AIDSTAR-One | CASE STUDY SERIES                                                                                           ...
AIDSTAR-One | CASE STUDY SERIESpartnerships between various ministries and a            among adults 15 to 49 years of age...
AIDSTAR-One | CASE STUDY SERIESpara la Mujer y las Familias (Police for Women and Families), whichis a special justice sys...
AIDSTAR-One | CASE STUDY SERIESby design in order to avoid any one agency, likely        CEPAM was formed in 1983, origina...
AIDSTAR-One | CASE STUDY SERIEShealth and counseling services. Additionally, in         can provide economic support, such...
AIDSTAR-One | CASE STUDY SERIESwere established with support from the Inter-                and protocols and accompanying...
AIDSTAR-One | CASE STUDY SERIESservices. This approach allows users of CEPAM’s          staff and counselors reported majo...
AIDSTAR-One | CASE STUDY SERIESmultifaceted needs of women experiencing                       overextending itself by tryi...
AIDSTAR-One | CASE STUDY SERIESDo not forget men: The lack of activities that           on a large scale, CEPAM is also st...
AIDSTAR-One | CASE STUDY SERIESparticularly sexual violence, and refer the survivor            Progress and Challenges und...
AIDSTAR-One’s Case Studies provide insight into innovative HIV programs and approachesaround the world. These engaging cas...
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AIDSTAR-One Civil Society and Government Unite to Respond to Gender-based Violence in Ecuador


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Although many in Ecuador do not recognize the link between gender-based violence (GBV) and HIV, the Ministry of Public Health has made an effort to include this link in guidelines and protocols to improve the national health sector response to violence. In partnership with the government, Centro Ecuatoriano para la Promoción y Acción de las Mujeres (CEPAM) is a major force in providing care and support to GBV survivors while raising awareness about this important issue. This case study documents CEPAM's leadership in the GBV response and the NGO's partnership with the Government of Ecuador to take a holistic approach to GBV services and prevention.

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AIDSTAR-One Civil Society and Government Unite to Respond to Gender-based Violence in Ecuador

  1. 1. AIDSTAR-One | CASE STUDY SERIES March 2012Civil Society and GovernmentUnite to Respond to Gender-Based Violence in Ecuador I n a small makeshift building outside a southern Quito hospital, 10 women sit together to share their stories as survivors of violence at the hands of their husbands or intimate partners. One woman tearfully asks the group whether it is true that she will be liable for her boyfriend’s debts if she leaves him, as her boyfriend has threatened her. Other women share their own similar stories of abuse and threats used against them by their partners. A social worker facilitates the discussion among the Myra Betron women, all grateful for a confidential space where they can talk about their struggles and seek answers to their questions aboutWomen participating in a violence a possible life beyond their violent group in a Quito hospitalwhere the Ministry of Public Healthis piloting specialized GBV services. The building, which houses not only the counseling room but also a space for medical examination and collection of forensic evidence, is part of an pilot initiative by Ecuador’s Ministry of Public Health (MSP) to institute comprehensive services for gender-based violence (GBV) in the health system. The initiative reflects lessons learned over more than a decade of collaboration between the government and the nongovernmental organization (NGO) Centro Ecuatoriano para la Promoción y Acción de las Mujeres (the Ecuadorian Center for Women’s Advocacy and Action, or CEPAM), a largely privately funded organization that is a leading proponent of the grassroots movement to eliminate GBV. In 2007, the government identified the eradication of GBV as a national priority and developed the National Plan for theBy Myra Betron Eradication of Gender Violence against Children, Adolescents and Women. In 2009, the government eliminated the ministry responsible for gender equality and promotion, the National Women’s Council, so the plan is now being implemented through government-civil societyAIDSTAR-OneJohn Snow, Inc.1616 North Ft. Myer Drive, 11th Floor This publication was produced by the AIDS Support and Technical Assistance ResourcesArlington, VA 22209 USA (AIDSTAR-One) Project, Sector 1, Task Order 1.Tel.: +1 703-528-7474 USAID Contract # GHH-I-00-07-00059-00, funded January 31, 2008.Fax: +1 703-528-7480 Disclaimer: The author’s views expressed in this publication do not necessarily reflect the views of the United Agency for International Development or the United States Government.
