FCV Health Knowledge Notes Gender Based Violence in Fragile, Conflict, and Violence (FCV) Situations Five key questions to be answered SUMMARY The importance of addressing gender-based violence (GBV) in FCV situations is increasingly recognized by countries and international humanitarian and development agencies. This note highlights the best practices in designing, implementing and evaluating a project involving addressing GBV in conflict and fragile situations. The note also provides an overview of the World Bank’s current engagement on GBV in fragile settings and internal resources available to TTLs. Photo credit: Dominic Chavez/World Bank Gender-based violence has long term effects on the WHY should we focus health of women, men and children who experience it. Q1 on GBV in FCV WHO estimates show that women who have experienced violence are 16 percent more likely to give birth to low situations? weight babies; are twice as likely to have an abortion; and are at a higher risk of contracting HIV/AIDS where the disease is pervasive. Moreover, victims of most types of Gender-based violence (GBV), as defined by the GBV often experience stigmatization, and often the crime World Health Organization (WHO), refers to physical, goes unreported. sexual, emotional and psychological abuse, or financial control by a person (or a group of people) that Displaced people and refugees have a high risk of cause harm to another person rooted in gender norms. GBV due to their vulnerability. This can take various forms including rape, forced and child marriages, or sex- Globally, over one-third of women report having selective genocide, with brutal long-lasting consequences experienced some form of physical or sexual for all genders and age groups. The risk of human violence. Another study estimates that about 7.6 percent trafficking also increases in fragile situations with the of young boys and 18 percent of girls experienced sexual majority of victims being women and children. abuse over the course of their childhood. It is likely that the actual incidence of abuse is much higher. For Investing in addressing GBV as a public health issue example, a 2005 study of male students aged 13 to 15 supports the emotional health of displaced years in Lebanon reports that 19.5 percent had populations and their rehabilitation. On a humanitarian experienced sexual abuse, defined as verbal harassment level, prevention and management of GBV helps to restore or inappropriate contact. Recent estimates show that 65 and maintain people’s basic human rights. As a public percent of women in Lebanon have experienced health measure, it reduces the risk of unnecessary mortality domestic violence, and about 18 percent suffered sexual and morbidity; and it helps to improve social conditions violence. Fragility and conflict create conditions that are among displaced populations which can also contribute to ripe for the exploitation of people. economic opportunity. 1 WHO should be targeted Q2 for GBV interventions? Women and girls are the most obvious victims of GBV in fragile situations. Beyond outright genocide, violence often takes the form of rape and sexual exploitation. This is used as a weapon of war to create fear and terrorize populations. This tactic has been used by conquering/occupying forces around the globe for centuries. Most recently, in Syria, young girls have been forcibly married, sold, and brutally raped, including gang Photo credits: Dominic Chavez; William Stebbins; Simone D Courtney/ rape, by ISIS. While estimates vary, studies suggest that World Bank sexual violence against female refugees is high. In a series of recent surveys of over 2000 South Sudanese refugees, 65 percent of females had experienced some form of boys also have a role in creating safe spaces for all, such physical or sexual violence, for example. In another as in refugee camps and migration routes, to reduce the smaller survey of Syrian refugee women (n=385), 32 risk of GBV. percent reported gender-based violence. Service providers and security personnel including Unaccompanied children are especially at risk for GBV. emergency responders, peace keeping forces, healthcare Since they are alone, their vulnerability to sexual violence workers, and teachers have a very important role to play. and coercion increases. They are also prime targets for Health services providers are among the first points of human trafficking. There were over 28 million child contact for refugees and displaced populations. Training refugees, including 200,000 unaccompanied children them to recognize and respond to GBV is critical. Similarly, across 80 countries who applied for asylum between 2015 teachers in camps, and other service providers who come and 2016. Violence against children does not only take in contact with vulnerable groups, can help reduce the place when they are on the move. In situations of fragility, incidence through understanding how to recognize signs it can take place anywhere. Young girls in Nigeria, for of GBV and take