In 2014, Nepal introduced a GBV Clinical Protocol to support the health sector in responding to the needs of GBV survivors. Since December 2017, the UKAid-funded Nepal Health Sector Support Programme (NHSSP) has been working with Nepal’s Ministry of Health and Population (MoHP) to develop training sites and roll out the protocol.
The GBV Clinical Protocol is a guide that educates health service providers on the nature of GBV in Nepal, and outlines the needs and delivery of health services for survivors and those at risk. It also aims to improve coordination between health and other sectors including the police, social welfare, and civil society organisations to strengthen support for survivors.
By June 2018, NHSSP had helped set up training sites at three major hospitals. 125 hospital staff had been trained on the scale of GBV in Nepal, its impact on women’s health, how to identify women at risk and offer more appropriate medical care, how to help survivors understand their rights, and understand how to connect them to other community support services.
Improving the response of health services
The training has given health staff a greater understanding of the magnitude of the problem of GBV in Nepal, patterns of violence in the surrounding community, and the impact of violence on women’s health.
Those that took part reported that they are now more committed to addressing and sensitively responding to GBV in their work. It helped them reflect on their standards of care, and ensure privacy and confidentiality for all their patients.
Participants learned that it was important to ask if a woman is experiencing violence in order to provide accurate diagnosis and offer the most appropriate care. Many conditions, such as chronic pain or reoccurring sexually-transmitted infections, can be difficult to diagnose or treat without knowing about a woman’s experience of violence. Therefore, staff who fail to consider the possibility that women are living in violent situations may not be able to provide effective or appropriate treatment and care, including counselling.
“Before, I saw problems that did not fit into what I had learned,” said one participant, a doctor from Koshi Zonal Hospital. “Now I am more efficient. I have a new approach, and I know that many pathologies for which I did not find an explanation have to do with violence. In addition to being more humane, now I see the patient as a whole.”
Taking a more holistic approach towards health care for women who have experienced violence may also help prevent further and more serious situations. Some doctors explained that before the training, they were not confident about providing medico-legal services including appropriate documentation of evidence. However, through this competency-based training, they now have the skills and knowledge to do so. “Before, I thought (that addressing GBV) was not part of my job,” expressed a medical officer based at Bharatpur Hospital. “I limited myself to medical treatment, but ignored the psychological and legal aspects and simply didn’t ask questions about them. Now, when I identify [a case of violence], I make appropriate referrals to legal or psychological services or what survivor wishes.”
As well as looking at medical care, the training also provided guidance on how to raise awareness about GBV as a public health problem through campaigns and community-based education efforts. Managers were supported to promote a work environment with zero tolerance for violence and sexual harassment.
There have been visible signs of improvements in service delivery to GBV survivors since the delivery of the training, including better coordination and referrals within and between hospital departments.
The training highlighted the need to strengthen the role of One Stop Crisis management Centres’ (OCMC) in prevention and rehabilitation services. First introduced in 2011, OCMCs coordinate a comprehensive range of services for survivors of GBV, providing not only treatment for physical and psychological ailments, but also offering legal protection, personal security, and rehabilitation services. Within a short period, the OCMCs at all three training sites reported an increased number of GBV cases being supported. Ten months following the trainings, Bharatpur Hospital saw an increase of 105% of cases treated, while Koshi Hospital and Lumbini Hospital saw an increase of 257% and 161%, respectively.
Other notable changes include providing education and livelihood support to survivors and following up with survivors to see whether they are still experiencing violence, and whether commitments of support are being implemented.
Plans for 2019
Given the success of the training, the MoHP plans to scale-up the training to other hospitals, to further build the capacity of service providers to reach and respond to survivors of GBV. In 2019, GBV training sites will be developed in three more provinces to roll-out the GBV Clinical Protocol. Refresher training in Koshi and Bharatpur hospitals is also planned to update and motivate staff, and to extend the training to new or recently-transferred staff.
NHSSP will continue to strengthen the capacity of emergency departments in each of the hospitals, given the crucial role they play in the identification, management and referral of cases, and the overall responsiveness of the hospital, in handling survivors of GBV with dignity and care.