Results are presented by components of the Health System Framework to Address VAW . Adapted to the WHO health systems building blocks , the Health Systems Framework on Violence Against Women identifies components within each health systems building block which constitute a health systems response . Figure 1: Strengths and Gaps by Component of Health Systems Framework on Violence Against Women. VAW = violence against women; NGO = non-governmental organization.
1a.Health providers supporting survivors
Regarding health provider attitudes towards sexual and domestic violence in these settings, a 2019 review of one-stop centers (OSCs) found staff engaged in victim-blaming . Though Brazil criminalizes domestic violence, many health providers are “still reluctant to engage with the issue .” A previous study among health providers in Rwanda showed universal agreement with the statement, “A man who rapes a woman cannot control his behaviour ,” indicating normalization with the belief that men are not capable of controlling sexual urges.
1b. Responding to survivors
The first step of a survivor-centered response is identification. The WHO recommends identification through questions based on the presenting conditions and history, a process known as “clinical enquiry .” Identification of violence based on presenting signs and symptoms differs from “routine enquiry,” in which clients are universally screened for violence, which is not recommended outside of antenatal care and mental health services as universal screening can overwhelm health systems [5, 13]. In addition to identification of violence, the 2013 WHO guidelines delineate the role of health systems in provision of women-centered clinical response and first-line support, indicating that referring women to care is insufficient, but that health facilities have a responsibility to provide first-line sensitive support for survivors of VAW.
Within 12 health facilities of Rwanda,routine enquiry for VAW was integrated into family planning and antenatal counseling, even though provider training did not include gender sensitization and key aspects of women-centered care . Project staff reported that disclosure rates of violence were extremely low (1–2 percent in the first six months) of this routine enquiry pilot . Providers reported feeling overstretched and overburdened, while client feedback indicated that providers were inquiring about violence insensitively. These challenges precluded the expansion of routine enquiry.
In Bangladesh, nongovernmental organization (NGO) clinics implemented a routine screening pilot for identification of violence among women seeking health services. The NGO Health Service Delivery Project (NHSDP) was a health service delivery project in Bangladesh funded by the United States Agency for International Development. This project supported the delivery of reproductive, maternal, and child health services through a network of rural and urban local NGO clinics that targeted poor and underserved women of reproductive age . The NHSDP trained its staff on VAW, implemented a routine screening pilot, and developed a national protocol on health response to VAW.
For cases of sexual assault, protocols in Brazil emphasize the responsibility of nurses for identifying survivors and referring them to health providers and appropriate institutions; the protocols do not specify the role of other health providers other than nurses. In Nepal and Sri Lanka, responsibilities of health care providers include identification, confidentiality, and informed consent, provision of first aid and LIVES, history taking, medical management, medico legal services, referral, and follow up [29–30]. In Sri Lanka, the public health midwife is tasked with identifying issues related to VAW and referring and connecting survivors to the health system. Specific to sexual violence, medical officers are identified as responsible for medical management and response .
2. Health systems supporting health providers
2a. VAW in policy and implementation: leadership and governance
Government prioritization of resources and interventions is essential to changing practices. All settings have included VAW in their health policy and programmes. Even where the country’s social welfare departments are anchoring services (as in Bangladesh and Brazil), the role of health systems is delineated. However, these programs are not backed with directions from Ministries of Health on the role of each health facility. None of the settings provide legal sanction to domestic violence or rape, and in Bangladesh and Sri Lanka marital rape is not criminalized .
Policy gets translated to practice through appropriate financing. Allocation of funds are required for in-service training of providers, for appointment of trained staff for running OSCs, and necessary infrastructure. The funds for OSCs come from government ministries of health in Nepal, Sri Lanka, and Rwanda. In Bangladesh, the majority of the funding from OSCs comes from international donors (including the Danish government for the Multi-Sectoral Programme on VAW) . In Sri Lanka the OSC program is financed by the Ministry of Health, while international donors are only in a supportive role. The OSCs in Rwanda were initially co-funded by the United Nations and the government. Local level prioritization is well placed in Nepal where each Village Development Committee allocates 15 percent of its budget for women’s issues, the microplanning for which takes place at the Health Facility Management Committee. Funds are available to reimburse the healthcare and legal expenses incurred by survivors, even though complex regulations, and administrative hoops challenge access . In Brazil, funding allocations for VAW are decided are administered at the local levels within states.
