Early in her career, Dr Rukhsana Bashir, a clinician in Pakistan, was used to seeing women in her clinic with symptoms of pain, headaches, insomnia and depression. She would listen and treat each symptom, but the underlying causes went unnoticed.
She did not know that some of those women were experiencing gender-based violence (GBV) – a pervasive health challenge throughout the country and world, and one she personally had experienced.
Approximately, 34% of ever married women in Pakistan have experienced spousal violence, either physical, sexual or emotional, in their lifetime, with rates increasing as high as 52% in Khyber Paktunkhwa Province.
“It never came to my mind that these women might be experiencing gender-based violence,” says Dr Bashir, who works at the Family Planning Association of Pakistan’s Family Health Hospital in the city of Lahore.
Now years later, Dr Bashir has been trained by WHO to use its clinical and policy guidelines: Responding to intimate partner violence and sexual violence against women. She further trains health workers how to provide survivor-centred care including how to ask about violence and how to provide first-line support.
Dr Bashir is one of more than 1000 doctors, nurses, hospital administrators and community health workers, including midwives who were trained between 2018-2020 as part of the roll out of the clinical and policy guideline package by Pakistan’s Ministry of National Health Services Regulation and Coordination and provincial health departments, with technical support from WHO and sister UN agencies, to strengthen the country’s health systems response to gender-based violence.
Thanks to the training she received, Dr Bashir has changed her practice. Unexplained symptoms of chronic pain or headaches, insomnia or depression, lead her to ask more questions to women about potential violence at home.
“When women come to the clinic, they don’t think that they are going to discuss the problem [of violence], but I have to ask them a few bold questions. In the beginning they are afraid and don’t want to tell me anything, but you have to identify their problems. Only then can you offer better services and treatment.”
A decade long effort to support survivors
The training Dr Bashir completed is part of a decade long effort WHO’s Pakistan office to work with the Government to strengthen the health and multisectoral response to gender-based violence. However, in order to strengthen the health sector response, the country needed manuals, job aids and trainings for health workers. In 2010 there were none.
In response, the Government developed a national protocol for medico-legal care for gender-based violence survivors in 2011. This was accompanied by ongoing policy dialogues and advocacy to strengthen health sector response to gender-based violence.
In 2017, the WHO clinical handbook: Health care for women subjected to intimate partner violence or sexual violence, was adapted and piloted in selected provinces and districts. The adaptation process, led by the Government and WHO, included multiple stakeholders, such as provincial ministries of health, UN Women, UNFPA, non-governmental organizations, medical associations and health workers.
As a result, the Pakistani clinical handbook for health workers on the management of sexual and gender-based violence, and localized job aids and materials for training providers were produced. The Government and WHO conducted 30 trainings for master trainers, health workers, and medico-legal experts in four provinces.
“Before the training, there was no awareness of this issue, no reference books,” says Dr Yahya Gulzar, WHO Pakistan, Punjab Office. “Health workers did not consider gender-based violence a health issue for them to respond to. Now, they are clear that it is their responsibility, particularly to identify cases and provide support and treatment in a holistic manner.”
More cases being reported, but challenges remain
Today, trained health workers are identifying more cases of gender-based violence.
“When I joined the gender-based violence training, I was not familiar with the topic,” says Dr Fauzia Afridi, a clinician and master trainer at the Social Security Hospital in Khyber Paktunkhwa. “It was challenging for me to learn. With training, I am now able to not just identify women presenting with medical issues, but am able to treat her using the LIVES approach (i.e. first-line support). This has been life changing in my practice as a doctor.”
While the care health workers provide has improved, much remains to be done to reduce the stigma and raise awareness about women’s rights. Many women do not disclose violence to trained health workers or ask for it not to be listed in their medical report for fear of repercussions from family members. Women are also reluctant to use psychological support services because of stigma around mental health.
Referral systems to other support services, such as shelters or counselling for survivors, are weak because many health workers lack knowledge of what is available. There are also few private spaces within health facilities for women to have confidential conversations with the provider.
While trainings of health workers are expanding, the Government, WHO and partners are working to institutionalize health worker trainings for long-term sustainability. For example, a pre-service training course is being developed with the Khyber Pakhtunkhwa Medical University in partnership with UNFPA to build the capacity of trainee doctors in the country.