Meeting Expert VCM OPS

Expert meeting on
Health-sector responses
to violence against women
17–19 March 2009
Geneva, Switzerland
ISBN 978 92 4 150063 0

Expert meeting
on health-sector responses
to violence against women
17–19 March 2009,

Geneva, Switzerland
WHO Library Cataloguing-in-Publication Data
Expert meeting on health-sector responses to violence against women, 17-19 March 2009, Geneva, Switzerland.
1.Domestic violence - prevention and control. 2.Aggression. 3.Female. 4.Spouse abuse. 5.Gender identity. 6.Health
care sector. I.World Health Organization.
ISBN 978 92 4 150063 0 (NLM classification: WA 308)

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Expert meeting on health-sector responses to violence against women
Contents
Abbreviations v
Acknowledgements vi
Introduction 1
Aims of the meeting 2
Summary of evidence on effectiveness of health-sector interventions 3
Key themes emerging 5
National policy context 5
The development of networks and partnerships 5
Forms of violence addressed 6
Approaches to training health-care professionals 6
Approaches to the identification of violence against women 6
Documentation of abuse and forensic evidence collection 7
Framework for recommendations for health-sector responses to violence against women 8
1. Enabling environment 8
2. Training 8
3. Systems and services 9
4. Accountability and monitoring 10
5. Research and surveillance 10
6. Approaches to psychosocial and emotional support 11
7. Non-negotiable issues and principles (ethical and safety issues, documentation) 12
8. Screening 12
9. The development of networks 13
10. How to link violence against women with child protection in the guidelines 13
11. Mandatory reporting 14
12. The role of health-care services in responding to men as victims and perpetrators 14
13. The role of the health sector in prevention and the role of health promotion 15
References 16
Appendix: Country case-studies 17
Case-study from Thailand 17
Challenges encountered/lessons learnt 17
Case-study from Mexico 17
Case-study from Scotland 18
Lessons learnt in the development and implementation of the intervention 19
Challenges encountered 19
Case-study from Malaysia 20
Measures taken 21
Case-study from India: the Centre for Enquiry into Health and Allied Themes (CEHAT) 22
iii
Case-study from Romania 23
Case-study from Hong Kong 24
Case-study from the Philippines: Project HAVEN (Hospital Assisted Crisis Intervention for Women
Survivors of Violent Environments) 25
Key gaps and issues that remain 26
Case-study on sexual violence in selected African countries 26
Case-study from Maldives: the Family Protection Unit (FPU) 28
Case-study from Yemen 28
Case-study from Iraq 29
Case-study from Mozambique 31
iv
Abbreviations
CEHAT Centre for Enquiry into Health and Allied Themes

CFPS Child and Family Protection Services
CSA childhood sexual abuse
FPU Family Protection Unit
GBV gender-based violence
GO government organization
HAVEN Hospital Assisted Crisis Intervention for Women Survivors of Violent Environment (Philippines)
IGMH Indhira Gandhi Memorial Hospital (Maldives)
IPV intimate partner violence
MCGM Municipal Corporation of Greater Mumbai
MOH Ministry of Health
NGO nongovernmental organization
OSCC one-stop crisis centre
SGBV sexual and gender-based violence
STI sexually transmitted infection
SV sexual violence
UNPF United Nations Population Fund
VAW violence against women
WCCCPU Women and Children’s Crisis Centre and Protection Unit (Philippines)
WHO World Health Organization
v
Acknowledgements
We are grateful to the experts who supported and attended this meeting.
Dr Eman Alkobaty Ms Ionela Cozos

Director General East European Institute for Reproductive Health (EEIRH)
Women’s Affairs 1 Moldovia Street
Ministry of Public Health and Population 540493 Targu-Mures
PO Box 299 Romania
Sana’a
Yemen Dr Aurora del Río Zolezzi
Directora General Adjunta de
Dr Amalia Ayala Equidad de Género
WHO Ministry of Health
PO Box Apartado 1072 Mexico City
San Salvador Mexico
El Salvador
Ms Padma Deosthali
Ms Lorraine Bachus Coordinator Centre for Enquiry into Health & Allied
Research Fellow Themes (CEHAT)
London School of Hygiene and Tropical Medicine Research Centre of Anusandhan
49–51 Bedford Square Trust Sai Ashray
London WC1E 7HT Aram Society Road
United Kingdom Vakola, Santacruz (E)
Mumbai-55
Ms Teresa Balayon India
Executive Officer
Women’s Crisis Center Dr Ana Flavia D’Oliveira
3/F ER-Trauma Building University of Sao Paulo
East Avenue Medical Center Medical School
East Avenue, Quezon City 1102 Preventive Medicine Department
Philippines Sao Paulo
Brazil
Ms Jaqueline Campbell
1000 Fell St. #210 Professor Gene Feder
Baltimore, MD 21231 Professor of Primary Health Care
United States of America Academic Unit of Primary Health Care
University of Bristol
Dr Nicola Christofides 25 Belgrave Road
School of Public Health Bristol BS8 2AA
Health Sciences Faculty United Kingdom
University of Witwatersrand
7 York Road Dr Siti Hawa Ali
Parktown 2193 School of Health Sciences
South Africa University Sains Malaysia
Kampus Kesihatan 16150
Ms Katie Cosgrove Kubang Kerian, Kota Bharu
National Programme Manager Kelantan
Directorate of Healthcare Malaysia
Policy and Strategy
Scottish Government Dr Aseel Jaleel
c/o Glasgow Homelessness Partnership Senior Registrar in Gynaecology
Granite House Indhira Gandhi Memorial Hospital
31 Stockwell St Male
Glasgow G1 4RX Maldives
Scotland
Dr Bartilol Kigen PARTNER AGENCIES

Deputy Head of Division
Reproductive Health Jill Keesbury
Ministry of Health Population Council
Nairobi Nairobi
Kenya Kenya
Dr Nduku Kilonzo An-Sofie Van Parys

LVCT University of Ghent
PO Box 19835-00202 Ghent
Nairobi Belgium
Kenya
Ms Galina Lesço SECRETARIAT

Head of Youth Health Friendly Center Neovita
Chisinau Department of Reproductive Health (RHR)
Republic of Moldova Ms Jane Cottingham
Dr Claudia Garcìa Moreno
Mrs Faiza Majeed Dr Christina Pallitto
WHO Iraq
Amman Department of Injuries and Violence Prevention
Jordan (VIP)
Dr Christopher Mikton
Dr Francelina Romao
Ministry of Health
Maputo
Mozambique
Dr Chanvit Tharathep
Director, Health Service System Development Bureau
Department of Health Service Support
Ministry of Public Health
Bangkok
Thailand
Dr Agnes Tiwari
Associate Professor & Assistant Dean
Department of Nursing Studies
L9 Ka Shing Faculty of Medicine
The University of Hong Kong
4/F, William MW Mong Block
21, Sassoon Road
Pokfulam
China, Hong Kong SAR
Professor Charlotte Watts

London School of Hygiene and Tropical Medicine
Keppel Street
London WCIE 7HT
United Kingdom
vii
viii
Introduction
V iolence against women and girls (VAW) is a

major public health and human rights issue,
with sexual violence (SV) and intimate partner
in most settings, particularly where resources are
limited. It is important to consider the range of
issues that need to be addressed to enhance service
violence (IPV) being among the most pervasive. provision. These include: how to ensure that the
Research, initially from North America and response becomes institutionalized (i.e. changing
Europe, but increasingly from other settings, has individual behaviour and organizational culture);
demonstrated the high prevalence of violence how to maintain multisectoral collaboration and
against women globally and its negative physical collaboration with women’s nongovernmental
and mental health outcomes, in both the short and organizations (NGOs); how to ensure that women
long term (Heise et al., 1999; Campbell, 2002). Health are not placed at further risk by any intervention;
professionals frequently, and often unknowingly, the range of forms of violence it is realistic to
come into contact with women affected by abuse, as address in different health-care settings; which
they make extensive use of health-care resources. health-care settings are most appropriate for
offering these services; should there be routine
Health professionals have been identified as being screening for partner violence or more selective
in a unique position to create safe and confidential enquiry for improved clinical management; and
environments for facilitating disclosure of violence what are the key lessons about provider training in
and offering appropriate support and referrals to terms of minimum content and duration.
community and other resources. Although much
of the evidence for health-sector interventions The meeting aimed to review current evidence and
to address IPV originates from North America models of provision of care and address the range
(Feder et al., 2009), many low- and middle-income of challenges identified in providing services for
countries are actively seeking to address intimate victims of violence against women, particularly
partner and sexual violence, by integrating specific intimate partner and sexual violence, in order to
services into the health-care setting. Approaches initiate the process of developing guidelines for
to this were outlined in a background paper the health sector response to these problems.
that was disseminated prior to the World Health (See agenda and participants list.) Following
Organization (WHO) expert meeting on health- a review of the evidence, models of care from
sector responses to IPV and SV, March 2009. different countries were presented. This led to
the identification of key themes that need to be
Despite the opportunities for greater health-sector addressed by the health sector and a list of themes
involvement in responding to VAW, and the range to be addressed by the guidelines on Health
of promising models being implemented in a Sector Response to Violence against Women to be
diverse range of settings, this remains a challenge developed by WHO.
1
Aims of the meeting
1. To review the evidence and experiences of

implementation and evaluation of health-sector
interventions for VAW.
2. To identify key elements of an appropriate

health-sector response, with a focus on
resource-poor settings.
3. To explore the potential advantages and

disadvantages of different models of health-
sector responses, and the implications for the
replication and scale-up for these models.
4. Building on the above, to develop a detailed

outline for guidance to the health sector on
an appropriate response to women suffering
violence.
2
Summary of evidence on effectiveness of health-sector

