Photo Credits &copy;&nbsp;DailyNews/2020
Egypt is facing a remarkable challenge concerning sexual and gender-based violence (SGBV), which poses huge negative health, social and economic impacts on the community. In 2014, the direct and indirect economic cost of violence against women is estimated to be at least EGP 2.17 billion (Untitled Nations Population Fund [UNFPA], 2015). According to the latest Demographic Health Survey, around three in every 10 married women have experienced spousal violence, including sexual assault (El-Zanaty and Associates, 2015). With the rise of SGBV incidents in the MENA region lately (CARE, 2020), a wide discussion over the healthcare services provided to the survivors is emerging in the public sphere. Love Matters and the Tadwein Gender Research Center have launched online campaigns to promote the importance of providing holistic care for sexual violence survivors; the absence of accessible, comprehensive affordable health services for sexual violence survivors in Egypt has been discussed in a previous Alternative Policy Solutions (APS) commentary (APS, 2020; Dostor, 2020). In light of the World Health Organization&rsquo;s (WHO) recommendations which emphasize integrating SGBV healthcare services in every health facility, Egypt is establishing its first units dedicated to providing health services for sexually and gender-violated women (WHO, 2003).
Around a month ago, the National Council for Women (NCW), the UNFPA, and some Egyptian universities decided to allocate units in Obstetrics and Gynecology (OB/GYN) departments to address SGBV survivors&rsquo; needs. The Cairo University hospitals (Al-Qasr Al-&lsquo;Ainy) have launched the first so-called ''safe woman'' unit. Ain Shams University and Mansoura University subsequently established similar units, and soon another unit shall be established in Assiut University. The launching events of Al Qasr Al-&lsquo;Ainy and Ain Shams units, held in the respective university hospitals, were covered by various media outlets, promoting the readiness of the units to receive violated women and provide them with comprehensive care. ''Safe Woman'' units aim to provide medical, legal and psychological support for violated women. The units are open from 8 am until 2 pm, and all the services provided are free of charge.&nbsp;
Informative interviews with university officials reported that the main responsibilities of the unit are to:
<ul style="text-align: justify;">
<li aria-level="1">Provide the violated women with the medical care needed, including emergency contraception pills in case of rape.</li>
<li aria-level="1">Refer her to psychiatrists to receive psychological support.&nbsp;</li>
<li aria-level="1">Refer her to the forensic medicine department upon the woman&rsquo;s request.</li>
<li aria-level="1">Provide awareness of the other services available for violated women, such as the hotline for reporting and legal services and the shelters provided by the Ministry of Social Solidarity.&nbsp;</li>
</ul>
Given how recently the units were established, it is quite difficult to evaluate their functionality and effectiveness, especially with the scarcity of the information regarding their operations. Hence, the commentary aims to discuss the functionality of creating separate units to serve SGBV survivors rather than mainstreaming the services in all health facilities. From a public health perspective, health services for SGBV survivors should be accessible, sustainable and equitable to all types of survivors. There is no doubt that establishing such units is crucial. However, the main issues that can be anticipated from creating independent units with ''feminine'' names are: the social stigma, a lack of sustainability and a lack of inclusiveness.&nbsp;
<h3>The Naming and Social Stigma &nbsp;&nbsp;&nbsp;&nbsp;</h3>
Establishing separate units for addressing culturally sensitive issues is usually associated with a stigma that may jeopardize survivors&rsquo; access to the units. A similar model was previously used for addressing youth&rsquo;s sexual and reproductive health needs in Egypt when UNFPA, along with the General Organization for Teaching Hospitals and Institutes, developed Youth Friendly Clinics (YFCs) in teaching hospitals. Studies evaluating the YFCs reported that social stigma was common and that it was one of the barriers that resulted in low utilization of the service (Family Health International [FHI] 360, 2009).&nbsp;
Al Mansoura University Hospital realized the stigma that might arise from creating a separate unit for SGBV survivors and that they may be perceived as places for empowering women to disobey their husbands. Hence, they named it the ''orange clinic'' to avoid any name that could explicitly be linked to SGBV. Names given to health entities dealing with sensitive issues such as SGBV survivors needs to be nuanced in order to protect the health rights of the victims and safeguard their recuperation period from stigma or discrimination. It can be argued that the units were created within OB/GYN departments to reduce the stigma, however, it would have been more practical and sustainable if all OB/GYN clinics were equipped to be able to deal with SGBV survivors.&nbsp;
<h3>Access, Sustainability and a Holistic Approach&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</h3>
The fact that such an initiative was not led by the Ministry of Health indicates that SGBV is not on its list of priorities. It might appear a positive step forward that the NCW took the lead in responding to the huge demand for health services for violated people, including women. However, addressing the health needs of SGBV survivors should not be restricted to helping women. Although the majority of SGBV survivors are women, restricting the services to women and OB/GYN clinics shapes another form of exclusion to children, men and other marginalized populations such as migrants and refugees who are more exposed to SGBV. Access to such services should be available for all survivors regardless of their gender.
