Awareness and understanding of GBVR vouchers and services
Qualitative findings demonstrated a low of awareness of the GBVR voucher and lack of understanding of the benefit package offered. In particular, providers and health managers exhibited a poor understanding of what the benefit package entailed. There were also conflicting statements on the procedures to be followed while providing medical treatment to survivors. For example, some providers stated that the law requires clients to report to the police first and obtain the police medical examination report (also known as the “P3” form) in order to get treatment. There also appears to be lack of clarity on who is mandated to fill in the P3 form. This led to calls for additional training and clarification on procedures to follow in offering GBVR services.
"They need to include other things – for example, train on counseling on how to handle rape care, which has been challenging. Also, train on the P3 forms [post-rape forms], which are not well known….also train on long-term family planning methods and more nurses should be trained on emergency contraception because they are few (IDI, service provider)."
In addition, many participants commented that the GBVR services voucher is little known by beneficiary communities and those with some level of knowledge lacked adequate information on the service package and where the accredited facilities were located. In particular, the majority of women (both those who had used other vouchers and those who had not) indicated that they did not know the GBVR services sites or they had difficulties accessing the accredited facilities. A participant, for instance, noted:
"I know of the safe motherhood and family planning vouchers. This one you are asking I have never heard about it (FGD, voucher user)."
"We have not been given information adequately by the voucher distributors; they should put more effort so that the vouchers are brought near. Some do not know about the vouchers; they are not enlightened. Educate people because many have not heard about the GBV voucher you are asking [us about]. Educate them in the barazas [weekly meetings held by chiefs and assistant chiefs] at the chief’s place by bringing educators (FGD, voucher user)."
Stigma and access barriers
Although providers acknowledged that the GBVR services voucher has expanded access to services among some segments of the poor, it was widely believed by many community members that GBV is a minor offence or “family matter” that can be easily dealt with. Many families withhold information on sexual GBV-related cases with the intent to protect the family name. Similar views were held by government officers, VMA managers and members of the community who observed that deeply-rooted stigma hampers access to GBVR services.
"… When we talk about gender-based violence in our area, people still don’t understand it very [well], and people relate it to the family. What if I go tell my husband about it? What will happen to my marriage? How will the people in the community perceive me? What about my family members, how will they perceive me? That is why you see the uptake is low. People are trying to safeguard their families, no matter how bad things are [perceived in the community] (IDI, service provider)."
"I think it (GBV) is much stigmatized. If we can de-stigmatize that system then it would be better. People will access it. Most of these rape cases or violence occurs at home. It’s by people who know you within the families, so when it is taking place within the family, these are the same people who are supposed to take you to hospital. Do you want to expose that your father has raped you or your brother or your cousin? So most of them take place within the family. Even if it is known, it is discussed within the family and that matter is closed (IDI, District Officer)."
"The gender violence voucher is a bit tricky because not many mothers will come in and say I was raped because of the stigma (IDI, VMA Manager)."
"I think also…there is fear to go to health facility. Fear of being known that she had been raped or something like that, so she keeps it to herself and can’t tell anybody. So you find these cases are not reported and they can’t get the cards for subsequent services (FGD, voucher user)."
Discussions with voucher distributors also revealed community members’ perceptions that there are hidden costs in the voucher program and a reluctance to use free services. There is evidence in the narratives that community members were skeptical about the GBVR services voucher being entirely free. As one voucher distributor explained:
"I believe it is not used because it is only found in the facility [as the distribution point]… I, as a voucher distributor based in the community, know that the locals believe I have two vouchers with me; none is free, so how can the GBV voucher be free? I think maybe they go to the facilities and are not aware the GBVR services are free. Before, GBV costs were around 1000 shillings, now if they don’t know about the information they think they will be charged when they go there (FGD, voucher distributor)."
To address some of the barriers to GBVR services mentioned, voucher distributors and the VMA field managers recommended that community sensitizations be intensified by working closely with local authorities and administration to create general awareness of the GBVR services vouchers and information on where to obtain services. Additionally, voucher distributors felt that they should be allowed to hand out GBVR services vouchers in the community to dispel the belief that they are for sale.
Opportunities and challenges for GBV voucher program functioning
Poor understanding of GBVR service voucher program, lack of essential commodities and the dearth of trained personnel mean that most facilities do not have the capacity to adequately provide comprehensive GBVR services. The situation is dire for rural-based facilities that face perennial shortages of supplies and understaffing. For instance, health providers at a recently upgraded sub-district hospital (from health centre status) indicated that although they were endorsed to offer GBVR services, they lacked essential supplies and personnel to support the services. There was also a common perception that the referral service was rarely used by patients because of the long distances covered and time taken to access services.
