Skip to main content
  • Research article
  • Open access
  • Published:

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



There is an increasing focus on readiness of health systems to respond to survivors of violence against women (VAW), a global human rights violation damaging women’s health. Health system readiness focuses on how prepared healthcare systems and institutions, including providers and potential users, are to adopt changes brought about by the integration of VAW care into services. In VAW research, such assessment is often limited to individual provider readiness or facility-level factors that need to be strengthened, with less attention to health system dimensions. The paper presents a framework for health system readiness assessment to improve quality of care for intimate partner violence (IPV), which was tested in Brazil and Palestinian territories (oPT).


Data synthesis of primary data from 43 qualitative interviews with healthcare providers and health managers in Brazil and oPT to explore readiness in health systems.


The application of the framework showed that it had significant added value in capturing system capabilities - beyond the availability of material and technical capacity - to encompass stakeholder values, confidence, motivation and connection with clients and communities. Our analysis highlighted two missing elements within the initial framework: client and community engagement and gender equality issues. Subsequently, the framework was finalised and organised around three levels of analysis: macro, meso and micro. The micro level highlighted the need to also consider how the system can sustainably involve and interact with clients (women) and communities to ensure and promote readiness for integrating (and participating in) change. Addressing cultural and gender norms around IPV and enhancing support and commitment from health managers was also shown to be necessary for a health system environment that enables the integration of IPV care.


The proposed framework helps identify a) system capabilities and pre-conditions for system readiness; b) system changes required for delivering quality care for IPV; and c) connections between and across system levels and capabilities.

Peer Review reports


Violence against women (VAW) is a global human rights violation affecting at least 1 in 3 women globally [1], with adverse health, social, and economic consequences [2]. International organisations have called upon countries to develop health system responses to prevent and respond to such violence [3]. This call became even more urgent during the COVID-19 pandemic that saw a rise in reports of VAW [4,5,6].

Intimate partner violence (IPV) - one of the most prevalent forms of VAW - refers to behaviour by a current or past intimate partner that causes physical, sexual or psychological harm [7]. It is associated with interacting individual, interpersonal, community and structural and social/cultural factors, and underpinned by gender inequality. To overcome some of its adverse health effects, survivors tend to use health services at an increased rate [8, 9] than non-abused women. Furthermore, despite studies suggesting that health services are the first entry points for disclosure of such violence [7], the health systems response to IPV has lagged behind [9]. It follows that the interventions designed to respond to women who are affected by such violence are also complex and require change at multiple levels [9]. This includes the adoption of systemic approaches to integration and implementation of services which enable exploration of the many factors affecting effective service delivery [8, 10]. The integration of an IPV response within healthcare requires establishing procedures and building specific skills (such as empathic listening, validation and assisting with referrals to other services) that may require more time than is allocated per patient [11]. It also requires a change in the institutional medical culture (from ‘treat’ to ‘care and support’) [10] and in the structural factors (from normalisation to unacceptance) [12]. Furthermore, when new programmes to improve response to VAW are implemented, it is important to first assess the readiness of the receiving health system [10, 13]. However, limited information on the impact of integration and the necessary pre-conditions for achieving it continue to hamper successful integration of IPV into existing services and programmes [9, 14]. The integration of IPV care should be supported by a thorough assessment of the readiness of health systems. This should provide insight into which key services, procedures and resources (including trained/skilled providers) should be in place for a health care facility to offer care to survivors of violence [7, 15].

Conceptualising health system readiness for integrating services and interventions

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.

Conceptual framework

Extending previous work based on the WHO building blocks [15, 17, 28], we developed a conceptual framework focusing on core system readiness capabilities (processes and conditions enabling health systems to be ready to adopt and implement a new intervention). The development of the initial framework occurred in two phases. First, a rapid review of studies on health system barriers and enablers to integrating IPV care [10, 11, 14, 29, 30] and on readiness and health systems strengthening [10, 16, 19, 28, 30,31,32,33,34] was undertaken by MC (and SM) to identify capabilities for the framework. Following the review, the framework’s key dimensions relating to health systems readiness and assessment were identified and described. The initial framework – as represented in Fig. 1 below - consisted of seven key health systems dimensions: six based on mainstream health system frameworks (governance and leadership; resources and infrastructure; information and documentation; service delivery; health workforce and coordination) [15, 35] and one cross-cutting dimension of values [36]. It focused on both macro (national and subnational levels) and meso/facility-level factors and their interconnections to assess the material capacity of the designated health facilities and understand operational readiness at organisational/facility levels.