  2. 2. AIDSTAR-One | CASE STUDY SERIESpartnerships between various ministries and a among adults 15 to 49 years of age. An estimatednumber of local NGOs who provide technical 36,000 adults aged 15 and older are living with HIV,assistance and expertise in GBV, led by CEPAM. of which approximately 11,000 are female (Joint United Nations Programme on HIV/AIDS 2011). MenCEPAM has been a major force in providing care who have sex with men, transgender people, andand support to GBV survivors as well as raising sex workers are the populations most at risk for HIV.awareness about the issue both in Guayaquil in Prevalence of HIV is estimated to be 19.3 percentGuayas Province, where it is located in Ecuador, among men who have sex with men in the capital,and nationally. This case study documents both Quito, with higher prevalence in Guayaquil andCEPAM’s comprehensive response to GBV, along the coast (International HIV/AIDS Alliancewhich has been honed over many years, and the 2010). Despite some advances in recent years,organization’s partnership with the Government access to high-quality health care, such as HIVof Ecuador to address GBV holistically through testing and counseling, remains inadequate, andboth provision of services and prevention there are gaps in services for the most vulnerableinterventions. Methods used to develop this case populations. Stigma and discrimination, resultingstudy include a review of program reports and from a culture of machismo and misinformationevaluations; interviews with CEPAM’s management, about HIV, contribute to HIV transmission andrepresentatives of government agencies, and hinder progress toward achieving universal accessselected donor organizations; and focus group to prevention services. HIV prevention effortsdiscussions with CEPAM staff, community with women have focused largely on preventionvolunteers, and users of GBV services and youth of mother-to-child transmission. Gender-basedprograms. violence has not been viewed as a driver of HIV, and therefore the national HIV response has notGender-based Violence and included official significant strategies to address GBV. One exception is an incipient effort in theHIV in Ecuador MSP to include the link between GBV and HIV in guidelines and protocols as well as training modulesGender-based violence: As in many to improve the health sector response to violence.countries worldwide, GBV in Ecuador is a commonoccurrence that is widely accepted by society.According to the 2004 Demographic and Maternal-Infant Health Survey, approximately one in three (31 Policy Environmentpercent) ever-married or -partnered women aged15 to 49 years had experienced physical intimate Currently, Ecuador has strong political will andpartner violence in their lifetime (Centro de Estudios comprehensive laws and policies regarding Población y Desarrollo Social 2004). Over 40 The Law against Violence toward Women and thepercent had experienced verbal or psychological Family (Law 103) was enacted in 1995, but fewviolence, and 11.5 percent had experienced rape. women who experience GBV actually report thisThe survey also found that about seven percent of to the authorities or seek judicial redress due toall females aged 15 to 49 had been forced to have multiple reasons that include lack of knowledgesex. about their rights; stigma, shame, or fear of discrimination; fear of reprisal from the perpetrator;HIV: Ecuador has a concentrated HIV epidemic and the complexity of the legal system, amongwith a national average prevalence of 0.4 percent others. Ecuador does have a system of Comisarías2 AIDSTAR-One | March 2012
  3. 3. AIDSTAR-One | CASE STUDY SERIESpara la Mujer y las Familias (Police for Women and Families), whichis a special justice system meant to deal with domestic violence BOX 1. POLICE FORin a specialized and efficient manner (see Box 1). However, there WOMEN AND FAMILIESare only 33 units of the Police for Women and Families set up In 1994, Ecuador establishedthroughout the entire country, 7 of which are in the two largest its first Police for Womencities—Guayaquil and Quito—while the remaining 26 are spread and Families in Guayaquilamong 215 districts. Thus, according to one expert interviewed, as a way to guarantee thatmany women still have to pass through the formal justice system, domestic violence does not gowhere women face further discrimination and abuse. For example, unpunished. Staff can only attendCEPAM legal staff noted that many public servants in the justice to cases that involve what aresystem believe that a woman can provoke sexual violence due to considered minor infractions;her actions or the manner in which she dresses. anything more—that is, anyLaw 103 also requires the police, personnel of the Ministry of offense or injury that causesGovernment, and health professionals to report any cases of GBV a three-day absence fromof which they are aware to the authorities. In 2008, Ecuador passed work—is considered a crimea revised constitution that also recognizes the rights of vulnerable and is referred to the police.groups, including women, children, and adolescents, to be free Punishment imposed by thefrom violence, mistreatment, and sexual exploitation. There are still Police