Strengthening Health System Responses to Gender-based Violence in Eastern Europe and Central Asia

A resource package

Standards for service delivery

Survivors of gender-based violence do not always seek help from specialized agencies or disclose their problem when they do seek help. They often come to agencies for various purposes, for health-care or social services, housing programs, courts and others. If they are aware of the situation and if their interventions are sensitive and survivor-friendly, these agencies have a great potential to recognize the problem and to serve as a “door opener” to specialized services, such as women’s shelters. 

Find below key qualitative and quantitative standards for service providers.

Qualitative standards

Safety, security and human dignity

Services need to ensure that all interventions prioritize the safety and security of survivors and respect their dignity (WAVE 2006 and 2010). Safety must also be provided for the staff. Potential safety risks have to be evaluated and routine safety assessments and specific safety planning with the survivor of violence need to be carried out (Virtual Knowledge Centre 2011). General services such as health facilities, social services or general shelters are often not adequately provisioned to comprehensively protect and support women survivors of violence and their children. Specialized services, such as women’s shelters/refuges, are necessary from a safety perspective, since they provide women survivors of violence with anonymity (keep their whereabouts secret) and don’t allow men to enter. (WAVE 2010). With regards to ensuring dignity of survivors, care providers need to ensure availability of female examiners where requested, and promote bodily integrity in examinations. Furthermore services should ensure access to family planning, contraception, and where legal, safe abortions (WHO, 2008 quoted in Virtual Knowledge Centre 2011).

Right to self determination
It is important to respect survivors’ rights to make decisions about their lives. Very often, relatives, friends and professionals in care organizations try to tell the woman what to do. But such advice can create even more pressure on the woman and is rarely hel. The aim of an intervention is to end violence, not to end a relationship. The right to self-determination is an important principle. (WAVE 2006).

Respecting the principle of self determination, requires that health care professionals make themselves aware of the needs and wishes of patients with respect to both their treatment and their interactions with police, the legal system or other referrals. Within the health services all steps taken should be based on informed consent i.e. the provision of information about the procedure to be performed and medication to be given and any side-effects (Virtual Knowledge Centre 2011).

The principle of autonomy requires that survivors should be able to get health care without interacting with any other service before, or as a condition of, gaining health care. They should not have their name passed to any other agency, including a non-governmental organization, social workers or researchers, unless they agree to such a referral. Autonomy is obviously reduced in settings where there is mandatory reporting and in situations where the survivor is a child and needs protection from agencies, often from family members (excerpted from Jewkes, 2006 in: Virtual Knowledge Centre 2011)

Advocacy for survivors
“There is no excuse for violence”. Countering violence means adopting a clear stance and condemning violence against women in all its forms as well as holding the perpetrator accountable. Trying to remain neutral about what has happened means running the risk of tolerating violence. Adopting a clear stance against any form of violent behavior expresses condemnation of violent acts (but not condemnation of the perpetrator as a person). Survivors seeking help should never be asked to offer proof of the violence they have suffered. It is important that care providers listen carefully, convey that believe the survivor and to respond with the utmost respect and without prejudice (WAVE 2006).

Privacy, confidentiality and anonymity
Care providers need to ensure privacy during any conversation with the survivor so that no one in the waiting room or in adjoining areas can overhear (Virtual Knowledge Centre 2011). To protect a woman’s rights and her integrity, it is necessary that she be able to decide which information about her will be passed on to others, this also applies with regards to family members. Therefore, no information should be passed on by health professionals or other care/counseling services without the woman’s consent. Exceptions should and must be made if the life and health of women or children are at stake (i.e., suicide attempts, acute danger from the violent partner, or women abusing their children). Women should also have the right to receive counseling and support without having to reveal their identity (WAVE 2006). Services should have a confidentiality policy. Strict measures should be in place so that staff only discusses cases with other providers when strictly necessary, and in a manner that cannot be overheard (Virtual Knowledge Centre 2011).

The main aim of all services should be to empower women survivors of violence and their children by, inter alia, making sure they know their rights and entitlements and can make decisions freely in a supportive environment that treats them with dignity, respect and sensitivity. Services should always aim at supporting survivors to choose the course of action in dealing with the violence instead of feeling powerless in order for the survivors to re-gain control of their lives and to promote their right to autonomy and self-determination (WAVE 2010/Virtual Knowledge Centre 2011).

Accessibility of services
Seeking help can be a difficult process, in which survivors of violence have to approach many different agencies before they finally receive help. Services should be easily accessible and widely known. It is the task of society to offer help to the survivors and not the survivor’s task to search for or sometimes even struggle to find help (WAVE 2006). Support services should be available free of charge, equitably distributed across regions and crisis provisions such as emergency health services, women’s helplines and shelters should be available 24hours, 7 days a week (WAVE 2010) and provide translation if needed.

Support for children
Children are always affected by the violence against their mother, especially in cases of family violence and they are often abused as well. Therefore all help services should also have the resources to adequately support the children, according to their age and their needs (WAVE 2010). If mothers have to bring their children to a different service, or services (if they have children of different ages), they might easily feel overburdened and end up with the feeling that the help system is demanding instead of supporting (WAVE 2006).