Fig. 1
figure 1

Initial conceptual framework for assessing health systems readiness to integrate IPV response. Legend: IPV = intimate partner violence; MOH = Ministry of Health; VAW = violence against women

The framework was organised around two levels of analysis: macro (structural) and meso (organisational - functioning of the organisation - and service delivery and health workforce) levels. The framework identified overarching elements of core system readiness capabilities (processes and conditions enabling health systems to be ready to adopt and implement a new intervention) for each of these two levels. The macro level of the framework focuses on structural capabilities, such as a clear policy framework and governance structure (i.e., accountability mechanisms), which affect how integrated care for IPV can be delivered. A key question at this level is whether laws and policies are available to support and guide an IPV health system response. The existence of strong governance (e.g. IPV law) is critical, but not always a guarantee for legitimizing (and financing) interventions and the work of motivated providers [37, 38]. For a health system to be ready to integrate IPV services, evidence shows that supportive leadership, including political will from high-level policy-makers and health managers, and tangible support, including financing for training staff, information systems, and service infrastructure, are critical elements that also influence other capabilities [14].

Coordination at national and subnational levels within health and across sectors (either through inter-agency committees or multi-sectoral teams) was also found to be essential because IPV response requires ongoing support from a range of sectors and organisations and an increased understanding and trust between organisations about their respective roles [39,40,41].

The meso level of the framework considers organisational, service delivery and provider-level capabilities which encompass organisational culture, structures, resources, but also processes and continuous interactions across structures and levels that are necessary for integration of IPV services and that lead to change. The key questions here are whether the organisation and the health services are sufficiently functional to deliver IPV care, and if health providers are prepared to respond to IPV cases. Having sufficient technical elements (often affected by macro-level capabilities), including resources - human, financial and material – clear protocols, a private space, adequate supplies, training and mentoring/support systems, and referral networks is necessary to enable IPV care [15]. For instance, it is known that linkages between referral structures (within health and across sectors) facilitate a comprehensive response to IPV [42, 43]. However, other issues are essential in shaping individual provider readiness, and particularly the agency and motivation of health providers. Although training of all staff is an enabling factor for implementing IPV care [14], it is not sufficient without staff motivation and self-efficacy [9]. Addressing staff values and attitudes around IPV and harnessing support and commitment from health managers are also necessary to ensure a conducive and enabling environment [14, 20, 38, 42], especially when paired with supportive interdisciplinary teams [10, 37].


During the second phase of the development, the initial draft framework was reviewed and discussed by researchers of the Healthcare Responding to Violence and Abuse (HERA) study – a mixed-method intervention study that aimed to strengthen the primary care response to IPV in Brazil and Palestine (including all co-authors and 1 advisor [SM]) [44]. This was to determine if the framework was practical and understandable, and to discuss whether it was necessary to remove or add any element considered redundant or missing. The initial framework’s capabilities guided the development of related data collection tools (including topic guides for qualitative interviews and checklist for facility observations) for exploring health system readiness – one of the HERA study aims - in the formative phase of the study.

During this phase of the framework development, primary data collected from Brazil and Palestine between June and December 2017 (as part of the HERA study) were analysed using the framework’s dimensions to explore its appropriateness for capturing readiness capabilities. Multiple qualitative data sources (explained in Table 1 – also for each Phase of the framework development) included 43 qualitative interviews with key health stakeholders (Brazil = 16 providers and 4 managers; oPT = 10 providers, 2 managers and 11 key informants) and 4 facility observations (2 per country). The methodology and the country specific data analysis is reported elsewhere [13, 45]. Data analysis of the formative data was synthesized and revealed some gaps in the appropriateness of the framework to identify readiness capabilities. Subsequently, there followed a third phase in which the framework was adapted and refined to include issues that were missing.

Table 1 Description of multiple data sources and contribution to readiness analysis

This paper presents the results of this refinement process, drawing on examples from the primary data to illustrate and explain the framework dimensions, its application and its refinements.


Appropriateness of the framework

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].

Table 2 Summary of key findings of health systems readiness assessment in Brazil and Palestine

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.

Further refinements and finalisation of the readiness framework after analysis of Brazil and oPT data

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).

Fig. 2
figure 2

Final conceptual framework for assessing health systems readiness to integrate IPV response

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.

Application of the framework

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].

Table 3 Country adaptations of the HERA intervention according to key readiness gaps

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].


The proposed framework identifies: a) what system capabilities and pre-conditions are needed for a health system to be ready to provide IPV care; b) what system changes are required to deliver quality care for survivors of IPV; and c) what connections exist between and across systems’ levels and capabilities and where positive interactions and bottlenecks may be. In particular, the application of our framework to our primary data enabled us to detect anticipated preparedness gaps within different health system dimensions and allowed a nuanced analysis of the interactions between them.

