Conduct a situational analysis of the health sector

As a first critical step a situation analysis and mapping should be conducted to determine the health sector’s existing role vis-à-vis violence against women and girls. This type of assessment is crucial to planning, standardizing quality of care among different types of service providers and in coordinating efforts. Periodic assessments will also help monitor the success of efforts and point to gaps and challenges that should be addressed (Bott et al., 2004).

A comprehensive situational analysis should take place at a variety of levels. At the national and sub-national level, the focus might be on implementation of laws, policies and protocols as well as coordination structures, funding and other resources. At the facility level, the focus might be on institutional policies and protocols as well as the range and quality of services. At the provider level, a situational analysis might investigate knowledge, behaviour and provider practices. At the community level, a situational analysis will investigate the nature and type of violence, help-seeking behaviour, health needs, and perceived accessibility and quality of services.

The situational analysis can be seen as an intervention itself, as it initiates public discussion of violence against women and girls, raises awareness, and opens dialogue among key actors and within the community. However, it is critical that all research on violence against women is action-oriented, such that the goal of the research is to improve the well being of survivors.

When planning a situational analysis, it is critical to operate under ethical guidelines and abide by the World Health Organization’s ethical and safety standards for collecting information on violence against women and girls (see resources below).

WHO TO ASSESS

WHAT TO ASSESS

HOW TO ASSESS

Key stakeholders and actors responsible for developing policies and protocols;
Key stakeholders and actors involved in coordination;
Key stakeholders and actors involved in providing services;
Members of the community;
Leaders of the community;
Women’s organizations.

At the national and sub-national levels:

Whether there are laws and policies in place to promote protection for women and girls and support the delivery of ethical and safe health services.
Whether health plans, protocols or other guiding frameworks are in place and whether they are funded.
The level of implementation of policies, plans and protocols, including gaps and bottlenecks, infrastructure, human resource capacity, access barriers by different sub-groups of the population, resource flows among other institutional and administrative factors.
Whether an institutional coordination mechanisms exists at national and/or sub-national level, how it is functioning, which stakeholders are involved and who is not that should be.
Whether prevention services are being undertaken, to what extent, by whom (government, women’s groups, non-governmental organizations or others), for which target audience(s) and the effectiveness of those interventions.

At the level of service delivery (facility and provider):

Which health services exist for survivors of domestic violence, sexual violence and other forms of violence against women and girls that are prevalent in the country or region.
Which entities are providing them (government, women’s groups, non-governmental organizations, others).
Where services are concentrated and where there are gaps.
How they are being financed and what the costs are for survivors.
The level of quality and user experiences.
Who is accessing them and who is not.
What services are provided at different types of health facilities (including hospitals, the emergency rooms of hospitals, one stop centres, reproductive health clinics; during prenatal care; within HIV/AIDS voluntary testing and counselling or prevention, treatment and care programmes).
Whether the facilities provide safety (e.g. security guard, police presence) and confidentiality (e.g. substituting the survivor’s name with a patient number or alias).

At the community level:

Key forms of violence.
Help-seeking behaviour and availability of referral services.
Obstacles to help-seeking.
Vulnerabilities and needs of marginalized groups.
Review existing assessments
Conduct key informant interviews with relevant stakeholders
Conduct focus groups
Undertake site observation

Adapted from Ward, J., 2010, Guidelines on Coordinating GBV Interventions in Humanitarian Settings. New York: GBV AOR Working Group. and Bott, S., Guedes, A., Guezmes, A. and Claramunt, C., 2004. Improving the Health Sector Response to Gender-Based Violence: A Resource Manual for Health Care Professionals in Developing Countries. New York: IPPF/WHR. Available in English and Spanish.

Case Study: The “Critical Path” in Central and South America (Pan American Health Organization)