steps for its prevention. These groups example, are repeatedly kidnapped by Boko Haram, in also need to be properly trained and supported so that they northern parts of Nigeria, to serve as child brides for their themselves do not become perpetrators of violence. men (with the most famous case being of the 276 school girls kidnapped from their hostel in Chibok). Community leaders are a target population as well since they serve as gatekeepers and role models in their People who identify as LGBTI are also especially communities. This holds for refugee camps and temporary vulnerable to sexual abuse and violence during times of settlements of displaced populations. Engaging them as conflict. In Syria and Iraq, for example, homosexual men champions can help to create greater acceptance of health are being brutally executed. In several countries, lesbian and social services and prevent negative behaviors. women have been subjected to ‘corrective rape’ by men to ‘cure them’. Development agencies and civil society are also stakeholders in eliminating GBV. In fragile or conflict Men and boys are a key target population for prevention situations, staff have a responsibility not only provide much of GBV. They can be both perpetrators and victims of needed services, but to ensure that they conduct violence. GBV against men and boys takes the form of sex- themselves with integrity and ensure that vulnerable selective genocide, especially at the early stages of conflict populations are not exploited. (such as in Rwanda and Sudan), and sexual abuse. For example, in a survey of 520 Syrian refugees 10.8 percent of men and boys admitted to having experienced sexual Note: The Inter-Agency Standing Committee’s (IASC) violence. Comparable proportions of non-partner sexual latest guidelines on gender based violence interventions violence are reported by refugee men in Rumbek (9 provide a fuller profile of ‘at-risk’ groups and why they may percent) and Juba (6 percent) in South Sudan. Men and become victims of violence. 2 Figure 1.1 Types of Gender-Based Violence in Humanitarian Emergencies Source: UNFPA 2012 BOX 1.1 International Guidelines for Addressing GBV in Q3 WHAT interventions FCV Situations should be considered?  Inter-Agency Standing Committee’s (IASC) Guidelines for Integrating Gender-Based Violence Gender-based violence has long term repercussions. Interventions in Humanitarian Action (2015) While the complexities of gender, social, and cultural norm  Violence Against Women and Girls (VAWG) that contribute to gender-based violence are too broad to Resource Guide developed by the World Bank, discuss here, suffice it to say that in conditions with poor IADB, the Global Women’s Institute at GWU, and protections for certain groups of a population (such as ICRW (2015) women, young girls and boys, LGBTI), perpetrators are empowered. In fragile and conflict affected settings, there is  UNFPA’s Guidelines on Gender-Based Violence a breakdown of most protections, putting these populations in Humanitarian Settings (2005) at greater risk. Figure 1.1 outlines the nuanced shape of  UNHCR’s Guidelines for Gender-based Violence gender-based violence in fragility and conflict settings. in Humanitarian Settings: Focusing on Prevention Understanding these differences is important for planning and Response to Sexual Violence in Emergencies and implementing interventions that will have maximum (2005) effect. Interventions to address GBV must also take a long- Other Related Resources term approach with an immediate, emergency  UNFPA’s Minimum Package of Essential Services response, and a longer-term rehabilitation approach. (MISP) for providing reproductive and maternal Evidence shows that effective responses to GBV in conflict health services and gender-based violence settings have been varied. The IASC, ICRC, WHO, prevention/management in humanitarian settings UNHCR, UNFPA, UNICEF, and the empirical literature (2015). have outlined good practices in providing supports to victims of GBVs. Box 1.1 presents some of the key  Inter-Agency Gender-based Violence Case guidelines on how and where to integrate GBV Management Guidelines (2017) interventions. 3 The IASC guidelines are the most recent and updated For example, in the DRC, community-based health services set of guidelines for planning, designing, and have had success in reaching victims of violence in South monitoring interventions at the implementation level. Kivu, where access to services was otherwise limited. The guidelines include modules for different sectors including health. The main takeaways from the guidelines Examples of community-based interventions include: for the health sector are:  Provision of community-based psychological and  Develop and/or standardize protocols and policies for social support for survivors/victims. GBV-related health programming.  Community level behavior change interventions that  Engage all stakeholders, especially victims/survivors, actively engage community leaders, men and women in designing policies and programs. for prevention of GBV.  