The innovation of this framework lies in its systemic approach to readiness - by merging and adapting constructs from scholarship on organisational [22, 51], service [15, 52], and provider [19, 53, 54] readiness for change. Our framework recognises the centrality of human and institutional relationships, ideas and interests, values and norms, affinities and power dynamics. These are as important as the more tangible resources commonly measured such as organisational policy, legal and material resources and structures such as infrastructure, supplies, management information systems, and financing [55].

While measuring indicators that are rapidly observed by patients seeking care – e.g. staff attitudes and waiting times – can be helpful, it is important to study how upstream factors, such as supportive management practices (e.g. prioritising discussion of IPV in regular meetings, monitoring implementation of IPV services and offering feedback to providers; allowing providers to attend IPV training) matter, for example by influencing health providers’ morale and confidence, and by creating a positive implementation climate. The latter is about the providers’ collective perception that the intervention is supported, expected and rewarded in the organisation There is increasing recognition in the health systems literature that health professionals do not act in isolation and that governance, effective and supportive management and structural factors also determine the performance of health systems and their providers [56, 57]. How health providers engage with and are supported by the health system matters because it shapes the quality of care they are able to provide, as well as how they engage with the communities they serve to promote health. Leadership of, and engagement with, senior managers in the health system is an evident organizational facilitator for integrating IPV services, especially horizontal leadership that encourages health workers [28, 37]. Despite that, evidence on the role of management practices in influencing the quality of care – especially at district or facility levels – is limited in LMICs and is mostly documented in fields other than VAW [50, 58,59,60]. Furthermore, health managers also operate within the system’s constraints (e.g. reduced resources, high workload, centralised decision-making, low motivation to implement IPV care; institutional norms) and within institutionally sanctioned rules that govern behaviour and structure relationships that may affect sustainability of integrated IPV care [61]. Future research should include a better understanding of managerial systems’ constraints and what leadership qualities management cadres should have and how these can be nurtured and sustained.

Our analysis of the primary data in both countries highlighted a missing level within the initial framework: the micro level, which includes elements such as women’s readiness (to engage with what it is offering as a response to IPV) and community support. A novelty of the conceptual framework is the capabilities related to the women and community engagement and the need to also consider how the system can sustainably involve and interact with clients (women) and communities to ensure and promote readiness for integrating change. Without this, other health system capabilities are weakened (as we saw for instance in our findings in relation to low women’s referral uptake [44]). The inclusion of this dimension was not sufficiently addressed in the initial WHO building blocks model [62] though subsequently mentioned in the WHO VAW management response [15]. The testing of the initial framework in Brazil and Palestine highlighted that community trust and engagement, while decisive to reducing stigma and enabling women’s access to IPV care, was limited. Key to acceptability (and therefore uptake) of VAW services is communities’ and clients’ awareness of and trust in the new services and in the providers who offer them [13, 27]. A recent review on women’s expectations after IPV disclosure also reiterated the importance emotional connection with providers and maintaining women’s autonomy in the response approach [63]. The experience of the COVID-19 pandemic has also revealed just how valuable community engagement is to build trust in health systems in all settings to ensure support, compliance to social measures and vaccine uptake. Innovative bottom-up opportunities have emerged reinstating the roles of families, communities and of NGOs in supporting the overall health of populations during COVID-19 [64, 65].

Besides clinical effectiveness, perceptions of the quality of care by clients and communities are likely to be the key drivers of utilization [58]. Patients’ trust in services has also been shown to be an important element of perceived quality [45] and responsiveness [65]. The incorporation of women’s and communities’ perspectives is crucial for identifying the needs and preferences of survivors [15], but also social and gender norms that may affect demand and uptake of VAW services. In particular, traditional views on restrictive gender roles and IPV, and stigma towards IPV are renowned barriers to help-seeking for abused women [66, 67], and have to be addressed when providing IPV care. Meso-level capabilities that address stigma and gender inequality (e.g. training opportunities addressing gender norms; skills to be able to support women through an autonomous process of change and decision-making, and staff’s ability to respect confidentiality) can positively affect client and community trust. More participatory and ethnographic research is warranted on how community engagement is related to successful implementation of IPV interventions, particularly to understand ‘trust’ and barriers to access and help-seeking behaviours and how to strengthen the linkages between community and health-based services.