"We normally refer to the District Hospital though the [GBVR] vouchers have been given to the sub district hospitals too. But the laboratory facilities are not in the sub district facilities so the best thing is they should equip the labs in the sub district hospitals (IDI, service provider)."
"Also this person may come and most of the hospitals of this category may not be able to handle those cases of sexual violence. They may not have the ARVs [antiretroviral drugs] to give; they may not have the tests to do. So you may have come, you’ve been raped and then you are referred to another institution so that system takes time and you feel it’s not really worth it. Therefore most of them give up on the way (IDI, service provider)."
Many community distributors explained that marketing GBVR services vouchers was a difficult task given the longstanding social and cultural taboos observed in most communities. Moreover, the poor understanding of the voucher was a result of the single source marketing strategy used to promote the services (only voucher distributors were used to sensitize the community about these services). According to the distributors, multiple sensitization strategies are required to break the barriers. Many felt that over reliance in them or their peers to pass on critical GBVR services information is not enough to break some of the barriers that communities still hold. To counter these barriers the distributors noted that important additional information should be availed to community members.
"I support that a strong road show should be done about the gender violence voucher so that it can be in public domain. We also as distributors should be given the GBV voucher so that when we are in the community, where they know our telephone numbers they can inform us about it. And when she contacts the distributor, you will tell the patient to go to the accredited hospital and confirm that there will be no payment as she will be afraid that now I’m going to be charged because they are normally afraid about being charged (FGD, voucher distributor)."
"It (GBV voucher) is not being used due to the lack of enough information. I can say that information on where the voucher is given and where one can get and use the voucher is not known in this community especially in the interior areas (FGD, voucher distributor)."
Our findings also suggest that the utilization of the GBVR services voucher is to a great extent affected by the perceived quality of care provided at various facilities. Women and voucher distributors noted that some facilities are not entirely trusted by the community. Many distributors were of the view that community members distrust staff’s ability to maintain client confidentiality and offer quality services. It was felt that some facilities score poorly in service provision leading to reluctance to visit such centers. Focus group discussions with community opinion leaders reinforced concerns that facilities lacked designated units to attend to sexual assault survivors. In most cases, survivors had to follow the same procedures used by regular patients.
"I believe it (GBV voucher) is not used because it is distributed in the facility. This facility treats them badly, even rape cases, and they do not have faith in them (FGD, voucher distributors)."
"There is a problem with the gender violence desk when you seek services for sexual assault because you will go through the same process a sick person goes through (FGD, community health workers)."
Service providers noted that some accredited facilities, especially public facilities, lack the required equipment and supplies. Some clients apparently seek care, but experience delays in receiving appropriate treatment due to frequent stock-outs. The participants also reported that not all providers, especially those in rural facilities, have the necessary skills to handle GBV cases. As a result such facilities often end up referring clients even though a majority of the population are poor and cannot afford the transportation costs.
"…even I, as facility manager, don’t know for example if they (GBV survivors) did come to my place what am I supposed to do? I just do my first aid and just check to see that they are physically okay. Then for the further management I just refer them to facility xxxxxx. In between, I don’t know what is happening (IDI, facility manager)."
Challenges with seeking legal redress
The most common reason stated as preventing GBV survivors from seeking justice was the inability of the criminal justice system to apprehend and prosecute the perpetrators. According to respondents some individuals in position of power such as village elders or the provincial administration collude with suspects to drop the charges, ensure that the cases are concluded in favor of the suspects, or that the cases take longer than necessary before a ruling is passed. In addition, many respondents felt that the law enforcement agencies are not well trained to handle sexual assault cases. The significance of seeking legal redress and whether individuals ever get justice emerged as a sub-theme within this discussion. The subject drew various reactions, for example:
"If you take a sexual case to the police, you know the way the police handle such cases [the survivors] are really treated so badly. They don’t feel like going back or following up that matter, so I think there should be good customer care (IDI, service provider)."
"… ..you know the community fears breach of confidentiality, so we should inform them [survivors] that when they seek medical assistance the matter would be confidential. If the report goes directly to the police stations or the elders, the matter would not be confidential, so the best thing is to seek medical treatment without going through the police and elders (FGD, voucher distributor)."
In summary, inadequacy of the investigative process and legal representation was cited as undermining the due process of the law. It was felt that at times the police lacked the ability to successfully investigate and see the cases to the prosecution stage. Lack of resources on the part of the community to afford legal representation is also a deterrent. There were also ambiguities on which procedures to follow; it is not clear to providers whether one should seek treatment first or report to the police.