AIDSTAR-One Public Sector Response to Gender-based Violence in Vietnam


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Gender-based violence (GBV) is widely recognized as both a cause and a consequence of HIV infection. To help program managers integrate GBV prevention and response strategies into existing HIV, family planning, and reproductive health services, AIDSTAR-One conducted three case studies in countries where GBV services were available. This case study documents Vietnam’s Improving Health Care Response to Gender-based Violence project—a public sector intervention that builds on a medical model and links survivors to ongoing counseling and support.

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AIDSTAR-One Public Sector Response to Gender-based Violence in Vietnam

  1. 1. AIDSTAR-One | CASE STUDY SERIES January 2012Public Sector Response toGender-based Violence inVietnam N guyen Thi Ahn first learned about the Women’s Counseling Center for Health three years ago. She had come to the Duc Giang General Hospital (DGGH) hospital for treatment of her arm, which she feared her husband had broken during a beating. She had suffered verbal and physical abuse from her husband and, at times, from her mother-in-law, for almost 20 years; both had threatened to throw her out of the Kai Spratt house and keep her from her children. Though she worked hardVietnam Duc Giang General to earn more money and tried to be a good wife and homemaker,Hospital her husband and mother-in-law continued to insult or beat her. She felt hopeless and depressed. She was very surprised when the nurse asked whether the injury might be due to abuse at home, but she answered shyly that yes, her husband had done it. A short time later, the nurse accompanied her to a quiet room on the third floor called the “Women’s Counseling Center for Health,” where a counselor politely asked about her arm and what was happening at home. For the first time ever, Thi talked about her problems without being blamed. The counselor said she was experiencing “gender-based violence,” which was illegal and which she did not have to tolerate. They talked about her alternatives—she felt she did not have the option of leaving her husband, and she could not bear the thought of leaving her children. Thi went home with the counselor’s phone number. A week later, she called back and made another appointment. With the counselor, she made a plan to beBy Kai Spratt and Thi Thu safe if her husband and mother-in-law abused her again. Over time,Trang she returned every few months for further counseling. The Women’s Counseling Center for Health had become her lifeline.AIDSTAR-OneJohn Snow, Inc.1616 North Ft. Myer Drive, 11th Floor This publication was produced by the AIDS Support and Technical Assistance ResourcesArlington, VA 22209 USA (AIDSTAR-One) Project, Sector 1, Task Order 1.Tel.: +1 703-528-7474 USAID Contract # GHH-I-00-07-00059-00, funded January 31, 2008.Fax: +1 703-528-7480 Disclaimer: The author’s views expressed in this publication do not necessarily reflect the views of the United Agency for International Development or the United States Government.
  2. 2. AIDSTAR-One | CASE STUDY SERIESThe women’s counseling center, which provideswomen with a safe space to discuss the violence in “When I began to work on this proj-their lives, is a central part of the Improving Health ect I thought doctors’ responsibilityCare Response to Gender-based Violence project.The project, implemented from 2002 to 2009 in two was just to cure disease, but nowHanoi hospitals by the Hanoi Department of Health I realize that as human beings weand the Population Council, is an example of a cannot refuse to help women; manypublic sector intervention that builds on a medical women are in difficult situations.model and links survivors to ongoing counselingand support. Based on findings from the pilot I definitely needed the training toproject, the Vietnamese Government has approved help increase my communicationthe scale-up of this model to primary care hospitals skills with my colleagues and I be-throughout the country. came involved in many other activ- ities…I also supported a colleagueBackground experiencing gender-based vio- lence; she left her abusive husband,Gender-based violence (GBV) is under-reportedand under-researched in Vietnam (Gardsbane et has remarried and is very happyal. 