Additionally, it is known that restrictive gender norms and gender inequalities are replicated and reinforced in health systems (across all levels) contributing to gender inequalities in health [68, 69]. Based on the growing recognition that gender equality/inequality is a key social stratifier in health systems [70, 71], the final framework included consideration of gender equality and also articulated its intersection with other social identities (e.g. class, age, race etc) that further contribute to inequalities in health and health care [72, 73]. Our findings pointed also to the power imbalances within the hierarchy of the health systems and how this could also impact on IPV response, especially in relation to assistant nurses and community health workers, who are often female and less influential. The inclusion of a gender and intersectional lens was a second new addition to the initially conceptualised framework, which cut across all levels. The work on VAW is pivotal for giving prominence to gender inequalities in the health system and adopting a gender lens to the analysis and ensure women’s participation in leadership, as suggested elsewhere [74, 75].

Another central feature of our framework is the importance of linkages and interactions between capabilities at each system level, which also became evident when testing the framework in Brazil and Palestine [13, 45]. The interconnection across system levels and capabilities is necessary to ensure that the focus remains systemic and recognizes the complex feedback loops between and among all the levels and factors. Rather than fall back to one level (e.g., only provider, or clinical), all readiness factors need to be assessed, and the reciprocal interactions made visible across system levels. Even when frontline providers have substantial discretion in their interpretation of regulations and freedom to adapt treatment protocols, their actions may still largely depend on upstream factors related to institutional capacity, legal sanctions and institutional norms [58]. For example, the limited guidance on IPV and the hierarchical referral system in place in Palestine limited the role and the authority of the GBV Focal Points within the Ministry of Health [13].

With a readiness lens, it is possible to design more tailored interventions that consider facilitators and barriers at different levels of the health system, and that recognise the critical importance of working closely with managers and stakeholders. In addition, our conceptual framework for the readiness assessment has proven useful in highlighting significant systemic issues for developing health system interventions and their evaluation [44].

Limitations of the framework

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.


In this paper, we present a new conceptual framework for analysing and understanding health system’s readiness for integrating IPV response into healthcare services that has been tested in two sites. A new contribution of our framework is that it captures system capabilities beyond the availability of material resources and technical capacity of providers to encompass, for instance, stakeholders’ values, confidence and motivation and their connection with clients and communities. This can inform a better understanding of how health systems can reach communities and people who need to access health services. Future research should also determine the ways in which community or organizational preparations are related to implementation success.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.



Gender-based violence


Health care providers


Healthcare Responding to Violence and Abuse


Intimate partner violence


Low- and middle-income countries


Ministry of Health


Non-governmental organisations


Violence Prevention Nucleus


Occupied Palestinian territories


Primary health care


Theory of Change


Violence against women


World Health Organization


  1. World Health Organisation. Violence against women prevalence estimates, 2018: global, regional and national prevalence estimates for intimate partner violence against women and global and regional prevalence estimates for non-partner sexual violence against women. Geneva: World Health Organization; 2021.

    Google Scholar 

  2. World Health Organization. London School of Hygiene and Tropical Medicine, South African Medical Research Council. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: WHO; 2013.

    Google Scholar 

  3. World Health Assembly. Global plan of action to strengthen the role of the health system within a national multisectoral response to address interpersonal violence, in particular against women and girls and against children. 69th world health assembly. Geneva: WHO; 2016.

    Google Scholar 

  4. Fraser E. "Impact of COVID-19 pandemic on violence against women and girls". UK Department for International Development. 2020.

  5. Roesch E, Amin A, Gupta J, García-Moreno C. Violence against women during covid-19 pandemic restrictions. BMJ. 2020;369:m1712.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Viero A, Barbara G, Montisci M, Kustermann K, Cattaneo C. Violence against women in the Covid-19 pandemic: a review of the literature and a call for shared strategies to tackle health and social emergencies. Forensic Sci Int. 2021;319:110650.

    Article  CAS  PubMed  Google Scholar 

  7. World Health Organization. Responding to intimate partner violence and sexual violence against women. WHO clinical and policy guidelines. Geneva: World Health Organization; 2013.

    Google Scholar 

  8. Bonomi A, Anderson M, Rivara F, Thompson R. Health care utilization and costs associated with physical and nonphysical-only intimate partner violence. Health Service Res. 2009;44:1052–67.

    Article  Google Scholar 

  9. García-Moreno C, Hegarty K, Lucas d'Oliveira AF, Koziol-MacLain J, Colombini M, Feder G. The health-systems response to violence against women. Lancet. 2015;385:1567–79.