Although other units will be opened soon in Upper Egypt, including in Assiut University Hospital, there is still a concern over the centralization of the established units. In the case of Assiut, university hospitals are still inaccessible to its suburbs and villages on the periphery. It is needless to mention that the units are not open 24/7, which consequently leads to using emergency rooms and primary health care units that are ill-equipped to respond to SGBV survivors (APS, 2020).
COVID-19 poses another barrier to access to units. With the rise of SGBV incidents in the time of COVID-19 (CARE 2020), it is important to question whether this modality is of any help to violated women during the lockdown. Given that outpatient clinics of the university hospitals are closed during COVID-19, the question arises as to how ''Safe Woman'' units will accommodate the demand during the pandemic. Globally, the health sector is shifting towards telehealth, including services for SGBV survivors (United Nations Fund for Children [UNICEF], 2020). More up-to-date and contemporary solutions should have been established to provide effective and timely services that ensure sustainability. For example, Johns Hopkins University has developed the mobile application &lsquo;MyPlan&rsquo; to help survivors of intimate partner violence explore a safe way forward, with maximum confidentiality; MyPlan provides them with resources, risk assessments, and tailored safety action plans (Our Story &mdash; myPlan, n.d.). Between 2010 and 2018, there were more than 100 mobile applications developed to prevent SGBV, educating users (including health workers) on how to deal with SGBV and provide emergency response to SGBV survivors (Eisenhut et al., 2020).
<h3>Lack Of Coordination and Connectivity Between the System and the Units&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</h3>
It is worth noting that lately, UNFPA has been coordinating a lot of the efforts to combat SGBV and provide services for SGBV survivors, particularly women. However, there is no actual referral system between previous UNFPA-led initiatives and the &ldquo;Safe Woman&rdquo; units. This will not only result in fragmentation of the system but also leaving a lot of survivors behind.&nbsp;
For instance, in collaboration with the Ministry of Youth and Etijah (Youth and Development Consultancy), UNFPA has established ''the women and girls&rsquo; safe spaces'' (WGSS) project to support GBV survivors, particularly refugees and migrants. WGSS aims to provide &ldquo;safe&rdquo; places for refugee women and girls to socialize, receive social support and access multisectoral GBV services. However, no actual coordination or active referral pathway exists between the WGSS units and other pre-existing initiatives for SGBV survivors. This lack of coordination between ''Safe Woman'' units and refugee services raises an important concern over treatment of SGBV survivors from the refugee and migrant community. The same applies to the SGBV specialized police units established in the security directorates. While the Ministry of Interior has established certain units inside police stations to facilitate SGBV incident reporting and combat SGBV, there is no referral pathway between these units and ''Safe Woman'' units. ''Safe Woman'' units refer survivors to the security unit of the university hospital for reporting, not to the SGBV-specialized police unit of Ministry of Interior. Creating separate units for addressing the health needs of SGBV survivors adds nothing but more fragmentation to the health system.&nbsp;
<h3>Monitoring and Evaluating the Efficacy of Units&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</h3>
There is no doubt that establishing ''Safe Woman'' units reflects an important shift towards acknowledging the need for providing health services to SGBV survivors. However, building separate units, with different parties involved in the units&rsquo; financing and management, might jeopardize the sustainability, accessibility and standardization of services provided. Informative interviews from officials from the various hospitals indicated that there are no unified standard operating procedures for the units. Overseeing the activities and managing the operations of each unit is the responsibility of the head of the unit, resulting in varying practices across and within university hospitals. For instance, Mansoura University Hospital decided to allocate different coordinators in the different hospital departments to identify potential cases. While that might not be the case in other hospitals, the absence of unified operating procedures would make it difficult for the units to evaluate their efficacy. Likewise, no information system links the different units in each university hospital, which raises more questions on the quality of the monitoring and evaluation of the units.&nbsp;
<h3>Moving forward</h3>
<ul style="text-align: justify;">
<li aria-level="1">
The ''Safe Woman'' units can be a start for more comprehensive healthcare services for SGBV survivors if a rigorous monitoring and evaluation plan is established to evaluate their impact. To this end, training staff on collecting relevant data in confidentiality is crucial for the success of the units. Evaluating should be conducted with transparency; this will enable units to implement more culturally appropriate, effective and inclusive practices. There should be a clear plan for documenting SGBV survivors&rsquo; experiences using ''Safe Woman'' units, including tracking referrals and collecting survivors&rsquo; feedback. The data generated from the units can be the only source of information on the numbers, rates and patterns of SGBV against women in Egypt, especially with the absence of national studies on SGBV.&nbsp;
