Over the last 25 years, violence against women, particularly intimate partner violence and sexual violence, has been increasingly recognised as a human rights violation and a public health problem with grave consequences for women’s health. The Sustainable Development Goals (SDGs) include a target specifically focused on eliminating all forms of violence against women and girls.1 While many governments are addressing this issue, which is experienced by 1 in 3 women worldwide,2 the health system response to violence against women requires further scrutiny.
In 2016, the World Health Assembly endorsed a global plan of action to strengthen the role of health systems in addressing interpersonal violence, especially violence against women, girls and children.3 Many regions and countries have also introduced multisectoral plans and health protocols for addressing the issue. World Health Organization (WHO) recommendations4 and experience from countries emphasise the need for system-wide readiness for responding to violence against women, including as part of Universal Health Coverage (UHC). However much more needs to be done to implement these plans and recommendations.5
Strengthening the health systems response
All health providers, not only specialists, must be trained to understand the needs of survivors, to show empathy and be ready to offer confidential first line psychological support. Yet, health worker training and health protocols alone are not enough. The whole health system needs to be “ready”, including with sufficient budget and resource allocation, to support a qualitative response to violence against women that is integrated into existing health services, such as for sexual and reproductive health, HIV, child and adolescent health, mental health and emergency care among others. Importantly survivors must have a safe space in which to speak and share their experiences. Ongoing mentoring and supportive supervision are necessary to sustain quality care to survivors of violence.6 A health system response also includes ensuring available, functioning and coordinated referral pathways are in place, both within and outside of health, for women affected by violence to access care and support in a timely way.
Gender equality and power
Responding to violence against women needs more than a technical approach. Women centred care considers the specific needs of survivors, including the stigma experienced by women as well as the roots of violence against women: gender inequality and power disparities. For example, the societal normalization of violence against women means, despite protocols and guidelines, there can be (initial) resistance to implementing a response and to the allocation of resources. Stigma and safety fears, including perpetrator retaliation, prevent many women from disclosing violence or seeking help. Survivors who do seek support may be challenged by service providers who have their own gender discriminatory attitudes, may fear violence from women’s’ partners or being involved in legal proceedings. A lack of time to care for survivors is also a concern. Healthcare providers must be supported to critically reflect on their own values and norms that perpetuate unequal gender power relations to improve women-centred care for those who seek help.
For example, as part of an HIV prevention programme, LVCT Health, a Kenyan non-government organisation, trained HIV counsellors to provide psychosocial counselling and support to women at risk of, or who had recently experienced, intimate partner violence.7 The training helped providers critically reflect on their own attitudes and harmful gender norms within society, and on the need to keep women’s right to self-determination at the centre of their response. The pilot programme showed positive outcomes for women, such as reduced stress and improved wellbeing. Women also had more confidence in communicating with their partners and felt their relationships had improved.7 The programme reinforced the value of women-centred care and that it was both important and feasible for providers within existing services, such as HIV testing and counselling, to give care and support to survivors of violence.
High level political commitment
High level commitment and sufficient budget allocation for addressing violence against women is key to the development and implementation of national strategies as well as the health system response. For example, Brazil’s strong feminist movement and the government’s special secretariat for women (2003-2016) put the issue of violence against women onto the national policy agenda. In 2007, a national agreement on tackling violence against women was developed8 and municipal and state level guidelines for responding to violence against women across sectors were established. The health sector identified higher numbers of women affected by violence and accessing health care.9 Unfortunately, a change in government saw the end of the secretariat which contributed to a decline in political commitment and lower budget allocations for addressing violence against women in health and other sectors.
The way forward
It is possible to build gender responsive health systems that offer women-centred care to survivors of violence. The lessons can be applied to all areas of women’s health and UHC more broadly. It is critical all health professionals, including doctors, nurses and midwives understand the need for such a response and receive pre-and in-service training on violence against women.10 The health system, as a whole and at the facility level, must be supported by sustained political will and commitment to address the issue, and have sufficient capacity and resources to respond effectively to survivors of violence with care, dignity and respect. An effective health system response to violence against women needs to be part of an integrated approach across sectors to eliminate violence against women and girls and achieve the SDGs.
Megin Reijnders is a consultant with WHO working on the health system response to violence against women.
Lina Digolo is a senior associate working on strengthening prevention programs that work at the intersection of violence against women and their children.
Ana Flavia d’Oliviera is assistant professor at Departamento de Medicina Preventiva – Faculdade de Medicina da Universidade de São Paulo.
This work was supported by the World Health Organization’s Department of Sexual and Reproductive Health, and the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization. The views expressed are those of the authors and do not necessarily represent the policy of their organisations.
- Transforming our world: the 2030 Agenda for Sustainable Development. New York: United Nations; 2015
- Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization; 2013
- Global plan of action to strengthen the role of the health system within a national multisectoral response to address interpersonal violence, in particular against women and girls, and against children (WHA 69.5). Geneva: World Health Organization; 2016
- Clinical and policy guidelines for responding to intimate partner violence and sexual violence against women. Geneva: World Health Organization; 2013
- García-Moreno C, Hegarty K, d’Oliveira AF, Koziol-McLain J, Colombini M, Feder G. The health-systems response to violence against women. Lancet. 2015. April 18;385(9977)
- Strengthening health systems to respond to women subjected to intimate partner violence or sexual violence. Geneva: World Health Organization; 2017.
- Assessing the effectiveness of a combined facility and community level Intimate Partner Violence and HIV interventions in Kenya: a quasi-experimental study. LVCT Health, 2019. https://lvcthealth.org/wp-content/uploads/2020/03/Intimate-Partner-Violence-Researcn-2019-Report-LVCT-Health-compressed.pdf
- Kiss L, d’Oliviera AF, Zimmerman C, Heise L, Schraiber LB, Watts C. Brazilian policy responses to violence against women: government strategy and the help-seeking behaviors of women who experience violence. Health & Human Rights. 2012. June 15;14(1)
- Violência contra a Mulher – vítimas de agressões anteriores têm 151 vezes mais chance de morrer por homicídio ou suicídio, in EcoDebate, ISSN 2446-9394, 7/02/2019, https://www.ecodebate.com.br/2019/02/07/violencia-contra-a-mulher-vitimas-de-agressoes-anteriores-tem-151-vezes-mais-chance-de-morrer-por-homicidio-ou-suicidio/
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