interventions
Professor Gene Feder presented an overview of the partner violence, morbidity and mortality show
evidence for health-sector interventions to address that it is a major public health problem and
partner violence, from two systematic reviews that potentially an appropriate condition for screening
he has led. (Feder et al., 2009; Ramsay, Rivas & Feder, and intervention. There are several short screening
2005). Ramsay et al. (2005) published a systematic tools that are relatively valid and reliable for use in
review of controlled evaluations of interventions health-care settings. There is sufficient evidence
to reduce violence and promote the physical and that screening for partner violence is acceptable
psychosocial well-being of women who experience to women. However, the acceptability of partner
partner violence. The review concluded that violence screening among health-care professionals
advocacy interventions can reduce the levels of varies widely, and the overall evidence showed that
abuse, increase social support and quality of life, the UK National Screening Committee criteria for
and lead to increased use of safety behaviours and implementing a universal screening programme
accessing of community resources. This form of were not met.1 In terms of the effectiveness of
intervention is particularly beneficial to women interventions for women who have been identified
who have left the abusive relationship, who are through screening, there is insufficient evidence
actively seeking professional help or are in a refuge to implement a screening programme for partner
setting. However, it is not clear whether advocacy violence against women in health services, with
is an effective intervention for abused women the possible exception of screening in antenatal
identified in health-care settings, due to the lack of settings. The question of when clinicians should ask
studies and their relatively poor design. There is also about partner violence is a major issue. The focus
some evidence that psychological interventions should be on getting a low threshold for asking,
are likely to improve women- and child-centred by thinking about “clinical enquiry” as opposed
outcomes for women who have disclosed partner to routine screening. Health professionals should
violence. System-based interventions involving be trained to ask directly about partner violence
changes within the health-care system, for example, when women present with certain conditions, such
can, with some degree of staff training and as injuries; symptoms of anxiety, depression or
supportive materials, increase the rates of referral substance abuse; sexually transmitted infections
to specialist agencies in the short term. However, (STIs); repeat non-specific symptoms; recurrent
from studies with longer-term follow-up, there is gynaecological symptoms; and during the course
evidence that reinforcement and training of new of antenatal/prenatal care. The way the questions
staff is needed to sustain this effect. There is no are asked is important as it can discourage women
clarity from studies about whether reinforcement (e.g. “you’re not a victim of domestic violence are
and structural changes help to improve outcomes you?”). Screening tools have been developed and
for women. tested and coupled with training in how to ask they
have been shown to increase the identification of
Other recently published systematic reviews by women suffering violence.
Feder et al. (2009) and Ramsay et al. (2002; 2005)
explored the question of whether screening for
partner violence fulfils the public health criteria
1 The US Preventive Services Task Force similarly reviewed the
for a screening programme. The reviews found benefits and harms of screening for family violence evidence and
that even at the lower prevalence estimates of found no studies examining its effectiveness. (U.S. Preventive
Services Task Force, 2004; Nelson et al., 2004).
3
There have been some concerns about routine Professor Jacqueline Campbell presented an
screening in the context of mandatory reporting overview of the largely North American evidence
of partner violence to authorities. Mandatory for the adverse health consequences associated
reporting is on the statute books in some states with partner violence (see Campbell, 2002).
of the United States of America and in several Professor Campbell discussed a new surveillance
countries. Studies of women’s views show that system that has been implemented in the USA,
women do not want mandatory reporting and where men and women are asked about IPV.
that it may deter them from seeking health care.
(Rodriguez et al., 1998) Mandatory reporting is a There was discussion within the group about
breach of patient confidentiality and autonomy the need to clarify the debate around gender
when a competent person does not want the symmetry, i.e. that women and men are equally
violence reported. It also requires strong evidence violent. This is an issue in the developed world
of potential benefit, which at present is absent. where surveillance systems ask men and women
Studies show that what women want from the same questions about partner violence. It
health-care providers is: (i) before disclosure or is important to include questions about fear,
questioning: to try and ensure continuity of care; injury and contextual factors that may help to
(ii) to make it possible for women to disclose improve the understanding of the differences
current and past abuse; (iii) when the issue of as well as the similarities in the experiences of
partner violence is raised, not to pressurize women women and men. For example, in the British Crime
to fully disclose; (iv) that the immediate response Survey, although the reported prevalence of
to disclosure is to ensure that women feel they intimate partner violence was similar for men and
have control over the situation and to address women, a question on living in fear of the partner
any safety issues; (v) that in later consultations, demonstrated clearly how the experiences were
the health-care provider should understand the qualitatively different for women and men. Women
chronic nature of the problem and provide follow- reported experiencing more threats and fear, as
up support. well as injuries (Mirrlees-Black, 1999).
4
Key themes emerging
The meeting reviewed different models of health The development of networks and
care provision for violence against women (see partnerships
Annex 1 for a more detailed presentation of case-
Partnerships between the health-care sector and
studies). The discussions of the models presented
other statutory bodies and NGOs are critical to
led to the identification of the key themes discussed
the success of VAW interventions, since many
below.
women will present with complex multiple needs.
In the Romanian case-study, a basic protocol
National policy context outlining the roles and responsibilities of different
The importance of having national policy directives organizations was developed and the Romanian
underpinning strategies to address violence against Ministry has used this as a national standard for
women was evident in many of the presentations. multisectoral working.
Some countries had specific policies in place
Mutual respect of institutional and organizations’
for addressing VAW (e.g. Mexico, Romania and
needs and resources is necessary for successful
Scotland) or linked violence against women to
government organization (GO)/NGO
related issues such as sexual health, safer pregnancy,
collaboration. In Malaysia, a health-advocacy
gender equality, human rights and child protection.
network brings together women, NGOs and
In countries such as China, Iraq and Yemen, violence
ministries of health. However, historically there
against women is not recognized as a priority issue,
has been a lack of acceptance of women’s NGOs
making it difficult to develop a national response
as partners in responding to VAW. In the Hospital
within the health sector. For example, in Yemen
Assisted Crisis Intervention for Women Survivors
violence against women is framed within the wider
of Violent Environment (HAVEN) in the Philippines,
context of violence and injuries, as opposed to
the model is a collaboration between government
gender-based violence (GBV).
and nongovernment agencies. In Thailand,
One of the challenges identified was securing network strengthening is a key component of the
high-level “buy-in”. Having prevalence data, from one stop crisis centres.
national or local surveys, on the extent of different
In Mexico, there are different referral pathways
forms of violence against women gives the issue
depending on the severity of the violence. Women
greater visibility and the data can be used as a tool
are initially provided with medical treatment
to encourage governments to address the issue.
and counselling within the health-care setting.
Government has to be engaged at the highest level
However, those at high risk, requiring immediate
in order to make sure that health-sector responses
safety or “death prevention”, are referred to
to the problem are monitored and accountable. In
specialized VAW services such as refuges.
many examples, ministries of public health were
However, one of the challenges of multisectoral
responsible for approving and funding intervention
working is the documentation and sharing of
models, while setting national targets (e.g. Mexico’s
information across organizations for the purposes
programmes to address IPV, Scotland’s National
of documenting the woman’s experiences and
Gender-based Violence Programme and the one-
coordinating support plans.
stop crisis centres (OSCCs) in Thailand.)
5
Forms of violence addressed core team then trains their own colleagues and
the training has been well received compared to
Some intervention models had a broad focus
training provided by non-health-care providers.
in terms of the types of VAW being addressed.
A training cell consists of core groups of trainers
In the Scottish National Gender-based Violence
from different hospitals. The training is a nine-
Programme, the definition of VAW includes intimate
day educational programme on violence against
partner violence, rape and sexual assault, child
women. The content includes domestic violence
sexual abuse, commercial sexual exploitation,
awareness, the health implications and role of
harmful traditional practices, and sexual
health-care providers in responding to patients,
harassment and stalking. Broadening the scope to
and a follow-up module that focuses on the skills
include all forms of VAW helped to engage health-
needed for screening women for domestic violence.
care professionals. This approach also facilitates
linkages between the intervention programme
In the Romanian case-study, a joint training
and a range of national policies and legislative
programme was developed for the police,
frameworks. Levers at a national level include the
health-care providers, social workers and other
National Strategic Framework on Violence Against
service providers. This approach fits well with
Women (formerly the Domestic Abuse Strategy);
the overarching philosophy of the Romanian
National Training Strategy on Domestic Abuse
intervention model, which is to develop
(now Violence Against Women); National Strategic
partnerships between organizations so that there is
Approach for Survivors of Childhood Sexual Abuse;
a supportive multisectoral network that promotes
National Domestic Abuse Delivery Plan for Children
communication between organizations and
and Young People (developed under the auspices
facilitates support for women.
of Getting it Right for Every Child); and a legislative
obligation under the Public Sector Duty for Gender
Equality Act 2006; and a commitment to addressing Approaches to the identification of
inequalities (Better Health, Better Care). violence against women
Approaches to the identification of abused women
Other models, such as the HAVEN case-study ranged from screening all women to selective
from the Philippines, the one stop crisis centres in screening. In the Mexican case-study, the focus of
Thailand and Malaysia, and the Romanian case- the intervention is early diagnosis to target women
study also address a broad spectrum of VAW. The in the early stages of the abuse trajectory. The
Hong Kong case-study focused on partner violence approach to identification of abuse is made through
during pregnancy, while other models, mainly identification of symptoms as opposed to routine
from African countries, focused on sexual violence, screening – for example, if a woman presents with
particularly post-rape care. depression, anxiety or repeat STIs.
Approaches to training health-care There must be a supportive environment in order

professionals for routine screening for abuse to take place – for
example, with regard to confidential space, staff
Tthe Indian case-study on the Centre for Enquiry
training, clinical guidelines and protocols, as well
into Health and Allied Themes (CEHAT) presented
as ongoing monitoring of routine screening. In
an interesting approach to delivering training,
the Malaysia one-stop centres, there is no routine
based in a hospital setting. A core group of trainers
screening due to the lack of infrastructure (e.g.
was established, consisting of doctors and nurses
lack of financial support and staff shortages, lack
who have undertaken intensive training. This
of commitment at all levels, and a lack of regular
approach helps to promote a sense of ownership
review of the work protocol). Similarly, in Hong
of the work and their roles within the project. The
6
Kong, routine screening for partner violence during plays in any presenting medical conditions. Records
the antenatal period was discontinued when the containing documentation of abuse should be kept
project did not received ongoing funding. The in a confidential environment, but easily accessible
Scottish case-study provides an example of the to professionals involved in the woman’s care. It
kind of infrastructure needed to support a routine is also important to recognize that documenting
enquiry programme. Under Scotland’s National violence against women in an unsafe way can
Gender-based Violence Programme, routine enquiry create unintended harmful outcomes.
will be introduced in a staged and incremental way
by targeting priority settings such as mental health, In the Thailand case-study, part of the medical
maternity, sexual health, addictions, community record goes to the OSCC and the other part stays in
nursing and accident and emergency. There will be the health-care facility. This procedure is detailed
monitoring and evaluation of routine enquiry using in the clinical guidelines for health professionals.
a paper-based system in all health-care settings. Furthermore, only professionals involved in the
The national programme is run by a national team case can access the part of the medical record that
consisting of a programme manager, three regional contains documentation of the violence. However,
advisers, a research manager, an information and there can be disadvantages to this approach, for
performance manager and an administrator. There example if health professionals do not look at the
is national guidance in terms of a set of tools and background medical records and are therefore not
resources on gender-based violence and routine aware of the violence. In the Maldives case-study
enquiry, as well as local training consortia. There are the hospital-based Family Protection Unit (FPU)
also funds for dissemination of information and to has two different forms for documenting violence
raise staff awareness. experienced by an adult or a child. Medical-legal
forms are completed for each client and sent to the
police through the chief executive officer’s office.
Documentation of abuse and The case notes of all clients who come into contact
forensic evidence collection with the FPU are stored in the FPU database. A
Accurate and meticulous documentation of abuse monthly report is sent to concerned authorities at
is needed in order to enable a woman to obtain the end of each month. Hospital staff are trained
the protection she needs. Careful documentation and orientated to FPU activities. In the Mozambique
and photographs of injuries provide compelling case-study, general practitioners and surgeons are
evidence and may increase the likelihood that a being trained to undertake high-quality medico-
perpetrator is brought to justice. It is also critical legal assistance. Similarly, in the Maldives case-
that each professional involved in the woman’s study, medical staff receive training in collecting
care understands the potential role that the abuse forensic medical evidence.
7
Framework for recommendations for health-sector