for Women and Familiesseveral barriers that prevent due justice for perpetrators of GBV. can include prison time for upFor example, police often take bribes from perpetrators to refrain to seven days, reparation forfrom processing cases, and health providers fear involvement in injuries or goods destroyed, orlengthy court deliberations, threats from perpetrators, and slander community service. Protectionby lawyers. These concerns among health care providers are orders are also issued on requestmore acute in some rural and small communities where providers of the plaintiff.are well known. Despite supportive laws and policies, much work Source: Camacho and Jácomestill needs to be done to change the underlying social norms that 2008.accept GBV.The government has also recognized GBV as an issue affectinghuman rights, public health, development, and citizen safety(Republic of Ecuador 2007) through specific policies and programs.Most notably, President Correa passed Presidential Decree No.620 in 2007, which identifies the eradication of GBV as a statepolicy. Based on this decree, a team of experts developed theNational Plan, which was to be implemented by multiple agenciesthat span a broad range of sectors, including governance, publichealth, education, justice, women, children, and families. TheNational Plan is coordinated by a technical secretariat made up ofrepresentatives from the Ministry of Justice, Ministry of Education,MSP, Ministry of Government, the Ministry of Economic andSocial Investment (MIES), the National Council of Children andAdolescence, and the National Institute of Children and Families.The formation of this multi-sectoral coordinating body was done Civil Society and Government Unite to Respond to Gender-Based Violence in Ecuador 3
  4. 4. AIDSTAR-One | CASE STUDY SERIESby design in order to avoid any one agency, likely CEPAM was formed in 1983, originally with thean underfunded one, to be unduly burdened with vision of promoting and defending women’s rightsleading the implementation of the plan. and improving the disadvantaged status of women in Latin American society. At that time, the focusOver the past three years, since the launch of the of CEPAM’s work was to support the developmentNational Plan, the government and its partners of women’s community-based organizations andhave made considerable progress in establishing groups to increase the visibility of women’s issues,the infrastructure and human resources needed including the undervaluation of domestic workto begin ensuring access to justice and scale-up and women’s limited participation as leaders inof comprehensive services for GBV survivors, the community. CEPAM also attended to women’sincluding health services and psychological, social, reproductive health needs, which were oftenand economic support. The National Plan is still neglected by Ecuadorian society at its early stages of implementation in part due tolimited technical capacity and insufficient funding. This led the organization to identify violenceOn one hand, government is reliant on civil society against women as a key determinant of women’sprograms that have many more years of experience health. In 1990, CEPAM opened a health centeraddressing GBV but are limited in size and scope; in Guasmo, one of the poorest neighborhoodson the other, the government has not assigned a of Guayaquil. This center, run largely by localbudget for the National Plan in its entirety. Instead, women working for a minimal stipend, gave theeach government agency named in the National women of Guasmo access to a broad range ofPlan is responsible for designating funds to achieve health services, including management of theits objectives. As a result, the greatest progress has consequences of domestic and sexual violence—been made in improving laws and access to justice the most common reason for women’s returnand implementation of a national campaign to visits. The Guasmo center was also CEPAM’s firstchange social norms that perpetuate GBV (see Box experience in collaborating with the government in2). The improvement of health and social services service provision. Over 12 years of collaboration,is still limited to small-scale, formative efforts that CEPAM, the community, and the provincialare being supported by organizations like CEPAM. government developed a model of care with special emphasis on sexual and reproductive health and GBV, which is now financed and successfully run by the provincial government. Key to the successCEPAM Program Objectives is the fact that the primary physician had been an employee of CEPAM for 15 years; currently, herCEPAM’s mission is to develop new attitudes, employment contract is both with CEPAM and withpractices, and public policies that improve people’s the MSP.lives by promoting gender equality between menand women. The organization’s specific objectives Shortly after the establishment of the Guasmoare preventing and mitigating the effects of Health Center, CEPAM also began offering advisoryviolence against women, and promoting sexual legal services for women dealing with such issuesand reproductive health and rights through service as divorce, property rights, government registrationprovision, advocacy, awareness-raising, and for legal identity cards, and GBV. Based on highbehavior change and community mobilization community demand, this program moved fromcampaigns. informing women of their basic rights to offering4 AIDSTAR-One | March 2012
