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

A resource package

2.1. International standards to strengthen health system responses to gender-based violence

2.1.1  States obligations under international human rights law

GBV is a violation of women’s human rights. According to international human rights law, states are therefore obliged to prevent, investigate and prosecute violations and to provide women survivors with redress, which includes protection, support and compensation. This obligation also involves a duty to improve the response of the health sector to GBV. The content of state obligations is specified in a number of international human rights conventions and declarations (from the United Nations, the Council of Europe and the Organization for Security and Cooperation in Europe )

This sub-chapter provides an overview of select human rights documents guiding the health system’s response to GBV in the region of Eastern Europe and Central Asia

United Nations

United Nations Convention on the Elimination of all Forms of Discrimination against Women

The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW)was adopted by the United Nations (UN) General Assembly in 1979. It provides a legally binding framework for state measures to end discrimination against women in all spheres of life: the political, economic, social, cultural, civil or any other field. All states in Eastern Europe and Central Asia have ratified CEDAW and are therefore obliged to implement its provisions in their countries.

Interestingly, the Convention does not explicitly mention violence against women. The reason for this omission is that in the 1970s, when the text of CEDAW was drafted, GBV, in particular violence committed in the home, was not yet regarded as a human rights issue. The CEDAW Committee closed this gap in 1992, when it adopted General Recommendation No. 19 on violence against women. This document clarifies that GBV against women constitutes a form of “discrimination,” and is therefore covered by the Convention (for the Committee’s definition on GBV, see section1.1). In 1994, the CEDAW Committee adopted another important document, General Recommendation No. 24 on women and health, which specifies the obligations of states to enddiscrimination against women in the field of health care and to ensurewomen’s equal accessto health care services. Importantly, General Recommendation No. 24 also addresses the health sector’s role in responding to GBV. Both General Recommendations specify the obligations of state parties to CEDAW to eliminate GBV, including through strengthening the response of the health care system:

CEDAW standards for an effective state response to GBV (General Recommendation No. 19):

  • Ensure thatlaws against GBV give adequate protection to all women. Effective legal measures include penal sanctions, civil remedies and compensatory provisions.
  • Implement gender-sensitive training of public officials including judges and police.
  • Provide women survivors with effective complaint procedures and remedies, including compensation.
  • Establish or support appropriate protective and support services for women who have experienced or are at risk of violence, rape, sexual assault and other forms of GBV. This includes an obligation to provide shelters, specially trained health workers, rehabilitation and counselling services, and to ensure that such services are accessible to rural women.
  •  Undertake preventive measures, including public information and education programmes to overcome attitudes, customs and practices that perpetuate GBV.
  • Compile statistics and research on the extent, causes and effects of GBV, and on the effectiveness of measures to prevent and respond to violence.

CEDAW standards for strengthening the health system’s response to GBV (General Recommendation No. 24):

  •  Enact and implement laws, policies, protocols and procedures to address violence against women and girls and to provide appropriate health services.
  •  Implement a comprehensive national strategy to promote women’s health throughout their lifespan, including interventions responding to GBV and ensuring access to high quality and affordable health care, including sexual and reproductive health services.
  • Remove all barriers to women’s accessto health services, education and information.
  •  Ensure women’s access to health services in line with women’s human rights, including their right to autonomy, privacy, confidentiality, informed consent and choice. Further, services should be delivered in a way that they respect women’s dignity and are sensitive to women’s needs and perspectives. This implies, among others, prohibiting coercive practices such as non-consensual sterilization or mandatory testing for sexually transmitted diseases.
  • Gender-sensitive training to enable health-care workers to detect and manage the health consequences of GBV. Training curricula should include comprehensive, mandatory, gender-sensitive courses on health and women’s human rights, in particular GBV.
  • Ensure adequate protection and health services, including trauma treatment and counselling, for women in especially difficult circumstances, such as women trapped in armed conflict and refugee women.
  • Ensuring complaint procedures and sanctions against health care professionals guilty of sexual abuse of women patients.