2c. Health infrastructure
Providing privacy and confidentiality, availability of medicines and other supplies constitute infrastructure. In all the settings, data showed that providing privacy to the survivor emerged as a challenge. Additional challenges in all five settings included lack of furniture, information and communication material, instruments, and medicines, use of space and equipment designated for OSCs by other departments, and excessive patient load leading to overcrowding. In Nepal, OSCs were ranked as providing better privacy and confidentiality than health facilities, and this was attributed to the protocolized nature of VAW response at the OSCs. Ascore card used to rank OSCs in Nepal showed 82 percent of assessed OSCs operating with adequate space and equipment or supplies . In all other settings, infrastructural challenges included lack of adequate health provider training besides the lack of space to ensure privacy.
2d. Health workforce training/development
Stakeholder training is built into the implementation plans in all contexts, with varying results. Frequent staff turnover remains a challenge to capacity building on VAW response. Health provider training programs in Nepal focus on improving competency and skills; nurses are mandated to identify survivors and doctors to provide medical treatment and to report medico-legal cases. Nepal addressed staffing gaps in its 2016 revised OSC Operational Guideline by appointing a minimum of one medical doctor and two to three staff nurses the OSC or as on call for 24-hour provision of service. A 2020 report on Nepal’s OSCs indicates the majority addressed these staffing changes to be operational 24 hours a day . Following training on health systems response, providers noted a new sense of responsibility they felt to support the survivor get justice, while noting that doctors not being relieved from their regular duty if they have to attend a court hearing at some hospitals remains a challenge . The United Nations Population Fund (UNFPA) and NGO partners in Bangladesh support the government in providing staff training; they have developed a screening checklist, referral flow-chart, counselling guideline and provided training to the providers for essential services in their clinic networks . A monthly review meeting with health providers, outreach workers, and their supervisors is conducted. The National Protocol for Health Sector Response to VAW in Bangladesh requires health providers to provide psychological first aid to survivors, medico legal examination and proper documentation. Sri Lanka focuses on training and capacity building too, both for health providers and the public health midwife. Sri Lanka introduced VAW as a module for public health midwives focused on knowledge-building, skill development for addressing and preventing VAW in the community, as well as on positive provider-client interaction and communication . Since 2015 the government in Rwanda has focused on strengthening and scaling its OSC model in all provinces, improving documentation, implementing quality assurance standards, providing specialized support to children and adolescent survivors, training providers on first-line support for survivors and post-GBV health care, making appropriate referrals, and strengthening referral pathways, with help from its non-governmental partners.
In Sri Lanka, of all health providers who are trained in responding to VAW, one person gets designated as the nodal person, and s/he is given an additional four-day training on responding to VAW survivors. The nodal person works across the ministries of health and of women affairs. In Nepal the OSCs have designated staff for managing/responding to cases that come, and usually a nurse or paramedic and a psychosocial counsellor . Information on the process of designating a nodal person for managing VAW cases from the other three contexts is vague.
While all countries reported that they train in-service providers, there was no documentation on impact of training on provider knowledge, attitudes, or practices. In Brazil, the Ministry of Health assembled an optional online curriculum for medical professionals on interpersonal and intimate partner violence . However, till date, this training has been completed by less than 10 percent of the professionals, indicating a lack of uptake. In Bangladesh, in addition to initial training, the NGO Health Service Delivery Project integrated discussion on provider attitudes on VAW into monthly meetings between health staff and supervisors besides refresher trainings . In Nepal, a 2016 study indicated a lack of training and knowledge around VAW among health providers . While impact data on provider change in attitudes resulting from training on VAW were not available, staff nurses who received psychosocial counselling training noted how they have changed the language they use with survivors and have become aware of how to show sensitivity, respect, and empathy to survivors . Nepal’s Ministry of Health and Population introduced an in-service for medical doctors on autopsy and clinical medico-legal training, although training has not been initiated in recent years.