  5. 5. AIDSTAR-One | CASE STUDY SERIESBOX 2. GOALS AND STRATEGIES OF THE 2007 NATIONAL PLAN FOR THEERADICATION OF GENDER VIOLENCE AGAINST CHILDREN, ADOLESCENTS ANDWOMEN11. Transforming sociocultural patterns that dictate that gender violence is natural: A major component of the National Plan is the countrywide mass media communication campaign, “Reacciona, Ecuador: El Machismo es Violencia” (React, Ecuador: Machismo Is Violence), which includes television spots, posters, and other social media. The budget for the National Plan currently allocates most of its resources to this component of the plan.2. Strengthening a comprehensive system to protect and restore the rights of GBV survivors: This component entails strengthening existing GBV services so that they provide a multi-sectoral response. As an initial step, the MIES is supporting five civil society organizations throughout the country that are already providing these multi-sectoral services, including CEPAM in Guayaquil. The MIES is also slated to provide financial support to five shelters for women and children who are experiencing violence. The Ministry of Government is piloting the integration of multi- sectoral services (psychological and socioeconomic support, legal advice, and referrals to health services) into two public justice centers in Chone and Durán. These centers bring together various actors in the justice sector, including the police, prosecutors, and the Police for Women and Families, to provide relevant services to those in need. Finally, in 2009, the MSP developed and released new guidance on integrated care for survivors of violence, which updated previous protocols released in 1995. The MSP is training health care providers on these norms and is pilot testing the integration of specialized rooms and services for GBV survivors—including medical, psychological, and social services—in six hospitals throughout the country.3. Developing a registry to document cases of GBV in Ecuador: The goal of this component is to have one national registry that will receive information from various institutions in the health, justice, and education sectors. However, interviewees for this case study said that this component of the plan has made little progress.4. Increasing access to justice: This component is designed to reduce impunity for perpetrators of GBV; provide free, efficient, and immediate access to justice for victims; and ensure that the investigative process does not revictimize survivors. Case study interviewees reported that progress on this component has mainly consisted of integrating multi-sectoral services into the Police for Women and Families and prosecutors’ offices, where women report cases of violence. However, in 2004 and 2009, laws were revised to detail responsibilities for providers (collecting forensic evidence and providing expert opinions) and judicial entities (procedures for processing or prosecuting cases). The MSP has also made efforts to increase the number of forensic doctors in the country—currently there are just 53— through training and accreditation. Finally, interventions under this component include workshops to transform sexist and misogynistic attitudes among police and judges who are easily bribed by perpetrators and thus prevent due justice.5. Institutionalizing the response to GBV outlined in the National Plan: This component, designed to ensure a sustainable response to GBV, includes assigning budgets; coordinating activities across sectors and at national, provincial, and municipal levels; decentralizing services and activities; and monitoring and evaluation. The objective of this component is to ensure that strategies to respond to GBV are an obligatory fixture in each ministry. To date, very little has advanced under this objective. Challenges identified include limited budgets, which have not been optimized and channeled to high-priority interventions agreed upon by all sectors; the government’s inexperience in coordinating with civil society; and lack of technical capacity and political will at lower levels of government.1 The advances highlighted in Box 2 are for the timeframe of 2007 to 2009, prior to data collection for this case study, which was done mid-2010. Civil Society and Government Unite to Respond to Gender-Based Violence in Ecuador 5
