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

A resource package

2.3. The role of health professionals in responding to gender-based violence

A wide range of health professionals are likely to come into contact with women who have experienced GBV and therefore provide an important entry point for women’s access to health care. These professionals include:

  • General practitioners,
  • Doctors specialized in emergency assistance, accident surgery, intensive care, orthopedics, surgery,
  • Obstetricians and gynecologists, family planning specialists,
  • Assistants in doctor’s offices,
  • Hospital nurses, nurses providing at-home care, geriatric nurses,
  • Midwives,
  • Dentists,
  • Psychiatrists, psychotherapists, clinical psychologists, doctors with diploma in psychology,
  • Ear, nose and throat doctors, eye specialists,
  • Company physicians, public health officers,
  • Physiotherapists,
  • STI and HIV/AIDS clinics professionals, and
  • Clinical social workers (adapted from BMWFJ 2010).

It is important to keep in mind that not only doctors have an important role in identifying and responding to GBV. Therefore, trainings and other efforts to strengthen health system responses to GBV should also target nurses and physiotherapists who might spend more time with patients than doctors. Furthermore, survivors may be less reluctant to talk to medical assistants, clinical social workers and reception staff. Reception and administration staff may alert doctors and nurses to concerns if they observe behaviour in the waiting room or around making appointments that makes them suspicious of GBV (Johnson 2010).

In order to be sustainable, efforts to improve the response of the health system to GBV need to target several levels:

  • the level of the actual health care provider (staff level),
  • the level of health facilities, such as hospitals, clinics, health centres or doctor’s practices (management level), and
  • the level of health policy (policy makers and public administration).

The present guidelines mainly focus on the role of health care staff (2.3.1) and management in health care facilities (2.3.2); the level of health policy will be addressed only briefly(2.3.3).

2.3.1 The level of health care staff

The following list summarizes key elements of the role of health care staff in responding to GBV. Each element will be addressed in greater detail in chapter 3 as well as in the training package provided in part II – please refer to the respective chapters for further information.

  • Understand the symptoms of GBV
  • Provide the patient with information on GBV and its consequences on women’s health
  • Ask questions about GBV in case of clinical symptoms that indicate possible experience of GBV
  • Create a friendly and confidential environment, listen to the patient and give her validating messages
  • Collect the patient’s medical history and undertake a medical examination
  • Provide appropriate medical and psychological care
  • Document the health consequences of GBV
  • Provide the patient with information and referral to other service providers, as needed (such as specialized medical, women’s shelter, crisis centre)
  • Assist the patient in safety planning
  • Ensure follow-up care

2.3.2 The level of health facilities

The management of health facilities is responsible for providing the institutional framework enabling health care professionals to perform their role. In particular, this includes the following:

  • Putting in placewritten guidelinesand protocolson how to handle cases of GBV, and ensuring that all staff members are familiar with them and with the procedures for implementing the guidelines in their everyday work (WAVE 2006).
  • Ensuring top-down management support, including financial support toensure the long-term sustainability of efforts to integrate GBV into health system responses (WHO 2013).
  • Ensuring that services provided promote human rights principles and non-discrimination, and are women and girls-centered. Services must be acceptable, i.e., which implies that “delivered in a way that ensures that a woman gives her fully informed consent, respects her dignity, guarantees her confidentiality and is sensitive to her needs and perspectives.” This means that systems, processes and services are developed, implemented and evaluated based on the needs and desires of the woman or girl receiving the care (CEDAW GR 24).
  •  Providing an adequate infrastructure to ensure the patient’s privacy, safety and confidentiality, e.g. through providing a private room for consultations, requiring that consultations are held without presence of a partner, putting in place a system for keeping records confidential or giving instructions to staff on explaining legal limits of confidentiality, if any (UNFPA 2001).
  •  Sensitizing staff and building their skillson how to recognize and respond to GBV, with the aim to create a climate that demonstrates to patients that “GBV can be discussed here.” Training should address the entire staff. Apart from improving practical clinical skills, such as recognizing the signs of GBV or documenting injuries, health care staff also need to understand the issue of GBV as well as the specific local context, for instance the views of the local community on GBV or the words people use when talking about GBV (UNFPA 2001). Training efforts should not be undertaken in an isolated manner, but be implemented alongside other changes in the system of care and referral pathways (Lo Fo Wong et al 2006, Garg et al 2006, all cited in WHO 2013). For WHO guidelines on staff training, see box 7 below. For further information on how to set up training activities and a comprehensive training package, see part II.
  • Providing staff and patients with information materials, such as checklists for doctors and nurses summarizing the steps of the intervention, leaflets or small cards informing patients about their legal rights and service providers, posters on GBV to be displayed in waiting rooms, consulting rooms or bathrooms (UNFPA 2001, WHO 2013) or directories of service providers to whom the patient can be referred for further services.
  • Providing support to health care staff delivering care(WHO 2013). Working with survivors of GBV is emotionally challenging. Health care staff may experience survivors of GBV as difficult patients – being passive and dependent, always returning to the violent partner. Further, common feelings such as worries about the safety and well-being of the patient, fear of a violent perpetrator for oneself and one’s family or having own experiences of violence in the past can lead to exhaustion and even trauma of the health care provider. In order to support staff capacities to protect themselves and to cope with difficult situations, health facilities should provide staff with training on the dynamics and consequences of GBV, as well as possibilities for supervision (Perttu et al 2006).
  • Networking and building coalitions with other organizations working on the same issue, with a view to ensuring a multi-sectoral, coordinated response. As part of an overall referral mechanism, this might include other doctors or hospitals in the same community, government bodies such as police, child welfare or psychosocial services, as well as women’s shelters or crisis centers. Networking and coalition building can contribute in increasing efficiency in service provision. For instance, other organizations may become partners for referring patients (both to and from the health facility) and working together can therefore help to provide the patient with the best possible support without duplicating services. Further, networks and coalitions provide a forum for exchanging knowledge and tools which other partners can pick up for their work. These for a can also be used for joint advocacy for improving existing or creating new laws and policies. Protocols are an effective tool to specify the roles and responsibilities of different organizations involved in a coalition, as well as procedures for interventions and referrals (UNFPA 2001, WHO 2013). For more information on referral systems, please refer to chapter 4.
  • Implementing a system for monitoring and evaluating to assess the impact ofinterventions undertaken to improve the facility’s response to GBV (WHO 2013). Monitoring and evaluation is an important aspect of assuring quality in service provision, with a view of ensuring accountability of service providers to service users, to their institution and society in general (WAVE 2006). For more information on monitoring and evaluation, please refer to chapter 5 and IPPF 2010.