The Pan American Health Organization’s work on violence against women started with the “Critical Path” Study which documented and provided the first in-depth understanding of what happened to women once they broke their silence an actively sought help: from state services, church and schools in their community, and even neighbours and family members. The “Critical Path” study was carried out in 16 communities of the 10 countries that were included in the two Pan American Health Organization projects to address violence against women and girls. These countries were: Belize, Bolivia, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, Panama and Peru. The study communities reflected the diversity of rural and urban settings in Latin America, as well as that of its ethnic groups. The Pan American Health Organization and its Ministry of Health counterparts selected the study communities based on size, the availability of basic services and the existence of non-governmental organizations and/or women’s organizations. From each community, participants included 15-27 women aged 15 years or older, who were presently experiencing violence and who had contacted a service provider within the previous 24 months. A minimum of 17 providers from among the various types of service centres were interviewed in each community. Data analysis was based on the interpretation of structured questionnaire. Interviews were recorded and transcribed for detailed analysis. The researchers worked closely with community teams to develop their skills and knowledge for collecting, analyzing, and utilizing the results. The Critical Path uses an interactive, qualitative methodology with a standard protocol that is translated and adapted for various ethnic groups. Information is collected through in-depth interviews with women and semi-structured interviews with service providers in health, law enforcement, legal/judicial, education, religious, and non-governmental organization sectors, as well as through focus groups with community members. For an explanation of the research protocol used in the Critical Path, as well as research tools including key informant interviews with sector representatives, individual survivor interview guide and focus group guidelines, see the publication in English and Spanish.

Following from the Critical Path research a subsequent protocol was developed for the purposes of rapid assessment. Conducting a simplified “Critical Path” Survey can be a useful method when it is necessary to generate basic information but there is not enough time, resources, or staff to carry about a more comprehensive study like the one described above. Using a simplified “Critical Path” Survey involves interviewing survivors of violence and those who might provide services such as the health, legal, police and non-governmental organizations in order to assess how the experience is for the survivor and be able to improve quality and enable survivors to overcome bottlenecks identified at different pints of the health and referrals continuum. For a description of the “rapid assessment protocol” and examples of the adapted tools, see the manual in English and Spanish.

Source: excerpted from Velzeboer, M., Ellsberg, M., Arcas, C., and Garcia-Moreno, C., 2003. Violence against Women: The Health Sector Responds. Washington, DC: PAHO, pp. 9-11.

Additional Resources for Research:

Putting Women First: Ethical and Safety Recommendations for Research on Domestic Violence against Women (WHO, 2001). Available in English, French and Spanish.

Ethical and Safety Recommendations for Interviewing Trafficked Women (WHO, 2003). Available in Armenian, Bosnian, Croatian, English. Japanese, Romanian, Russian, Serbian and Spanish.

Researching Violence against Women: A Practical Guide for Researchers and Activists; Chapter 2: Ethical Considerations for Researching Violence Against Women (Path 2005), Available in English.

WHO Ethical and Safety Recommendations for Researching, Documenting and Monitoring Sexual Violence in Emergencies (WHO, 2007). Available in English and French.

Illustrative Tools for Situational Analyses:

How to Conduct a Situation Analysis of Health Services for Survivors of Sexual Assault: A Guide (Sexual Violence Research Initiative, 2006). Available in English.

Needs Assessment Checklist for Clinical Management of Survivors of Sexual Violence (Pan American Health Organization, 2010). Available in English and French.

A Practical Approach to Gender-Based Violence: A Programme Guide for Health Care Providers and Managers (Billings/UNFPA, 2001). The guide provides detailed guidance on planning and implementing GBV assessment and treatment into reproductive health services in low resource settings. Available in English, French and Spanish.

“Conducting a Rapid Diagnosis of the Situation” in Improving Health Sector Response to Gender-based violence: A Resource Manual for Health Care Professionals in Developing Countries (International Planned Parenthood Federation/Western Hemisphere Region, 2004). See pp.18-21. Available in English and Spanish.

Situación De Los Servicios Médico- Legales Y De Salud Para Víctimas De Violencia Sexual En Centroamérica (Claramunt M. and Cortes M./PAHO, 2003). See annex 3, “Contenido de informes nacionales, pp 61-67; Cuadro, #8, “Existencia de profesionales por tipo de institucion Honduras,” p. 23; Cuadro #14, “Numero de instancias por pais,” p. 31; “Cuadro #17, “numero de instancias por 100,000 habitantes en Belice,” p. 32. Available in English.

Twubakane Gender-Based Violence/Preventing Mother to Child Transmission Readiness Assessment (IntraHealth International, 2008). Available in English and French.

Ver y Atender! Guia Practica para Cononcer como Funcionan los Servicios de Salud para Mujeres Victimas y Sobrevivientes de Violencia Sexual (Troncoso, E., D. Billings, O. Ortiz and C. S. Suárez/ IPAS and UNFPA, 2006). Available in Spanish.

Organizational Assessment for Agencies Serving Victims of Sexual Violence (The National Resource Sharing Project and the National Sexual Violence Resource Center, 2010). This tool was developed to assist organizations that serve victims of sexual violence in identifying strengths and strategies to improve their practice. The assessment is available in English.

See additional facility assessment resources in Identify the needs of a facility through an assessment.

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