responses to violence against women
Participants reflected on the case-studies and 2. Training

discussion groups of the previous days to identify
Training providers should consider the intrinsic
key elements of a health-sector response to VAW,
motivations for health professionals to learn
with a focus on resource-poor settings. These will
about violence against women. For example, in
inform the development of WHO recommendations.
the Romanian case-study, health professionals
The themes identified are presented next.
are motivated to attend training because they
accumulate credits to continue to practise
1. Enabling environment in their role. However, a core motivation for
National policies and procedures should be clinicians is to effectively respond to the
in place, as it may be difficult to work in an health-care needs of their patients and this
environment where laws and policies do not can be linked to the prevalence and health
recognize violence against women as a problem consequences of VAW.
or may even sanction, for example, men Minimum components should include:
“disciplining” their wives. awareness raising to sensitize clinicians to
Before embarking on training health the issue; listening to women and how to ask
professionals, it is necessary to engage and about partner violence; how to support and
managers to address the issue and secure validate disclosure; care pathways within and
organizational “buy-in” at a senior and strategic external to the system; ethical issues (safety
level within the health-care setting. and confidentiality); legal issues (situation and
rights); child protection; and documentation
Existing initiatives should be used to transform and record keeping.
health systems, for example by linking violence
against women to existing priorities such as HIV Electronic or paper audits of disclosure, docu-
counselling and testing, and making pregnancy mentation and referral should be maintained,
safer. which can be fed back to health professionals.
Basic service-provision principles include: Gender inequalities must be part of the training,
privacy and confidentiality; good since part of the aim is to change organizational
communication skills; and policies for culture as well as raise individual awareness.
addressing institutional violence such as sexual Integral to any training response is
harassment, bullying, and providers’ own consideration of how to address violence in
experiences of violence. the health-care system itself.
Care pathways for abused women must be Agencies involved in the care pathway should
available. be named and involved in the training process.
There must be a budget allocation for VAW. The care pathway, both internal and external,
must be clearly defined during the training.
Models of training may vary according to

the aims of the intervention and what health
professionals are expected to do after the
training.
8
The training needs to be adjusted according to Midlevel management needs training in order to
the needs of personnel and reflect the clinical be convinced about the importance of the issue
context in which they are working. and understand what is needed.
Training must recognize time limitations and Training should be included in undergraduate
what can realistically be achieved. curricula, induction programmes, and in-
service sessions for continuing professional
There is a need to consider how the training is
development.
delivered, by whom, and the advantages and
disadvantages of different models. For example, Obtaining accreditation for the training will give
it may be beneficial for the trainer to be a health it credibility and get “buy-in” from health-care
professional, in order to gain more acceptance managers and policy-makers.
for policy changes among staff.
Multidisciplinary training may be beneficial

3. Systems and services
in terms of enabling different professionals The minimum response that any health-care
to understand each other’s roles and setting should provide, regardless of whether
responsibilities, and it can promote coordination it is in a low- or high-resource country, is:
of care and information sharing within the listening; documentation of what the woman
health-care setting. However, unidisciplinary is saying, any injuries, and, if sexual violence
training might be preferable if there are time has occurred, documentation of any forensic
constraints and health professionals are required evidence; validation of the woman’s experiences
to enquire about different forms of VAW. and a non-judgemental response; medical
treatment; information about what services can
It may also be beneficial to consider joint assist immediately if there is a crisis, and in the
training between the health-care organization long term. Support must be based on what the
and external agencies, in order to facilitate the woman wants and continuity of care should be
referral process and promote an understanding maintained whenever possible.
of what kinds of support different organizations
can provide. In South Africa, multisectoral The next level of support should include: safety
training has been used, which was lengthy, but planning; referrals within the health-care facility
it was possible to cover many issues. to professionals who have more experience of
dealing with partner violence, or to external
There is a need to include administrative specialist organizations.
workers, cleaners, porters and security staff in
some training, in order to raise awareness and It may be possible to have a core group of heath
sensitivity around the issue of violence against and social care professionals within the facility
women, as these workers often have close who receive additional training, in order to
contact with patients. provide more in-depth emotional support after
women have disclosed abuse. The core group
Supervision and reinforcement are necessary can provide more ongoing support and risk
after the initial training, in order to sustain the assessment, ensure continuity of care and make
competencies health-care professionals acquire. referrals to external organizations. There may be
This may include case conferences or updates at more resources within the health sector than in
staff meetings. It is important to identify and use external NGOs.
all existing opportunities to provide support to
staff. Depending on one “champion” within the
health-care facility will not ensure long-term
sustainability of the service if the burden falls
9
on one person. It is important to define what we 5. Research and surveillance

mean by “champion”. The role has to be built into
There is a need for more research on the
the management system of a health-care system
effectiveness of interventions in relation to
so that it becomes part of someone’s remit.
outcomes for women and children, as well as on
Therefore, if that person leaves, the role still has
their cost effectiveness.
to be fulfilled.
Surveillance tends to focus on injury and will
Developing networks must be led by the
not provide accurate information about the
government and should include the women’s
health burden of violence. Other approaches are
unit, ministries of health, NGOs, criminal justice
needed to get a more complete picture of the
system, police, internal affairs and health-care
problem.
service. In order to establish the network, it may
be necessary to rely on allies and interested Existing injury-surveillance systems make
persons in the first instance until it becomes the underlying issue of gender-base violence
institutionalized or part of core business. difficult to identify. It is important to ensure
that the sex of the victim and the relationship
The health-care-delivery system should identify
of the probable perpetrator to the victim can be
existing services and compare them with the
documented.
guideline or standard. Any gaps should be filled
by systematic implementation of these services When developing surveillance systems, care
to improve their accessibility, quality, efficiency must be taken to ensure that they are not
and effectiveness. cumbersome and time consuming. The smaller
the amount of surveillance data collected, the
4. Accountability and monitoring better the quality.
A monitoring system must be part of any health- There may not be enough data on VAW in some
sector response to VAW, to demonstrate that the countries to convince governments to address
problem exists and provide data on the number the issue. However, prevalence studies do not
of cases. have to be large and it is possible to collect
and use local data on prevalence to develop
There should be regular case reviews to monitor
advocacy.
the quality of service and support health
professionals in responding to VAW. It is important to recognize that there is limited
research funding, and intervention studies
Debriefing support should be made available to
should be prioritized over studies that only
health professionals.
measure prevalence or health consequences
A system should be in place to learn from of partner violence. Therefore, it may be more
women’s experiences of the service in order to cost effective to include additional research
improve quality. questions in intervention studies. For example, it
is possible to collect data on baseline prevalence
Interagency meetings should occur at a local
of partner violence and cost-effectiveness within
and national level.
intervention studies, as well as doing nested
Clinical guidelines for responding to VAW must qualitative studies on health professionals’ views
be in place and their implementation should be and experiences of the intervention.
monitored.
10
6. Approaches to psychosocial and a new training curriculum is providing doctors

