Welcome, this is part 2 of our India Case Study. So we're going to reflect on some of the lessons learned from our guest speakers and from some of the information that we've heard about the unique context of India, and what that means for prevention, policy, and care for survivors. So what sets India apart? We've heard here that violence is truly prevalent in about one in three women, yet this is also on par or comparable with our international and global estimates of violence against women. What is unique about India and the context of South Asia is some of the forms of violence, including dowry related crimes. We've also heard from Dr. Anita Raj about the prevalence of child marriage and how this puts young women at risk in particular for gender based violence. We've learned that India's one of the few settings where adolescent women are actually at greater risk of partner violence relative to adult women. We've also seen from a policy perspective that some of the higher profile media cases, the events of 2012, have really sparked international attention and also a policy response. We've seen from some of our providers that there are shortages in support services in some areas. We've seen some of the best practices, but we also know that in many areas, particularly rural settings, women don't have the same level of access to support services and types of NGOs. Historically, we've heard from PUDMA and others that this context of women's limited empowerment and decision making in families can put them at risk for violence and render them with few options other than tolerating abuse from a partner. Finally, through our examples and some of our case studies, we've tried to really highlight some of the innovation in violence prevention. And also really in addressing violence in the health sector. So where are we in terms of integrating violence support in the health sector? We've heard that since 2005 there's been provision for medical care in cases of violence against women. And that's part of the Protection of Women from Domestic Violence Act. Yet in practice this hasn't been integrated the way that it could be, in part because of lack of clinical protocols and guidelines in this area. More recently in 2014, we learned that there's a national directive on the health sector response specific to sexual violence, and that's from the ministry of health and family welfare. We're also learning at some changes in the ways that violence is documented. So some of the leadership and some of the work that Cehat is doing is changing the ways in which sexual violence and gender based violence are reported and documented. And that's a gender sensitive proforma, something that is new and very innovative. Making sure that we're moving away from judgmental language and non-scientific documentation to something that is gender neutral, something that is non-victim blaming. And really documenting the necessary elements. We've also learned through the assembly of case studies that we've had that there are really many models for connecting victims with care when we're thinking about women that are coming into the health sector. So this is achievable through links, simply links with support organizations like Swayam. At a second level, or a somewhat higher level, we see that there are on site services like public hospital crisis centers, Dilaasa is the example here. And finally, we've also seen that we can integrate a gender based violence response even within primary care. Across these three areas we've heard that provider sensitization and training on identifying and supporting victims of abuse is really key to making those connections happen. We've also learned that policy prevention and support are really integrated. When we heard from Swayam we learned that they blend very intentionally. They're direct support for survivors with their prevention activities, and also, their policy advocacy. When we look at the example of Cehat, we see that they're working on the public hospital based crisis center Dilaasa. They're weaving in these protocols for responding to domestic violence, as well as sexual assault. But they're also working on developing this comprehensive health sector model for responding to sexual violence. Very much working to integrate that into practice. And finally, when we think about the legal or the policy aspect of all of this, they're developing these gender sensitive protocols for public interest litigation, and now even the supreme court. So again, policy, prevention, and support are very much integrated when we're thinking about a comprehensive response to gender-based violence. We've also learned about the value of advocacy, emotional support, and validation. We learned that an empathetic validating response to violence is key when we're thinking about frontline healthcare providers. This is very much aligned with the WHO guidelines. This is ever more important because we've learned about some of the barriers that this obtaining support and care that are global, but also very unique in some ways to the Indian context. Part of this is the emphasis on sexual violence from strangers. And this really minimizes the prevalence and the burden of violence from partners. It's emphasized in our policy documents, it's emphasized in some of the media narratives. And so understanding that an emphasis on sexual violence might minimize violence from partners, is really critical, and we've heard that from our providers throughout. We've also heard about familly-instigated and also simply internalized blame and shame around violence. Some of the reasons that women do not come forward for care. We heard that from Padma, we heard that from Anu in talking about the Swayam work. And we have also heard that this is perpetuated in the justice system. Why is this so important for us? It's one of the areas that we can overcome as frontline providers, as providers that are working with victims of violence and possible victims of violence. Being knowledgeable about these barriers to obtaining support or even disclosure helps us anticipate and respond to that. We've also heard that the group context, including those support groups, and the workshops can really enhance that sense of empowerment can act as a buffer. This is reminding us that getting women connected with support services can really, really help them. Whether or not it's going to protect them from their perpetrator, we don't know. We're never able to guarantee that. But what we do know is that we can foster resilience by connecting women with care. So moving more concretely to some of the clinical implications we have heard again from our direct servers providers that support is really the most valuable element of receiving assistance for violence. And again, our health care system conserve as a conduit for support and also referral to those support providers. There's some unmet needs as part of this as well. In order to really realize this, we've gotta improve that referral system to support providers like Swayam. They've got a great system in place, and for those of us that are working in settings where we might not have that referral system in place to those providers, that's something that we can really work on to strengthen on making sure we have those connections and those referral that works to care. We can identify and support domestic violence survivors in addition to sexual assault. We've focused heavily in India, part of the media narrative and part of the narrative on India really emphasize this over the cap passed several years has been around sexual violence. And so we've gotta broaden our lens to really also be addressing domestic violence, intimate partner violence, as a driver as well of the abuse that women are facing. Finally, we heard that we really must support women who may fear reporting, that violence is the source of given injury or given health problem. As we heard, many women are reluctant to name a source of an injury. They may make up all kinds of other excuses for them. So we've gotta be attentive to that. Anticipate it, and create a space where people do feel really comfortable in disclosing, so that we can provide that level of support. Again, the WHO guidelines can really serve us here, in giving us a rubric for listening, validating, supporting, and referring. So thinking about the policy response. This is obviously taking place against a landscape of social dynamics and also the policy dynamics that are driving, in some sense in very direct ways, the health sector response. So we've heard that we've had this legal mandate since 2005 with relatively minimal integration practice and this is really changing now. This is really changing, in part with the medical and legal protocols for the treatment of sexual violence that just emerged. And, of course, there's still work to do. So we also learned that the conviction rates for sexual violence really range very widely within India. So this is a challenge for us in terms of insuring that victims have access to justice or even feeling like we have something to offer them when they're coming forward to the healthcare sector. We've also learned that there is often limited institutional policy for addressing violence in the health sector. This is an area that we can work with our administrators, to realize the integration of some of these protocols really into practice. We can draw on some of the lessons learned from Sanita and Padma in terms of how we can strengthen that system. And again, the legal and the policy narratives very much emphasize the sexual violence. So currently in 2015, despite the fact that we now have these protocols for sexual assault, we don't yet have these parallel protocols for domestic violence. There's work underway to develop them, thanks to Cehat and others, but they're not yet active at a national level. In the interim our WHO guidelines can be very helpful, however, there is really a need to push forward and generate some national level protocols. Because we know that the ways in which violence is responded to and the options for survivors the processes are very much dictated, often times, by other elements of national policy. So we want those to be tailored. We want to be able to have documentation that's providing very direct instruction around this issue, specifically of domestic violence. So this is an area for advocacy. And it's a reminder to us that, even though the guidelines themselves, specific to India, do really emphasize sexual assault, we really want to keep pushing that and try to figure out how we can implement and develop truly guidelines around domestic violence as well. Again our WHO guidelines are helpful in the interim, so that is our best step here now, as well as some of the lessons learned from Cehat. Thanks.
