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

A resource package

2.5. Principles and standards for service provision

Women survivors of violence have different needs, depending on their individual situation, the severity of theviolence experienced and the consequences. At the same time, there are a number of minimum standards and principles to guide the provision of health services to all women survivors of violence, regardless of the type or setting of the violence experienced (WHO 2013).

Box 8: Standards for GBV support services according to the Istanbul Convention

  • Services are based on a gendered understanding of violence against women and focus on the human rights and safety of the victims.
  • Services are based on an integrated approach, which takes into account the relationship between victims, perpetrators, children and their wider social environment.
  • Services aim at avoiding secondary victimization.
  • Services aim at the empowerment and economic independence of women victims of violence.
  • Services allow, where appropriate, for a range of protection and support services to be located on the same premises.
  • Services address the specific needs of vulnerable persons, including child victims, and services are made available to them.

Source: Article 18 Istanbul Convention

The following sub-chapters detail the principles and standards that should guide the health care response to GBV (please note that some of them may overlap). The section 2.5.1 examines the Gender-sensitive approach, the section 2.5.2 Survivor-/women-centred approach,  and finally the section 2.5.3 provides information on  integrating the response to GBV into existing health services.

2.5.1 Gender-sensitive approach

Health-care providers need to have an understanding of the gender-based nature of violence against women (WHO 2013, Article 18 Istanbul Convention), the root causes of which are “a manifestation of historically unequal power relations between women and men, which have led to domination over, and discrimination against, women by men” (preamble Istanbul Convention). Services therefore needto demonstrate an approach which recognizes the gender dynamics, impacts and consequences of violence against women (WAVE 2011).

Health services should take into account the needs of specific groups of women and girls, including those belonging to marginalized groups. This includes women with physical or mental disabilities; women living in rural or remote areas; pregnant women and women with young children; women with a national or ethnic minority background; migrant women, including undocumented migrants and asylum seeking and refugees; lesbian and bi-sexual women; transgender persons; sex workers; HIV positive women; substance abusing women; homeless women; older women; girls and adolescent women (Articles 12, 18 Istanbul Convention and Explanatory Report, WAVE 2011,UN Women Virtual Knowledge Centre) and girls involved in early/forced/child marriage. Women belonging to these groups may face an increased risk of experiencing violence: Perpetrators often choose them as targets because they know that these women are less likely to be able to defend themselves, or seek prosecution of the perpetrator and other forms of reparation, because of their situation (Article 12 Istanbul Convention - Explanatory Report).

Health service providers need to respect the diversity of service users and apply a non-discriminatory approach (WAVE 2011). This implies that all women survivors, regardless of the characteristics listed above, have equal and full access to health care and receive care at the same level of quality. Furthermore, health services need to be appropriate and tailored to the particular needs and specifics of service users (Article 18 Istanbul Convention, UN Women Virtual Knowledge Centre). Providers need to identify and address any barriers faced by women belonging to specific groups in accessing health services.

When women experience intimate partner violence, children are always affected too, either directly (being subject to violent acts) or indirectly (witnessing violence against their mother). Therefore, health service providers contacted by women survivors should be able to understand the impact of violence on children (for more information, see section 1.7.3). They should be equipped to help them access adequate care and support, according to their age and their needs (WAVE 2010) – if needed, through providing referrals to other service providers in the same facility or externally, as appropriate.

Box 9: How to incorporate a gender and human rights perspective into the work of a health facility

Management can work towards incorporating a gender and human rights perspective into the organization’s work in many ways, for example, by:

  • Collecting, reading and distributing educational material about gender and human rights.
  • Encouraging staff in the institution to attend workshops on gender and human rights.
  • Building alliances with local organizations and individuals working on issues of health, gender and human rights.
  • Evaluating whether the organization incorporates a gender and human rights perspective into its work.
  • Identifying ways to strengthen the institution’s commitment to gender equity and human rights.
  • Carrying out an organization-wide exercise such as “Evaluating Quality of Care from a Gender Perspective,” a methodology developed by IPPF/WHR (2000).
  • Ensuring that anyone hired to educate or train staff about violence against women has a grasp of gender and human rights issues.
  • Ensuring that your organization’s approach to violence is based on a gender and human rights framework.
  • Developing or strengthening policies that acknowledge patient rights and prohibit sexual harassment

Source: IPPF 2010

2.5.2 Survivor-/women-centred approach

A survivor- or women-centred approach implies that those who develop and deliver health care to survivors of GBV prioritize the survivor’s rights, needs, and wishes, with a view to

  • creating a supportive environment in which the survivor treated with respect and dignity,
  • promoting the survivor’s recovery, and
  • promoting the survivor’s ability to identify and express her needs and wishes and reinforcing her capacity to make decisions about possible interventions (UNICEF 2010, cited in UN Women Virtual Knowledge Centre).