    Article  PubMed  Google Scholar 

  10. Hegarty K, McKibbin G, Hameed M, Koziol-McLain J, Feder G, Tarzia L, et al. Health practitioners' readiness to address domestic violence and abuse: a qualitative meta-synthesis. PLoS One. 2020;15(6):e0234067 PubMed PMID: 32544160. Pubmed Central PMCID: PMC7297351. Epub 2020/06/17. eng.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Goicolea I, Vives-Cases C, San Sebastian M, Marchal B, Kegels G, Hurtig AK. How do primary health care teams learn to integrate intimate partner violence (IPV) management? A realist evaluation protocol. Implement Sci. 2013;8:36 PubMed PMID: 23522404. Pubmed Central PMCID: Pmc3617002. Epub 2013/03/26. eng.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Hudspeth N, Cameron J, Baloch S, Tarzia L, Hegarty K. Health practitioners’ perceptions of structural barriers to the identification of intimate partner abuse: a qualitative meta-synthesis. BMC Health Serv Res. 2022;22(1):96.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Colombini M, Alkaiyat A, Shaheen A, Garcia Moreno C, Feder G, Bacchus L. Exploring health system readiness for adopting interventions to address intimate partner violence: a case study from the occupied Palestinian territory. Health Policy Plan. 2019;35(3):245–56.

    Article  PubMed Central  Google Scholar 

  14. Colombini M, Dockerty C, Mayhew SH. Barriers and facilitators to integrating health service responses to intimate partner violence in low- and middle-income countries: a comparative health systems and service analysis. Stud Fam Plan. 2017;48(2):179–200.

    Article  Google Scholar 

  15. World Health Organisation. Strenghtening health systems to respond to women subjected to intimate partner violence or sexual violence. Geneva: A manual for health managers; 2017.

    Google Scholar 

  16. Leung TP-Y, Bryant C, Phillips L, Hegarty K. GPs' perceived readiness to identify and respond to intimate partner abuse: development and preliminary validation of a multidimensional scale. Aust N Z J Public Health. 2017;41(5):512–7.

    Article  PubMed  Google Scholar 

  17. Dennis ML, Owolabi OO, Cresswell JA, Chelwa N, Colombini M, Vwalika B, et al. A new approach to assess the capability of health facilities to provide clinical care for sexual violence against women: a pilot study. 2019.

    Book  Google Scholar 

  18. Weiner B. A theory of organizational readiness for change. Implement Sci. 2009;4(1):67. PubMed PMID.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Leung T, Phillips L, Bryant C, Hegarty K. How family doctors perceived their ‘readiness’ and ‘preparedness’ to identify and respond to intimate partner abuse: a qualitative study. Fam Pract. 2018;35(4):517–23.

    Article  Google Scholar 

  20. Gadappa S, Prabhu P, Deshpande S, Gaikwad N, Arora S, Rege S, et al. Innovations in implementing a health systems response to violence against women in 3 tertiary hospitals of Maharashtra India: improving provider capacity and facility readiness. Implement Res Pract. 2022;3:26334895211067988.

    Google Scholar 

  21. Dutton MA, James L, Langhorne A, Kelley M. Coordinated public health initiatives to address violence against women and adolescents. J Womens Health. 2015;24(1):80–5 PubMed PMID: PMC4302966.

    Article  Google Scholar 

  22. Weiner BJ, Amick H, Lee SY. Conceptualization and measurement of organizational readiness for change: a review of the literature in health services research and other fields. Med Care Res Rev. 2008;65(4):379–436 PubMed PMID: 18511812. Epub 2008/05/31. eng.

    Article  PubMed  Google Scholar 

  23. Kelly P, Hegarty J, Barry J, Dyer KR, Horgan A. A systematic review of the relationship between staff perceptions of organizational readiness to change and the process of innovation adoption in substance misuse treatment programs. J Subst Abus Treat. 2017;80:6–25.

    Article  Google Scholar 

  24. World Health Organization. WHO global strategy on people-centred and integrated health services. Geneva: WHO; 2015. p. 48.

    Google Scholar 

  25. Dada S, Tunçalp Ö, Portela A, Barreix M, Gilmore B. Community mobilization to strengthen support for appropriate and timely use of antenatal and postnatal care: a review of reviews. J Glob Health. 2021;11:04076 PubMed PMID: 35003714. eng.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Mathpati MM, Payyappallimana U, Shankar D, Porter JD. 'Population self-reliance in health' and COVID-19: The need for a 4th tier in the health system. J Ayurveda Integr Med. 2022;13(1):100354 PubMed PMID: 32982108. Pubmed Central PMCID: PMC7505632. Epub 2020/09/29. eng.

    Article  CAS  PubMed  Google Scholar 

  27. Topp SM, Abimbola S, Joshi R, Negin J. How to assess and prepare health systems in low- and middle-income countries for integration of services-a systematic review. Health Policy Plan. 2018;33(2):298–312 PubMed PMID: 29272396. Pubmed Central PMCID: PMC5886169. Epub 2017/12/23. eng.

