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

A resource package

4.3. Steps for developing and implementing an effective referral system

4.3.1 Undertaking a situation analysis and mapping of existing services

At the outset, it is recommended to conduct a comprehensive situation analysis to assess the overall legal and institutional environment of a referral system. Also, developing a referral system does not necessarily mean establishing new services, but ratheridentifying existing services and agencies that will be included into the referral system. Therefore, it is important to obtain a comprehensive picture on services available and gaps, if any. This assessment seeks to identify entry points and potential partners to participate in a referral system. It may also point to gaps in services, capacities and resources that the referral system should address. The following data should be collected and analyzed:

  • the nature, causes and extent of GBV in the region/country;
  • the legislative framework, including criminal law and specific laws on GBV, if any, as well as laws regulating protection measures, and progress and gaps in implementation;
  •  the role, capacity and track record of the police, criminal justice system an civil courts in responding to GBV;
  • the overall organization of the health care system;
  • the existence of special policies or protocols regulating the health system’s response to GBV;
  • the availability existing specialized and general services for survivors of GBV in the country, region and/or municipality; and
  • the extent to which survivors access these services and any obstacles preventing them from doing so.

The assessment should not be limited to the national level, but also look into the regional and local situation, for example, to find out if whether regional or local referral systems are already in place and if so, which actors are involved in it.

When doing the analysis, it is advisable to draw on a mix of sources, in order to obtain a picture as complete and objective as possible. While official government reports do include relevant data and information, it is also recommended to take into account the views of NGOs. These organizations often not only have valuable day-to-day experience in working with survivors of GBV, but also might have different perceptions of the availability of quality services and the status of implementation of legislation, compared to governmental entities.

Recommended research tools and methodologies:

Desk research: Researchers may want to consult the following recommended resources for country-specific data:

Qualitative interviews and focus group discussions with service providers identified through desk research and service users. For specific guidance on planning and implementing these research methodologies on the context of health and GBV, refer to WHO/PATH 2005. When planning interviews or focus group discussions, it should be kept in mind that the process of identifying interview partners/participants can already provide useful insights. The searching for suitable governmental and non-governmental interview partners might show for instance, the extent to which responsibilities for GBV have been clearly assigned within government departments, the level of priority that is assigned to the role of the health sector in addressing GBV, or the level of technical and staff resources within NGOs working in the field of GBV and health. Furthermore, the process of asking questions in itself is an important part of awareness raising on the part of interview partners. When doing interviews through seeking written responses, it is recommended to call the persons in charge before sending a questionnaire, which increases the likelihood of receiving an answer.  

Please refer to Annexes 4 and 5 for two questionnaires, which offer guidance for mapping and analyzing services for survivors of GBV through desk research and interviews aimed at developing a referral system. Users are encouraged to adapt and change the questionnaires to the local context, for example through selecting those parts that suit their needs or through combining or shortening certain elements.

4.3.2  Setting up a referral directory

Following the mapping of GBV service providers in the relevant geographical area (section 4.3.1), the information collected should be organized in a referral directory. This should include in particular contact information, as well as information on types of services provided, the population served and any eligibility criteria. A referral directory tool can help to ensure that health care providers are familiar with existing options for referrals – be it as part of an existing formal referral mechanism or in the absence thereof. Please refer to Annexes 4 and 5 for two sample forms that can be used to compile a directory of referral organizations. Management should provide copies of this directory to all health care staff of their facility that interact with women patients, so that they can use it as basis for referrals. In case of resource constraints, the facility should have at least one copy in a convenient, accessible place (IPPF 2010).

Management should gather feedback from health care providers about how well the directory is working, to make sure that the format is workable and to find out whether providers faced any difficulties in making referrals. It is important to update the directory on a regular basis, to avoid giving women misinformation, which might put them at risk (IPPF 2010).

4.3.3 Formalizing the partnership

Referral systems for survivors of GBV are likely to be most effective when they are based on a formal cooperation agreement among all agencies involved. Such an agreement can take the form of a Memorandum of Understanding or an inter-agency protocol. The main aim of such a document is to formalize the co-operation among agencies and to define respective roles and responsibilities, key principles of service provision as well as a referral pathway (e.g. to whom to refer the survivor, when, where and how). The agreement should be discussed by all participants of the referral system and signed by the authorized representative of the respective agency.

Before a Protocol is adopted, the partners of the referral system need to take time to develop a collaborative working relationship based on mutual trust. This requires, among others, that all members agree on a common understanding of GBV and a common vision on how to respond to it. For instance, it must be ensured that all referral agencies understand violence against women as gender-based, rather than reducing it to a matter of family protection or family reconciliation. All partners should be willing to share with their counterparts how their institution is handling cases of GBV and to accept feedback from other members on what might be changed to improve service provision and working together (adapted from Hagemeister et al 2003).

Components of effective referral systems

  • A joint understanding of the purpose of the partnershipthat all partners can subscribe to and are willing to commit resources to. The joint vision should describe in no more than one sentence what the partners want to achieve. The process of developing a vision is almost as important as the vision itself.
  • A workable structure that fits into more general local structures and consists of a strategic group that is mandated to define targets for and in consultation with partner agencies, and an operational arm thatis supported by thematic sub-groups. Strategic direction and operational delivery need to be supported by effective resources and accountability mechanisms.
  • A joint strategy, describing strategic aims and indicators for their achievement, accompanied by an operational action plan that defines key outcomes and outputs planned, the persons responsible for producing the outputs, a timeline, budget, and a system of review and quality control.
  • The involvement of strategic leaders at the strategic direction level, middle managers with access to staff at the operational delivery level, and front-line staff at the level of sub-groups who implement plans and are consulted on possibilities for action. NGO representatives need to be part of this process.
  • The action plan must be matched byadequate personal and financial resources.
  • While the coordinator plays a facilitating role, it is the participating agencies’ activities that make the partnership work.
  • Training of all professionals involved that challenge existing myths and aim to develop skills and confidence in staff, reflecting the local context, procedures and services available. Partners should contribute to developing key messages for training and involve managers and supervisors in training, both as participants and co-trainers.
  • Developing a useful dataset to implement and monitor the partnership. This includes agreeing on a basic dataset to support the strategy, agreeing on aims and indicators and regularly reviewing data from the partner agencies during partnership meetings.
  • The existence of policies, protocols and standard operating procedures to support sustainability and accountability of the partnership (adapted from Standing Together Against Domestic Violence 2011).

For an example of how a formal local referral mechanism was developed in Kyrgyzstan, embedded in a national-level multi-sectoral framework, see box 26 (section 4.1).

4.3.4 Providing staff with information resources

Informing the patient of available services is a prerequisite to help her identify the most suitable options. Written information materials given to women need to be discreet to avoid perpetrators finding them. 

Examples of information resources that health facilities can provide to staff include the following:

  •  A referral directory listing relevant services with contact information and eligibility criteria (see section 4.3.2 and Annex 7);
  • Posters with tear-off slips, pamphlets, or brochures in examination rooms and women’s toilets so that patients can take them away or read in private (WHO 2013);
  • Small pocket size lists of useful phone numbers (WHO 2013; see figure 7 for an example of palm size business card);
  • Phone numbers printed in the form of bar codes on stickers, lip balms or other small items that many women have in their handbag, giving info on support services in a low risk way (see figure 8 below); and
  • Key rings with information on support services hidden inside the key ring fob (see figure 9 below) or with personalized alarm and torch (see figure 10 below).

Figure 7: Palm size business card with useful phone numbers (Hammersmith and Fulham, London, UK)

Figure 8: Phone number of women’s helpline in form of barcode

Figure 9: Butterfly key ring with safe information inside

Figure 10 Personal alarm key rings