Are We Asking Too Much of the Health Sector? Exploring the Readiness of Brazilian Primary Healthcare to Respond to Domestic Violence Against Women

Abstract

Background: There is growing recognition of the health sector’s potential role in addressing domestic violence (DV) against women. Although Brazil has a comprehensive policy framework on violence against women (VAW), implementation has been slow and incomplete in primary healthcare (PHC), and little is known about the implementation challenges. This paper aims to assess the readiness of two PHC clinics in urban Brazil to integrate an intervention to strengthen their DV response. Methods: We conducted 20 semi-structured interviews with health managers and health providers; a document analysis of VAW and DV policies from São Paulo and Brazil; and 2 structured facility observations. Data were analysed using thematic analysis. Results: Findings from our readiness assessment revealed gaps in both current policy and practice needing to be addressed, particularly with regards to governance and leadership, health service organisation and health workforce. DV received less political recognition, being perceived as a lower priority compared to other health issues. Lack of clear guidance from the central and municipal levels emerged as a crucial factor that weakened DV policy implementation both by providers and managers. Furthermore, responses to DV lost visibility, as they were diluted within generic violence responses. The organizational structure of the PHC system in São Paulo, which prioritised the number of consultations and household visits as the main performance indicators, was an additional difficulty in legitimising healthcare providers’ time to address DV. Individual-level challenges reported by providers included lack of time and knowledge of how to respond, as well as fears of dealing with DV. Conclusion: Assessing readiness is critical because it helps to evaluate what services and infrastructure are already in place, also identifying obstacles that may hinder adaptation and integration of an intervention to strengthen the response to DV before implementation.

Mapping the health systems response to violence against women: key learnings from five LMIC settings (2015–2020)

“…In Bangladesh [ 33 ], Nepal [ 29 ], Rwanda [ 37 ] and Sri Lanka [ 32 ], OSCs are located within hospitals. While Brazil does not have OSCs, hospitals around the country provide response to sexual violence including medical services and psychosocial counseling [ 38 , 46 ]. While Rwanda and Sri Lanka’s OSCs were set up by the health system, the OSCs in Bangladesh and Nepal are set up as large multi-sectoral programmes with delineated health sector roles and responsibilities [ 26 , 29 , 33 , 37 ].…”

“…The Ministry of Health and Family Welfare is responsible for ensuring health service provision for VAW response services across hospitals and OSCs [ 33 ] Bangladesh has OSC Cells at 47 out of 62 district hospitals and in 20 of the largest sub-district health complexes which provide information on services available for VAW including health care, police assistance, legal advice, psychosocial counseling, rehabilitation activities, and reintegration programmes [ 33 ] Brazil Universal and free public health care is provided to all Brazilians as a constitutional right within the Unified Health System [ 49 ] Hospitals around the country provide response to sexual violence including medical services and psychosocial counseling [ 46 ]. In Brazil, a violence prevention nucleus is responsible for multi-sectoral coordination, training, and surveillance of domestic violence cases at primary health clinics [ 38 ] Since 2017, seven women’s houses have been established across regions of Brazil. There are no centers at local levels [ 38 ].…”

“…In Brazil, a violence prevention nucleus is responsible for multi-sectoral coordination, training, and surveillance of domestic violence cases at primary health clinics [ 38 ] Since 2017, seven women’s houses have been established across regions of Brazil. There are no centers at local levels [ 38 ]. Approximately 60 hospitals around the country with programs respond to sexual violence [ 46 ] Nepal Health care services in Nepal are provided by both public and private sectors.…”

“…In Brazil, protocols include a team approach implemented to responding to VAW, in which all medical cadres are deemed responsible for clinical response, identification, treatment, and referral [ 23 ]. A violence prevention nucleus consisting of a social worker, psychologist, and nursing technician is responsible for multi-sectoral coordination, training, and surveillance of domestic violence cases at primary health clinics [ 38 ]. In Nepal and Sri Lanka, responsibilities of health care providers include identification, confidentiality, and obtaining informed consent, providing first aid and LIVES, 1 history taking, medical management, medico legal services, referral, and follow up [ 31 , 32 ].…”

“…A 2020 review of one-stop centers (OSCs) found that staff engaged in victim-blaming in most settings [ 18 ]. Though Brazil criminalizes domestic violence, many health providers are “still reluctant to engage with the issue [ 23 ].” Even staff within violence prevention nucleus felt unprepared to respond to VAW and were uncertain about their roles and referral pathways for survivors [ 38 ]. Data from health providers in Rwanda showed acceptance and normalization of VAW [ 40 ].…”