    Article  PubMed  Google Scholar 

  28. Williams I. Organizational readiness for innovation in health care: some lessons from the recent literature. Health Serv Manag Res. 2011;24(4):213–8 PubMed PMID: 22040949. Epub 2011/11/02. eng.

    Article  Google Scholar 

  29. Meyer SR, Rege S, Avalaskar P, Deosthali P, García-Moreno C, Amin A. Strengthening health systems response to violence against women: protocol to test approaches to train health workers in India. Pilot and feasibility. Studies. 2020;6(1):63.

    Google Scholar 

  30. Mikton C, Mehra R, Butchart A, Addiss D, Almuneef M, Cardia N, et al. A multidimensional model for child maltreatment prevention readiness in low- and middle-income countries. J Commun Psychol. 2011;39(7):826–43.

    Article  Google Scholar 

  31. Cluss PA, Chang JC, Hawker L, Scholle SH, Dado D, Buranosky R, et al. The process of change for victims of intimate partner violence: support for a psychosocial readiness model. Womens Health Issues. 2006;16(5):262–74 PubMed PMID: 17055379. Epub 2006/10/24. eng.

    Article  PubMed  Google Scholar 

  32. Murillo P, Sebastian MS, Vives-Cases C, Goicolea I. Factors associated with primary care professionals' readiness to respond to intimate partner violence in Spain. Gaceta Sanitaria SESPAS. 2018;32(5):433–8 PubMed PMID: 28545740. Epub 2017/05/27. Factores asociados a la respuesta a la violencia del companero intimo en atencion primaria de salud en Espana. spa.

    Article  Google Scholar 

  33. Meyer SR, Rege S, Avalaskar P, Deosthali P, García-Moreno C, Amin A. Strengthening health systems response to violence against women: protocol to test approaches to train health workers in India. Pilot Feasibility Stud. 2020;6:63 PubMed PMID: 32426157. Pubmed Central PMCID: PMC7212611. Epub 2020/05/20. eng.

    Article  PubMed  PubMed Central  Google Scholar 

  34. World Health Organisation. Handbook for the readiness assessment for the prevention of child maltreatment. Geneva: WHO; 2013.

  35. World Health Organization. Everybody business : strengthening health systems to improve health outcomes : WHO’s framework for action. Geneva: World Health Organisation; 2007.

    Google Scholar 

  36. de Savigny D, Adam T. Systems thinking for health systems strengthening. Geneva: Alliance for Health Systems and Policy, World Health Organisation; 2009.

    Google Scholar 

  37. Goicolea I, Marchal B, Hurtig AK, Vives-Cases C, Briones-Vozmediano E, San Sebastian M. Why do certain primary health care teams respond better to intimate partner violence than others? A multiple case study. Gaceta Sanitaria SESPAS. 2019;33(2):169–76 PubMed PMID: 29233579. Epub 2017/12/14. eng.

    Article  Google Scholar 

  38. Joyner K, Mash B. A comprehensive model for intimate partner violence in south African primary care: action research. BMC Health Serv Res. 2012;12(1):399. PubMed PMID.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Colombini M, Mayhew SH, Ali SH, Watts C. One Stop Crisis Centres: A Policy Analysis of the Malaysian Response to intimate partner violence. Health Res Policy Syst. 2011;9:25.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Rees K, Zweigenthal V, Joyner K. Implementing intimate partner violence care in a rural sub-district of South Africa: a qualitative evaluation. Glob Health Action. 2014;7:24588. PubMed PMID: 25226415. Pubmed Central PMCID: Pmc4165045. Epub 2014/09/17. eng.

    Article  PubMed  Google Scholar 

  41. Tesser CD. Medicalização social (II): limites biomédicos e propostas para a clínica na atenção básica. Interface Comunicação Saúde Educação [online]. 2006;10(20):347–62.

    Article  Google Scholar 

  42. Colombini M, Mayhew S, Ali S, Shuib R, Watts C. An integrated health sector response to violence against women in Malaysia: lessons for supporting scale up. BMC Public Health. 2012;12(1):548. PubMed PMID.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Turan JM, Hatcher AM, Odero M, Onono M, Kodero J, Romito P, et al. A community-supported clinic-based program for prevention of violence against pregnant women in rural Kenya. AIDS Res Treat. 2013;2013:10.

    Google Scholar 

  44. Bacchus LJ, Alkaiyat A, Shaheen A, Alkhayyat AS, Owda H, Halaseh R, et al. Adaptive work in the primary health care response to domestic violence in occupied Palestinian territory: a qualitative evaluation using extended normalisation process theory. BMC Fam Pract. 2021;22(1):3 PubMed PMID: 33388033. eng.

