Civil Society and Government Unite to Respond to Gender-based Violence in Ecuador
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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Civil Society and Government Unite to Respond to Gender-based Violence in Ecuador
By Myra Betron
In 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 women, all grateful for a confidential space where they can talk about their struggles and seek answers to their questions about a possible life beyond their violent relationships.
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 the 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 society partnerships between various ministries and a number of local NGOs who provide technical assistance and expertise in GBV, led by CEPAM.
CEPAM has been a major force in providing care and support to GBV survivors as well as raising awareness about the issue both in Guayaquil in Guayas Province, where it is located in Ecuador, and nationally. This case study documents both CEPAM's comprehensive response to GBV, which has been honed over many years, and the organization's partnership with the Government of Ecuador to address GBV holistically through both provision of services and prevention interventions. Methods used to develop this case study include a review of program reports and evaluations; interviews with CEPAM's management, representatives of government agencies, and selected donor organizations; and focus group discussions with CEPAM staff, community volunteers, and users of GBV services and youth programs.
Disclaimer: The authors' views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
Gender-based Violence and HIV in Ecuador
Gender-based Violence: As in many countries worldwide, GBV in Ecuador is a common occurrence that is widely accepted by society. According to the 2004 Demographic and Maternal-Infant Health Survey, approximately one in three (31 percent) ever-married or -partnered women aged 15 to 49 years had experienced physical intimate partner violence in their lifetime (Centro de Estudios de Población y Desarrollo Social 2004). Over 40 percent had experienced verbal or psychological violence, and 11.5 percent had experienced rape. The survey also found that about seven percent of all females aged 15 to 49 had been forced to have sex.
HIV: Ecuador has a concentrated HIV epidemic with a national average prevalence of 0.4 percent among adults 15 to 49 years of age. An estimated 36,000 adults aged 15 and older are living with HIV, of which approximately 11,000 are female (Joint United Nations Programme on HIV/AIDS 2011). Men who have sex with men, transgender people, and sex workers are the populations most at risk for HIV. Prevalence of HIV is estimated to be 19.3 percent among men who have sex with men in the capital, Quito, with higher prevalence in Guayaquil and along the coast (International HIV/AIDS Alliance 2010). Despite some advances in recent years, access to high-quality health care, such as HIV testing and counseling, remains inadequate, and there are gaps in services for the most vulnerable populations. Stigma and discrimination, resulting from a culture of machismo and misinformation about HIV, contribute to HIV transmission and hinder progress toward achieving universal access to prevention services. HIV prevention efforts with women have focused largely on prevention of mother-to-child transmission. Gender-based violence has not been viewed as a driver of HIV, and therefore the national HIV response has not included official significant strategies to address GBV. One exception is an incipient effort in the MSP to include the link between GBV and HIV in guidelines and protocols as well as training modules to improve the health sector response to violence.
BOX 1. POLICE FOR WOMEN AND FAMILIES
In 1994, Ecuador established its first Police for Women and Families in Guayaquil as a way to guarantee that domestic violence does not go unpunished. Staff can only attend to cases that involve what are considered minor infractions; anything more—that is, any offense or injury that causes a three-day absence from work—is considered a crime and is referred to the police. Punishment imposed by the Police for Women and Families can include prison time for up to seven days, reparation for injuries or goods destroyed, or community service. Protection orders are also issued on request of the plaintiff.
Source: Camacho and Jácome 2008.
Currently, Ecuador has strong political will and comprehensive laws and policies regarding GBV. The Law against Violence toward Women and the Family (Law 103) was enacted in 1995, but few women who experience GBV actually report this to the authorities or seek judicial redress due to multiple reasons that include lack of knowledge about their rights; stigma, shame, or fear of discrimination; fear of reprisal from the perpetrator; and the complexity of the legal system, among others. Ecuador does have a system of Comisarías para la Mujer y las Familias (Police for Women and Families), which is a special justice system meant to deal with domestic violence in a specialized and efficient manner (see Box 1). However, there are only 33 units of the Police for Women and Families set up throughout the entire country, 7 of which are in the two largest cities—Guayaquil and Quito—while the remaining 26 are spread among 215 districts. Thus, according to one expert interviewed, many women still have to pass through the formal justice system, where women face further discrimination and abuse. For example, CEPAM legal staff noted that many public servants in the justice system believe that a woman can provoke sexual violence due to her actions or the manner in which she dresses.
