Scaling up Gender-Based Violence Prevention and Response in Nairobi and Coast, Kenya

This Pathfinder technical update summarises elements of a programme called APHIAplus Nairobi-Coast Health Service Delivery project (2011-2016) that, as part of a larger health systems strengthening mandate, facilitated the expansion of a gender-based violence (GBV) prevention and response programme to six districts in Nairobi and five counties in Coast province in Kenya and presents recommendations to strengthen Kenya's GBV response
efforts.

Funded by the United States Agency for International Development (USAID), the programme was created in answer to a call by the Kenyan government (GOK) and partners to respond to GBV and the possibility of HIV resulting from sexual violence. The programme builds on a 2009 effort aimed to enhance GBV prevention and response efforts in Nairobi's informal settlement of Kibera, Kenyatta National Hospital (KNH), and nearby health facilities by: "1) raising community awareness about the prevalence, effects, and causes of GBV, citizens' rights and protection under the law, and existing services; 2) engaging communities - including men - in prevention and response efforts; 3) supporting the establishment of a 'one-stop shop' model GBV Recovery Center at KNH; and 4) the formation of grassroots GBV working groups for overall coordination of activities."

In 2011, this model was expanded to 21 hospitals and health centres using Pathfinder's Integrated Systems Strengthening model, intending to reinforce the interaction of community and health systems to prevent GBV and improve availability of services as well as the services themselves for survivors. "The strategy aims to mobilize communities to shift the sociocultural norms and inequities that are at the root of GBV; foster supportive policies; enhance the delivery of quality medical, psychosocial, and legal services for survivors; and strengthen multisectoral collaboration and coordination through community and facility structures and processes." (Figure 1 in the document has key programmatic elements.)

Communication elements include:

• strengthening referral mechanisms;
• cultivating male involvement through sexual and reproductive health (SRH) champions raising awareness and leading dialogues;
• involving schools in youth education and teacher engagement;
• using mass media (Sita Kimya film screenings - described below - and theatre performances, national campaigns, and radio shows);
• training community members and peer educators as paralegals; and
• offering counseling and education on GBV, antiretroviral therapy adherence, economic empowerment, and legal literacy forums.

"Sita Kimya (I Will Not Be Silenced) is a 45-minute film depicting fictional GBV stories to spur community reflection and dialogue around sociocultural norms and gender inequities that fuel GBV....Trained facilitators guide discussion and also provide referrals [at screenings]...Given the film's focus on urban issues, APHIAplus partnered with local theater groups to perform plays that speak to forms of GBV that may be more prevalent in rural settings, such as forced and early marriage, and female genital cutting."

Policy and service strengthening strategies include:

• Assessing facilities for capacity and conditions.
• Building provider capacity through: continuing medical education, on-the-job training, training of trainers, and supportive supervision.
• Analysing and reviewing data and cases for district health management teams and for community volunteer and service provider teams.
• Working on policy changes, guideline formation, and advocacy through participation in the national GBV Working Group and national Gender and Equality Commission activities and ensuring grassroots participation of local working groups
• Offering free legal aid and counselling through subcontracting organisations

Progress to date includes establishment of 5 service delivery locations, training of 3,000 providers and 385 district health teams, creation of 12 emergency safe spaces and shelters, collection of forensic evidence for more than 17,000 GBV cases in the prosecution process, and a "network of 12 GBV working groups that lead and coordinate the multisectoral response and dialogue with national efforts."

Recommendations include the following:

• Establish government ownership of social protection for survivors.
• Improve facility-level documentation of GBV cases.
• Strengthen data collection, for example, protection and support mechanisms to incentivise health workers to travel and attend court hearings and to improve accuracy of documentation.
• Address issues in legal response, for example, delays in processing of cases due to a shortage of eligible legal personnel.