In order to implement this approach, management of health care facilities need to make sure that care providers have the necessary resources and tools at their disposal (UN Women Virtual Knowledge Centre).

Box 10 summarizes the elements of a women-/survivor-centred approach to health care (see below).

Box 10: Elements of women-centred care and first-line response

Women who disclose any form of violence by an intimate partner (or other family member) or sexual assault by any perpetrator should be offered immediate support.

Health-care providers should, as a minimum, offer first-line support when women disclose violence. First-line support includes:

  • being non-judgmental and supportive and validating what the woman is saying;
  • providing practical care and support that responds to her concerns, but does not intrude;
  • asking about her history of violence, listening carefully, but not pressuring her to talk (care should be taken when discussing sensitive topics when interpreters are involved);
  • helping her access information about resources, including legal and other services that she might think helpful;
  • assisting her to increase safety for herself and her children, where needed; and
  • providing or mobilizing social support.

Providers should ensure:

  • that the consultation is conducted in private and
  • confidentiality, while informing women of the limits of confidentiality (e.g. when there is mandatory reporting).

If health-care providers are unable to provide first-line support, they should ensure that someone else (within their health-care setting or another that is easily accessible) is immediately available to do so.

Source: WHO 2013 Recommendation 1

Ensuring thepatient’s safety

Any health care intervention must prioritize the safety of women survivors and their children as the highest concern (WHO 2013,WAVE 2006).

This means first, that health care services need to refrain from any action, even well-intentioned, that might put women survivors at risk of experiencing further violence. As underlined in the WHO Guidelines, “any intervention must be guided by the principal to “do no harm”, ensuring the balance between benefits and harms” (WHO 2013). For example, a health professional trying to convince a patient to return to her violent partner or asking her about violence in the presence of a potentially violent partner can increase the risk of experiencing further violence.

Additionally, health care professionals need to assist female patients who experienced GBV to increase safetyfor herself and her children, where needed (WHO 2013). This includes assisting the patient in assessing potential safety risks and developing a safety plan.

In practice, health facilities and other institutions not specialized on working with women survivors of violence are often not adequately equipped to provide comprehensive protection and support to women survivors of violence and their children. Therefore, referral pathways linking health care providers to specialized services, such as women’s shelters that provide women survivors of violence with anonymity, keep their whereabouts secret and do not allow men to enter, should be established(WAVE 2011).

Furthermore, health service providers need to be familiar with any available protection measures under their country’s legislation, such as protection orders and the legal requirements and procedures for their application.

For more information on principles for communicating with survivors, please refer to section 3.1.4. For more information on risk assessment and safety planning, please refer to section 3.4. For more information on referrals, please refer to chapter 4.

Ensuring the patient’s dignity and providing a supportive and validating environment

Health services should aim at avoiding secondary victimization (Article 18 Istanbul Convention), thus, a situation in which service providers, rather than supporting the healing process, may further add to the suffering to the victim, for instance through inappropriate communication or behaviour. To this end, health care professionals should be supportive and non-judgmental and validate what the patient is saying. When asking about the patient’s history of violence, they should listen carefully, without pressuring the survivor to talk. Care should be taken when discussing sensitive topics and interpreters are involved (WHO 2013).

Health service providers need to take a clear stance against GBV and condemn violence in all its forms. Trying to remain neutral about what has happened means running the risk of tolerating violence. Health care professionals should convey the message that there is no excuse for violence, they believe the patient’s story and that it is the perpetrator, not the survivor, who is responsible for the violent behaviour. By no means should health professionals blame a survivor for violence; also, they should respect a patient’s decision not to separate from a violent partner (WAVE 2006, WAVE 2011).

