This report was commissioned by Medica Afghanistan and medica mondiale in September 2016.
The overall goal of the transnational health training project (THTP) is to contribute to improving the health sector response to violence against women (VAW) and thus to the empowerment and stabilization of women survivors of sexual and gender based violence (SGBV).
The objective is to increase access to healthcare services for women and girls affected by SGBV through improving the quality of care of the healthcare services at the local and national level. The project aims at sensitizing the Ministry of Public Health (MoPH) at the national and provincial level on the need for improved knowledge, skills and attitudes regarding trauma and its consequences for women and their children.
The present baseline study, commissioned to Thousand Plateaus Consultancy Services, was designed to inform medica mondiale and Medica Afghanistan about the current situation regarding the quality of care for survivors of SGBV. The baseline study collected quantitative and qualitative data through exit surveys with female patients, Knowledge, Attitudes and Practice (KAP) surveys and FGDs with health staff, health facility check-lists, FGDs with women in shelters, and interviews with key stakeholders.
• In the exit survey with women, 7% of patients had been treated for abuse-related health concerns in the services they had received that day at the facility; 3% for injuries sustained during physical or sexual abuse; 8% for self-inflicted injuries; 7% for emotional consequences of abuse; and none for a mandated virginity exam. 12% reported that their healthcare provider had asked them questions regarding whether they were experiencing physical or sexual abuse.
• Only 4% had reported abuse to their healthcare provider where two said that their healthcare provider had encouraged them to report their abuse, and one that their healthcare provider had reported their abuse to authorities. Two had received information regarding laws that protect them from abuse from their healthcare provider. Only one woman had received information regarding physical consequences of abuse, regarding the mental and emotional consequences of abuse, and regarding supportive services available.
• 22% of patients surveyed had been treated for abuse-related health concerns, 23% for self-inflicting injuries, 7% received treatment for the emotional consequences at some point in their life.
• 28% of patients surveyed agreed with some justification for SGBV and among the patients surveyed 84% are at risk of domestic abuse.
• 81% of patients agreed that the facility is always open and staff is present during its normal operating hours; 86% of patients interviewed in the 7 GBV and trauma - sensitive health care in Afghanistan exit survey agreed that there are female staff members available when they need to seek health services at the facility; 37% of patients disagreed that sometimes the healthcare treatment and support that health providers at the facility provide are not in line with cultural norms related to gender, religion, or society.
• 47% of patients reported that there was some type of monetary cost associated with the services they had received. Of those who reported having to pay fees, 9% paid for services, 78% for medication, and 10% for tests or laboratory fees.
• The majority of patients interviewed were Dari-speaking (95%), and services were mainly reported to be given in Dari (92%), with very few reporting receiving services in other languages. 11% of patients reported that in the past year, there had been a time when they wanted to see a doctor, nurse, or other healthcare worker but were unable to because their family member/s didn’t allow them to seek treatment.
• 60% of patients surveyed agreed that if there is no female healthcare professional available, it is okay for a woman to seek treatment from a male healthcare professional. 19% agreed that if a woman is being abused by her husband, it is a private family matter and she should not seek help from public facilities.
• 45% of patients surveyed agreed that they would feel offended if a healthcare provider asked them about physical or sexual abuse. Only 55% agreed that they would feel comfortable seeking treatment at a healthcare facility if they experienced abuse from a family member and 51% agreed that they would feel comfortable seeking mental health treatment.
• The physical and emotional safety of patients and staff is low with hospitals scoring below 50% with patients and staff is low with hospitals scoring below 50% with Malalai hospital in Kabul scoring only 13%. Safety was seen as a major problem for hospital staff where patients generally feel safe at the health facilities.
• Trustworthiness, that is supported by clear information sharing practices and having policies in place that ensure services are clear, including establishing boundaries, informed consent, and clear establishment of roles and responsibilities for both clients and staff, scored between 50 and 60%, which could be interpreted as moderate level of trustworthiness. Patients felt trustworthiness as higher, which could be interpreted as lack of comparison in terms of what constitutes quality of services due to a disrupted health system till at least a decade ago.
• In terms of choice and control, the CCTIC framework looks at to what extent the program’s activities and settings maximize both client and staff experiences of choice and control. Facilities in Kabul scored between 60 and 70%, with facilities in Herat and Balkh scoring around 50%. In terms of choice, on a scale from 0 to 5, on average patients rated the health services they had received a 3.72, suggesting a generally high level of perceived choice with the lowest recorded in Balkh.
• In terms of collaboration, the CCTIC framework looks at to what extent the program’s activities and settings maximize collaboration and sharing of power between staff and clients, and to what extent the program’s activities and settings maximize collaboration and sharing of power among staff, supervisors, and administrators. Health facilities scored low in terms of collaboration, with scores between 30 to 35% in Kabul and with even lower scores - below 20% - in Balkh and Herat. On the other hand, exit surveys with patients conclude on high collaboration in the relationship between patients and health staff.
• In terms of empowerment activities and settings prioritize both client and staff empowerment and skill-building and the extent to which staff members have the resources necessary to do their jobs well. Hospitals scored mostly over 60% with a relatively high staff and patient empowerment with the exception of Malalai hospital in Kabul, which scored only 28%. The exit surveys with patients revealed a high level of perceived empowerment of patients.
• Trauma screening practices scored low in all hospitals, with only Rabia Balkhi scoring 27% and the remaining facilities 0%. The finding is also compounded by the KAP survey with health staff, who showed varying levels of appropriate practice when working with a survivor of GBV.
• Based on the findings of the health staff KAP survey, 17 respondents (81%) reported receiving training on trauma prevalence, impact, and recovery. When asked about training specific to Creating Cultures of Trauma-Informed Care (CCTIC), the participants overall reported low levels (less than half) of training.
• Health workers’ attitudes relating to SGBV are of concern and these mostly did not report appropriate attitudes.
• Four health workers felt that preventing, detecting and managing GBV is not part of the work of a health provider (19%) and three that violence against women is a family matter and not a matter of public health policy (15%). Eight (38%) believe that 8 GBV and trauma - sensitive health care in Afghanistan health service providers do not have time to inquire about GBV. Notable is the discomfort in health providers for addressing IPV as almost half do not feel comfortable discussing IPV or sexual violence with patients as over half (11 respondents, 52%) think that asking patients about IPV could offend them.
• Other worrisome responses provided from health workers were related to knowledge of the prevalence of SGBV in Afghanistan, consequences of GBV specifically related to HIV/AIDS, and risk factors related to women experiencing and reporting violence. Only 52% of surveyed health workers accurately identified that Afghanistan has specific laws on GBV/IPV.
• Health workers demonstrated mixed competency in terms of practice related to GBV. There were mixed findings in terms of how providers should assess risks of GBV, with the majority of respondents (95%) indicating they should ask the client if she has ever been hurt, 86% asking if she is currently in danger, and concerning is that 81% indicated they could ask what she may have done to be abused as to avoid it in the future. However, only around half of the respondents indicated they could assess risk by asking the woman if violence has increased in the past year (52%) and asking if she worries about the safety of children (62%).
• Health workers scored high in terms of compassion satisfaction, which is related to satisfaction of one’s ability to be an effective caregiver in their job.