Improving health system readiness to address violence against women and girls: a conceptual framework

There is increasing focus on health system readiness to respond to survivors of violence, to identify gaps and better understand why some approaches to integration may be effective in one context, but not in others [13, 14] and how they affect already overstretched health systems. Existing evidence underlines the importance of organisational and individual readiness to support the implementation of interventions to address IPV in health systems [13]. Health system readiness has been used in various health contexts to refer to either a) providers’ ability to respond to a specific health issue (e.g. knowledge, motivation, attitudes) [10, 16]; b) services’ ability to assess availability, performance and quality of care offered (e.g. availability of services, infrastructures, supplies) [17]; or c) organizational readiness to implement a particular innovation (e.g. supportive environment, governance) [18]. Health system readiness focuses on how prepared healthcare systems and institutions - including providers and potential users - are to accept and implement the changes brought about by the integration of the new programme. In IPV research, such assessment is often limited to individual provider readiness [16, 19] or facility-level (or service-level) factors that need to be strengthened [15] with less attention – until recently [10, 20] - to broader health system dimensions (e.g. organisational issues such as governance and leadership) and their interactions [16, 21], which are harder to change. Two recent reviews on health providers’ barriers to address IPV highlight the importance of addressing organisational and structural factors for ensuring a supportive health system [10, 12].

The current literature on IPV and readiness has focused primarily on its measurement and specific tools were designed for this purpose. Provider readiness scales yield information on provider knowledge, self-efficacy, motivational and emotional readiness to respond to IPV, and are often used to assess training interventions. They fail, however, to consider contextual and health system factors that are beyond the control of the providers. To date, service readiness scholarship has focused on providing lists of indicators for service readiness inputs (e.g. availability and adequacy of infrastructure, supplies and resources), but does not offer a comprehensive framework for assessing health facilities’ capacity and preparedness to deliver and/or assimilate new services [17]. Organisational readiness for change scales have been used to assess readiness of healthcare organisations [22, 23] encompassing key domains such as staff motivation for change, resources, staff attributes and organisational climate (e.g., incentives, support, mentoring). However, most of these tools have failed to adopt a systemic approach to readiness that encompasses capabilities beyond providers’ preparedness and material and technical resources to include policy, leadership and governance issues, and clients’ and community awareness and engagement. Other limitations across these tools and measures include the lack of a cross-sector lens on health sector coordination of care with other services (e.g., police, legal services, non-governmental organisations and social services). They also do not pay attention to client and community engagement, which is an important and globally recognised strategy for advancing acceptability, demand, uptake and access to integrated care [24, 25] and for ensuring that health systems are better aligned to individuals’ and communities’ practices and needs [26]. Engagement is seen as an enabler in sexual and reproductive health integration to ensure client and community preparedness [25, 27]. Yet, community engagement is often overlooked in the health system response to IPV.

In this article we present a framework for health system readiness assessment to improve quality care for IPV [9, 15], which was tested and refined in Brazil and Palestine. This also lays the groundwork for developing further measures of readiness to integrate IPV services.

Using the framework’s dimensions to analyse HERA primary data from Brazil and oPT highlighted deficiencies in policy and practice that needed to be addressed to implement an effective response. The framework helped anticipate readiness gaps and understand system readiness capabilities and pre-conditions that were critical for integrating the HERA intervention within the existing health facilities. Table 2 below summarises the key country findings from the 43 qualitative interviews (based on the initial framework dimensions). Detailed country summaries are reported elsewhere [13, 45].

At macro-level, we found that governance did not automatically translate into effective implementation. In Brazil, the lack of a consistent and clear policy on IPV in primary health care (e.g. regarding provider roles, monitoring and client flows) and accountability structures affected IPV service implementation, as health providers and managers felt less confident in responding to IPV survivors [46]. Lack of training on IPV – showing lack of political will from top health managers - also affected providers’ knowledge and efficacy to work on IPV.

Additionally, the results of the data synthesis illustrated the importance of governance-related issues such as having political will, which in turn influenced the availability of clear guidance on roles and responsibilities for both health managers and clinicians, and for coordination. In both settings, it also validated the need to address the lack of perceived management support in the facility environment (evidenced by lack of training and support offered to providers), which impacted on providers’ confidence in responding to violence (and ultimately on their knowledge). The testing of the framework reiterated the vital influence of ‘software’ issues of the health system (e.g. values, leadership, support, power dynamics, relations) upon which collective readiness and commitment are contingent.

For both contexts, improving governance and capacity of the health workforce (IPV awareness, safety) to respond to IPV, were important elements that needed to be strengthened prior to adopting the new intervention. Furthermore, to overcome the lack of clarity around roles and the limited coordination, IPV specialists (Gender Based Violence (GBV) focal points in oPT and ‘Nucleus’ of Violence Prevention (NPV) staff in Brazil) participated in the initial training sessions of the pilot intervention.

In Brazil, although almost all health managers had limited knowledge and contact with IPV specialized legal and psychosocial services, personal contact and direct communication between social workers and external agencies boosted multi-sectoral collaboration [45]. Conversely, in Palestine, lack of clarity and specificity around roles and responsibilities across different healthcare providers and external services hampered collaboration [13]. The examples presented here clearly demonstrated the connections between capabilities across macro and meso levels.

Five themes emerging from the data synthesis led to refinements of the initial framework.

First, providers needed health managers and institutional support to respond to IPV. The importance of enlisting support and commitment from health managers was evident in Brazil and Palestine, where having committed IPV leaders (e.g., regional health managers in Brazil or GBV Focal Points at Ministry of Health in Palestine) was crucial for supporting the introduction – and continuous support - of new services [13, 45]. The importance of a supportive organisational environment was thus strengthened in our framework as a key readiness element, particularly in relation to having supportive managers, supportive teams and a supportive organisational culture that legitimises the key role of providers in IPV care and not condoning IPV. This capability was made more evident in the final framework.