emotional support with training to provide cognitive behavioural
therapy, but this is still to be evaluated.
In the guidelines it is important to distinguish
between what is psychosocial support given by The approach to service provision needs to be
a health-care professional that has first contact considered carefully, as the establishment of
with the woman, and longer-term support that specialized counselling services that are known
comes later from other professionals. to be related to violence can be stigmatizing
and provide a barrier to access. While it is im-
Women experiencing IPV will need different
portant to create linkages with existing services,
types of support at different points in time.
it is also important to avoid stigma that can be
Therefore, a ladder approach may be necessary
associated with certain types of counselling,
spanning basic emotional support and more
such as for HIV.
specialized counselling and therapy. Health-care
facilities should be prepared for and develop Health professionals should be prepared for
services for women who may need more some women to ask for help for their abusive
intensive support. partner, or a health professional may have
contact with the partner of a woman who
The starting point for psychosocial support is
has disclosed violence to them. Due to safety
recognizing women’s resilience. At a minimum,
concerns, health professionals should not
emotional support should include listening in a
seek to contact the woman’s partner, and
non-judgemental way. (Research from the Hong
the provider should not refer the couple for
Kong case-study has highlighted the importance
traditional couple counselling or therapy. There
of listening to women’s experiences.) The health
is some evidence that low-level couple violence
professional must assess the risk to the woman
can be addressed by couple counselling, but this
and evaluate her expectations and intentions,
is specialized treatment for low-level violence,
and seek to provide women with some options
with both partners assessed separately about
based upon this information.
what they want to do. This should not be
It is important to clarify what are useful confused with traditional marital therapy. In
messages to convey to women when providing general this approach is contraindicated.
emotional support. In the USA clinicians are told
It is important to recognize that psychosocial
to say “you are not to blame”, but no one has
and emotional support may differ for partner
tested whether this is a helpful thing to say to
violence and sexual violence, although cognitive
abused women, although survivors of partner
behavioural therapy has been shown to be
violence believe that it is. If there is limited time
effective for both IPV and SV. Post-traumatic
within the consultation then it is important to
stress disorder intervention for sexual violence
know what messages to convey to women.
victims is quite specialized and traditionally
For more specialized service provision, provided by psychologists, which presents
counsellors in the health-care facility should challenges for settings where there is a lack of
receive specialized training on how to manage trained psychologists or other mental health
cases of violence. This includes, for example, specialists.
nurses who provide counselling services,
The WHO guidelines should consider whether
psychologists and psychiatrists working in
the response to partner violence and sexual
mental health teams or wards. Professionals
violence will differ, how this will be addressed
should be equipped to deal with both partner
and at what level of health care different
violence and sexual violence. In South Africa,
interventions are to be provided.
11
Crisis-intervention models have been shown Health professionals must document cases
not to be effective. Programmes for men who accurately and meticulously without judgement.
perpetrate abuse only work if they want to They should not interpret what the woman
change. Identifying these men can be difficult. says, but provide an accurate account of what
she says and what is observed by the health
7. Non-negotiable issues and professional (e.g. injuries etc.). The medical
principles (ethical and safety issues, record should be kept somewhere confidential
documentation) and should not be accessible to the perpetrator
It is important to address contradictions or family members.
between medical ethics and the laws of the Personal details of the woman that can help to
country, particularly those related to mandatory identify her should not be shared for any form of
reporting. surveillance or monitoring.
It is important to consider the unintended Health professionals should not take actions
harmful consequences that may occur as a result that will stigmatize a person suffering from
of badly implemented interventions. violence.
There should be absolute confidentiality, and With regard to the perpetrator, he must be
information should only be shared with other made responsible for his actions, but there may
professionals if there is a real risk to the woman’s be scope to address other issues such as alcohol
life, a child is being abused, or a person discloses or substance abuse.
that they intend to harm or kill someone else.
While it is always preferable to do this with the
8. Screening
consent of the woman, in some cases it may
Using the public-health model, there is not
be necessary to do this without her consent.
enough evidence to recommend screening for
However, she should always be informed of
IPV across all health-care settings. In the context
what information is being shared, with whom
of antenatal care, it is possible to make a case for
and why.
asking at least once based on trial evidence, if it
There is a need to consider how to deal with can be done in a safe way without the partner
confidentiality in rural areas. For example, present. It may also be appropriate to screen in
in small towns it may be safer to submit a the context of pregnancy termination.
mandatory report to the police in another
The high prevalence of violence experience in
town.
women with mental health problems may justify
The safety of the woman disclosing abuse, and screening women who present with depression
her children, is always the main priority. It is and anxiety disorders.
important to believe what the woman is saying,
It may be more appropriate to ask women
empathize, and not belittle her experiences.
about IPV (or SV) if they present with certain
The health professional must listen carefully
health conditions. For example, an accident and
to the details, to be able to assess the risks and
emergency department asking every woman
support the woman to have a safety plan.
who attends with an injury, or, in a primary
The woman’s decision should prevail and she care setting, every woman who presents with
should be allowed to take action when she recurrent non-specific symptoms (like “tired all
wants to. The woman should have the right to the time”). This constitutes appropriate clinical
treatment irrespective of whether a criminal enquiry as opposed to screening all women.
case is pursued.
12
9. The development of networks 10. How to link violence against

Multi-agency collaboration is necessary, since women with child protection in
the health-care facility will not be able to meet the guidelines
women’s multiple and complex needs. Responding to cases of child abuse requires
additional competencies that need to be
In order for networks to be successful, there
provided in addition to training for intimate
should be an understanding of each partner’s
partner violence.
roles and responsibilities.
It is important to keep a gender equality
Health-care facilities should be part of a network
perspective and recognize the danger of
of organizations that can assist women affected
blaming the mother.
by intimate partner violence and/or sexual
violence. It may not be an efficient use of resources
to separate out services for intimate partner
There is a need for networks to meet regularly
violence and childhood abuse.
to review issues, strengthen networks and
integrate responses across sectors. (In the It is important to explore with women how
Romanian case-study, integration was critical their children are being treated by the
to support local partnerships and activities perpetrator, in a non-judgemental way.
focused on strengthening service provision
If a health professional is aware that a child is
across services. In the Malaysia case-study, they
being abused, this should always be reported
have state-level committees for the one-stop
for the necessary actions to be taken.
crisis centres, with regular joint training that is
cosponsored by different agencies.) When reviewing a woman’s situation in
follow-up consultations, it is also important
It is important to consider what can be done
to consider the safety of her children.
if there are no referral services within the
country or there are limited resources. It may be Health professionals may see different
necessary to have a core group of professionals patterns of child abuse.
within the health-care facility who receive more
intensive training (e.g. basic counselling skills, Children living in domestic violence
risk assessment and safety planning), to whom situations should not always be interpreted
women can be referred. as child abuse and will not necessarily
require mandatory reporting. Each case
Components of a successful network include: must be assessed individually in order to
broad partnerships between agencies; active make a judgement. Mandatory reporting of
local core groups; joint training; integrated all cases can result in unintended harmful
systems of referral; integrated information consequences. This form of reporting may
systems; and common behaviour-change- deter women from disclosing violence and
communication activities. could jeopardize their safety. However, it is
also important to recognize that persistent
witnessing of serious forms of domestic
violence is a child-protection issue.
In order to assess the impact on children,

try to speak to them on their own to get
more information and try to assess potential
sources of support for children from
13
significant others. Offer referral of children to 11. Mandatory reporting

therapeutic support services. Report children at
As noted in point 7, “Non-negotiable issues
risk according to mandatory laws, and consider
and principles”, there should be absolute
the woman’s level of fear about children being
confidentiality and information should only be
removed.
shared with other professionals if there is a real
In the USA there is a principle of keeping risk to the woman’s life, a child is being abused,
children safe by ensuring the safety of the or a person discloses that they intend to harm or
mother. It is important to support the non- kill someone else. While it is always preferable to
abusing parent. Professionals working in the do this with the consent of the woman, in some
child-protection system need to receive training cases it may be necessary to do this without
on domestic violence and vice versa. her consent. However, she should always be
informed of what information is being shared,
It is not clear whether the WHO guidance with whom and why.
should recommend asking women using
health services about childhood sexual The laws and legislation around mandatory
abuse (CSA). There is very little time during a reporting are likely to vary between countries
consultation to deal with a traumatic event and should be known to health-care providers.
that happened many years ago. However,
the guidance should at least provide 12. The role of health-care services
information on the link between intimate in responding to men as victims
partner violence and CSA to ensure that this and perpetrators
is not ignored. A woman may spontaneously The health sector may have a role in assisting
disclose CSA while she is disclosing IPV and perpetrators of violence, as most men will not
should be given the space to discuss this. It approach social services or criminal justice for
should be acknowledged that she has been help to address their violence. They are more
disempowered by her experiences of past likely to be present in general practice and
abuse. The population of women experiencing alcohol abuse services. The health sector should
IPV overlaps substantially with the population work collaboratively with other agencies and
of women who have experienced CSA. refer men externally, where any services exist,
Therefore, although the guidelines should not rather than providing support within the health-
recommend asking about CSA, they should care facility.
state that health professionals should be
prepared to respond to disclosures of child The recommendations need to consider what
sexual abuse. response should be offered to men who are
victims of sexual violence.
Health professionals working in mental health
services should receive extra training on If men’s violence is linked to alcohol or illicit
child sexual abuse, as they are more likely to drug abuse, then it is necessary to consider what
encounter women who are affected. kinds of services are available to deal with both
issues or how to integrate violence issues within
substance-abuse programmes.
If a health-care professional refers a male patient

for help with violence, then it may be necessary
for the partner to be aware of this.
14
13. The role of the health sector in

prevention and the role of health
promotion
The health-care sector also has a role in
primary prevention and health promotion, in
coordination with other agencies.
It is possible to integrate messages about

violence as part of routine health-promotion
activities. For example, in Moldova, family
doctors provide mother and child classes and
are able to do prevention work as this is part of
their job description. In Hong Kong, prevention
work is undertaken in antenatal classes (e.g.
talk about care of the newborn, impact on
relationship dynamics, etc.). In Mozambique,
nurses in health centres do a 15 minute session
on health promotion with all patients, not just
women, and the issue of domestic violence is
included. The health consequences and impact
on children are also discussed.
Other opportunities for primary prevention and

health promotion include positive parenting
and positive fathering, as in the Hong Kong
case-study.
It is also important to think about prevention

work with adolescents and young people who
use health-care services.
Health-care professionals need to consider

the language they use with women,
and use gender-sensitive language. The
issue of communications skills links with
recommendations for point 2, “Training
component”.
15
References
Campbell JC. Health consequences of intimate Ramsay J et al. Should health professionals screen
partner violence. Lancet, 2002, 359(9314):1331– women for domestic violence? Systematic review.
1336. British Medical Journal, 2002, 325:314–326.
Feder G et al. How far does screening women for Ramsay J, Rivas C, Feder G. Interventions to reduce
domestic (partner) violence in different health violence and promote the physical and psychosocial
care settings meet the UK National Screening well-being of women who experience partner violence:
Committee criteria for a screening programme? a systematic review of controlled evaluations.
Systematic reviews of nine UK National Screening London, Department of Health, 2005.
Committee criteria. Health Technology Assessment,
2009, 13:16. http://www.hta.ac.uk/1501 (accessed Rodriguez, MA et al. Patient attitudes about
10 March 2010). mandatory reporting of domestic violence –
implications for health care professionals. The
Heise L, Ellsberg M, Gottemoeller M. Ending Western Journal of Medicine, 1998, 168:337-341.
violence against women. Population Reports, 1999,
Series L(11):1–14. Tiwari A et al. A randomised controlled trial of
empowerment training for Chinese abused
Mirrlees-Black, C. Domestic violence: findings pregnant women in Hong Kong. British Journal of
from a new British Crime Survey self-completion Obstetrics and Gynaecology, 2005, 112(9):1249–
questionnaire. Home Office Research Study 191. 1256.
London, United Kingdom, Home Office, 1999.
U.S. Preventive Services Task Force. Screening
Nelson HD, Nygren P, McInerney Y, Klein J. Screening for family and intimate partner violence:
women and elderly adults for family and intimate recommendation statement. Annals of Internal
partner violence: A review of the evidence for Medicine 2004, 140:382-386.
the U.S. Preventive Services Task Force. Annals of
Internal Medicine 2004, 140:387-396.
Parker B, McFarlane J, Soeken K, Silva C, Reel S.

