Joined-up action on FGM

Piloting a new approach to fighting FGM

Following the publication in 2003 of the research report Strategies to prevent circumcision in girls, a policy brief was issued in Holland in 2004 recommending the establishment of the Commission to Fight FGM. Its subsequent reports have triggered a succession of actions. Their most important consequence was the initiation of pilot projects in six cities in 2006, and the subsequent roll-out of the pilot projects at national level in 2010 and 2011. The pilots were carried out in those big cities where most of the communities from countries where FGM is practised were living (Rotterdam, Amsterdam, The Hague, Utrecht, Eindhoven and Tilburg). Responsibility for fighting FGM was delegated to municipal level in 2012.

An important driver of this process was that the issue was taken up by the State Secretary for Health, Welfare and Sport, who issued policy briefs that detailed a clear policy on FGM and financed the pilots. The clear choice to favour prevention rather than prosecution has led to a series of initiatives to combat FGM and protect girls and women. The chain approach was used during the pilot projects, and after the projects finished the approach was instrumental in sustaining their benefits.

What is the chain approach?

The chain approach is an integrated approach to dealing with FGM, which links actors from different agencies together and involves the community. This enables all involved to adjust the way they work, share resources and take joint responsibility for the outcomes. This sort of collaborative method comes into its own since FGM is a complex issue that falls under the responsibility of a number of agencies and involves prevention, child protection, prosecution, healthcare for children and women and psychosocial care. Moreover, the strong cultural anchoring of FGM means that key members of communities of migrants from FGM-practising countries need to be involved. To guide the work of actors involved, the chain approach uses protocols for each sector, and the protocol for Youth Health Care (child protection) is monitored by the highest health authority.

In each municipality, a chain is determined, and the way of dealing with FGM is defined. All relevant actors need to be involved: youth health care, police, schools, midwives, maternity care, GPs, gynaecologists, paediatricians and advice and reporting points on child abuse (i.e. the medical and legal professions) as well as the key persons from the communities affected. Moreover, experts need to be found to prepare agreements and guidelines, and umbrella organisations should be involved in their implementation. Chain partners (including members of FGM-practising communities) need to have a clear idea of the role of each stakeholder when a case of FGM or a girl at risk is reported.

All actors are trained, and protocols are drawn up to explain in detail the roles and responsibilities of each actor in the chain, as well as instruments to support their activities. For instance, the Standpunt (for Youth Health Care) and protocols for youth care and medical care (including the minimum care level for FGM and background information on FGM) and FGM risk indicators for teachers have been developed. Regular meetings are organised so that each stakeholder knows the role of the other stakeholders. At the municipality level, chain meetings take place to encourage networking. The main activities of the chain approach are:

• developing and implementing guidelines;
• training professionals (YHC staff, YC staff, Council for Child Protection, midwives, gynaecologists; e-learning for YHC and midwives);
• training key persons from risk communities in order to promote their skills in conducting home visits and information sessions.

Evaluations show that this approach is effective. The target groups were successfully reached, and all actors involved know their roles in the process and their counterparts in the chain. Nevertheless, its impact remains difficult to measure since no baseline assessment was performed.

Positive evaluation

Two evaluation reports were carried out on the six pilot projects. They concluded that the Youth Health Care service had invested heavily to build the capacity of doctors and nurse, and was thus successful in detecting risk situations. It had developed educational materials and made efforts to embed capacity building and training into regular programmes and courses. Following the evaluation, the conversation protocol was reworked into the Standpunt, taking into account the recommendations made by the evaluators. The pilots succeeded in appointing focal persons, building their capacity and making structural agreements with organisations from various sectors. They thus provided knowledge about stimulating and obstructing factors when operating the chain.[1]

Community link is vital

A number of factors contribute to the method’s success. The first is that the chain should be complete, and should include actors dealing with prevention, prosecution, protection and service provision, thus forming a unique partnership. Secondly, it is crucial to gain the participation of key persons within the practising communities, because they can get the message across more easily. Thirdly, personal contacts between the actors and chain members have lowered the threshold for asking questions and referring cases. Resources for piloting, training, the development of protocols, the monitoring of the Standpunt by the Health Care Inspectorate (IGZ) and the registration of FGM in data systems (perinatal registration and digital files of Youth Health Care) have also been important.

The chain approach has run up against a number of obstacles, among them being a failure to establish baseline data at the start, the lack of financial support to continue the project (especially for key persons) and staff mobility meaning new people have to be trained. Some actors, such as the education system and general practitioners, are not closely enough involved. A particularly complex problem is how to ensure good collaboration between the medical and legal systems when these involve many actors, each with their own way of making decisions and taking action. And the issue is complex: peer educators and key persons regularly meet families experiencing multiple problems, with FGM being only one of them.

The rapid turnover of key persons is weakness, as they are crucial to gaining access to the communities affected by FGM. This is why their structural embedding and financing is of great importance.

Following some delays in allocating municipal, budgets, since 2011 the chain approach has been financed by the municipalities, each of which has its own policies and different-sized communities from FGM-practising countries. This is a sustainable framework. However a disadvantage of this financial devolution is that during the process the funding of key persons was dropped.