Health care providers also need to ensure that all interventions respect the dignity of the survivor (WAVE2006, WAVE 2011). To this end, health care facilities should ensure the availability of female examiners where requested and promote the patient’s bodily integrity in examinations (UN Women Virtual Knowledge Centre). Furthermore services should ensure access to family planning, contraception, and where legal, safe abortions (WHO 2008 cited in UN Women Virtual Knowledge Centre). Safeguarding women’s dignity is closely linked to measures aiming at ensuring privacy, such as private waiting areas, a private toilet and washing facility, and a private examination room (Jewkes 2006, cited in UN Women Virtual Knowledge Centre).

For more information on principles for communicating with survivors and working with interpreters, please refer to section 3.1.4, box 7 ( section 2.3) , and table 10 ( section3.1.4). For more information on the medical examination of survivors, please refer to section 3.2.

Ensuring privacy and confidentiality

Privacy and confidentiality of the consultation should be a priority for health professionals as stipulated in a number of internationally respected guidelines and policies (WHO 2013). To this end, providers should ensure that consultations are held in private so that no one in the waiting room or in adjoining areas can overhear the conversation (WHO 2013, UN Women Virtual Knowledge Centre).

Furthermore, health service providers should not share any information regarding a survivor without her informed consent. Staff should only discuss cases with other providers when strictly necessary and in a manner that cannot be overheard. In addition, health facilities should ensure that patient files are stored in a confidential manner. These and other measures should be regulated in a confidentiality policy for the facility and all health care staff should be trained on this policy(UN Women Virtual Knowledge Centre)

According to WHO, mandatory reporting of violence to the police is not recommended. If a country’s legislation does establish mandatory reporting, health care providers should inform patients of this obligation, as well as of any other limits of confidentiality (see box 11). It is therefore important that health care providers understand their legal obligations, as well as their professional codes of practice (WHO 2013).

Box 11: WHO guidelines on mandatory reporting

  •  Mandatory reporting of intimate partner violence to the police is not recommended, however, health-care providers should offer to report the incident to the appropriate authorities (including the police) if the women wants this and is aware of her rights.
  • Child maltreatment and life-threating incidents must be reported to the relevant authorities by the health-care provider, where there is a legal requirement to do so.
  •  Health care providers need to understand their legal obligations (if any), as well as their professional codes of practice, to ensure that women are informed fully about their choices and limitations of confidentiality.

Source: WHO 2013 Recommendations 37, 38

The WHO based its recommendations on a review of evidence on the impact of mandatory reporting laws (see table 8 for a list of the advantages and disadvantages identified). It concluded that evidence did not support mandatory reporting of violence to the police because it can infringe upon women’s autonomy and decision-making. “While a number of women supported mandatory reporting, there appears to be an equally large number who do not. In particular, abused women appear to be against mandatory reporting, especially if it involves the police. Women in these studies suggested that the decision about reporting should be up to the woman; and that the safety of the woman and her children should be the first priority. Furthermore, recovery should focus on healing for the victims, including through counselling” (WHO 2013).

Table 8: Mandatory reporting – advantages and concern

Good communications skills on the part of the health professionals contribute essentially to ensuring privacy and confidentiality of services (WHO 2013). 

For more information on principles for communicating with survivors, please refer tosection 3.1.4. For more information on the medical examination and documentation, please refer to sections 3.2 -3.3.

Ensuring the patient’s empowerment, autonomy and participation

All services provided to women survivors of violence should aim at supporting women’s empowerment (WAVE 2011). Empowerment of GBV survivor is the process of “helping women to feel more in control of their lives and able to take decisions about their future” (Dutton 1992, cited in WHO 2013). Intrinsically linked to empowerment is the principle of supporting women’s autonomy. Often, relatives, friends and professionals in service providing organizations try to tell the survivor what to do. However, such advice can create even more pressure on her and is rarely helpful (WAVE 2006).

Providing women with information on their rights and on legal and other services is a key strategy for empowerment, as it enables them to take informed decisions and to instill in them a sense of control of their lives (WHO 2013, Article 19 Istanbul Conventionand Explanatory Report). Health professionals can contribute to empowering survivors of GBV, for instance, through providing them with leaflets or brochures entailing information of their legal rights and of existing shelters, helplines, as well as socio-economic and other support services.