Law 103 also requires the police, personnel of the Ministry of Government, and health professionals to report any cases of GBV of which they are aware to the authorities. In 2008, Ecuador passed a revised constitution that also recognizes the rights of vulnerable groups, including women, children, and adolescents, to be free from violence, mistreatment, and sexual exploitation. There are still several barriers that prevent due justice for perpetrators of GBV. For example, police often take bribes from perpetrators to refrain from processing cases, and health providers fear involvement in lengthy court deliberations, threats from perpetrators, and slander by lawyers. These concerns among health care providers are more acute in some rural and small communities where providers are well known. Despite supportive laws and policies, much work still needs to be done to change the underlying social norms that accept GBV.
The government has also recognized GBV as an issue affecting human 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 state policy. Based on this decree, a team of experts developed the National Plan, which was to be implemented by multiple agencies that span a broad range of sectors, including governance, public health, education, justice, women, children, and families. The National Plan is coordinated by a technical secretariat made up of representatives from the Ministry of Justice, Ministry of Education, MSP, Ministry of Government, the Ministry of Economic and Social Investment (MIES), the National Council of Children and Adolescence, and the National Institute of Children and Families. The formation of this multi-sectoral coordinating body was done by design in order to avoid any one agency, likely an underfunded one, to be unduly burdened with leading the implementation of the plan.
Over the past three years, since the launch of the National Plan, the government and its partners have made considerable progress in establishing the infrastructure and human resources needed to begin ensuring access to justice and scale-up of comprehensive services for GBV survivors, including health services and psychological, social, and economic support. The National Plan is still in its early stages of implementation in part due to limited technical capacity and insufficient funding. On one hand, government is reliant on civil society programs that have many more years of experience addressing GBV but are limited in size and scope; on the other, the government has not assigned a budget for the National Plan in its entirety. Instead, each government agency named in the National Plan is responsible for designating funds to achieve its objectives. As a result, the greatest progress has been made in improving laws and access to justice and implementation of a national campaign to change social norms that perpetuate GBV (see Tab 4). The improvement of health and social services is still limited to small-scale, formative efforts that are being supported by organizations like CEPAM.
CEPAM Program Objectives
CEPAM's mission is to develop new attitudes, practices, and public policies that improve people's lives by promoting gender equality between men and women. The organization's specific objectives are preventing and mitigating the effects of violence against women, and promoting sexual and reproductive health and rights through service provision, advocacy, awareness-raising, and behavior change and community mobilization campaigns.
CEPAM was formed in 1983, originally with the vision of promoting and defending women's rights and improving the disadvantaged status of women in Latin American society. At that time, the focus of CEPAM's work was to support the development of women's community-based organizations and groups to increase the visibility of women's issues, including the undervaluation of domestic work and women's limited participation as leaders in the community. CEPAM also attended to women's reproductive health needs, which were often neglected by Ecuadorian society at large.
This led the organization to identify violence against women as a key determinant of women's health. In 1990, CEPAM opened a health center in Guasmo, one of the poorest neighborhoods of Guayaquil. This center, run largely by local women working for a minimal stipend, gave the women of Guasmo access to a broad range of health services, including management of the consequences of domestic and sexual violence—the most common reason for women's return visits. The Guasmo center was also CEPAM's first experience in collaborating with the government in service provision. Over 12 years of collaboration, CEPAM, the community, and the provincial 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 success is the fact that the primary physician had been an employee of CEPAM for 15 years; currently, her employment contract is both with CEPAM and with the MSP.