  6. 6. AIDSTAR-One | CASE STUDY SERIEShealth and counseling services. Additionally, in can provide economic support, such as the National1998 CEPAM established a center for adolescents, Institute of Family and Children.where peer educators provide information on sexualand reproductive health and life skills, including Guasmo Health Center: The Guasmo Healthways to address violence. Peer educators are Center now provides a full range of health services.taught to recognize and refer to CEPAM cases of Providers within general medicine, obstetrics, andviolence that they identify in schools or among their family planning services conduct GBV screeningpeers. when they suspect violence and provide follow-up care when violence is identified. Important featuresToday, CEPAM’s work on GBV, which includes of GBV services include regular training on GBVfamily violence (against children and adolescents), for clients and staff, psychological services forviolence against women, and sexual violence, survivors, and referral to specialized GBV servicesfocuses on service provision with complementary such as CEPAM for continuous counseling and toactivities for prevention and advocacy. In addition to the Police for Women and Families for legal follow-collaboration at the Guasmo Health Center, CEPAM up.operates a center that offers comprehensiveGBV services, including health, psychosocial Community-based rights counselors:support, and legal services, and is the site for peer Donor funding allowed CEPAM Guayaquil to traineducation, prevention activities, and CEPAM’s several “rights counselors.” These counselorsadministrative and research-related work. CEPAM serve as advocates for GBV survivors by orientingalso has legal staff on-site at the Police for Women survivors to their rights, referring them to GBVand Families and prosecutor’s office of Guayas services, and when necessary, accompanyingProvince as part of a pilot program supported by the them to services. Each counselor, a GBV survivor,national government, as described subsequently. underwent an intensive process of psychologicalCEPAM’s major GBV programs can be described support and training to become a communityas follows. educator and advocate for women’s rights, particularly related to GBV. The rights counselors refer GBV survivors to a network of services thatComprehensive GBV services: CEPAMin Guayaquil is one of the few organizations inEcuador that provides comprehensive services forGBV survivors, including legal aid, psychologicalcounseling services, access to medical attention,and social support. A multi-sectoral teamprovides these services, now at no cost thanksto government funding through the MIES. Whena survivor arrives at CEPAM for services, sheis first interviewed by an intake counselor whoidentifies her specific needs and assesses her risk.She is then referred to a service provider, suchas a psychologist, legal counselor, social worker, Myra Betronor doctor, depending on her immediate need. Ifnecessary, the survivor may also be referred to ashelter, specialized health service, or agency that Obstetrician and patients at the Guasmo Health Center.6 AIDSTAR-One | March 2012
  7. 7. AIDSTAR-One | CASE STUDY SERIESwere established with support from the Inter- and protocols and accompanying operationalAmerican Development Bank. Ten years after guidelines for integrated GBV services. Likewise,their training, these counselors are still known and the National Institute of Family and Children (part ofconsulted by community members. the MIES) has sought CEPAM Guayaquil’s technical assistance to develop a service model for GBV. InPrevention activities: CEPAM Guayaquil addition, the MIES is supporting a pilot project toconducts prevention activities to complement its develop integrated services in the Police for Womenservice provision. These activities focus on three and Families of Guayas Province and in the Guayasmain areas: Province prosecutor’s office.1. Raising awareness of the right to live free of CEPAM Guayaquil has also been tasked with a violence through workshops, discussions, and series of activities to support the MIES and MSP in films in the general community and in schools the implementation of activities under the National Plan. These include:2. Discussing masculinity, including nonviolence, • Training health providers working in hospital in youth sexual and reproductive health peer emergency rooms on how to identify and educator groups register cases of GBV, and how to provide comprehensive management in those cases,3. Conducting home visits to provide counseling including addressing concerns about HIV, other and education to improve parent-child sexually transmitted infections, and reproductive communication. healthAdvocacy and technical assistance to • Training a team of MSP trainers in six provincesthe government: CEPAM, as an organization on the updated MSP guidance on providingand part of the women’s movement made up of integrated care to survivors of GBVseveral organizations in Ecuador, conducts ongoingadvocacy with the government at municipal, district, • Establishing and piloting a center that specializesand national levels. Advocacy takes the shape in services for sexual violence for the MIESnot just of raising awareness and demanding • Developing a model for a legal response to GBVchange, but also working closely with government within the justice system, particularly on the partto design GBV response strategies and programs. of prosecutors, commissioners, and the police,For example, CEPAM participates significantly for the Ministry of Governmentin civil society roundtables held by the municipalgovernment of Guayaquil in order to encourage • Integrating a gender perspective, includingthe establishment of community-based structures GBV, within the National Institute of Familyto respond to GBV, which is now a process in and Children, which currently specializes indevelopment. addressing violence and abuse against children and adolescents.At the national level, CEPAM is currently providingtechnical assistance to help the MIES integrateits comprehensive model of services into public What Worked Wellinstitutions throughout Ecuador. The MIES hascontracted CEPAM in Guayaquil to provide Multi-sectoral approach: A defining featuretechnical assistance in the development of norms of CEPAM’s programs is that they provide multiple Civil Society and Government Unite to Respond to Gender-Based Violence in Ecuador 7