2e. Health information system
Documentation and information management in Nepal includes VAW data recorded at the national level on two different platforms, from all health facilities through the Health Management Information System (HMIS), and from the OSCs routed to the Prime Minister’s Office. The VAW data is disaggregated along sex, age, type of violence, caste, ethnicity and disability. Additional indicators note the services provided to survivors and referrals made. Rwanda and Nepal are the only countries in this study which report data on VAW through HMIS. Since 2012, Rwanda has worked on streamlining its quality of health data which is collected from the community health workers and health facilities to HMIS and has integrated facility-level as well as household-level data. The nationalized database in Bangladesh is not yet functional; however, its Bureau of Statistics collects household level survey data on VAW once every four years . A call center database accumulates the data on calls made by survivors documenting forms of assault, and referrals. The centralized system in Brazil records cases of VAW, though it was implied to the authors that the data is not reliable enough. Nonetheless, the reporting at the state level in Brazil is better managed than at the federal level. Sri Lanka does not capture data on medico-legal cases nor reports through HMIS.
2f. Service delivery
Service delivery for VAW includes psychosocial support, medical treatment, multi-sectoral referral including within health . A One-Stop Center (OSC) provides multi-sectoral case management for survivors, including health, welfare, counselling, and legal services under one roof with the intention of minimizing referrals and the need to have survivors repeat their account . Descriptions of the OSCs in each setting as well as available data on coverage and service quality are provided in Additional File 1.
OSCs were found to be the most dominant model of care implemented by the health systems in four countries (Nepal, Bangladesh, Sri Lanka, and Rwanda) in which OSCs are set up in hospitals. Brazil is the exception, with OSCs managed as separate centers providing services to survivors (judicial services, specialized police for assistance to VAW survivors, shelter assistance, psychosocial support, and economic livelihoods support) which do not include medical support. While Sri Lanka and Rwanda’s OSCs were set up by the health system, the OSCs in Bangladesh and Nepal are set up as large multi-sectoral programmes with clear health sector roles and responsibilities.
In all settings, OSCs are present in hospitals within all districts within the country, with the exception of Brazil, in which OSCs called Houses for Women are at the regional level and are not hospital-based. Staff at OSCs are designated and trained in protocols detailing response to VAW. Referrals to OSCs come largely from police and directly from communities (Additional File 1). OSCs have created space for provision of counseling to survivors of violence in the hospital. GBV protocols specify that hospital departments, especially emergency and specialized departments, should refer clients for additional medical services at OSCs. However, as seen in Additional File 1, internal hospital referrals are not captured as a source of referral to OSCs. Gaps remain in training of health providers in identification of signs and symptoms of VAW.
2g. Coordination and community engagement
Coordination to facilitate internal and other sectoral referrals and community engagement are important axes of the Health Systems Framework to Address VAW. OSCs in Nepal have protocolized multisectoral coordination such as with the legal, judicial, and livelihoods. The referral pattern of OSC survivors shows community awareness about services as a portion of survivors reach OSCs directly . In Sri Lanka’s 2016 Demographic and Health Survey, 13 percent of surveyed women were aware of Mithuru Piyasa services . In Sri Lanka since the Mithuru Piyasa centers are located within the hospital, intra-facility referrals are relatively smooth, though other-sectoral referrals are not formalized. Recognising the importance of engaging the community, Sri Lanka prioritized the use of information education communication material, with public health midwives responsible for community engagement. Given their access to the community, they remain critical for identifying survivors, especially those women who otherwise would continue to bear the violence in silence .
In the rest of the settings, structured intersectoral coordination and referral are lacking. Changes within the federal system in Nepal have resulted in uneven funding of multi-sectoral services for VAW survivors, such as safe homes and rehabilitation services . The NGO Jhpiego oriented select community health volunteers in Nepal for identification and referral of survivors, showing that with appropriate training and safety mechanisms, community health workers can raise community awareness about VAW, facilitate support for survivors, and help prevent harmful practices . In Bangladesh, while the Multi-Sectoral Programme on VAW does not have an explicit community engagement component, the initiative runs TV ads and radio spots for public awareness on the availability of VAW services . The world’s largest NGO (Building Resource Across Communities, or BRAC), as well as other NGOs, have implemented programs focusing on improving community engagement and awareness of VAW, though these services are not directly linked to the Multi-Sectoral Programme on VAW . In Brazil, networks of psychologists and social workers, activists, and women-led organizations increase awareness on VAW, though efforts are not formally linked to available OSC services. Rwanda’s Protocol on Treatment of Survivors of VAW demonstrates a model of inter-sectoral coordination for VAW and includes provisions for safety planning and community resources for survivors, though formal coordination with other sectors for VAW support is not protocolized .