Mapping the health systems response to violence against women: A comparative analysis of five LMIC settings (2015-2020)

Abstract Background Violence against women (VAW) is prevalent globally, and the health sector is a key entry point for survivors to receive care. However, documentation on the rollout of health system response to violence against women is lacking in low and middle-income countries. This paper maps the operationalization of health systems response to violence against women in five low- and middle-income countries (LMIC) to identify core learnings. Methods We selected five LMIC contexts that were actively addressing national-level health system response from 2015 to 2020 and where we had access to practitioners directly engaged in national rollout. We synthesized publicly available data and program reports according to the components of the Health Systems Framework to Address VAW. Results One-stop centers were found to be the dominant model of care located in hospitals implemented by the health systems in four countries except Brazil, where one-stop centers are not located in hospitals and do not provide health services. While each setting has implemented in-service training as key to addressing provider knowledge, attitudes and practice, significant gaps remain in addressing frequent staff turnover, provision of training at scale, and documentation on the impact of training. Health system protocols for VAW address sexual violence but do not uniformly include clinical and health policy responses for other forms of violence. In Brazil, Nepal, and Sri Lanka, harmful practices such as virginity testing remain within clinical protocols. Providing privacy to survivors within health facilities was a universal challenge. Conclusions Significant efforts have been made to address provider attitudes towards provision of care and in protocolized delivery of care to survivors, primarily through one-stop centers. Improvements can be made in data collection on training impact on provider attitudes and practices, in provider identification of VAW survivors, and in prioritization of VAW within health system budgeting, staffing, and political priorities. Beyond hospital-based one-stop centers at tertiary and district levels, primary health facilities need to provide first-line support for survivors to avoid delays in response to VAW as well as for secondary prevention.