Enable inter- and intra-agency information-sharing on  Provision of food and nutrition support for displaced GBV incidents and take a multi-sector, cross-cutting populations. approach.  Ensure confidentiality, compassion, and quality of care In the medium to longer term, more comprehensive for survivors of GBV, and referral pathways for multi- interventions that focus on mainstreaming GBV sectoral support. interventions may be implemented within the health sector.  Implement monitoring and evaluation throughout the These include, but are not limited to: project cycle.  Establishment or strengthening of referral mechanisms for victims of violence for more comprehensive mental and physical care, as well as Taking a long-term approach: access to legal and other resources. Immediate and longer-term interventions  Expansion and integration of GBV and reproductive health services within the health system as part of the The health sector has a pivotal role to play in managing and essential package of services. preventing gender-based violence in any setting. In fragile and conflict situations, first aid and emergency health  Conduct ongoing training and supportive supervision workers are among the first points of contact for victims of of health staff. violence. It is essential that these personnel are aware and  Ensure quality of care through regular evaluations and equipped to provide support to these people. assessments. Key immediate health interventions include: Finally, in the longer-term, the health sector can also  Training health personnel / emergency responders on collaborate with other sectors through linking victims and recognizing signs of GBV, treatment, counselling, their families with social and economic programs that referral mechanisms, and rights issues. empower victims of violence as part of larger efforts to reintegrate and rebuild. For example, education and  Provision of reproductive and maternal health services income generation programs for girls and women. and ‘dignity kits’ as part of the package of basic/essential health services. In addition, multi-sectoral interventions may also target  Provision of health services to manage GBV. This may perpetrators and victims through and economic include provision of emergency contraception, post- empowerment and livelihood programs that enhance exposure prophylaxis for HIV, administration of rape people’s ability to reintegrate, improve their self-esteem, kits, emergency counselling, and referrals for more and provide economic independence – focusing on comprehensive mental and physical health services. sustainability over a longer period of time. At the community level, good interventions include advocacy and community programs to reduce stigma, engage men At the same time, especially when resources are limited, and boys, and change behaviors. community level interventions may be adapted to reach large groups of populations that have been exposed to violence. 4 WHAT is the World Bank Q4 doing to address GBV? BOX 1.2 Voices from the Field What are the challenges Common Challenges Emerging from Task and lessons learned? Team Leader Interviews  Poor understanding of what gender-based violence encompasses, especially in terms of health sector 200+ World Bank projects that include GBV interventions. since 2012  Poor capacity, not only at the implementation level,  33 HNP operation projects that cover GBV; 10 in but also at the planning level. FCV situations (Table A.2)  Capacity challenges (skill, financial, other  5 non-lending HNP products; 1 in FCV countries resources) in scaling up or mainstreaming GBV interventions within the health sector. 800+ World Bank reports and  The devastation is so vast that economic and social papers on GBV, including: systems are disrupted, and GBV is not a high  World Development Report 2017: Gender Based priority for reconstruction and rehabilitation. Violence and the Law (2017)  Community Based Approaches to Intimate Partner Violence (2016) Key Lessons Learned  Gender-based Violence Prevention: Lessons from  Ensure a common understanding of what World Bank Impact Evaluations (2014) encompasses a health response to GBV so that  Violent Conflict and Gender Inequality (2013) there is a clear understanding of GBV interventions.  Sexual and Gender-Based Violence: What is the  Build capacity at all levels. This includes health World Bank Doing and What Have We Learned, A personnel as well as administrative staff, and the Strategic Review (2013) Ministry of Health.  GBV requires a multi-sectoral response, one that 4 World Bank resource websites engages at the individual and community level to on GBV promote safety and build social networks, along  Expertise: GBV Working Group with key investments in rule of law and jobs.  