Diversity & non-discrimination
All services open to survivors of gender-based violence need to respect the diversity of service users and apply a non-discriminatory approach (WAVE 2010). Supporting centers must ensure the same level of quality of care for all persons regardless of their gender, age, race/ethnicity, ability, sexual orientation, HIV status or any other characteristic. Services must be fully accessible to all survivors of gender-based violence and must take into account their special needs (Virtual Knowledge Centre 2011). The kind of support survivors need may differ according to the type of violence suffered and this makes it necessary to provide or refer to specialized services such as rape crises and sexual assault centers, women’s centers for survivors of sexual harassment in the workplace, young women’s shelters and women’s shelters for victims of trafficking or forced marriage (WAVE 2010).

Participation - involvement of the service users
Services need to promote service-user involvement in the development and evaluation of the service. Survivors should be regularly invited to participate in the evaluation of services and have the right to file a complaint to an independent body (for instance the ombudsperson) if they are not satisfied with the quality of the service (WAVE 2010).

Long-term support for survivors
The goal of stopping and preventing violence implies that services should not withdraw after emergency interventions. Survivors of violence need services that provide advocacy and support on a long-term basis, accompanying them through all the processes and coordinating the interventions. Some services, like women’s support services provide this necessary kind of support and it should be standard procedure that every survivor of violence is referred to long-term support services (WAVE 2006).

A coordinated response
Coordinated response services need to operate within a context of relevant inter-agency co-operation, collaboration and coordinated service delivery. The protection and needs of women survivor of violence should always be at the centre of multi-agency work (WAVE 2010). In order to ensure coordination among multi-sectoral actors, evidence chains and standard forms (sexual assault evidence collection kits) must be agreed by all sectors (Jewkes, 2006 quoted in Virtual Knowledge Centre 2011).

Holding perpetrators accountable
Services for survivors of violence need to apply the approach that there is no excuse for violence, that the perpetrator is always responsible for the abusive behavior and that he has to be held accountable (WAVE 2010). Holding perpetrators accountable and ensuring that violent acts are prosecuted and convictions obtained, is an important goal. But punishment alone is not enough. Abusers must also be prevented from committing further acts of violence, and they need to change their behavior.

Quality management in service provision
Services are accountable to the service users, to the organization and its members and to society in general. The activities and the conduct of the services must be transparent, comprehensible and evidence based.(WAVE 2006). Guaranteeing quality services is a management task and cannot be relegated to the sole responsibility of the front-line staff. It requires continuous planning, implementation, evaluation and improvement processes (European Foundation for Quality Management 1999-2003 quoted in: WAVE 2006).

Policy guidelines
Clear guidelines and protocols on how to handle cases of gender-based violence should exist in written form and all staff members should be familiar with them and with the procedures for implementing the guidelines in their everyday work. Health services should establish a system of routine inquiry; at least selective inquiry should be practiced in all health services.
(WAVE 2006)

Training of staff
Management must make sure that all staff members are adequately trained and familiar with the guidelines so that they are able to provide services of good quality (WAVE 2006). Training on gender-based violence should be an integral part of the basic training for every profession. All staff members who might be confronted with gender-based violence must receive adequate and ongoing training on the issue (WAVE 2006).

Continuous collection of data and compilation of statistics are necessary to evaluate, further develop and improve the agencies’ response to survivors of gender-based violence (WAVE 2006). However, service providers need to prioritize the well being of survivors and the delivery of services over data collection or any other secondary objectives (Virtual Knowledge Centre 2011).

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Quantative Standards

According to recommendations by the European Parliament and the Council of Europe Task Force to Combat Violence against Women, a minimum standard of one family place in a shelter should be provided per 10,000 inhabitants. The Task Force also recommends that there should be one national women’s helpline 24/7 free of charge in every country and defines other minimum standards; as described in the previous chapter, only 36 per cent out of 44 countries in Europe fulfil these standards presently (Council of Europe 2006/ European Parliament 2011)

  • A minimum standard of one place for every 10,000 inhabitants should be guaranteed; further government should aim at providing a standard of one family place per 10,000 inhabitants, which amount to two places per 10,000 inhabitants. (one Family place = one place for one woman and her children , this makes on average two places per 10.000 inhabitants).
  • One rape crisis centre per 200,000 women.
  • One women’s centre for every 50,000 women, which provides crisis intervention as well as middle and long-term support to victims of all forms of violence or to special groups (i.e. specialised services for victims of trafficking in women or for women who have suffered sexual harassment in the work place).
  • One domestic violence intervention centre per district/province that provides pro-active support and advocacy to women survivors of violence after police interventions or interventions of health or other agencies;
  • Every woman victim of violence should have the right to be supported by an independent (domestic) violence advocate throughout all legal and institutional proceedings.
  • Sufficient numbers of specialised services for migrant/minority and refugee women. Outreach services to victims in rural areas.
  • Middle and long-term support and – if the woman wishes - therapy to overcome the traumatic experiences of violence.

Sources: WAVE 2004/Council of Europe/Liz Kelly/ Lorna Dubois 2008/Women's Aid England 2009

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