(1999). Testing an intervention to prevent further
abuse to pregnant women. Research in Nursing &
Health, 1999, 22(1):59-66.
16
Country case-studies
Case-study from Thailand Case-study from Mexico

Dr Chanvit Tharathep presented the one-stop Dr Aurora del Rio Zolezzi highlighted the
crisis centres (OSCCs) in Thailand. In 2000, importance of national-level policy and guidance
the government cabinet approved OSCC on responding to VAW, which include statements
implementation. In 2001–2002 there was a pilot about responsibility. In Mexico there are a number
project by the Ministry of Public Health for OSCCs of national strategies and legislative frameworks in
in 20 regional and general hospitals. The OSCCs place: (i) 2007 Article 6, General Law for Women’s
were expanded to 104 hospitals in 2004, and Access to a Life Free of Violence; (ii) 2000 Mexican
after the Domestic Violence Act in 2008 they were guidelines for addressing family violence in health-
expanded to 250 hospitals in 2008. Treatment care services. Although very little was done in
includes history taking, rape examination, HIV/ response to these guidelines, in 2002 the Federal
STI testing, pregnancy prevention, antiretroviral Government assigned 7.5 million dollars to address
drugs, and the provision of home shelter. A hotline VAW. In 2003 a national survey on IPV found that
has been set up in every province, which goes 33.3% of women had experienced some form of
directly to the hospitals. Other key components partner violence in the previous 12 months. By
of the intervention model include: training and 2005 all 32 states in Mexico had begun developing
skills improvement provided to all staff; network or consolidating programmes to address IPV.
strengthening; community empowerment; and Additionally, since 2006 VAW has been included
anti-violence socialization. In 2003, OSCCs were in the social health insurance system as a way of
seeing five cases of IPV daily across 17 hospitals scaling-up.
(or 1825 cases of violence against women and
children). In 2008 OSCCs were seeing 73 cases of In Mexico the approach to intervention is the
IPV daily across 582 hospitals (or 26 565 cases of public-health model and health promotion
violence against women and children). (violence prevention in adolescence), where
violence is portrayed as an unnatural behaviour.
The focus of the intervention model is on early
Challenges encountered/lessons learnt diagnosis and detection (not through routine
Intimate partner violence is the most common screening, but through clinical enquiry) to target
form of violence experienced by women. women in the early stages of violence. Support
offered to women may include: (i) counselling and
In 50% of cases alcohol was involved.
psychological treatment that focuses on helping
A multidisciplinary approach and management women to find a way out of the cycle of violence
is helpful. and assess different options; (ii) medical attention
to STI/HIV prevention; (iii) attention to injuries and
Network strengthening is helpful. to diseases associated with VAW; (iv) emergency
contraception; (v) medical abortion and legal advice
Integrated information management is in cases of rape; and (vi) death prevention through
important. referral to refuges. Dr del Rio Zolezzi described
three levels of attention that match different levels
There is a need to consider how different
of severity of violence: (i) essential first-contact
sectors can work together. Integrated strategic
units, e.g. emergency rooms; (ii) specialized VAW
formulation among all participants is necessary.
17
services; and (iii) highly specialized VAW services abuse, commercial sexual exploitation, harmful
such as refuges. In Mexico, health professionals traditional practices, and sexual harassment and
favour diagnosis of partner violence through stalking. Levers at a national level include the
symptoms detection as opposed to routine National Strategic Framework on Violence Against
screening (e.g. if a woman presents with depression, Women (formerly the Domestic Abuse Strategy);
anxiety, repeat STIs, etc.). If a woman discloses National Training Strategy on Domestic Abuse
partner violence, then further in-depth questions (now Violence Against Women); National Strategic
are asked before referring her to the appropriate Approach for Survivors of Childhood Sexual
organizations or professionals. If a woman reports Abuse; National Domestic Abuse Delivery Plan for
“no violence”, but the health-care professional Children and Young People (developed under the
suspects that she is a victim of violence, the auspices of Getting it Right for Every Child); and a
suspicion will be documented and she will be asked legislative obligation under the Public Sector Duty
again at her next visit. for Gender Equality Act 2006 and a commitment to
addressing inequalities (Better Health Better Care).
Challenges encountered/lessons learnt The work programme has four key deliverables:
There is a need for: (i) implementation of routine enquiry in key priority
settings; (ii) guidelines for health-care providers;
more preventive work; (iii) production of an employee policy on GBV;
more detection at first-level contact; and (iv) improved multi-agency collaboration,
particularly in relation to child protection and
improved quality of services;
homelessness.
more epidemiological surveillance;
financial sustainability. The approach to routine enquiry will be staged

and incremental, by targeting key priority health-
care settings such as mental health, maternity,
Case-study from Scotland2
addictions, sexual and reproductive health,
Katie Cosgrove presented Scotland’s National
accident and emergency, and community nursing
Gender-based Violence Programme 2008–2011.
services. Targets have been set that are measurable.
Scotland’s national guidelines on health-sector
There will be monitoring and evaluation of routine
responses to IPV, published in 2005 were largely
enquiry using a paper-based system in all settings,
ignored and there was an identified need for
case tracking of some women, and evaluation of
structural change. The Healthcare Policy and
staff perceptions. However, routine enquiry will not
Strategy Directorate at the Scottish Government is
be introduced until the right physical environment
responsible for overall management and direction.
is secured (e.g. having policies in place etc.). There
The programme will be implemented across the
will also be annual reporting of results to the
NHS in Scotland, which comprises 14 local health
Scottish Government. The programme is run by a
boards and 8 special health boards that have a
national team consisting of a programme manager,
national remit.
three regional advisers, a research manager, an
information and performance manager and an
In order to engage health-care providers, it was
administrator. There is national guidance in terms
necessary to broaden the scope to all forms of VAW,
of a set of tools and resources on GBV and routine
including IPV, rape and sexual assault, child sexual
enquiry, as well as local training consortia. The
programme includes funds for dissemination of
2
A web site for the programme and its materials is in the
information and to raise staff awareness.
process of being established. The main document outlining the
programme can be found at: http://www.sehd.scot.nhs.uk/mels/
CEL2008_41.pdf
18
Women who disclose abuse in these settings There are two main reporting mechanisms into
may be offered counselling or therapy if required. the Scottish Government. This is important in
Where there is an ongoing relationship, e.g. with helping boards to understand where and how
a health visitor, there may also be advocacy and information on their progress is being reported.
emotional support. In all settings, however, women
would be offered information on local services Challenges encountered
for women experiencing abuse, and referred on
The geography of Scotland has required the
to them as appropriate. In the implementation of
programme to be developed in a way that
the programme, it is also expected that staff will
meets the different needs of urban, rural and
undertake risk assessment with each woman and
island communities. The number of boards and
support her in creating a safety plan. Although
their hugely varied demographics mean there
there is variation across the country, every health
is a need to design and agree individual targets
board area has a multi-agency partnership on
and performance measures against which to
VAW, which offers different support to women, and
measure progress.
health services would refer women to these local
initiatives. There is a national helpline for domestic Lack of national datasets for recording of
abuse and another for rape and sexual assault, and disclosures, etc., is a major problem and one that
women would be given details of how to access is difficult to resolve within the timescale of the
these. programme. Accurate data will consequently
be difficult to gather. Given the above, the
Lessons learnt in the development and development of the monitoring and evaluation
implementation of the intervention framework presents a key challenge in seeking
to reflect adequately the implementation of the
There is a need for communication across
programme.
the health directorates within the Scottish
Government to ensure appropriate inclusion At a conceptual level, it has been crucial to help
of this issue in strategic and operational boards understand that the programme is not
developments. interested merely in identifying the numbers of
service users who have been abused, and that
There is a need to ensure that information on
routine enquiry is a means to an end not an end
the evidence base for this work is clear and
in itself. It is designed to improve the health-
readily available to staff.
care assessment and response – the process has
It is important to identify where the differential therefore had to be slowed down in some areas
responsibilities lie and harness support, e.g. where there is inadequate preparation for its
the policy for employees will be developed implementation.
nationally through the staff governance team
There are competing priorities within boards
and then disseminated to the 22 health boards
that are focusing on meeting national health
rather than the boards individually creating their
targets.
own.
There is some degree of anxiety about the
Each board has been asked to identify a senior
impact of routine enquiry on staff, both
executive lead for the work and an operational
personally and professionally.
manager – this has been important in achieving
“buy-in” for the programme and a clear line of There is concern about the capacity of external
accountability for its implementation. agencies to absorb the anticipated increase in
referrals.
19
There are difficulties linking in to all the national that deal with the issue of VAW directly and
developments that have relevance for this indirectly. The interagency committee/network
work, e.g. in workforce development, strategic plays the role of the community arm for the OSCC.
frameworks for mental health, addictions, The interagency committee will examine issues
others, and identifying mechanisms to ensure its faced by survivors, work on the support system
integration and mainstreaming. between agencies, and also recommend policy
changes at relevant levels. The members of the
The scale of the training programme and
interagency committee come from all relevant
planning across 22 health boards, which has to
government agencies as well as NGOs. In some set-
be undertaken before the implementation of
ups, the interagency meeting is held on a monthly
routine enquiry, also presents a challenge.
basis to resolve any issues regarding the survivors
There is a variation in availability of services for and services, but most commonly they will meet
women across the country. once or twice a year to discuss overall issues
pertaining to the operation of the OSCC. This set-up
Case-study from Malaysia exists at all levels from federal to district level.
Dr Siti Hawa Ali presented the one-stop crisis centre