</li>
<li style="text-align: justify;" aria-level="1">SGBV-related health services should be mainstreamed for all SGBV survivors including children, men, refugees and migrants, as well as sex workers and the LGBT community. Providing such services from a rights-based and holistic approach at primary healthcare units and emergency rooms will reduce the social stigma associated with SGBV survivors. Any health facility should be able to detect, assess and support SGBV survivors within their standardized care packages. All medical personnel should be able to identify, detect and treat SGBV survivors.&nbsp;</li>
<li style="text-align: justify;" aria-level="1">Moreover, the fragmented healthcare system in Egypt needs to be integrated. New initiatives and solutions should be created to connect the different sectors and reduce barriers to healthcare services. To overcome the fragmentation, building an active referral system between the units and the pre-existing SGBV services can maximize their effectiveness. For instance, this can involve establishing an effective referral system with a case management program with NGOs, civil society groups and even private sector hospitals.</li>
<li style="text-align: justify;" aria-level="1">Policies should involve collaboration with different community groups and NGOs to raise awareness of the services the units provide and promote referrals; this helps to increase their utilization and improve the ability to rigorously monitor unit practices.&nbsp;</li>
<li style="text-align: justify;" aria-level="1">Most importantly, modern solutions should be integrated into the units to overcome the gaps proposed by the current model. University hospitals are highly affected by the COVID-19 response. Not only is access deterred by the lockdown, but also by the fact that medical staff are overwhelmed by the COVID-19 response. Mobile applications and online solutions should have been implemented to adapt to this pressure, overcome stigma and ensure sustainability in the context of COVID-19.&nbsp;</li>
</ul>
<hr>
References
<ul>
<li style="text-align: left;">Alternative Policy Solution (2020). Healthcare for Sexual Violence Survivors: How Far Have We Reached? <a href="https://aps.aucegypt.edu/en/articles/464/healthcare-for-sexual-violence-survivors-how-far-have-we-reached">https://aps.aucegypt.edu/en/articles/464/healthcare-for-sexual-violence-survivors-how-far-have-we-reached</a>&nbsp;</li>
<li style="text-align: left;">CARE International. (2020). Rapid Gender Analysis &ndash; COVID-19 Middle East and North Africa Region. Retrieved from: <a href="https://reliefweb.int/sites/reliefweb.int/files/resources/CARE-MENA-COVID-19-RGA-200720201.pdf">https://reliefweb.int/sites/reliefweb.int/files/resources/CARE-MENA-COVID-19-RGA-200720201.pdf</a>&nbsp;</li>
<li style="text-align: left;">Dostor. (2020). A campaign to raise awareness of the importance of psychological support for victims of sexual assault. [hamlat l-il-taw&lsquo;iyat bi-&rsquo;ihamiyat al-da&lsquo;m al-nafsi li-dahaya al-a&lsquo;tida&rsquo;at al-ginsiya] [In Arabic]. Retrieved from: <a href="https://www.dostor.org/3196145">https://www.dostor.org/3196145</a></li>
<li style="text-align: left;">Eisenhut, K., Sauerborn, E., Garc&iacute;a-Moreno, C., &amp; Wild, V. (2020). Mobile applications addressing violence against women: a systematic review. BMJ global health, 5(4), e001954.</li>
<li style="text-align: left;">El-Zanaty and Associates &amp; ICF International. (2015). Egypt Demographic and Health Survey 2014. Ministry of Health and Population and ICF International.</li>
<li style="text-align: left;">Family Health International 360. (2009). Meeting Adolescent Reproductive Health Needs in Egypt. Retrieved from: <a href="https://www.fhi360.org/sites/default/files/media/documents/Meeting%20Adolescent%20Reproductive%20Health%20Needs%20in%20Egypt%20UNFPA.pdf">https://www.fhi360.org/sites/default/files/media/documents/Meeting%20Adolescent%20Reproductive%20Health%20Needs%20in%20Egypt%20UNFPA.pdf</a>&nbsp;</li>
<li style="text-align: left;">Our Story &mdash; myPlan. (n.d.). myPlan. Retrieved 20 January 2021, from https://www.myplanapp.org/en/our-story.</li>
<li style="text-align: left;">United Nations Fund for Children. (202). Not just hotlines and mobile phones: GBV Service provision during COVID-19. Retrieved on Jan 8th from <a href="https://www.unicef.org/media/68086/file/GBV%20Service%20Provision%20During%20COVID-19.pdf">https://www.unicef.org/media/68086/file/GBV%20Service%20Provision%20During%20COVID-19.pdf</a>&nbsp;</li>
<li style="text-align: left;">Untitled Nations Population Fund. (2015). The Egypt Economic Cost Of Gender-based Violence Survey (ECGBVS). Retrieved from:&nbsp;<a href="https://egypt.unfpa.org/sites/default/files/pub-pdf/Costs%20of%20the%20impact%20of%20Gender%20Based%20Violence%20%28GBV%29%20WEB.pdf">https://egypt.unfpa.org/sites/default/files/pub-pdf/Costs%20of%20the%20impact%20of%20Gender%20Based%20Violence%20%28GBV%29%20WEB.pdf</a></li>
<li style="text-align: left;">World Health Organization. (2003). Guidelines for medico-legal care for victims of sexual violence. Retrieved on Jan 8th from <a href="https://apps.who.int/iris/bitstream/handle/10665/42788/924154628X.pdf;jsessionid=73FCB1C131285DB5D308A65084C6C5FC?sequence=1">https://apps.who.int/iris/bitstream/handle/10665/42788/924154628X.pdf;jsessionid=73FCB1C131285DB5D308A65084C6C5FC?sequence=1</a>&nbsp;</li>
</ul>

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