    Article  PubMed  PubMed Central  Google Scholar 

  45. d’Oliveira AF, Pereira S, Schraiber L, Aguiar J, Granusso R, Guida C, et al. Are we asking too much of the health sector?’ Exploring the readiness of Brazilian primary health care to respond to domestic violence against women. Int J Health Policy Manag. 2020;X(X):1–12.

    Google Scholar 

  46. Guedes AC, Stevens L, Helzner JF, Medina S. Addressing gender violence in a reproductive and sexual health program in Venezuela. In: Haberland N, Measham D, editors. Responding to Cairo case studies of changing practice in reproductive health and family planning, vol. 2002. New York: New York Population Council; 2002. p. 257–73.

    Google Scholar 

  47. Shaheen A, Ashkar S, Alkaiyat A, Bacchus L, Colombini M, Feder G, et al. Barriers to women’s disclosure of domestic violence in health services in Palestine: qualitative interview-based study. BMC Public Health. 2020;20(1):1795.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Signorelli MC, Taft A, Pereira PPG. Domestic violence against women, public policies and community health workers in Brazilian primary health care. Cien Saude Colet. 2018;23(1):93–102 PubMed PMID: 29267815. Epub 2017/12/22. eng.

    Article  PubMed  Google Scholar 

  49. Hay K, McDougal L, Percival V, Henry S, Klugman J, Wurie H, et al. Disrupting gender norms in health systems: making the case for change. Lancet. 2019;393(10190):2535–49.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Keynejad R, Semrau M, Toynbee M, Evans-Lacko S, Lund C, Gureje O, et al. Building the capacity of policy-makers and planners to strengthen mental health systems in low- and middle-income countries: a systematic review. BMC Health Serv Res. 2016;16(1):601 PubMed PMID: 27769270. eng.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Sharma SV, Upadhyaya M, Schober DJ, Byrd-Williams C. A conceptual framework for organizational readiness to implement nutrition and physical activity programs in early childhood education settings. Prev Chronic Dis. 2014;11:E190-E PubMed PMID: 25357258. eng.

    Article  Google Scholar 

  52. Jhpiego US. Centers for Disease Control and Prevention (CDC). Gender-based violence quality assurance tool: standards for the provision of high quality post-violence Care in Health Facilities. Baltimore: JPHIEGO; 2018.

    Google Scholar 

  53. Hegarty K, McKibbin G, Hameed M, Koziol-McLain J, Feder G, Tarzia L, et al. Health practitioners’ readiness to address domestic violence and abuse: a qualitative meta-synthesis. PLOS.One. 2020;16(6):e0234067.

    Article  Google Scholar 

  54. Short LM, Alpert E, Harris JM Jr, Surprenant ZJ. A tool for measuring physician readiness to manage intimate partner violence. Am J Prev Med. 2006;30(2):173–80 PubMed PMID: 16459217. Pubmed Central PMCID: PMC1451776. Epub 2006/02/07. eng.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Sheikh K, Gilson L, Agyepong IA, Hanson K, Ssengooba F, Bennett S. Building the field of health policy and systems research: framing the questions. PLoS Med. 2011;8(8):e1001073.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Topp S, Chipukuma J, Hanefeld J. Understanding the dynamic interactions driving Zambian health Centre performance: a case-based health systems analysis. Health Policy Plan. 2015;30(4):485–99.

    Article  PubMed  Google Scholar 

  57. Balabanova D, Mills A, Conteh L, Akkazieva B, Banteyerga H, Dash U, et al. Good health at low cost 25 years on: lessons for the future of health systems strengthening. Lancet. 2013;381(9883):2118–33.

    Article  PubMed  Google Scholar 

  58. Hanefeld J, Powell-Jackson T, Balabanova D. Understanding and measuring quality of care: dealing with complexity. Bull World Health Organ. 2017;95(5):368–74 PubMed PMID: 28479638. Epub 2017/03/20. eng.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Joyner K, Mash R. Recognizing Intimate Partner Violence in Primary Care: Western Cape, South Africa. PLoS One. 2012;7(1):e29540.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  60. Kwamie A, Hv D, Agyepong IA. Advancing the application of systems thinking in health: realist evaluation of the leadership development Programme for district manager decision-making in Ghana. Health Res Policy Syst. 2014;12(1):29.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Goicolea I, Mosquera P, Briones-Vozmediano E, Otero-García L, García-Quinto M, Vives-Cases C. Primary health care attributes and responses to intimate partner violence in Spain. Gac Sanit. 2017;31(3):187–93.