Programme of Action of the International Conference on Population and Development

The Programme of Action adopted at the 1994 International Conference on Population and Development (ICPD) in Cairo underlined the inextricable linkages between population and development as well as the important contribution of women’s empowerment and people’s access to education and health, including reproductive health to both individual advancement and balanced development. Advancing gender equality, eliminating violence against women and ensuring women’s ability to control her own fertility are acknowledged as cornerstones of population and development policies. To this end, countries committed, among others, to eliminate all forms of exploitation, abuse, violence and harassment against women, adolescents and girls. An important aspect of the Platform for Action is its focus on reproductive rights and reproductive health and the expressed commitment of governments to make reproductive health accessible through the primary health care system to all individuals at an appropriate age. The document defines reproductive health as “a state of complete physical, mental and social well-being in all matters to the reproductive system and to its functions and processes. It implies that people have the capability to reproduce and the freedom to decide if, when and how often to do so.” Reproductive health also includes sexual health, which aims at the enhancement of life and personal relations. The concept of reproductive rights includes: the right of individuals and couples to decide freely and responsibly on the number, spacing and timing of their children and to have the means and information to do so; the right to attain the highest standard of sexual and reproductive health; and the right to make decisions concerning reproduction free of discrimination, coercion and violence (UNDPI 1995).

Agreed Conclusions of the 57th session of the Commission on the Status of Women

The Commission on the Status of Women (CSW) at its 57th session in 2013 adopted Agreed Conclusions on “Eliminating and Preventing all Forms of Violence against Women and Girls.” Section A of the document calls for better implementation of existing laws and policies to end violence against women, by ensuring women’s access to justice, the development and implementation of effective multi-sectoral policies and strategies and the allocation of sufficient resources for their implementation. Section B lists measures to tackle discrimination and structural violence as root causes and risk factors for violence against women. Section C contains many detailed provisions for responses to the problem and mentions inter alia the need for independent women’s shelters and other services. Such services should be accessible, comprehensive and involve the coordination of all relevant actors, including police, judiciary, legal aid, health care and counseling services. The CSW also encourages the health sector to respond to GBV and to ensure accessible and quality health-care services. It calls upon governments to address the physical, mental and sexual and reproductive health consequences of violence against women and girls by providing accessible health-care services. Such services should be responsive to trauma and include affordable, safe, effective and good-quality medicines, first-line support, treatment of injuries and psychosocial and mental health support, emergency contraception, safe abortion where such services are permitted by national law, post-exposure prophylaxis for HIV infection, diagnosis and treatment for sexually transmitted infections, as well as forensic examinations by appropriately trained professionals. Further, medical professionals should be trained to effectively identify and treat women subjected to violence. Section D points out the need for research and comprehensive collection of data on violence against women, to ensure that the formulation of new laws and policies and the adaptation of existing standards are based on sound evidence. Several provisions of the Agreed Conclusions stress the important role of women’s NGOs in the work to end violence against women.

Council of Europe     

Council of Europe Convention on preventing and combating violence against women and domestic violence (Istanbul Convention)

On 7 April 2011, the Committee of Ministers of the Council of Europe adopted the Convention on preventing and combating violence against women and domestic violence. As it was adopted in Istanbul, this document is often referred to as the “Istanbul Convention”. The Convention will enter into force on 1 August 2014. As of 30 June 2014, eleven countries have ratified it, including the following EECA countries: Albania, Bosnia and Herzegovina, Montenegro, Serbia and Turkey. The Former Yugoslav Republic ofMacedonia and Ukraine have signed, but not yet ratified. The Istanbul Convention is also open for accession by non-member states of the Council of Europe. Therefore, countries such as Belarus or the Central Asian states could also accede to the Convention.

The Istanbul Convention provides a detailed, comprehensive and legally binding framework for state measures to eliminate GBV, covering, among others, the following areas:

  • Integrated policies and data collection: This includes an obligation to adopt and implement comprehensive and coordinated policies to prevent and combat all forms of violence that place the rights of the victim at the centre and are implemented through effective cooperation among all relevant organizations (Article 7); an obligation to support and effectively cooperate with relevant non-governmental organizations (Article 9); and an obligation to collect disaggregated relevant statistical data and support research on violence against women (Article 11).  
  • Prevention: Among others, the Convention establishes a duty to ensure training of relevant professionals dealing with victims of violence on gender equality, the prevention and detection of such violence, the needs and rights of survivors, as well as how to prevent secondary victimization. Such training should also address coordinated multi-agency co-operation to ensure comprehensive and appropriate referrals to services (Article 15).
  • Protection and support: States shall ensure access of victims to adequate support services to facilitate their recovery from violence. This includes health care and social services that are adequately resourced and staffed with professionals who are trained to assist survivors and refer them to appropriate services (Article 20). Further, the Convention foresees appropriate and easily accessible shelters and rape crisis or sexual violence referral centres that should exist in sufficient numbers (Articles 23, 25) and state-wide 24/7 telephone helplines that operate free of charge and provide confidential advice (Article 24). States shall ensure that victims receive adequate and timely information on available support services and legal measures in a language they understand (Article 19). The Convention also specifies a set of basic principles for service provision (Article 18, see chapter 2.5, box 8).

The Convention further establishes state obligations in the areas of legislation; investigation, prosecution and protection measures; migration and asylum; and international cooperation.

Organization for Security and Cooperation in Europe

Ministerial Council Decision No. 15/05 “Preventing and Combating Violence against Women”

All countries in Eastern Europe and Central Asia are participating states of the Organization for Security and Cooperation in Europe (OSCE) and therefore politically bound by the Ministerial Council Decision No. 15/05 “Preventing and Combating Violence against Women,”adopted in 2005.

The declaration addressesviolence against women as a violation of human rights and a threat to human security(preamble). It calls upon OSCE participating states to “take all necessary legislative, policy and programmatic monitoring and evaluation measures to promote and protect the full enjoyment of the human rights of women and to prevent and combat all forms of gender-based violence against women and girls." In particular, states should undertake, among others, the following measures:

  • Protection and support: to ensure that women victims have full, equal and timely access to justice and effective remedies, medical and social assistance, confidential counselling and shelter;to adopt and implement legislation that criminalizes GBV and establishes adequate legal protection; to provide in a timely manner physical and psychological protection for victims, including appropriate witness protection measures; and to investigate and prosecute the perpetrators;
  • Collect, analyze and disseminate comparable dataon violence against women and provide support to specialized NGOs and research on the issue;
  • In the context of prevention, the Declaration calls for measures to strengthen the economic independence of womenwith a view of reducing their vulnerability to all forms of violence;
  • It also addresses GBV against women and girls during and after armed conflict and emergenciesby calling upon states to bring perpetrators of crimes to justice and to take special measures to address the needs of women and girls in the post-conflict environment.

2.1.2  Other guidelines for health professionals

In 2013, the World Health Organization published a set of evidence-based guidelines to improve the health care response to intimate partner violence and sexual violence, titled “Responding to intimate partner violence and sexual violence against women. WHO clinical and policy guidelines.” This document seeks to provide healthcare providers with guidance on how to respond to violence against women. It also addresses policy makers, encouraging better coordination and funding of services, and greater attention to responding to violence against women within training programmes for health care providers. The guidelines cover the following areas:

  • identification and clinical care for intimate partner violence,
  • clinical care for sexual assault,
  • training relating to intimate partner violence and sexual assault against women,
  • policy and programmatic approaches to delivering services, and
  • mandatory reporting of intimate partner violence.

The WHO guidelines provide standards that can form the basis for national guidelines, and for integrating these issues into health-care provider education (WHO 2013). Its recommendations are incorporated in the present publication.

Box 6: Select international guidelines and manuals to strengthen health system responses to GBV

General guidelines

International Planned Parenthood Federation, Improving the health sector response to gender based violence: A resource manual for health care professionals in developing countries, 2010.
International Rescue Committee.
Clinical care for sexual assault survivors. New York, International Rescue Committee, 2008.
A Practical Approach to Gender-based Violence: A Programme Guide for Health Care Providers & Managers, author: Lynne Stevens (UNFPA 2001).
Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines, 2013.
War Trauma Foundation, World Vision International. Psychological first aid: Guide for field workers, 2011.
Preventing intimate partner violence and sexual violence against women. Taking action and generating evidence, 2010.
mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings, 2010.
Integrating Poverty and Gender into Health Programmes. A Sourcebook for Health Professionals. Module on Gender-based Violence, 2005.
Guidelines for medico-legal care for victims of sexual violence, 2003,

Guidelines for humanitarian settings:

Inter-Agency Standing Committee. IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva, Inter-Agency Standing Committee, 2007.
Inter-Agency Standing Committee Task Force on Gender and Humanitarian Assistance,
Guidelines for Gender-based Violence Interventions in Humanitarian Settings: Focusing on Prevention of and Response to Sexual Violence in Emergencies, 2005.
Inter-Agency Working Group on Reproductive Health in Crises,
Gender-based Violence. Inter-agency Field Manual on Reproductive Health in Humanitarian Settings, 2010.
International Rescue Committee, UNICEF,
Caring for Child Survivors of Sexual Abuse. Guidelines for health and psychosocial service providers in humanitarian settings, 2012.