Shortly after the establishment of the Guasmo Health Center, CEPAM also began offering advisory legal services for women dealing with such issues as divorce, property rights, government registration for legal identity cards, and GBV. Based on high community demand, this program moved from informing women of their basic rights to offering health and counseling services. Additionally, in 1998 CEPAM established a center for adolescents, where peer educators provide information on sexual and reproductive health and life skills, including ways to address violence. Peer educators are taught to recognize and refer to CEPAM cases of violence that they identify in schools or among their peers.
Today, CEPAM's work on GBV, which includes family violence (against children and adolescents), violence against women, and sexual violence, focuses on service provision with complementary activities for prevention and advocacy. In addition to collaboration at the Guasmo Health Center, CEPAM operates a center that offers comprehensive GBV services, including health, psychosocial support, and legal services, and is the site for peer education, prevention activities, and CEPAM's administrative and research-related work. CEPAM also has legal staff on-site at the Police for Women and Families and prosecutor's office of Guayas Province as part of a pilot program supported by the national government, as described subsequently. CEPAM's major GBV programs can be described as follows.
Comprehensive GBV services: CEPAM in Guayaquil is one of the few organizations in Ecuador that provides comprehensive services for GBV survivors, including legal aid, psychological counseling services, access to medical attention, and social support. A multi-sectoral team provides these services, now at no cost thanks to government funding through the MIES. When a survivor arrives at CEPAM for services, she is first interviewed by an intake counselor who identifies her specific needs and assesses her risk. She is then referred to a service provider, such as a psychologist, legal counselor, social worker, or doctor, depending on her immediate need. If necessary, the survivor may also be referred to a shelter, specialized health service, or agency that can provide economic support, such as the National Institute of Family and Children.
Guasmo Health Center: The Guasmo Health Center now provides a full range of health services. Providers within general medicine, obstetrics, and family planning services conduct GBV screening when they suspect violence and provide follow-up care when violence is identified. Important features of GBV services include regular training on GBV for clients and staff, psychological services for survivors, and referral to specialized GBV services such as CEPAM for continuous counseling and to the Police for Women and Families for legal follow-up.
Community-based rights counselors: Donor funding allowed CEPAM Guayaquil to train several "rights counselors." These counselors serve as advocates for GBV survivors by orienting survivors to their rights, referring them to GBV services, and when necessary, accompanying them to services. Each counselor, a GBV survivor, underwent an intensive process of psychological support and training to become a community educator and advocate for women's rights, particularly related to GBV. The rights counselors refer GBV survivors to a network of services that were established with support from the Inter-American Development Bank. Ten years after their training, these counselors are still known and consulted by community members.
Prevention activities: CEPAM Guayaquil conducts prevention activities to complement its service provision. These activities focus on three main areas:
1. Raising awareness of the right to live free of violence through workshops, discussions, and films in the general community and in schools
2. Discussing masculinity, including nonviolence, in youth sexual and reproductive health peer educator groups
3. Conducting home visits to provide counseling and education to improve parent-child communication.
Advocacy and technical assistance to the government: CEPAM, as an organization and part of the women's movement made up of several organizations in Ecuador, conducts ongoing advocacy with the government at municipal, district, and national levels. Advocacy takes the shape not just of raising awareness and demanding change, but also working closely with government to design GBV response strategies and programs. For example, CEPAM participates significantly in civil society roundtables held by the municipal government of Guayaquil in order to encourage the establishment of community-based structures to respond to GBV, which is now a process in development.
At the national level, CEPAM is currently providing technical assistance to help the MIES integrate its comprehensive model of services into public institutions throughout Ecuador. The MIES has contracted CEPAM in Guayaquil to provide technical assistance in the development of norms and protocols and accompanying operational guidelines for integrated GBV services. Likewise, the National Institute of Family and Children (part of the MIES) has sought CEPAM Guayaquil's technical assistance to develop a service model for GBV. In addition, the MIES is supporting a pilot project to develop integrated services in the Police for Women and Families of Guayas Province and in the Guayas Province prosecutor's office.