  8. 8. AIDSTAR-One | CASE STUDY SERIESservices. This approach allows users of CEPAM’s staff and counselors reported major life changesservices to receive psychological, health, legal, resulting from this process, including divorce fromand social work services all in one location—an an abusive partner, employment with CEPAM, andimportant factor for women who have limited resumption of formal studies. The organization haseconomic resources or time. An evaluation of empowered many participants to educate othersCEPAM’s services identified a key feature of their around sexual and reproductive health and rights.multi-sectoral work as the horizontal structure of Several community-based counselors and youthhow each team relates to each other, allowing educators interviewed reported that they continueservice providers to build close relationships with to provide information about GBV in the communityclients (Quevedo Terán and Condo 2010). Where and at CEPAM’s center.CEPAM cannot provide the specialized careneeded, a functional referral system is in place. “CEPAM has shown us that weThis system is not formalized through directories orstandardized referral procedures, but CEPAM staff as women are worthy, and we aresaid that they refer clients to organizations where important because we are pivotalthey know high-quality attention is provided. to our children…we can be goodExtensive follow-up and guidance for GBV examples for our children.”survivors: CEPAM staff follows women closely –Female GBV survivor and client ofthrough the long legal and counseling processes asan important strategy to help women out of violent CEPAM servicessituations. Because women perceive violence as anatural part of their intimate partner relationships, High credibility combined with advocacythey often resign themselves to staying with at multiple levels: Its many years of advocacytheir violent partners. CEPAM staff has found it and community mobilization have garnered strongeffective to motivate clients to continue with legal political support for CEPAM, improving the NGO’sor separation processes and self-transformation opportunities to seek sustainability. Because of itsthrough continual therapy, talks, or films about other national-level advocacy and its many years of workwomen who have survived violence. Recognizing in GBV, including collaboration with the government,that many women would prefer not to leave their CEPAM has been able to position itself as a leadingfamilies, CEPAM also coaches families on conflict expert on GBV in Ecuador. As such, CEPAM and itsmediation and communication skills in order to former and present staff have been involved in theencourage each member of the family to avoid the design of government structures and programs touse of violence in times of conflict. address GBV, namely the National Plan. This has helped the NGO secure government funding—forIncreasing individual awareness of GBV example, to support implementation of the Nationaland reproductive health rights: CEPAM Plan.Guayaquil has been able to raise awareness amongcommunity-based counselors about their rights with Government-civil society partnership:respect to GBV. Based on interviews conducted CEPAM’s collaboration with government hasduring the field work, community-based counselors resulted in improved quality of GBV services.said that CEPAM workshops have changed their Collaboration with the Police for Women andlives by allowing them to examine their experiences Families and the prosecutor’s office has improvedand get support from other participants. CEPAM understanding within the justice system of the8 AIDSTAR-One | March 2012
  9. 9. AIDSTAR-One | CASE STUDY SERIESmultifaceted needs of women experiencing overextending itself by trying to support theviolence. Likewise, the presence of CEPAM staff government’s efforts to scale up GBV services. Thisat the Guasmo Health Center raises the visibility can be particularly problematic if the governmentof these issues and sensitizes government staff. takes advantage of CEPAM’s good work withoutCEPAM, in turn, provides expertise and follow-up providing adequate funding and political, such as in social support, the government Moreover, government overdependence on CEPAMentities cannot. could very likely result in stymied government- run services and cause a vicious cycle of overdependence on CEPAM.Challenges Continuing culture of violence: InterviewNeed for coordination: CEPAM staff noted respondents said that the perception of violencethat collaboration with a multi-sectoral team as a “natural” part of life is a major barrier to theirrequires ongoing meetings and communication. work on