Health-care providers should support survivors in their decision-making. This can be done through presenting and discussing options and providing practical care and support that responds to the patient’s concerns, while respecting the patient’s autonomy; the woman should always be the one to make the decisions (WHO 2013). This requires that health professionals make themselves aware of the needs and wishes of patient with respect to both her treatment and her interaction with police, the legal system or other referrals. They should seek the patient’s informed consent, through informing her about the examination to be performed and medication to be given, including side effects (UN Women Virtual Knowledge Centre). Health professionals should refrain from passing on the survivor’s name or any other personal information about her to family members, other service providers, governmental bodies or researchers, unless she gives her informed 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 committing violence against their children) (WAVE 2006). Another exception is mandatory reporting, in which case health providers should inform survivors of their obligation to report (WHO 2013, see section 2.5.2).

Finally, health care providers should promote the participation of women survivors in the development and evaluation of the services provided. 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 2011).

Box 12 – Participation of service users in the development and evaluation of services

Example from Serbia:In 2006, the Belgrade-based Women’s Health Promotion Centre (WHPC) interviewed 240 women users of health centers to identify their needs for support and to identify gaps in existing health services. WHPC used the results of these interviews, together with the findings of focus group discussions among health care providers held in the same year, to develop education programmes for health care providers, which included the preparation of a training manual for health care providers titled “Violence against women – My professional responsibility.” The survey results were also used to inform the organization’s work to lobby the government for improved services and training of health care providers (Bacchus et al 2012).

For an example of an evaluation of maternity and sexual health intervention to improve the health professionals response to identify domestic violence and to refer survivors to a specialized service provider that took into account the perspective of both patients and health care professionals, see box 27 in section 5.2.

2.5.3 Human rights-based approach

A human rights-based approach (HRBA) to GBV seeks to redress the human rights violations that are both the root causes and the consequences of violence. A HRBA seeks to strengthen the capacities of rights holders (patients who experienced GBV) to understand, claim and enjoy their human rights, while at the same time building the capacity of duty bearers (including policy makers, hospital management, health professionals) to fulfill their obligations to encourage, empower and assist rights holders (UNFPA 2010b, UN Women Virtual Knowledge Centre, OHCHR/WHO undated).

Added value of applying a human-rights-based approach

  • A HRBA adds legitimacy to an intervention as it is based on universal human rights principles and standards as defined in international conventions and declarations (see section 2.1.1) and moves it from the optional realm of benevolence (charity) to the mandatory realm of law.
  • It establishes human rights of individuals (“rights holders”), as well as corresponding duties of state and non-state service providers, including health service providers (“duty bearers”) to respect, protect and fulfill these rights.
  • It underscores the importance of creating accountability mechanisms at all levels for duty bearers and ensures that service users are not passive beneficiaries, but active participants of their own development.
  • Being grounded in the full spectrum of civil, political, economic, cultural and social rights, it provides a holistic lens through which to address development challenges (UNFPA 2010b).

Implications of a human-rights based approach

A HRBA to strengthen the health system’s response to GBV requires that:

  • any policies, protocols, programmes or interventions to end are in line with human rights standards and
  • health services aim at empowering survivors and are delivered through a multi-sectoral and comprehensive response that involves both governmental and non-governmental stakeholders.

Further, it implies that those who develop and deliver health services:

  • assess the capacities of women survivors to access health care services, identify any immediate, underlying, and structural barriers and address them, for instance, through improving legislation or implementing information campaigns to inform survivors on available services to ensure that services are accessible to women survivors;
  • assess the capacities of health service providers to fulfill their obligations vis-à-vis survivors according to international and national laws, identify any barriers and design and implement strategies to overcome them, e.g. through development of policies and protocols, staff training or supervision;
  • monitor and evaluate the processes and outcomes of health system interventions to GBV, in accordance with human rights standards and principles; and
  • ensure national accountabilityof duty bearers for non-compliance with international or national standards or laws (UN Women Virtual Knowledge Centre, UNFPA 2010b).

The HRBA is closely linked to the principles of gender-sensitivity, diversity and non-discrimination, participation and inclusion, as well as empowerment (see section2.5). Please refer to box 9 (section 2.5.1) for suggested steps for incorporating a gender and human rights perspective into the work of a health facility. For more information on designing and implementing a HRBA to programming, please refer to UNFPA 2010b.