(OSCC) in Malaysia . In the last two decades, the Challenges encountered/lessons learnt
Ministry of Health (MOH) of Malaysia has shown At a conceptual level:
greater interest in the area of VAW. Although the
MoH did not emerge as one of the key players at There is still an ongoing debate on the
the outset, they have shown greater interest in involvement of medical personnel and
recent years. Their effort has been supported and the MOH in the issue of VAW. Some of the
encouraged by women’s NGOs, particularly since questions regularly raised are: Are emergency
the 1990s. departments the appropriate entry points for
VAW? Will social-health intervention become
OSCCs as an intervention model to respond to a required approach in dealing with this issue
VAW began at Kuala Lumpur Hospital, the main specifically and other health issues generally?
government tertiary-level hospital in the country in Does a multidisciplinary approach challenge
1993. This was subsequently replicated by Penang the dominance of the medical profession?
General Hospital in 1995, and by 1996 all general What would be the status of partnership
hospitals at the state level were instructed to set of women’s NGOs and the MOH in dealing
up an OSCC within their emergency departments. with the issue? Should gender perspective in
In 1997, all district hospitals were instructed to set health intervention and health policy be given
up OSCCs and provide the services accordingly. At importance?
present there are about 128 OSCCs in government The sustainability of services and models has
hospitals nationwide. also become one of the major issues that
the OSCC programme has to deal with. The
Basically, an OSCC provides integrated support
model started with the intention of supporting
to survivors of violence, within a hospital set-up.
survivors of VAW in the capital city of Malaysia;
This includes physical, forensic, and social as well
the MOH was not prepared with a blueprint
as emotional support services. Follow-up support
on how such a model should be replicated at
for both medical and non-medical needs is also
different levels or health set-ups. The fact that
given to the survivors as and when needs arise.
it was strongly supported by women’s NGOs
The integration of services is carried out both at
from the outset, especially in providing training
organizational level and among relevant agencies
and volunteers, has left the model in a situation
20
where it depends on the interest of individual Measures taken

medical or health personnel, or continuous Given the challenges, several steps have already
support from a women’s NGO. In other words, been taken to ensure that the OSCC model
it has become “champion dependent”, and survives. These include:
without these key “champions” the services may
not be provided satisfactorily. Reactivating the involvement of women’s NGOs
in supporting the OSCC services. This is currently
At service level, OSCC services can be tremendously done in two ways, with a third project planned:
improved if the following challenges are dealt with:
–– By involving them in research on the
Development of a dedicated team of staff, or health impact of violence (2007–2010).
improvement in the level of commitment from This research is conducted by the Women’s
medical/health staff to dealing with the issue Health Development Unit of Universiti Sains
of VAW at all levels, is necessary to ensure the Malaysia, which has invited the women’s
effectiveness of OSCCs. NGOs that deal with violence to be their
research partners. The aim of this partnership
Appropriate allocation of a budget would not
is to bring both the MOH and women’s NGOs
only assist the running of OSCCs, but also supply
back onto the same platform in promoting
the necessary recognition and accountability of
OSCC.
the service.
–– By developing the health-advocacy network.
The justice system relies heavily on the medical
The information based on the research
documentation. An integrated approach
will be used to help promote awareness of
towards medical reporting and documentation
the relationship between VAW and health.
is necessary not only to assist the justice system
Women’s NGOs and researchers from
but also to reduce the burden for a single
universities will be the core group in this
medical unit/department such as the obstetric
work.
and gynaecology department. At the same time,
it will also increase the importance of other –– Another country-wide research project on
medical assessments such as those done by health impact will also be carried out by the
psychiatrists and medical social workers. Women’s Development Research Centre of
Universiti Sains Malaysia. In this study, about
The OSCC model needs to keep abreast not only
400 nurses will be trained on the issue of
of medical procedures but also of the whole
VAW, as they will take part as data collectors
discussion on VAW and gender perspectives of
in the research.
the health sector. The work protocol requires
regular review, so that services can fulfil their Improving medical and health sciences
objective of being sensitive towards the needs curricula:
of survivors of interpersonal violence.
–– as part of the accreditation process, all
One of the greatest challenges faced by this medical schools in the country must indicate
model is to give an effective follow-up service that they have included the subject of
to survivors. In many situations survivors do not gender and health as well as violence on
return to the emergency department. . In cases their curriculum;
where survivors are suspected to be in danger of
–– some health sciences and medical schools
contracting HIV or STIs they may not be traced
have already included specific subjects
or may refuse a follow-up appointment. This
such as interpersonal violence as part of the
may enhance the silent growth of such illnesses.
regular curriculum they offer.
21
Developing an integrated model at local level: and health-sector personnel. Indeed, one is able
to observe more genuine interest among these
–– the OSCC service at the Hospital Universiti
personnel.
Sains Malaysia is currently a regular reference
for local practitioners. It has a dedicated
nursing team and a committed team of Case-study from India: the Centre
medical and social workers, as well as for Enquiry into Health and Allied
piloting an electronic documentation system Themes (CEHAT)
that ensures confidentiality and reduces the Ms Padma Deosthali presented work undertaken
practice of repeating questions to survivors by the Centre for Enquiry into Health and Allied
of violence. It also carries out monthly case Themes (CEHAT). Dilaasa, India’s first hospital-based
reviews with supervision. crisis department was established at KB Bhabha
Hospital, Bandra to make the public health-care
Improving networking:
system take account of the issue of domestic
–– OSCCs rely on a multidisciplinary approach violence. It was set up in 2001 as a collaboration
to be effective; therefore, strengthening of the public health department of the MCGM
the collaboration of the network is (Municipal Corporation of Greater Mumbai) and
critical to ensuring that survivors of CEHAT (the research centre of the Anusandhan
violent experiences receive the necessary trust). Another such department was initiated
support. The efforts made include regular at Kurla Bhabha Hospital in 2006. The strategic
collaborative training and regular meetings location of Dilaasa in a hospital has helped around
either during the monthly case conference or 1500 women facing domestic violence to access
by meeting annually at district or state level; services easily. Dilaasa means “reassurance”, and it
seeks to provide psychosocial support to women
Reviving OSCCs at local level:
survivors of domestic violence. The objectives are
–– at least three major hospitals from different to: (i) provide social and psychological support
states in the country have shown interest in to women coming to the department; (ii) assist
reviving their OSCC services. This may be the the key trainers of the five hospitals to train their
beginning of a revival that may be followed hospital staff on an ongoing basis; (iii) build
by other states and district hospitals. This capacity of the training cell members to train the
process will not only provide a revival for staff of the 16 hospitals and work towards making
the OSCCs that are less active, but will also the hospital patient friendly; and (iv) network with
provide an opportunity for a comprehensive other organizations working on women’s issues, for
evaluation of OSCCs in the country. mutual support and sharing.
Since the introduction of OSCCs throughout Training at Dilaasa is aimed at improving the
the country in 1996, the OSCC as a model has response of hospital staff to women facing
shown that it is not easy to attract health-sector domestic violence. The training programmes, such
involvement in VAW. It takes a long time to change as gender-sensitization training of the entire staff,
the mindset of medical and health personnel and to are conducted mainly by health professionals,
convince them that they are part of the detection, i.e. doctors, nurses and social workers, and target
treatment and prevention team. However, those screening women patients reporting for
having an OSCC set up in all hospitals has helped treatment in various departments of the hospital.
thousands of women and children who experience The training activities have now been expanded
violence, and it speeds up the development of to five hospitals across the city of Mumbai. This
an awareness about the issue among medical training is conducted by trained hospital staff
22
with support from CEHAT staff. Methods include: SAFE Kit is a “model kit for comprehensive care
(i) an orientation module that aims to develop an and documentation of evidence in cases of sexual
understanding of domestic violence as a health- assault”. The kit was designed to address issues
care issue, and the role of health-care providers of care and documentation in relation to sexual
in responding to patients; and (ii) a follow-up assault. Critical components of sexual assault
module that aims to build skills in screening intervention include: (i) consent; (ii) collection of
women for domestic violence and also provides evidence; (iii) documentation; and (iv) medical and
an understanding of the cycle of violence and psychological support.
specific needs of women living in violent homes.
Challenges encountered/lessons learnt
Within the intervention, a core group of trainers Difficulties have been encountered with health
has been established, consisting of doctors and professionals not wanting to document forensic
nurses who have undergone intensive training. evidence, in order to avoid appearing in court.
This helps to promote a sense of ownership
of the work and their roles within the project. A lack of institutional policies and guidelines
The members of the core team train their own has been found.
colleagues, and the training is well received There is a perception among some health
compared with non-health-provider training. professionals that VAW is not a health problem.
Having the core group develop their own proposal
and set up their own intervention in the hospital Health professionals are reluctant to become
proved to be successful, as it guaranteed their involved in cases of torture and conflict,
investment in the project. A training cell consists particularly when they involve the State.
of core groups of trainers from different hospitals.
The SAFE kit does not ensure a sensitive response:
They have developed a nine-day VAW educational
programme. Additionally, some nurses have
partial evidence collection is not offered with
been trained as counsellors to provide support to
SAFE;
women in the hospitals. Hence, there is potential
for nurses to play a large role, but this requires there is mandatory reporting of sexual assault
changes in national policy. Key intervention and rape to the police, which may deter some
components include a crisis-counselling model women from seeking help from health-care
based on feminist counselling principles, suicide- professionals;
prevention counselling, and education of
there is a lack of confidentiality and privacy, e.g.
mainstream health providers.
examinations for sexual assault and rape take
place on the labour ward;
In the counselling impact study, the focus of the
counselling was removing blame. Safety plans admission is mandatory.
were useful, though not always effective. It was
important for women to have a space where Case-study from Romania
someone listened and believed them and where
Ms Ionela Cozos presented Romania’s strategy
they could get immediate help in an emergency.
to address VAW. This model was selected by the
Even women facing extreme restrictions on their
United Nations Population Fund (UNFPA) as one
mobility were able to get help on the pretext of
of 10 case-studies of successful programming
going to the hospital.
for addressing VAW, and a similar model is being
adopted in Moldova. She highlighted the impor-
In addition to the counselling intervention, the
tance of the national policy context, as Romania
Sexual Assault Care and Forensic Evidence or
23
has many national strategies and legislative frame- between institutions; active local coordination
works that support work on VAW. These include groups that develop action plans and meet
the Law on Equal Opportunities Between Men and regularly; a joint training programme for health-
Women and the Law on Preventing and Combating care professionals, police, social workers and
Domestic Violence, in addition to the provisions other experts; an integrated system of referrals
under criminal law. Key actors involved in work on and services where everyone in the network
VAW include: national government institutions; understands the roles and responsibilities of other
local administration institutions; civil society; and members; and an integrated information system.
international partners such as WHO and UNFPA. What works well with regard to this approach
VAW is also a priority area for the Sexual and is the grass roots working at the highest levels
Reproductive Health Strategy (e.g. safe mother- of government, taking a multisector approach;
hood making pregnancy safer; family planning; building the technical and management capacity
abortion services; prevention and management of of professional staff; introducing an integrated
STIs and HIV/AIDS; prevention and management information system, important not only for
of infertility; sexual health of ageing people; sexual defining and quantifying the problem, but for
and reproductive health of adolescents and youth; tracking cases; and using the media as an ally.
and early detection of genital and breast cancer).
The programme has a broad remit and addresses Challenges encountered/lessons learnt
all forms of VAW. The objective of the programme is Partnerships are critical to the success of VAW
to enhance the capacity of governmental institu- projects and local authorities must be part of
tions at national and local levels, and of civil soci- the process.
ety, to formulate, implement and evaluate policies
to combat VAW. There is identified service provision Efforts to combat VAW must address victims and
for victims and perpetrators, and referrals are made perpetrators.
within a network of statutory organizations and Quality – high standards set by the lead
NGOs. institution tend to be adopted by partners.
Historically, the challenges encountered at a High-quality training and follow-up stimulates