GBV. CEPAM staff said, for example, thatWith the elimination of the National Women’s despite their significant impact within institutions forCouncil, the government has recognized the need public justice, many people in the justice sector stillfor a dedicated coordinating body to manage and know little about the rights of women, children, andprioritize the missions of each of the institutions youth with respect to violence. The justice sectorinvolved in implementing the National Plan. requires continuous, broad-based sensitization and behavior change campaigns to transform gender-Sustainability: CEPAM receives piecemeal inequitable norms and attitudes.funding from various international donors, whichresults in start-and-stop activities. In the case of thecommunity-based rights counselors, for example,when the donor-funded project that built their Recommendationscapacity and initiated activities came to an end, Take an integrated approach: An effectivethe counselors stopped meeting with multi-sectoral response to GBV requires an integrated approach—GBV networks to coordinate their detection and including health, legal, and social services, asreferral efforts. Similarly, several staff members well as economic support where possible—sonoted that they work on short-term contracts that that women can overcome their violent some cases were terminated because of lack of CEPAM has integrated into its activities reflectionsfunding. on gender norms and rights with the intent ofScale-up: In this early stage of implementing addressing myths about men’s and women’sthe National Plan in Ecuador’s major cities, there roles in relationships and promote gender equity.are many challenges to effectively reaching GBV Although it is not always possible to offer each ofsurvivors. In more remote areas of the country, these services in one location, organizations shouldwhere even fewer or no NGOs are present to build alliances with and refer to other organizationsprovide support, there are vast gaps in GBV that offer services they cannot offer. This approachservices. Ecuador is making a respectable effort facilitated CEPAM’s comprehensive response. Forto start but will face an even larger challenge in example, at the CEPAM Guayaquil Health Center,scaling up GBV services to the rest of the country. the obstetrician identified the need for on-site legal services, and at the Police for Women and Families,Overdependence on CEPAM by users mentioned that they would like to see medicalgovernment: CEPAM may run the risk of services. Civil Society and Government Unite to Respond to Gender-Based Violence in Ecuador 9
  10. 10. AIDSTAR-One | CASE STUDY SERIESDo not forget men: The lack of activities that on a large scale, CEPAM is also strengtheningwork with men to change norms and attitudes that and fostering community advocacy and citizenperpetuate violence is a significant gap in CEPAM’s participation in policy development to ensureprogramming. Some focus group participants said that the government fulfills its commitments tothat their male partners did not support the way addressing GBV.their attitudes had changed as a result of CEPAM’sservices, and several wished CEPAM would work Provide long-term technical assistancewith men as well. CEPAM’s Integrated Center for to governments to ensure sustainability:Adolescents and Youth does work with male youth, CEPAM’s experiences at the Guasmo Healthand the center is currently training three male Center, the Police for Women and Families ofyouth as facilitators on the topic of masculinity. Guayas, and the Guayas Province prosecutor’sFocus group discussions with youth indicated some office show that it is possible for government andpositive impact from these efforts, such as changes civil society to partner in the implementation ofin violent attitudes and behavior, particularly gang services. However, this is hardly an overnightviolence. As the organization grows, expanding process. It took 12 years for CEPAM’s modelthis work to adult men may be another important of care to be successfully transferred to thestrategy. At the very least, collaboration with other government, and the center’s coordinator remainsprograms that do work with men, or advocating for employed by CEPAM.such programs with the government, would be a Clearly establish roles andlogical next step. responsibilities within the partnership: The balance between civil society participationFrame GBV as a broader health and and government leadership is a fine one.development issue: CEPAM sees GBV as Interviewees cautioned that too much participationnot simply an issue for individual men and women and leadership by civil society can lead toin violent relationships, but as a social problem government over-reliance on civil society to assumerequiring action and mitigation from institutions responsibility in the response to GBV—resulting,and community members alike. GBV is a health for example, in a failure to fund activities plannedproblem that affects sexual, reproductive, maternal, under the leadership of civil society organizations.and mental health, as well as HIV, but it is also a One strategy to ensure that the government fulfillssocial problem with profound effects on community its