2.5.3 Integrating the response to GBV into existing health services

It is widely acknowledged that medical care for survivors of GBV should be integrated into existing services, rather than offered as stand-alone services (see box 13). This is because stand-alone health services for survivors of GBV may be difficult to sustain and may have a potential harmful effect. For example, an already under-staffed mental health service might run the risk of being further weakened, if had to provide services specifically for survivors of violence, rather than ensuring that all patients (including survivors of GBV) get the best possible care (WHO 2013).

Integrating medical care for survivors of GBV into existing services is also advisable as it may facilitate women’s easy access to a range of care and support services offered in one premise.

Box 13: WHO guidelines for policy makers on integration of GBV services

  • Rather than offering care for survivors of intimate partner violence and sexual violence as stand-alone services, such care should, as much as possible, be integrated into existing health services.
  • While a country needs multiple models of care for survivors of IPV and SV, at different levels of the health system (see table 7), priority should be given to training and service delivery at primary level of care.
  • A health-care professional (nurse, doctor or equivalent) who is trained in gender-sensitive sexual assault care and examination should be available at all times of the day or night (either on location or on-call) at a district/area level.

Source: WHO 2013 Recommendations 34-36

When considering a model of integrating GBV into existing health services, it is important to keep in mind that there is nothing like a “one size fits all” model: A model that might work in one setting may turn out not be effective in another setting. Therefore, policy makersshould take into account the specificities of the given context in which an intervention is operating and consider different models and their advantages and disadvantages (see table 9). To this end, they should promote evaluation of health system interventions to GBV to identify what works best and what is most cost-effective in a given setting (WHO 2013). For further information on evaluation, see chapter 5 and IPPF 2010. Whatever model is chosen, the overall aim should be to reduce the number of services and providers a women has to contact and to facilitate her access to needed services in a manner respecting her dignity and confidentiality and prioritizing her safety (WHO 2013).

Table 9: A comparison of different models of delivering care for survivors of violence against women

Box 14 provides an example from Austria of integrating GBV services into a hospital setting.

Box 14: Example from Austria – Setting up victim support groups in hospitals

In 2011, a new provision was introduced into the Austrian Health Facilities Act, establishing so-called “victim protection groups” in hospitals.[1] The law specifies that separate groups are to be set up for children survivors and adult survivors of domestic violence, respectively. In exceptional situations, hospitals may also establish one group providing support to both adult and minor survivors, or establish joint groups with other hospitals. The law defines two main purposes of the victim protection groups (early identification of violence and sensitization of health care providers on domestic violence) and specifies the composition of the groups (at least two doctors specialized in accident surgery and gynaecology/obstetrics, as well as nurses and health care professionals specialized in psychological and psychotherapeutic care). This law built on practice that already existed earlier in some hospitals in the country and transformed it into a legal obligation. To date several hospitals have set up victim support groups, including for example the General Hospital of the City of Vienna (AKH), Austria’s largest hospital. AKH set up a victim protection group in 2011 and adopted rules of procedure to further specify the group’s aims and tasks, as follows: providing advice to health care professionals in contact with survivors of domestic violence, sensitization of health care professionals, development of standardized procedures and guidelines for interventions, organization of trainings, and coordination of the different departments and case conferences. While the creation of victim protection groups has been widely welcomed, practice shows that a number of challenges still exist. Practitioners involved have identified the following prerequisites for the effective operation of the victim support groups: the creation of specific country-wide standards to guide the operation of the groups, the provision of adequate human and financial resources, making trainings on GBV mandatory for all health care professionals, ensuring stronger institutional support to avoid that an improved response rests on the responsibility of committed individuals, as well as effective cooperation both internally and with external stakeholders, such as shelters, police or general practice doctors.

Sources: Austrian Health Facilities Act; Rules of Procedure of the Victim Protection Group at the General Hospital of the City of Vienna; information provided by Anneliese Erdemgil-Brandstätter, Training project “Domestic violence – the role of the health sector”, 2014 

[1]More specifically, the law establishes an obligation of parliaments of Austria’s nine provinces to adopt laws for their province in order to set up such groups. This is because Austria is a federal state, with health care being part of the provinces (Länder).