CEPAM Guayaquil has also been tasked with a series of activities to support the MIES and MSP in the implementation of activities under the National Plan. These include:
- Training health providers working in hospital emergency rooms on how to identify and register cases of GBV, and how to provide comprehensive management in those cases, including addressing concerns about HIV, other sexually transmitted infections, and reproductive health
- Training a team of MSP trainers in six provinces on the updated MSP guidance on providing integrated care to survivors of GBV
- Establishing and piloting a center that specializes in services for sexual violence for the MIES
- Developing a model for a legal response to GBV within the justice system, particularly on the part of prosecutors, commissioners, and the police, for the Ministry of Government
- Integrating a gender perspective, including GBV, within the National Institute of Family and Children, which currently specializes in addressing violence and abuse against children and adolescents.
Goals and Strategies of the 2007 National Plan for the Eradication of Gender Violence Against Children, Adolescents, and Women (Box 2)(1)
1. 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.
What Worked Well
Multi-sectoral approach: A defining feature of CEPAM's programs is that they provide multiple services. This approach allows users of CEPAM's services to receive psychological, health, legal, and social work services all in one location—an important factor for women who have limited economic resources or time. An evaluation of CEPAM's services identified a key feature of their multi-sectoral work as the horizontal structure of how each team relates to each other, allowing service providers to build close relationships with clients (Quevedo Terán and Condo 2010). Where CEPAM cannot provide the specialized care needed, a functional referral system is in place. This system is not formalized through directories or standardized referral procedures, but CEPAM staff said that they refer clients to organizations where they know high-quality attention is provided.
Extensive follow-up and guidance for GBV survivors: CEPAM staff follows women closely through the long legal and counseling processes as an important strategy to help women out of violent situations. Because women perceive violence as a natural part of their intimate partner relationships, they often resign themselves to staying with their violent partners. CEPAM staff has found it effective to motivate clients to continue with legal or separation processes and self-transformation through continual therapy, talks, or films about other women who have survived violence. Recognizing that many women would prefer not to leave their families, CEPAM also coaches families on conflict mediation and communication skills in order to encourage each member of the family to avoid the use of violence in times of conflict.
Increasing individual awareness of GBV and reproductive health rights: CEPAM Guayaquil has been able to raise awareness among community-based counselors about their rights with respect to GBV. Based on interviews conducted during the field work, community-based counselors said that CEPAM workshops have changed their lives by allowing them to examine their experiences and get support from other participants. CEPAM staff and counselors reported major life changes resulting from this process, including divorce from an abusive partner, employment with CEPAM, and resumption of formal studies. The organization has empowered many participants to educate others around sexual and reproductive health and rights. Several community-based counselors and youth educators interviewed reported that they continue to provide information about GBV in the community and at CEPAM's center.
High credibility combined with advocacy at multiple levels: Its many years of advocacy and community mobilization have garnered strong political support for CEPAM, improving the NGO's opportunities to seek sustainability. Because of its national-level advocacy and its many years of work in GBV, including collaboration with the government, CEPAM has been able to position itself as a leading expert on GBV in Ecuador. As such, CEPAM and its former and present staff have been involved in the design of government structures and programs to address GBV, namely the National Plan. This has helped the NGO secure government funding—for example, to support implementation of the National Plan.
Government-civil society partnership: CEPAM's collaboration with government has resulted in improved quality of GBV services. Collaboration with the Police for Women and Families and the prosecutor's office has improved understanding within the justice system of the multifaceted needs of women experiencing violence. Likewise, the presence of CEPAM staff at the Guasmo Health Center raises the visibility of these issues and sensitizes government staff. CEPAM, in turn, provides expertise and follow-up care, such as in social support, the government entities cannot.