Second, the importance of openness to prioritise non-biomedical issues, which emerged as an important element for readiness, particularly in Brazil. IPV was less prioritised in relation to other health issues, especially when no physical injuries were reported. Whilst some providers’ narratives highlighted IPV as unacceptable (especially in Brazil), many still thought it was not part of their role (but more relevant for mental health specialists) and had expectations of “fixing” DV by pressuring the woman to denounce the abuse. Our findings, particularly the ones from Brazil, have demonstrated how an openness to consider and prioritise problems that are not usually defined as health issues from a traditional biomedical view is also important to IPV readiness at both macro and meso levels. This can help ensure there is political will to recognise and address IPV as a health priority. This capability was subsequently added to the revised conceptual framework (see Fig. 2) at both macro and meso levels (provider’s readiness).

Third, women’s distrust in health providers’ responses and community stigma emerged as barriers to readiness. In Palestine, most women lacked trust in disclosing IPV to health providers and in their ability to maintain confidentiality [47]. Community stigma resulted in women’s concealment of IPV and providers’ fear of getting involved proved to be a barrier to identifying and documenting cases of IPV survivors at the facility [13]. Two major capabilities that emerged from the data synthesis were also services being acceptable and accessible to clients, and community stigma hindering support and engagement. Beyond trust, acceptability also entailed whether the services were responsive to women’s needs and what the women and communities really wanted and expected. In Brazil, community health workers were seen as significant for IPV detection (and at promoting dialogue with the community on IPV), but often women asked them to respect their confidentiality by not reporting IPV to the clinic/facility for fear of stigma and retaliation [48].

Fourth, survivors’ and communities’ interactions and perceptions of VAW services were also shaped by traditional beliefs around IPV and gender roles [49]. This was apparent in our data synthesis in both countries, and particularly in Palestine. Women’s limited uptake of external referral services – due to fear of stigma and retaliation - was a finding in the formative (oPT) and evaluation phases of the HERA intervention in both countries. To address the limited IPV disclosure and uptake of IPV services by women, general information sessions were organised only with women using services (and not men) in oPT [13]. Following the data synthesis, a new ‘micro’ level dimension on women and community engagement was subsequently added when refining the framework.

Last, gender values and power inequalities within the health systems affected its readiness to respond to IPV. Although the application of the initial framework considered the influence of cultural and social norms on providers’ attitudes, values and motivation, we did not use a gender equality and intersectional lens in the analysis of the readiness data during our HERA pilot. We treated health providers and managers as homogeneous groups, without considering sex, gender relations and other social markers (e.g. class and race) that may have also affected their values, preparedness and their role as health care providers (in relation to IPV). However, our data showed instances where gender norms impacted on how health providers responded to IPV. For example, victim blaming emerged as a common barrier among health providers, in both countries, particularly among Palestinian male doctors. Additionally, in Brazil, the role of community health agents - often female and from the same community as some of the clients – was not fully explored. They were perceived to have less power (by other providers) within facilities in comparison to other health providers, but appeared to instil more trust from women in the community. Furthermore, in Brazil we overlooked the importance of personal experiences of violence among female health workers (which appeared strongly during the implementation of the intervention). It is important to acknowledge that health providers usually mirror the values and experiences of the communities they come from and many female health providers may be being subjected to IPV (and other forms of abuse) themselves (or condoning it). Therefore, when finalising the framework after the testing, it was decided to make gender equality and intersectional issues more visible across all levels, particularly in relation to organisation and heath workforce capabilities (meso) and structural ones (macro). A gender and intersectional analysis could have highlighted differences in values and beliefs between male and female providers and managers in Palestine that would have better informed the content of our intervention.

The final framework for assessing health system readiness to offer care for survivors of IPV is presented in Fig. 2.

The framework also informed adaptation of the intervention. Framework dimensions and emerging findings from the readiness analysis were discussed and validated during a meeting with HERA researchers (and co-authors). Findings from the formative phase of HERA were also presented at local participatory stakeholders’ workshops with health-policy makers, district health managers, NGOs and other key informants in each country. Stakeholders discussed adaptations to the proposed HERA intervention model that would be required to support the delivery of quality care for survivors of IPV through the HERA intervention. Readiness findings pointed to concrete actions and requisites in each system dimension important for delivering the intervention effectively and helped identify assumptions for the intervention Theory of Change (ToC). Table 3 shows examples of how the readiness findings were used to inform adaptations to the HERA intervention in Brazil [45] and oPT [13].

Although it was beyond the scope of the HERA intervention to address readiness gaps across all system levels, especially at macro level, having an understanding of the structural and contextual factors that could affect successful implementation of the intervention proved useful during the development of the ToC and the evaluation phase [50]. Evaluation findings from oPT show how some readiness gaps still persisted post-implementation, such as providers’ fear for their own safety and lack of management support [50].

We acknowledge the following limitations. First, although the framework was revised to include a micro level analysis around women’s and community engagement, it would require further testing to ensure such domains are being fully captured. Second, the same would be true for the adoption of a gender equality lens and whether it is possible to analyse gender and its intersection with other social determinants across all levels with the existing readiness capabilities.

Third, the operationalisation of the framework is complex and requires multiple sources of data collection and a multi-layered analysis. With the above caveats, we emphasize that the use of this framework allows a comprehensive analysis of readiness gaps and enablers across all levels of the health systems, which is critical for IPV interventions, even those with one-dimensional focus (on one specific systems level such as service-delivery or providers’).

Lastly, although the framework was conceived for LMIC context, however, with adaptations, it could be used in high income settings.