    Article  PubMed  Google Scholar 

  62. Sacks E, Morrow M, Story WT, Shelley KD, Shanklin D, Rahimtoola M, et al. Beyond the building blocks: integrating community roles into health systems frameworks to achieve health for all. BMJ Glob Health. 2019;3(Suppl 3):e001384.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Tarzia L, Bohren MA, Cameron J, Garcia-Moreno C, Doherty L, Fiolet R, et al. Women’s experiences and expectations after disclosure of intimate partner abuse to a healthcare provider: a qualitative meta-synthesis. BMJ Open. 2020;10(11):e041339.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Kenny S. Covid-19 and community development. Community Dev J. 2020:bsaa020.

  65. Cluver L, Lachman JM, Sherr L, Wessels I, Krug E, Rakotomalala S, et al. Parenting in a time of COVID-19. Lancet. 2020;395(10231):e64.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  66. Leonardsson M, San SM. Prevalence and predictors of help-seeking for women exposed to spousal violence in India – a cross-sectional study. BMC Womens Health. 2017;17(1):99.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Overstreet NM, Quinn DM. The intimate partner violence stigmatization model and barriers to help-seeking. Basic Appl Soc Psych. 2013;35(1):109–22 PubMed PMID: 23524454. Epub 2013/02/04. eng.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Hawkes S, Allotey P, Elhadj AS, Clark J, Horton R. The lancet commission on gender and Global Health. Lancet. 2020;396(10250):521–2 PubMed PMID: 32763153. Epub 2020/08/04. eng.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  69. Hay K, McDougal L, Percival V, Henry S, Klugman J, Wurie H, et al. Disrupting gender norms in health systems: making the case for change. Lancet. 2019;393(10190):2535–49 PubMed PMID: 31155270. Pubmed Central PMCID: PMC7233290. Epub 2019/06/04. eng.

    Article  PubMed  PubMed Central  Google Scholar 

  70. Morgan R, George A, Ssali S, Hawkins K, Molyneux S, Theobald S. How to do (or not to do) … gender analysis in health systems research. Health Policy Plan. 2016;31(8):1069–78.

    Article  PubMed  Google Scholar 

  71. Theobald S, Morgan R, Hawkins K, Ssali S, George A, Molyneux S. The importance of gender analysis in research for health systems strengthening. Health Policy Plan. 2017;32:v1–3.

  72. Crenshaw K. Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Rev. 1991;43(6):1241–99.

    Article  Google Scholar 

  73. Crenshaw K. Demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doctrine, feminist theory, and antiracist politics Routledge; 1989.

    Google Scholar 

  74. Theobald S, RinGs and ReBUILD. 2016. [cited 2022]. Available from:

  75. Vong S, Ros B, Morgan R, Theobald S. Why are fewer women rising to the top? A life history gender analysis of Cambodia’s health workforce. BMC Health Serv Res. 2019;19(1):595.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


The views expressed in this publication are those of the authors(s) and not necessarily those of the NIHR or the UK Department of Health and Social Care or of the authors’ organizations. We thank Dr. Amira Shaheen and Dr. Abdulsalam Alkaiyat (from An-Najah National University in Nablus) for leading the HERA study in oPT and, particularly, the formative data collection. We thank Iona Craigmile for designing Fig. 2. We also thank all the respondents (women, officials and health-care providers) who participated in the study.


The HERA research in Brazil and Palestine (including analysis of primary data in this paper) was funded by the Medical Research Council Global Challenges Research Foundation Award (Grant number: MR/P02510/1). The writing up of the paper was made possible by a National Institute of Health (NIHR) (17/63/125) using UK aid from the UK Government to support global health research.

Author information

Authors and Affiliations



All authors conceived the study design. All authors (but SM) were involved in analysing primary data from the research study. MC and SM were involved in reviewing literature on violence against women. MC drafted the initial manuscript and conceptualised Fig. 2. SM and LB contributed to the conceptualisation of Fig. 2. MC, LB and AFO contributed to analysis and interpretation of the secondary data. AFO, CGM, GF and LB reviewed the draft of the manuscript and provided critical revision. All authors approved the final manuscript and the figures.

Corresponding author

Correspondence to Manuela Colombini.

Ethics declarations

Ethics approval and consent to participate

Ethical clearance for the primary data collected in Brazil was obtained from University of São Paulo (document 2.079.832), São Paulo’s Health Department (document 2.142.949). Ethical clearance for primary data collected in oPT was obtained from An’Najah Ethic Committee. Ethical clearance from collaborating UK academic institutions (London School of Hygiene & Tropical Medicine and University of Bristol) was also obtained. Written informed consent was obtained from all participants. The study was performed in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Colombini, M., Mayhew, S.H., García-Moreno, C. et al. Improving health system readiness to address violence against women and girls: a conceptual framework. BMC Health Serv Res 22, 1429 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: