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LSHTM Gender Violence & Health Theme: Health systems and service response to violence 

Despite increasing recognition of violence against women (VAW) as a public health problem, health systems have been slow to track, anticipate, respond and prevent such violence. However, since the launch of the World Health Organization (WHO) clinical and policy guidelines for responding to VAW, several countries have implemented or used their principles in low resource settings, adapting them to their health systems and political contexts. This webinar presents findings, challenges and lessons learned from these efforts. 

Manuela Colombini, Assistant Professor at LSHTM and Avni Amin, Technical Officer, WHO will co-facilitate the webinar and Q&A discussion. The five presentations are:  

1. Ana Flavia de Oliveira: "Is training primary health care providers enough? Findings from a pilot study in Brazil"

Although the response to violence against women is institutionalised in Brazil, health care responses are fragmented. The presentation presents findings from the piloting of an adapted intervention (IRIS) to address VAW in primary health care (PHC) services. It provides insights on how the intervention raised identification and referral of domestic violence cases, but also shed light on other system challenges. Although important, training alone was not enough to institutionalise the VAW care within PHC. The importance of exploring health systems preparedness before intervention implementation is critical, including manager support; staff supervision; documentation and the regular reinforcement of the referral flow.

2. Ana Baptista: "Innovations on health systems response to violence against women – Experience of Mozambique using Quality Assurance Tool"

As part of the multisectoral mechanism for gender-based violence (GBV) response, the Ministry of Health Mozambique, in collaboration with , implemented high-quality GBV services in selected health facilities. Services were externally assessed from 2015 to 2019 using a tool containing 43 performance standards in seven areas of integrated GBV service provision and followed by action plans for performance gaps. Services improved from scores ranging from 0% to 10% in 2012, to 72% to 85% in 2015, and 80% to 94% in 2019. Performance assessments ensured reliable, sustained, integrated, quality services. This approach has been adopted by the Ministry of Health Mozambique and expanded to all facilities. 

3. Abdulsalam Alkaiyat: "Integrating violence against women in occupied Palestinian Territories: challenges and enablers"

The presentation provides key findings from  intervention in two primary health care clinics in occupied Palestinian Territories. Methodological innovations, including readiness assessment and stakeholders’ intervention planning workshop, helped yield critical information for developing and implementing the content of the intervention. The case study also highlights features of structural, political, and cultural context that affected health providers’ readiness and ability to implement the intervention. Findings also pointed to concrete actions in health system dimensions that were important for effective delivery, including values, leadership, financing, coordination and information. 

4. Sanjida Arora and Sonali Deshpande: "Innovations in implementing research to strengthen health provider capacity and facility readiness in responding to violence against women in Maharashtra, India"

They will present findings from implementation research in 3 hospitals in Maharashtra, India involving the training of 220 health providers in WHO guidelines for responding to VAW. The pieces of training used participatory methods to raise critical reflections about how power influences women’s experience of violence and how clinicians can respond with woman-centred first-line support. Knowledge, Attitude and Practice (KAP) data at baseline, post-training and post-6 months will be shared. Health facility readiness, assessed through observations in hospitals, will be shared. Improvements in facilities focused on infrastructure changes for privacy and confidentiality, establishing documentation of VAW in health management information system (HMIS), referrals for multi-sectoral coordination, and standard operating procedures (SOP) to guide care. 

5. Sharifullah Haqmal: "Health systems response to gender-based violence in Afghanistan – lessons learned from scaling up the national protocol"

This presentation will present baseline and end line results of provider training and facility readiness from scaling up Afghanistan’s national GBV protocol in 21 provinces. With 5000 providers trained and upgrading of facilities, we are learning that it is possible to improve skills and create a supportive health system in a post-humanitarian setting. Challenges include the cultural context, safety and security concerns, and difficulty in covering rural and remote areas. Health managers and policymakers must be sensitized to support providers to deliver care. Addressing mental health is an important entry point for responding to VAW in this setting. 

Speakers

Ana Flavia de Oliveira, Professor of Preventive Medicine at the University of São Paulo, and a medical doctor specialised in public health

She has been working on gender-based violence and primary health care responses since 1994. She has conducted research on prevalence and health consequences, women’s coping strategies and the health system response in relation to gender-based violence. She was Co-Principal Investigator of the Brazil study in the WHO multi-country study on women’s health and domestic violence against women, and have been collaborating with WHO and The Pan American Health Organization (PAHO) for 15 years. She is the Principal Investigator of the HERA studies in Brazil.

Ana Baptista, GBV Technical Advisor for JHPIEGO, Mozambique

She is a Mozambican physician, with 12 years of experience working in GBV programming advising the Ministry of Health, President’s Emergency Plan for AIDS Relief (PEPFAR), and World Bank-funded projects on Gender-Based Violence Response and Mitigation and outreach to communities in Mozambique. Currently, Ana is team leader overseeing Jhpiego’s GBV portfolio providing technical leadership to the DREAMS Initiative for HIV and violence prevention among adolescent girls and young women and to the World Bank Sexual Exploitation and Abuse Mitigation in development projects in Mozambique.  

Abdusalam Alkaiyat, Assistant Professor of Epidemiology at An-Najah National University, Palestine

He is also the post-doctoral scientific collaborator at the Swiss Tropical and Public health Institute in Switzerland. He has conducted research on domestic violence concerning health system response and capacity, and gender as a social determinant of health. He is the Co-Principal Investigator at An-Najah National University (ANNU) for and The National Institute for Health Research (NIHR) funded Global Health Group on health system responses to violence against women which extends the work of the HERA intervention.

Sanjida Arora, Research Officer at the Centre for Enquiry into Health and Allied Themes, Mumbai 

She has led the implementation research study on health systems response to VAW undertaken in collaboration with WHO. 

Sonali Deshpande, Associate Professor & Unit Head of OBGY Department at Aurangabad Medical College 

She is a postgraduate teacher, examiner and tertiary centre technical coordinator of emergency obstetric care. She is a trainer for gender in medical education and building healthcare providers’ capacity in responding to VAW.

Sharifullah Haqmal, National Professional Officer (NPO) for gender, equity and rights program, WHO Kabul Afghanistan

He has led the implementation of GBV treatment protocol project between 2015-2020 to be scaled up in 34 provinces of Afghanistan and almost 7000+ health care providers trained. 

^REFERENCES

• ^{D’ Oliveira, AF. Pereira S, Bacchus L. Feder G, Schraiber L, Aguiar JM, Bonin R, Graglia C, Colombini M. Are we asking too much of the health sector? Exploring the readiness of Brazilian Primary Healthcare to respond to domestic violence against women. 2020 IJHPM}
• ^{Bacchus, Loraine J; Alkaiyat, Abdulsalam; Shaheen, Amira; Alkhayyat, Ahmed S; Owda, Heba; Halaseh, Rana; Jeries, Ibrahim; Feder, Gene; Sandouka, Rihab; Colombini, Manuela; (2021) Adaptive work in the primary health care response to domestic violence in occupied Palestinian territory: a qualitative evaluation using Extended Normalisation Process Theory. BMC Family Practice, 22 (1). 3.}
• ^{Shaheen, A., Ashkar, S., Alkaiyat, A., Bacchus, L., Colombini, M., Feder, G., & Evans, M. (2020). Barriers to women's disclosure of domestic violence in health services in Palestine: qualitative interview-based study. BMC Public Health, 20(1), 1795. doi:10.1186/s12889-020-09907-8}
• ^{Colombini, M., Alkhayyat, A, Shaheen, A., Garcia Moreno, C., Feder, G., Bacchus, LJ. Exploring health system readiness for adopting interventions to address domestic violence: a case study from the Occupied Palestinian Territory. Health Policy and Planning (2019): czz151.}
• ^{JPHIEGO (2015). Recognizing Gender-Based Violence as a Clinical and Multi-Sectoral Issue:  A Case Study of Jhpiego’s Support to the Ministry of Health in Mozambique.}
• ^{WHO (2018). WHO project improves health care sector’s response to gender-based violence in Afghanistan.}