Brief: Violence Against Women and Girls  Mental health interventions with multiple points of  Blog: Working to Address Gender-based Violence entry/service are a good investment. in Fragile Situations  Collaboration with partner organizations and other  Webpage: Fragility, Conflict, and Violence non-state stakeholders to leverage knowledge, skills, reach, and financial resources is important. Note: Table A.1. presents list of FCV situations Q5 HOW should we evaluate GBV interventions? Evaluation evidence on the effectiveness of GBV interventions is scarce. This is due to a number of reasons, ranging from ethical considerations and measurement issues to timeframe of evaluations and the long term nature of GBV interventions. Moreover, rigorous quantitative impact evaluations of GBV interventions are limited, and in majority of these, small sample sizes often pose measurement challenges. When planning an evaluation, a mixed method approach may be able to provide more insights. Box 1.3 presents several toolkits and resources available to guide practitioners interested in evaluating GBV interventions. These include both quantitative and qualitative methods. 5 BOX 1.3 Guidelines on Evaluating GBV Interventions  Inter-Agency Standing Committee’s (IASC) Guidelines for Integrating Gender-Based Violence Interventions in Humanitarian Action  Toolkit for Monitoring and Evaluating Gender-Based Violence Interventions Along the Relief To Development Continuum by USAID  Measure Evaluation’s Training Module on Monitoring and Evaluation of GBV Prevention and Mitigation Programs goes over key issues in data collection and how to develop an M&E framework.  The Reproductive Health Response Consortium’s (RHRC) Gender-based Violence Tools Manual for Assessment, Program Design, Monitoring and Evaluation in conflict-affected settings includes qualitative and quantitative methods for data collection, sample questionnaires, and guidelines on codes of conduct.  The Strengthening Health System Responses to Gender-based Violence in Eastern Europe and Central Asia Resource Package developed by WAVE and UNFPA discusses several alternative approaches to RCTs for GBV evaluating GBV interventions including outcomes mapping, most significant change technique, and the quality of life battery method.  Proportion of health service providers trained to Indicators for Measuring GBV recognize, refer, and/or clinical care for sexual assault survivors/GBV survivors The Sustainable Development Goals (SDG) Framework  Knowledge of health personnel on GBV related recommends the following outcome indicators for standards of operation measuring the prevalence of GBV. While these focus on  Number of health personnel trained on GBV service women and girls, at the project level, these can be adapted provision that are female for men and boys and multiple age groups.  Attitudes of service providers towards survivors of GBV  Proportion of population subjected to physical, psychological or sexual violence in the previous 12 In addition to outcome and output indicators, the IASC months guidelines also recommend several types of monitoring  Proportion of young women and men aged 18–29 indicators for inputs at the planning and administration years who experienced sexual violence by age 18 level, such as:  Proportion of ever-partnered women and girls aged 15 years and older subjected to physical, sexual or  Inclusion of GBV-related questions in health psychological violence by a current or former intimate assessments and/or surveys partner in the previous 12 months, by form of  Proportion of female participation in health violence and by age assessments and/or surveys  Proportion of women and girls aged 15 years and  Number of health facilities with trained personnel on older subjected to sexual violence by persons other GBV guidelines than an intimate partner in the previous 12 months,  Inclusion of GBV prevention and management in by age and place of occurrence health funding proposals and strategies  Proportion of women aged 20–24 years who were  Female participation in program design married or in a union before age 15 and before age  Existence of a standard pathway for GBV referrals 18  Existence of national policies meeting international  Proportion of girls and women aged 15–49 years who standards for GBV related health services/clinical care have undergone female genital mutilation/cutting, by for sexual assault survivors age These examples of measurement indicators highlight how At the same time, it is important to monitor inputs and different dimensions of GBV related health policies, outputs, especially from the project perspective. While this programs, and projects can be evaluated. The choice of is not an exhaustive list, several key service delivery indicators should be based on factors such resource indicators that can be adapted to FCV situations include: availability, ease of collecting data, and the time frame, while aiming to ensure that GBV interventions are  Availability of social services for GBV victims within monitored and data is available by different demographics acceptable distance such as age, and gender. 