Please refer to Annex 1 for a table summarizing key elements of quality health care for women that management in health facilities may wish to consult.

Table 7: Types of clinical policies and protocols recommended for health facilities

Box 7: WHO guidelines on in-service training of health care providers

Health care providers should receive in-service training on intimate partner and sexual violence against women. Such training should:

  • enable health care providers to provide first-line support to patients who experienced violence;
  • teach appropriate skills, including when and how to inquire about violence, the best way to identify violence and to provide clinical care, and how to conduct forensic evidence collection where appropriate;
  • address basic knowledge on violence and relevant laws, knowledge of existing support services, inappropriate attitudes among health-care providers (e.g. blaming women for violence), as well as own experiences of violence;
  • integrate both intimate partner violence and sexual violence in the training programme, given thematic overlaps between both issues and the limited resources available; and
  • cover different aspects of the response to violence, such as identification, safety assessment and planning, communication and clinical skills, documentation and provision of referral pathways.
     

Source: WHO 2013 Recommendations 30-33

2.3.3 The level of health policy makers and public administration

While health care staff and health facilities play a key role in the daily health system response to GBV and the provision of services to survivors, efforts at these levels will have limited impact unless there is a specific health policy on the issue of GBV that guides the work of staff and facilities to integrate the response to GBV into health care. Without a basis in health policy, there is a risk that efforts to improve the provision of care to survivors of GBV remain ad hoc initiatives of individual providers or particular facilities, rather than being institutionalized within the health sector (WHO 2005). At the same time, adopting policies cannot be an end in itself – in order to be implemented, they need to be widely disseminated among health care providers, as well as the public (WHO 2005). Further, health care management and staff need to be trained on existing policies. 

Some countries have addressed the role of the health sector as part of wider GBV policies or action plans. For example, the Government of Armenia has integrated, among others, the following measures into its 2011-2015 Strategic Action Plan to Combat Gender Based Violence:

  •  provision of information by health care institutions to survivors of violence and individuals at risk of violence about GBV and its consequences, HIV/AIDS, about existing services for survivors and the organizations providing them as well as minimum standards for service provision;
  • establishing a 24-hour helpline in health care institutions;
  • elaborating minimum standards for health care and other services provided by shelters;
  •  introducing mechanisms to involve social workers and psychologists in the provision of medical aid services by primary health care services and hospitals;
  •  elaborating standards for identifying survivors of GBV and for recording, reporting and referral procedures in the field of health care; and
  •  organizing training courses for public health specialists in the areas of identification, recording, reporting and referrals (Government of Armenia 2011).

The Turkish Government adopted a National Action Plan on Combating Domestic Violence against Women (2007-2010). Two of its goals focus on improving the provision of health services and on establishing a multi-sectoral response to domestic violence, respectively. Among others, the following measures are foreseen:

  •  incorporation of the topic of GBV into the routine work and household visits of the midwives and nurses working at the primary level health institutions;
  • setting up special units within health institutions for provision of health services to women survivors of violence, involving both medical and non-medical experts;
  • preparation and signing of memoranda of understanding amongst relevant institutions that define the cooperation framework, the authorities involved and their responsibilities;
  • establishment of local coordination committees with the participation of governorates, local security forces, gendarmerie, municipalities, universities, professional organizations and the mufti’s office, and NGO representatives in order to work on prevention of violence against women (Republic of Turkey 2007).

For guidance on developing National Action Plans on Violence against Women, please refer to UN Women, Handbook for National Action Plans on Violence against Women, 2012 (UN Women 2012).

Another approach to address the health system’s response to GBV is the adoption of special protocols or policies, usually issued by the Ministry of Health, that specify the role of health care professionals in the response to GBV and provide guidance through defining standards for services provided and steps to be taken as well as providing tools. For instance, the Ministry of Health of the Republic of Serbia has adopted a Special Protocol for the Protection and Treatment of Women Victims of Violence. Following an introduction on basic terms and concepts, the Protocol provides background information and guidelines for the following steps of a health care intervention:

  •  acknowledging and identifying violence,
  •  responding to the health consequences of violence,
  •  risk assessment and safety planning,
  •  referrals to other services, and
  • ending the interview.

For example, the Protocol lists examples of recommended as well as potentially harmful statements and suggests direct and indirect questions that health care staff can ask to verify the existence of violence. It also provides a template for recording and documenting violence which includes a checklist for risk assessment and a form for collecting contact information of other service providers that can be compiled in a referral directory (Republic of Serbia 2010).

Please refer to Annex 3 for a table compiling select policies and protocols on the health sector’s response to GBV.