Need for coordination: CEPAM staff noted that collaboration with a multi-sectoral team requires ongoing meetings and communication. With the elimination of the National Women's Council, the government has recognized the need for a dedicated coordinating body to manage and prioritize the missions of each of the institutions involved in implementing the National Plan.
Sustainability: CEPAM receives piecemeal funding from various international donors, which results in start-and-stop activities. In the case of the community-based rights counselors, for example, when the donor-funded project that built their capacity and initiated activities came to an end, the counselors stopped meeting with multi-sectoral GBV networks to coordinate their detection and referral efforts. Similarly, several staff members noted that they work on short-term contracts that in some cases were terminated because of lack of funding.
Scale-up: In this early stage of implementing the National Plan in Ecuador's major cities, there are many challenges to effectively reaching GBV survivors. In more remote areas of the country, where even fewer or no NGOs are present to provide support, there are vast gaps in GBV services. Ecuador is making a respectable effort to start but will face an even larger challenge in scaling up GBV services to the rest of the country.
Overdependence on CEPAM by government: CEPAM may run the risk of overextending itself by trying to support the government's efforts to scale up GBV services. This can be particularly problematic if the government takes advantage of CEPAM's good work without providing adequate funding and political support. Moreover, government overdependence on CEPAM could very likely result in stymied government-run services and cause a vicious cycle of overdependence on CEPAM.
Continuing culture of violence: Interview respondents said that the perception of violence as a "natural" part of life is a major barrier to their work on GBV. CEPAM staff said, for example, that despite their significant impact within institutions for public justice, many people in the justice sector still know little about the rights of women, children, and youth with respect to violence. The justice sector requires continuous, broad-based sensitization and behavior change campaigns to transform gender-inequitable norms and attitudes.
Take an integrated approach: An effective response to GBV requires an integrated approach—including health, legal, and social services, as well as economic support where possible—so that women can overcome their violent situations. CEPAM has integrated into its activities reflections on gender norms and rights with the intent of addressing myths about men's and women's roles in relationships and promote gender equity. Although it is not always possible to offer each of these services in one location, organizations should build alliances with and refer to other organizations that offer services they cannot offer. This approach facilitated CEPAM's comprehensive response. For example, at the CEPAM Guayaquil Health Center, the obstetrician identified the need for on-site legal services, and at the Police for Women and Families, users mentioned that they would like to see medical services.
Do not forget men: The lack of activities that work with men to change norms and attitudes that perpetuate violence is a significant gap in CEPAM's programming. Some focus group participants said that their male partners did not support the way their attitudes had changed as a result of CEPAM's services, and several wished CEPAM would work with men as well. CEPAM's Integrated Center for Adolescents and Youth does work with male youth, and the center is currently training three male youth as facilitators on the topic of masculinity. Focus group discussions with youth indicated some positive impact from these efforts, such as changes in violent attitudes and behavior, particularly gang violence. As the organization grows, expanding this work to adult men may be another important strategy. At the very least, collaboration with other programs that do work with men, or advocating for such programs with the government, would be a logical next step.
Frame GBV as a broader health and development issue: CEPAM sees GBV as not simply an issue for individual men and women in violent relationships, but as a social problem requiring action and mitigation from institutions and community members alike. GBV is a health problem that affects sexual, reproductive, maternal, and mental health, as well as HIV, but it is also a social problem with profound effects on community and national development. Linking GBV to these wider development concerns can place the issue at a higher priority level and increase support for its eradication. In Ecuador, where citizen safety is a priority, framing GBV as a problem of security was strategic to CEPAM's efforts to advance the GBV agenda in higher reaches of government.
Mobilize and engage others: To improve its long-term political and financial sustainability, CEPAM Guayaquil found it necessary to increase advocacy to persuade the government to assume greater responsibility in providing GBV services. Realizing that true change requires advocacy on a large scale, CEPAM is also strengthening and fostering community advocacy and citizen participation in policy development to ensure that the government fulfills its commitments to addressing GBV.