6 Table A.1: Harmonized List of FCV Situations (FY19) Middle East Latin East & South East Asia & East & West Africa & North America & South Asia Africa Pacific Central Asia Africa Caribbean Central African Burundi Rep. Kiribati Yemen, Rep. Haiti Kosovo Afghanistan Congo, Dem. Marshall Chad Rep. Islands Djibouti Micronesia, Comoros Congo, Rep. Fed. Sts. Iraq Eritrea Cote d’Ivoire Myanmar Lebanon Papua New Mozambique Guinea Bissau Guinea Libya Solomon Somalia Gambia, The Islands Syria West South Sudan Liberia Timor-Leste Bank/Gaza Sudan Mali Tuvalu Zimbabwe Sierra Leone Togo Live link available at: Harmonized List of FCV Situations Table A.2: HNP GP Projects with a GBV focus Approval Project ID Project Name Country Task Team Leader date AFCC2/RI- Great Lakes Emergency Hadia Nazem Samaha, Patricia Maria P147489 Sexual and Gender Based Violence & Africa 2014 Fernandes, Verena Phipps-Ebeler Women's Health Project Additional Financing Nigeria State P157977 Nigeria Ayodeji Oluwole Odutolu 2016 Health Investment Project Ethiopia Health MDGs P4R Additional P160108 Ethiopia Anne Margreth Bakilana 2017 Financing Nepal Health Sector Management P160207 Nepal Kari L. Hurt, Vikram Menon 2017 Reform Program P160846 Health Sector Support Project Bangladesh Patrick M. Mullen, Kari L. Hurt 2018 P163387 Jordan Emergency Health Project Jordan Fernando Montenegro Torres 2017 AFCC2/RI-Southern Africa P155658 Tuberculosis and Health Systems Africa Ronald Upenyu Mutasa 2016 Support Project Additional Financing NG-Polio Ayodeji Oluwole Odutolu, Ana P158557 Nigeria 2016 Eradication Support Project Besarabic Bennett, Shunsuke Mabuchi Transforming Health Systems for P152394 Kenya Yi-Kyoung Lee, Jane Chuma 2016 Universal Care P123394 Punjab Health Sector Reform Project Pakistan Tayyeb Masud 2013 Strengthening Universal Health P148435 Costa Rica Eleonora Del Valle Cavagnero 2016 Insurance in Costa Rica P144688 Health System Improvement Project Albania Lorena Kostallari 2015 Mozambique Primary Health Care Humberto Albino Cossa, Furqan P163541 Mozambique 2018 Strengthening Program Ahmad Saleem Sri Lanka - Second Health Sector P118806 Sri Lanka Kari L. Hurt 2013 Development Project Health System Strengthening and P152799 Turkey Ahmet Levent Yener, Claudia Rokx 2016 Support Project Regional Disease Surveillance P154807 Western Africa John Paul Clark, Francois G. Le Gall 2016 Systems Enhancement (REDISSE) 7 Nigeria States Health Investment Ayodeji Oluwole Odutolu, Fatimah P120798 Nigeria 2012 Project Abubakar Mustapha Sahel Women's Empowerment and Christophe Lemiere, Margareta Norris P150080 Western Africa 2015 Demographics Project Harrit Nicaragua Strengthening the Public P152136 Nicaragua Amparo Elena Gordillo-Tobar 2015 Health Care System Congo, DRC Health System Strengthening P157864 Democratic Hadia Nazem Samaha 2017 Additional Financing Republic of Health System Support Project Alain-Desire Karibwami, Laurence P156012 Burundi 2017 ("KIRA") Elisabeth Marie-Paule Lannes Health System Support Project Central African P153030 Paul Jacob Robyn 2015 Additional Financing Republic Zimbabwe Health Sector Development P163976 Zimbabwe Ronald Upenyu Mutasa 2018 Support Project III - AF Central African Moulay Driss Zine Eddine El Idrissi, P119815 CF-Health System Support Project 2012 Republic Paul Jacob Robyn P163476 Lebanon Health Resilience Project Lebanon Nadwa Rafeh 2017 Health System Strengthening for Congo, P147555 Better Maternal and Child Health Democratic Hadia Nazem Samaha 2015 Results Project (PDSS) Republic of Additional Financing for the Improving P163313 Maternal and Child Health Through Haiti Andrew Sunil Rajkumar 2017 Integrated Social Services Project Supporting Psychosocial Health and P146591 Liberia Preeti Kudesia 2015 Resilience in Liberia HNP Non-Lending Projects HIV Incentives Evaluations in P151327 Africa Marelize Prestidge 2019 Swaziland Erika Marie Lutz, Alaa Mahmoud P164946 Investing in the Early Years Ethiopia 2018 Hamed Abdel-Hamid Making mental health a global P159620 World Patricio V. Marquez, Sheila Dutta 2018 development priority SN - Health Result Based Financing P145230 Senegal Maud Juquois, Christophe Lemiere 2019 (RBF) impact evaluation Papua New P165595 PNG Nutrition Study Aneesa Arur 2019 Guinea Note: Projects in FCV countries/situations that are tagged for gender-based violence The FCV Health Knowledge Notes Series highlight operational tips to resolve health issues in FCV situations. These Notes are supported by the Middle East and North Africa Multi Donor Trust Fund and The State and Peacebuilding Fund (SPF). The SPF is a global fund to finance critical development operations and analysis in situations of fragility, conflict, and violence. The SPF is kindly supported by: Australia, Denmark, Germany, the Netherlands, Norway, Sweden, Switzerland, the United Kingdom, as well as IBRD. Authors: Sameera Al-Tuwaijri, Global Lead, Population and Development, Health, Nutrition, and Population, World Bank Group Seemeen Saadat, Consultant - Gender and Health Specialist, Health, Nutrition, and Population, World Bank Group For more information on other HNP topics, go to www.worldbank.org/health