political and financial level included: varying levels involvement by other partners.
of involvement of national and local authorities;
difficulties in identifying local partners; limited Case-study from Hong Kong
local resources; and conflicting local priorities. Dr Agnes Tiwari presented health-sector approaches
Challenges encountered at a technical level to addressing VAW in Hong Kong. In terms of a
included: the lack of specialized services; a lack of health-sector response to VAW, there is no national
common protocols; training needs; infrastructure; strategy, no budget allocation, no training for
and monitoring (e.g. in terms of multiple health professionals, and no integration between
definitions, events versus cases, aggregation/ services. The first population-based survey of
reporting, and multiple entry points). pregnant women in Hong Kong was conducted in
2005–2006. The sample consisted of 3245 patients.
The solution was to develop an integrated Of these, 296 (91%) reported being abused by their
approach involving a national framework and partners in the previous year; 216 (73%) reported
policies, with local partnerships. The philosophy psychological abuse; and 80 (27%) reported physi-
of this model is to integrate services for victims cal or sexual abuse. Dr Tiwari presented the results
with prevention efforts and build a network for of a published study of a randomized controlled
communication and support. The components trial of an intervention tested on 110 pregnant
of this approach include: broad partnerships Chinese women between 2002 and 2003. (Tiwari et
24
al., 2005). Women who received the empowerment Interventions should be theory based, evidence
intervention (which was adapted from an inter- based and protocol driven.
vention in the USA by Parker et al., 1999) reported
It is important to have a well-trained and
reduced psychological and minor physical abuse,
committed research team.
reduced symptoms of postnatal depression, and
improved health-related quality of life post-delivery Clinicians and practitioners should be involved
compared to the control group (Tiwari et al., 2005). in the research.
Unfortunately, the intervention did not receive Close monitoring is necessary to ensure
ongoing funding, so there is no practice of intervention fidelity and adherence.
routine screening for IPV in Hong Kong. The focus It is unethical and unsafe not to give the control
therefore of Dr Tiwari’s research is now on primary group any treatment.
prevention. Dr Tiwari referred to two new primary
prevention projects that she is involved in: (i) the
Case-study from the Philippines:
positive fathering project; and (ii) the positive
Project HAVEN (Hospital Assisted
parenting project. In the positive fathering project
Crisis Intervention for Women
the emphasis is on couple communication, coping
Survivors of Violent Environments)
with Chinese and western expectation and beliefs
Ms Teresa Balayon presented project HAVEN
about childbirth and the postpartum period. The
(Hospital Assisted Crisis Intervention for Women
positive parenting project focuses on the family as
Survivors of Violent Environments), which was
a whole, with trained voluntary workers to support
established at the hospital-based crisis centre at
parents and children. The project also emphasizes
East Avenue Medical Centre in the Philippines
child-friendly parenting in order to decrease
Women and Children’s Crisis Centre and
physical punishment and negative verbal messages.
Protection Unit (WCCCPU). The model utilizes a
Capacity-building strategies include: (i) having a holistic and integrated approach to addressing
“champion” within the health-care setting, which VAW, underpinned by collaboration between
is immensely helpful to raise the profile of the government and NGOs. The original purpose
research team, create open lines of communication, of the intervention was to (i) mainstream and
make public their recognition of the research, institutionalize experiences of NGOs in the health-
and provide financial back-up when needed; care-delivery system, to provide medical, health
(ii) providing exposure to the issue for faculty and psychosocial services for women-victim
through practice in shelters for abused women survivors, in an environment that is gender sensitive
and providing health assessment and education; and woman friendly; and (ii) institutionalize
(iii) designing and implementing courses for government and NGO collaborative response, with
undergraduate and postgraduate students on the long-term goal of replicating the hospital-based
partner violence prevention and intervention; and crisis centre in all government hospitals.
(iv) providing continuing education sessions at the
The intervention model addresses a broad
College of Obstetrics and Gynaecology.
spectrum of violence, including IPV, sexual
Challenges encountered/lessons learnt assault and trafficking. Current objectives within
the intervention model include: (i) to provide
It is not necessary to reinvent the wheel when
gender-sensitive and holistic health care to
researching interventions, but they should be
women and children victims/survivors of violence;
culturally appropriate.
(ii) to create and sustain a woman- and child-
sensitive environment within the hospital; (iii) to
25
sensitize and reorient personnel at all levels and Responses to VAW must recognize the inherent
departments of the hospital, to the issue of VAW; capacities of victim-survivors to cope with
(iv) to develop a career path or subspecialty in a failure of social institutions to eliminate
health and GBV; (v) to develop a systematic and conditions that create abuse and violence.
gender-sensitive documentation and monitoring
Holistic, complementary, and integrated victim-
system; (vi) to develop training materials that have
centered perspectives and approaches as well as
evolved from experiences of staff of the WCCCPU;
interdisciplinary and multidisciplinary studies of
and (vii) to assist the Department of Health in
GBV are critical to responses of the health sector
developing a model for replication in government
to VAW.
hospitals.
Health services must continuously improve
Services provided to victims include crisis interven- their response to VAW through education and
tion, counselling, medical treatment, legal refer- training, environmental scanning, coordination
ral and temporary shelter. Support programmes with the community, periodic organizational
include education and training, survivors’ support, assessment, and planning involving survivors
policy advocacy and monitoring, documentation, and other service providers.
and generation of knowledge. Ms Balayon also
referred to the context in which the intervention Mutual respect of institutional and
occurred. There was a strong demand for woman- organizational needs and resources is
centred approaches to VAW, responsive national necessary to successful government and NGO
machinery for women’s concerns, receptive govern- collaboration.
ment officials and hospital administrators, com- Compliance with international standards
mitted women’s organizations, and commitment requires appropriate complementary
from governments to international standards of mechanisms at mid and local levels.
responses to VAW.
Key gaps and issues that remain
Challenges encountered/lessons learnt Provision of after-care for survivors of VAW.
There have been shifts in policy regarding
Conceptual and values clarification of
government/NGO collaboration.
stakeholders.
Periodic turnover of medical personnel can
Assessment of current responses to VAW.
cause difficulties.
Improving compliance to intervention
Lack of access to services among poor and
standards.
disadvantaged women is challenging.
Management of knowledge generated from
Problems have been encountered with
current responses to VAW.
implementation of the WCCCPU protocol within
the hospital system. How to create a culture that is free of violence
and abuse.
Inappropriate implementation of national laws
and local government ordinances has caused
problems.
Case-study on services for sexual
violence in selected African
It is important to eliminate vestiges of unequal countries
power relations at interpersonal, institutional Dr Jill Keesbury presented a review of services
and structural levels. for sexual violence in selected African countries.
Generally, services to meet the needs of survivors
26
are weak and poorly understood. There is a lack of One-stop shops are not the only way, or the
documented experiences about what works, and ideal model for delivering SGBV services.
the focus is on prosecuting the perpetrator rather One-stop shops are resource intensive, there
than caring for the survivor. Furthermore, the needs are issues around sustainability, there is urban
of survivors vary greatly depending on sex, age, the bias and questions about what works in rural
nature of the assault, disease epidemiology, legal areas, and they have not been evaluated in
options available and sociocultural context. low-resource settings. Alternative models
include integrated care within existing health
Most African countries are characterized by a lack facilities, linking to the police; strengthening
of dedicated medico-legal services or by poorly police services and linkages to health centres;
organized and separate services. The African regional and a victim advocate or “buddy system” where
sexual and gender-based violence (SGBV) initiative integrated services are not available.
of the Population Council incorporates 9 countries
Legal concerns can serve as a barrier to accessing
and 20 partners. Key elements included in the
medical and other management services. Public
response are: (i) medical (e.g. management of SV
barriers include: not wanting to prosecute
at first point of contact with the survivor, sensitive
family members, transportation costs may act
approaches to managing child survivors of SV, and
as a disincentive to visiting a second point of
encouraging and enabling presentation by male
contact, and limited or incorrect awareness of
survivors, screening for signs and symptoms of
the requirements for receiving care. Health-care-
violence during consultations); (ii) justice system
provider barriers include: limited or incorrect
(e.g. collection of forensic evidence and creation
awareness of the requirements for delivering
of a chain of evidence that can be used during
care, limited awareness of forensic evidence-
prosecution, strong links between medical and
collection procedures, and unwillingness or
police facilities to enable incidents to be referred
inability of health-care providers to present
in either direction); and (iii) community (e.g.
evidence in court.
psychological counselling, new or strengthened
community-based prevention strategies that are The majority of survivors reporting sexual
relevant and appropriate for the local context, to assault are children or adolescents, yet services
convey messages about IPV in prevention strategies). are commonly designed for adults.
The objectives of the SGBV network are to: Very little is know about addressing the
(i) pilot innovative approaches to SGBV service immediate and long-term psychological needs
strengthening; (ii) document the feasibility of these of survivors in Africa, and the feasibility, safety
approaches; and (iii) promote evidence-based and effectiveness of addressing intimate partner
policies and programmes across the region. violence in low-resource health services.
While the need for a multisector response is