Provide long-term technical assistance to governments to ensure sustainability: CEPAM's experiences at the Guasmo Health Center, the Police for Women and Families of Guayas, and the Guayas Province prosecutor's office show that it is possible for government and civil society to partner in the implementation of services. However, this is hardly an overnight process. It took 12 years for CEPAM's model of care to be successfully transferred to the government, and the center's coordinator remains employed by CEPAM.
Clearly establish roles and responsibilities within the partnership: The balance between civil society participation and government leadership is a fine one. Interviewees cautioned that too much participation and leadership by civil society can lead to government over-reliance on civil society to assume responsibility in the response to GBV—resulting, for example, in a failure to fund activities planned under the leadership of civil society organizations. One strategy to ensure that the government fulfills its role is to limit civil society participation, in initial phases of implementation, to representatives and organizations that compete for technical assistance roles. There should be a mechanism for input from all parties involved in the partnership. In addition, the government should ensure appropriate funding levels for all aspects of the National Plan, which includes prevention and resources as well as awareness raising.
CEPAM staff currently counsel survivors about the potential health consequences of violence, particularly sexual violence, and refer the survivor or her family to facilities where sexually transmitted infection services and HIV testing and post-exposure prophylaxis are available. CEPAM would like to provide these services but does not have the resources or the proper facilities (such as a laboratory), and current law allows the provision of post-exposure prophylaxis only at hospitals. Yet in hospitals, the availability and accessibility of these services are limited because providers still have limited knowledge about survivors' needs and rights to these services. CEPAM will continue to advocate to persuade the government to decentralize provision of post-exposure prophylaxis, emergency contraception, and HIV testing for GBV survivors, to increase access to these critical services.
Centro Ecuatoriano para la Promoción y Acción de las Mujeres Guayaquil. 2007. Conociendo…Exigimos Nuestros Derechos: Guías de Capacitación Sobre Violencia Intrafamiliar y Derechos de Familia. Guayaquil, Ecuador: CEPAM Guayaquil.
Ministerio de Salud Pública del Ecuador. 2009. Normas y Protocolos de Atención Integral de la Violencia de Género, Intrafamiliar Y Sexual por Ciclos de Vida. Primera edición. Quito, Ecuador: Ministerio de Salud Pública del Ecuador.
Camacho, G., and N. Jácome. 2008. Mapeo de las Comisarías de la Mujer y la Familia en el Ecuador 2008. Quito, Ecuador: Centro de Planificación y Estudios Sociales.
Joint United Nations Programme on HIV/AIDS. 2011. Country Profile: Ecuador. (accessed March 2011)
Quevedo Terán, A., and T. Condo. 2010. Evaluación de la Calidad de los Servicios de Atención a la Violencia de Género, Intrafamiliar y Sexual 2009-2010, CEPAM. Guayaquil, Ecuador: CEPAM Guayaquil.
Republic of Ecuador. 2007. Plan Nacional para la Erradicación de la Violencia de Género hacia la Niñez, Adolescencia y Mujeres. Quito, Ecuador: Gobierno Nacional de la República del Ecuador.
The author would like to thank CEPAM staff in Guayaquil who took the time to organize interviews with key informants and program participants and accompany her during the process. These include Patricia Reyes, Tatiana Ortiz, Marjorie Lopez, Laura Sanchez, Annabelle Arevalo, and Sara Martillo. Likewise, the author appreciates the time of all key informants among CEPAM staff as well as the provincial and national government. In particular, information and leadership provided by Miricam Alciver and Mercy Lopez at the government level were invaluable. The author acknowledges Rosa Salazar for her documentation of focus group discussions with CEPAM's Guayaquil staff and participants. Thanks to the U.S. President's Emergency Plan for AIDS Relief Gender Technical Working Group for their support and careful review of this case study. Finally, heartfelt thanks go to the survivors of violence who shared their stories.
Betron, Myra. 2012. Civil Society and Government Unite to Respond to Gender-Based Violence in Ecuador. Case Study Series. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.