Author: Cathy Green, Technical Lead, Community Health Systems, Health Partners International, January 9, 2017The elimination of all forms of violence against women and girls is a key priority of the United Nations Sustainable Development Goals (SDGs). In Zambia, where gender-based violence (GBV) rates have been persistently high, the government is taking important steps to address the issue. Between 2014 to 2016 the Comic Relief-funded More Mobilising Access to Maternal Health Services in Zambia Programme (MORE MAMaZ) worked with the Ministry of Health (MOH) and district health management teams (DHMTs) in five districts to support the process of integrating a focus on GBV into the national Safe Motherhood Action Group (SMAG) initiative, part of the government's safe motherhood policy response. Complementary supply- and demand-side interventions were supported within a community health systems strengthening initiative that aimed to improve women and girls' access to maternal and newborn health services. The positive results achieved suggest that there is considerable potential to scale up these interventions both within and outside Zambia in future.

Background

Despite a favourable policy environment with the introduction of an anti-GBV law, GBV statistics in Zambia remain high. Of women aged 15-49 years, 43% have experienced physical violence at some point in their lives, 37% in the previous 12 months. Moreover, 17% of women and girls have experienced sexual violence, and 10% have experienced violence while pregnant (2014 Zambia Demographic and Health Survey).

GBV is a driver behind the high HIV rates in Zambia. It damages women’s mental health and well-being, and can affect unborn babies if the violence occurs during pregnancy. GBV also has extensive economic and social impacts as women and girls who are affected forego opportunities for social interaction and income-generation. The widespread nature and persistence of GBV, coupled with the fact that many Zambian women accept GBV as a normal, routine part of life points to the difficulty of changing attitudes and practices.

Continuing the work of a predecessor programme, MAMaZ (2010-2013), which was funded by UK Aid through the Department for International Development, the Comic Relief-funded MORE MAMaZ programme (2014-2016) took steps to integrate a focus on GBV into the training of Safe Motherhood Action Group volunteers.

Baseline studies implemented by MAMaZ in 2010 revealed that women’s low status within gender relations led to physical violence in some households. GBV was often associated with heavy drinking in locations where cheap alcohol was readily available. The baseline studies also revealed that GBV was a silent issue at community level, with the prevailing social norm being that “whatever happens within the household, stays within the household.” Even in instances where other community members recognised that family, friends or neighbours were suffering as a result of GBV, there was a reticence to intervene.

Strategy

Maternal health, and specifically safe pregnancy and delivery, was used as an entry point to begin to address GBV. Community discussion groups involving men and women of all ages provided an opportunity to reflect on the steps that men could take to lighten women’s work burden during pregnancy, take care of their health and nutrition, and generally enhance their well-being. This non-confrontational entry point led on to discussions about GBV, since many disagreements at household level were said to arise as a result of women being perceived as not working hard enough during pregnancy. A focus on ‘sad memories’ where community members recounted instances of where women or babies in the community had been injured as a result of GBV, led to discussions about the steps that communities could take to avoid such situations in future.

A focus on peer education, where male SMAGs worked with other men to share their stories and ideas for change, was adopted as a key programme strategy. Male SMAGs shared their own stories about GBV during discussion group sessions, and door-to-door visits to individual households. Some recounted how they had beaten their wives in the past but had recognised the damage this had done, both physically and mentally.

Based on the community discussions, intervention communities embraced a ‘Zero Tolerance for Wife Beating’ campaign. SMAGs composed songs about the campaign and used these as a medium to spread the anti-GBV messages. This traditional method of information dissemination, helped to shift prevailing social norms about the acceptability of GBV.

SMAG volunteers encouraged community members to report GBV, and organised themselves so that they could intervene where necessary. The support of traditional leaders was sought to reinforce the importance of the campaign. Traditional leaders readily embraced the campaign, in the knowledge that the government legislation legitimised their efforts. Their inputs ranged from cautioning or fining perpetrators of GBV, and threatening to, or actually reporting, men to the police.

At health facility level, front-line health providers were given a training on social exclusion. This looked at the links between GBV, exclusion, and low service utilisation. Health providers’ capacity to identify the least-supported women, including those affected by GBV, and to counsel and put them in touch with support services was built.

The programme’s gender empowerment approach increased women’s and girls’ knowledge of their right to a safe pregnancy, promoted their participation in programme activities, and created opportunities for community-wide reflection on disabling social and gender norms that affected women’s well-being and how these could change. The empowerment strategy created an enabling backdrop for the work on GBV, where improvements in women’s and girls’ confidence to speak out and articulate themselves, and to share their worries with others, challenged the taboos around GBV.

Results

The MORE MAMaZ GBV interventions resulted in transformative change for women. Intervention communities reported a very significant reduction in GBV. Some communities perceived that GBV had been eliminated altogether, with these changes attributed to the work of the SMAG volunteers. These changes were captured in the programme’s statistical endline survey, where 89% of male and 88% of female survey respondents reported that wife beating had declined. Comparable results in control sites were 72% and 76% respectively. In intervention districts, 79% of men and women attributed the decline in GBV to the work of the SMAGs, compared to 23% and 24% respectively in control sites. SMAG volunteers in the intervention sites were widely credited with having reinforced anti-GBV messages espoused by national government and the Church, allowing these to be operationalised in practical ways at community level.

Other significant changes included the willingness of former perpetrators of GBV to act as peer educators to other men. Peer discussions were handled sensitively with SMAG volunteers who recognised that men who were violent were from their family, or friends and neighbours. This constructive approach created space for men to change while retaining their pride and self-esteem. Significant changes in drinking habits were reported as a result of the SMAGs’ emphasis on reducing alcohol consumption in support of the anti-GBV campaign.

Community members reported greater harmony in the home. SMAG volunteers appeared more willing to intervene to address or prevent cases of wife battering, and there was greater willingness on the part of victims to report GBV and to seek justice, including through the traditional governance system.

Results from the supply-side intervention were also positive. An evaluation of this component found that front-line health providers trained by the programme reported that their increased probing in clinics made women more willing to talk about GBV. Although health staff were supposed to refer these cases to the police, after the training they spent more time counselling women, trying to interview domestic partners, and suggesting other forms of community support for the women. Hence the supply-side intervention reinforced and complemented the community-based intervention.

MORE MAMaZ and its government partners at national and district level demonstrated the feasibility of integrating a focus on GBV into the national safe motherhood policy response. The demand and supply-side interventions proved to be culturally sensitive, effective and low cost. They lend themselves to further scale up, both within and outside Zambia.

For further information on MORE MAMaZ's anti-GBV work, including lessons learned and policy implications, click here.

This blog was written by Cathy Green, Technical Lead, Community Health Systems, Health Partners International. Email: cathygreenhpi@gmail.com. Click here for Health Partners website. Twitter: @healthpartners; @cathygreenhpi

MORE MAMaZ was implemented by a consortium comprising Transaid, Health Partners International, Development Data and Disacare.

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