RESULTS ................................................................................................................ 32 3.1. Level 1: Assessing the readiness of the policy environment ..................................................... 32 3.1.1. General findings on the policy environment related to GBV ................................................................... 32 3.1.2. Key informants’ perceptions on the dissemination of laws and policies ................................................. 33 3.1.3. Key informants’ perceptions on the enforcement of laws and policies................................................... 33 3.1.4. Obstacles and gaps perceived by key informants .................................................................................... 34 3.1.5. Key informants’ perceptions on the role of the health sector in managing GBV .................................... 35 3.1.6. Key informants’ perceptions on available services and existing resources in the health sector ............. 36 3.1.7. Key informants’ perceptions on meeting needs at the health care sector level to improve GBV management ...................................................................................................................................................... 36 Page 2 of 106 3.1.8. Key informants’ perceptions of obstacles women must overcome when they seek GBV services within the health sector ................................................................................................................................................ 37 3.1.9. Key informants’ perceptions on the people who need GBV services the most and the people who have the most limited access to these services .......................................................................................................... 38 3.1.10. Key informants’ perceptions on the link between GBV/HIV/AIDS and the integration of GBV services in ANC/PMTCT service delivery .......................................................................................................................... 39 3.1.11. Readiness to manage GBV with laws and policies ................................................................................. 40 3.1.12. Findings .................................................................................................................................................. 44 Conclusions on the readiness of the policy environment to respond to GBV .................................. 46 3.2. Level 2: Assessing the readiness of the health sector to manage GBV ...................................... 47 3.2.1. Findings on providers’ knowledge related to GBV ................................................................................... 48 3.2.2. Findings on the providers’ attitudes and beliefs ...................................................................................... 50 3.2.3. Perceptions and experiences of providers on the integrated management of GBV in ANC/PMTCT services ............................................................................................................................................................... 55 3.2.3.1. Referring victims of violence ............................................................................................................ 56 3.2.3.2. Health services support system for victims of violence ................................................................... 56 3.2.3.3. Perceptions on the victims’ readiness to report the acts of violence they experienced ................. 57 3.2.3.4. Providers’ perceptions on the risk of violence for ANC/PMTCT clients ........................................... 57 3.2.3.5. Providers’ knowledge of existing laws and regulations ................................................................... 58 3.2.3.6. Providers’ perception on the government’s and the community’s role in the management of GBV ....................................................................................................................................................................... 59 3.2.3.7. Existing GBV services in health facilities ........................................................................................... 59 3.2.3.8. Existing treatment for GBV victims .................................................................................................. 59 3.2.3.9. Providers’ perceptions on a possible integration of GBV into ANC/PMTCT services ....................... 60 3.2.3.10. Providers’ opinion on the need for a good integration of GBV in ANC/PMTCT service delivery ... 61 3.2.3.11. Perceptions on the clinical management of rape ........................................................................... 62 3.2.4. Current practice related to GBV ............................................................................................................... 62 3.2.5. Assessing the readiness of health facilities to manage GBV: Availability of key components to support GBV service delivery ........................................................................................................................................... 63 3.2.6. Assessment of the health system by ANC services’ clients ...................................................................... 66 3.2.6.1. Perception and experience of violence by ANC clients .................................................................... 66 3.2.6.2. Management of violence by the victims .......................................................................................... 67 3.2.6.3. Perception on the assistance provided to victims of violence ......................................................... 68 3.2.6.4. Assessing the assistance provided