role is to limit civil society participation, in initialand national development. Linking GBV to these phases of implementation, to representatives andwider development concerns can place the issue organizations that compete for technical assistanceat a higher priority level and increase support for roles. There should be a mechanism for input fromits eradication. In Ecuador, where citizen safety is a all parties involved in the partnership. In addition,priority, framing GBV as a problem of security was the government should ensure appropriate fundingstrategic to CEPAM’s efforts to advance the GBV levels for all aspects of the National Plan, whichagenda in higher reaches of government. includes prevention and resources as well as awareness raising.Mobilize and engage others: To improveits long-term political and financial sustainability,CEPAM Guayaquil found it necessary to increaseadvocacy to persuade the government to assume Future Programminggreater responsibility in providing GBV services. CEPAM staff currently counsel survivors aboutRealizing that true change requires advocacy the potential health consequences of violence,10 AIDSTAR-One | March 2012
  11. 11. AIDSTAR-One | CASE STUDY SERIESparticularly sexual violence, and refer the survivor Progress and Challenges under IMPACT 2010. Availableor her family to facilities where sexually transmitted at services and HIV testing and post- aspx?id=28 (accessed March 2011)exposure prophylaxis are available. CEPAM would Joint United Nations Programme on HIV/AIDS. to provide these services but does not have Country Profile: Ecuador. Available at resources or the proper facilities (such as a en/regionscountries/countries/ecuador (accessed Marchlaboratory), and current law allows the provision of 2011)post-exposure prophylaxis only at hospitals. Yet inhospitals, the availability and accessibility of these Quevedo Terán, A., and T. Condo. 2010. Evaluación deservices are limited because providers still have la Calidad de los Servicios de Atención a la Violencialimited knowledge about survivors’ needs and rights de Género, Intrafamiliar y Sexual 2009-2010, these services. CEPAM will continue to advocate Guayaquil, Ecuador: CEPAM persuade the government to decentralize Republic of Ecuador. 2007. Plan Nacional para laprovision of post-exposure prophylaxis, emergency Erradicación de la Violencia de Género hacia la Niñez,contraception, and HIV testing for GBV survivors, to Adolescencia y Mujeres. Quito, Ecuador: Gobiernoincrease access to these critical services. g Nacional de la República del Ecuador.RESOURCES ACKNOWLEDGMENTSCentro Ecuatoriano para la Promoción y Acción de The author would like to thank CEPAM staff in Guayaquillas Mujeres Guayaquil. 2007. Conociendo…Exigimos who took the time to organize interviews with keyNuestros Derechos: Guías de Capacitación Sobre informants and program participants and accompanyViolencia Intrafamiliar y Derechos de Familia. Guayaquil, her during the process. These include Patricia Reyes,Ecuador: CEPAM Guayaquil. Tatiana Ortiz, Marjorie Lopez, Laura Sanchez, Annabelle Arevalo, and Sara Martillo. Likewise, the authorMinisterio de Salud Pública del Ecuador. 2009. Normas appreciates the time of all key informants among CEPAMy Protocolos de Atención Integral de la Violencia de staff as well as the provincial and national government.Género, Intrafamiliar Y Sexual por Ciclos de Vida. In particular, information and leadership provided byPrimera edición. Quito, Ecuador: Ministerio de Salud Miricam Alciver and Mercy Lopez at the governmentPública del Ecuador. level were invaluable. The author acknowledges Rosa Salazar for her documentation of focus group discussions with CEPAM’s Guayaquil staff andREFERENCES participants. Thanks to the U.S. President’s Emergency Plan for AIDS Relief Gender Technical Working GroupCamacho, G., and N. Jácome. 2008. Mapeo de las for their support and careful review of this case study.Comisarías de la Mujer y la Familia en el Ecuador 2008. Finally, heartfelt thanks go to the survivors of violenceQuito, Ecuador: Centro de Planificación y Estudios who shared their stories.Sociales.Centro de Estudios de Población y Desarrollo Social. RECOMMENDED CITATION2004. Encuesta Demográfica y de Salud Materna eInfantil. Available at Betron, Myra. 2012. Civil Society and Government Unitenuevo05/indice.htm (accessed March 2011) to Respond to Gender-Based Violence in Ecuador. Case Study Series. Arlington, VA: USAID’s AIDS Support andInternational HIV/AIDS Alliance. 2010. Ecuador. Alliance Technical Assistance Resources, AIDSTAR-One, TaskCountry Studies: A Global Summary of Achievements, Order 1. Civil Society and Government Unite to Respond to Gender-Based Violence in Ecuador 11
  12. 12. AIDSTAR-One’s Case Studies provide insight into innovative HIV programs and approachesaround the world. These engaging case studies are designed for HIV program planners andimplementers, documenting the steps from idea to intervention and from research to practice.Please sign up at to receive notification of HIV-related resources,including additional case studies focused on emerging issues in HIV prevention, treatment,testing and counseling, care and support, gender integration and more.