clear, how best to organize cooperation and
Legislation and policies, multisectoral collaboration between sectors for policy and for
frameworks, guidelines, protocols and delivery is not clear. At facility level there is the
validated training curricula are essential for question of where to situate services; at systems
ensuring coordinated responses to SGBV. level, links with police and judiciary, and links
Medical management is quite well developed. with prevention services need to be addressed;
Police protocols for evidence collection and and at policy level, decisions need to be made
treatment of survivors are available. However, about involvement of ministry of gender or
psychological support and treatment of children social services.
and males remains weak.
27
Case-study from Maldives: the A total of 188 staff at IGMH have been trained and
Family Protection Unit (FPU) orientated to FPU activities, including 41 doctors,
117 nurses and 30 paramedical staff. Various staff
Dr Aseel Jaleel presented the work of the Family
members have attended external training courses,
Protection Unit (FPU) at Indhira Gandhi Memorial
conferences and workshops on GBV and health-
Hospital (IGMH) in the Republic of Maldives.
sector responses, including a workshop on the
Qualitative research conducted in 2004 highlighted
forensic investigation of rape cases. Advocacy
the need to establish a support service in the health
materials for health-care professionals include
sector to address GBV. The aims of the intervention
information on the services provided by the FPU,
model are to: (i) improve the responsiveness of the
referral procedures and the responsibilities of
health sector to GBV and child abuse; (ii) establish
health-care professionals. Advocacy materials
a dedicated FPU to deal effectively and sensitively
for patients include information on the services
with cases of abuse at the hospital; (iii) develop
provide by the FPU, location of the service and
specific hospital protocols and procedures for
issues of confidentiality.
dealing with abuse cases; (iv) develop and display
advocacy materials; (v) train/sensitize all hospital
staff on GBV, identifying signs and symptoms of
GBV, following protocols, effective documentation Strengthening institutionalization of FPU
of abuse and appropriate referrals; (vi) train medical services at IGMH
staff personnel in collecting forensic evidence; Designating a FPU coordinator
(vii) develop a confidential database of all abuse
cases that can produce data on the number of Improving the physical capacity of the FPU
cases; (viii) have dedicated staff working for the
Improving the pathway of care
FPU at IGMH; (ix) offer a safe, child-friendly and
comfortable space for examinations and private Developing guidance and information material
counselling; and (x) offer on-site counselling and to raise staff awareness
referral to outside support services.
Screening for gender-based violence and child
abuse
Between 15 August 2005 and 27 February 2009, the
total number of cases referred to the FPU included Strengthening the capacity building of health
105 GBV, 270 child-protection issues, 47 other cases personnel on identification and management of
and 95 unmarried pregnancy cases, giving a total victims of abuse
of 517 cases. The FPU has two different forms for
documenting violence experienced by an adult Strengthening the referral system between the
or a child. Child-abuse cases are referred to the hospital and other sectors in providing support
Child and Family Protection Services (CFPS) using services to abused women and children
a referral form, and adult clients are provided with
Raising public awareness about the existence of
the contact numbers of counselling agencies.
FPU services and the unacceptability of GBV and
Medical-legal forms are completed for each client
child abuse
and sent to the police through the chief executive
officer’s office. Case notes of all clients who come
Case-study from Yemen
into contact with the FPU are filed at the FPU.
Dr Eman Alkobaty presented the Violence and Injury
Information about the client, including name and
Prevention Programme in Yemen that was initiated
address, are stored in the FPU database. A monthly
by the Ministry of Public Health and Population in
report is sent to concerned authorities at the end of
2004. However, the programme was not active for
each month.
some time due to the lack of resources. In 2008,
28
the programme merged with the Injury Prevention There is poor coordination between the relevant
Programme funded by the WHO (Injury and partners at government level and NGOs who
Violence Prevention Department). The Ministry of work on the issue of VAW (e.g. Ministry of Public
Public Health implemented a surveillance system Health and Policy, Ministry of Justice, Ministry
on violence and injuries in 10 major hospitals that of Interior Affairs, Ministry of Social Affairs and
were equipped with computers. Doctors are trained Labor and NGOs).
to use a special form to document cases of violence,
and a training manual on diagnosis of violence Case-study from Iraq
cases will be developed by a multidisciplinary team Dr Faiza A Majeed presented the challenges of
of health-care professionals (e.g. forensic doctors, addressing VAW in Iraq. The status and situation
gynaecologists, paediatricians). Guidelines for of Iraqi women has deteriorated with three wars
addressing violence against children and adults since the mid-1980s, which resulted in a decade
were developed. The surveillance system has been of sanctions. The Iran–Iraq war, with an estimated
implemented since July 2009, when doctors in the one million soldiers killed, created a segment
emergency departments in the 10 hospitals were of “traumatized women and girls” who suffered
trained. Since Yemen has no data on the extent over the loss of their families. Different forms
of different forms of VAW, the new system will of VAW exist apart from IPV, for example sexual
generate data. harassment, detention, and torture for political
reasons. The events in Iraq after the 2003 war,
The presentation highlighted how difficult it is
particularly the sectarian conflicts, led to an
to develop work on VAW in a country where the
increase and emergence of new forms of VAW that
national policy context does not recognize VAW as
are continuously threatening Iraqi women’s rights
an abuse of human rights. VAW is not considered
to security, mobility and access to health care and
as a significant issue in itself, but is framed within a
education, as well as employment. This includes
wider context of violence and injuries, which makes
targeted killings of women to settle political, ethnic
it more difficult to give it any visibility.
or family scores; threats by militant groups to force
women to restrict their movement in public; and
violation against women’s rights, such as forced
VAW is not a priority issue and there is a lack of early marriage of young girls, induced by economic
awareness about the issue. and sociocultural factors.
VAW is not an explicit component in the
The social stigma attached to sexual violence crimes
programme.
prevents many women from accessing medical
There is a lack of local/national data on the treatment or seeking psychosocial counselling, as
extent of VAW. reporting can also lead to other social and cultural
consequences such as rejection or even honour-
There is a culture of silence, which creates
related murder for having caused shame to the
further stigma around the issue of VAW.
family. Vulnerability and exposure to violence has
There is a lack of systems. increased among internally displaced women.
Women may be forced into trading sex for food
Resources are deficient.
and shelter for their families, especially in refugee
There is a lack of services to support abused situations (among widows). The extent of sexual
women in terms of legal support and social and assault of female prisoners is unknown.
medical care.
The Iraq Family Health Survey measured the extent
of domestic violence and found that among women
29
surveyed, 83.1% experienced controlling behaviour Case-study from Mozambique

from their husbands, 33.4% emotional violence,
Dr Francelina Romao presented the health-sector
21.1% physical violence and 13.9% physical
response to VAW in Mozambique. A survey
violence during pregnancy. In the past five years,
conducted in 2005 showed that 54% of women
there have been 21 000 reported cases of VAW, 400
had been victims of physical or sexual violence
reported rape cases between 2004–2005, and 150
at some point in their lives. In 2002, nurses and
women beheaded in 2006.
doctors working in health units providing 24 hour
services in Maputo town received training. The
Dr Majeed discussed a new victim-assistance
objectives were to improve the quality of care and
project in Kurdistan. Four pilot injury-surveillance
documentation of violence. The central hospital of
projects have been implemented. There is a
Maputo developed a standard protocol to assist
joint project on combating VAW in three areas –
victims of sexual violence. National surveillance
northern, central and southern Iraq. Stakeholders
on trauma, of which violence is a component, was
include various government ministries, NGOs and
introduced in 2008 in every provincial and central
civil society. The project outcomes are to ensure
hospital.
that: (i) VAW is integrated within the government’s
policies, as well as civil society organizational
In 2008, GBV was discussed at a national annual
programmes, services and activities; (ii) the
meeting with all hospital managers, where the
institutional, technical and operational capacities
standardized protocol was discussed and approved.
of key government ministries and civil society
This council is chaired by the Minister for Health.
are strengthened to adequately respond to the
Medico-legal specialists exist in only three central
needs of VAW survivors; and (iii) positive change
hospitals. In 2009, general practitioners and
in perceptions and attitudes among community
surgeons will be trained to undertake high-quality
leaders and local communities, especially
medico-legal assistance. Health-care professionals
adolescents, in relation to gender equity and
coordinate with NGOs that can provide counselling
equality, including VAW, is achieved.
and support related to psychological and legal
matters. However, most of these activities are
being implemented in major urban areas only. In
The sociocultural context in Iraq makes it 2009, there was comprehensive training of nurses
difficult to address the issue of VAW. working in mother and child care covering 300
There are ongoing efforts in Iraq to improve nurses in Maputo. They are also developing a
the country’s performance on human rights, programme where women can obtain assistance
especially women’s rights. in the health unit (like a one-stop shop) to prevent
revictimization. The next step is to improve
There is a lack of legislative frameworks to coordination between health care and the police.
protect women from violence and regulate and
institutionalize the fight against VAW.
There is a lack of services for survivors of VAW

in Iraq.
There is a shortage of human resources and

financial support.
There needs to be improved coordination

between different United Nations agencies and
NGOs, to avoid duplication.
30

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Expert meeting on

ISBN 978 92 4 150063 0

17–19 March 2009,

ISBN 978 92 4 150063 0 (NLM classification: WA 308)

CEHAT Centre for Enquiry into Health and Allied Themes

Dr Eman Alkobaty Ms Ionela Cozos

Dr Bartilol Kigen PARTNER AGENCIES

Dr Nduku Kilonzo An-Sofie Van Parys

Ms Galina Lesço SECRETARIAT

Professor Charlotte Watts

V iolence against women and girls (VAW) is a

Aims of the meeting

1. To review the evidence and experiences of

2. To identify key elements of an appropriate

3. To explore the potential advantages and

4. Building on the above, to develop a detailed

Summary of evidence on effectiveness of health-sector

Key themes emerging

Approaches to training health-care There must be a supportive environment in order

Framework for recommendations for health-sector

Participants reflected on the case-studies and 2. Training

 Models of training may vary according to

 Multidisciplinary training may be beneficial

on one person. It is important to define what we 5. Research and surveillance

6. Approaches to psychosocial and a new training curriculum is providing doctors

9. The development of networks 10. How to link violence against

 In order to assess the impact on children,

significant others. Offer referral of children to 11. Mandatory reporting

 If a health-care professional refers a male patient

13. The role of the health sector in

 It is possible to integrate messages about

 Other opportunities for primary prevention and

 It is also important to think about prevention

 Health-care professionals need to consider

Parker B, McFarlane J, Soeken K, Silva C, Reel S.

Case-study from Thailand Case-study from Mexico

 financial sustainability. The approach to routine enquiry will be staged

Dr Siti Hawa Ali presented the one-stop crisis centre

where it depends on the interest of individual Measures taken

Historically, the challenges encountered at a  High-quality training and follow-up stimulates

 While the need for a multisector response is

surveyed, 83.1% experienced controlling behaviour Case-study from Mozambique

 There is a lack of services for survivors of VAW

 There is a shortage of human resources and

 There needs to be improved coordination

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Models of training may vary according to

Multidisciplinary training may be beneficial

In order to assess the impact on children,

If a health-care professional refers a male patient

It is possible to integrate messages about

Other opportunities for primary prevention and

It is also important to think about prevention

Health-care professionals need to consider

financial sustainability. The approach to routine enquiry will be staged

Historically, the challenges encountered at a High-quality training and follow-up stimulates

While the need for a multisector response is

There is a lack of services for survivors of VAW

There is a shortage of human resources and

There needs to be improved coordination