2010). Several small-scale studies revealed that now.”the prevalence of GBV in Vietnam ranges widely –Doctor, Hanoi Department offrom 16 to 37 percent for physical violence, and 19 Health Servicesto 55 percent for emotional violence, while sexualviolence and sexual harassment are rarely reported(Jonzon et al. 2007; Nguyen 2006; Vu et al. 1999). is viewed as a private family issue and is explainedA 2006 national survey with 9,300 households as resulting from poverty, alcohol or drug abuse, orreported that in the preceding 12 months, 21.2 stress among family members.percent of families had reported at least one of the Communities are not well equipped to address orthree forms of violence (physical, verbal, coerced change attitudes about GBV. When conflicts occursex); husbands were the most frequent perpetrators in families or between neighbors, they are often(Huong 2008). In everyday life, verbal abuse, brought to Reconciliation Committees,1 government-slapping, and coerced or forced sex are often not mandated bodies whose members are drawn fromconsidered violence in Vietnam (United Nations local communes,2 and mass organizations such asPopulation Fund [UNFPA] 2007). the Women’s Union, Students’ Union, and Farmers’Cultural norms (some might argue based on Union. Members are generally not trained onConfucian philosophy) position Vietnamese women general counseling skills, GBV, or legal rights andas subservient to their father, husband, or eldest laws. Women or men experiencing GBV may seekson (after the husband’s death). It is acceptable divorce under the Marriage and Family Law, butfor a man to use violence to “teach his wife” if hedeems she has made a mistake, though wives 1 These committees were formalized through the Ordinance on thecannot similarly punish a husband’s mistake. There Organization and Activities of Reconciliation at the Grassroots Level (Socialist Republic of Vietnam 1998).is shame and secrecy associated with GBV, which 2 An administrative unit below the district level.2 AIDSTAR-One | January 2012
  3. 3. AIDSTAR-One | CASE STUDY SERIESreconciliation is the culturally preferred and legally organizations, families, and individuals supportrequired solution; divorce is sought only when equality, reject discrimination, and provideviolence is intolerable (UNFPA 2007). oversight, investigation, and response to violations of gender equality. This law targets several issues,GBV and HIV: The link between GBV and HIV from wage disparities between men and womenis not well documented in Vietnam, and women to gender-based discrimination. Some provisionsseeking services for GBV-related injuries or address GBV, physical damages, psychologicalillnesses are rarely offered HIV testing. Women who counseling, and protection of legitimate rights. Therequest HIV testing, prevention of mother-to-child law includes provisions for safe sex, especiallyHIV transmission services, antiretroviral therapy, protection against HIV, as well as actions that canor care and support services at U.S. Government- be taken against perpetrators of violent acts. It alsofunded programs are not routinely screened for requires that gender be mainstreamed into lawGBV. and policy development and into state bodies and organizations. The Ministry of Labor, Invalids andUntil now, the risk of HIV for women has not been Social Affairs is responsible for implementing theperceived as a priority. Vietnam’s HIV epidemic is Gender Equality Law and building the capacity ofconcentrated in most-at-risk populations, especially state organizations to enforce it.among people who inject drugs and sex workers.The 2009 national estimation and projection report In 2007, the government passed the Law onfor 2007–2012 showed that HIV prevalence among Domestic Violence Prevention and Control,3 whichthe general adult population (15 to 49 years of defines domestic violence as “an act intentionallyage) is expected to reach 0.31 percent during this committed by a family member, which causesperiod, stabilize at 30 percent among people who harm or possibly causes harm in physical,inject drugs, and increase to 9.7 percent among sex emotional, and economic terms to another familyworkers, remaining highest in urban centers. During member” regardless of sex, age, or relationshipthis period, the ratio of infected men compared to the victim(s) (Huong 2008, 39). The Ministryto infected women is expected to decrease to of Culture, Sports and Tourism is responsible for2.6:1 as a result of increased transmission from overall implementation of the law and is expectedinfected men to their wives and regular sex partners to collaborate with other ministries to develop and(Ministry of Health 2009). Given the link between disseminate guidance for implementation. TheGBV and HIV risk in other countries, it is prudent for law includes provisions for punishing perpetrators,Vietnam to integrate HIV testing into GBV services establishing shelters for domestic violenceand GBV screening into all HIV services. survivors, intervening through community-based conciliation committees, expanding access to family-centered counseling, promoting “trustedPolicy Environment addresses” in communities (homes where survivors can seek short-term protection or support), andThe 1959 Vietnam Constitution endorses equality regular monitoring and supervision of the law’sbetween men and women in all aspects of political, implementation. The law is rather broad, coveringeconomic, cultural, social, and family life. Adopted any intentional act committed by a family member,in November 2006, the Gender Equality Lawpromotes gender equality in all areas of social 3 The term “gender-based violence” was not acceptable to parliamentar- ians because it is viewed as a foreign concept (Center for Studies andand family life, and mandates that all agencies, Applied Sciences in Gender, Family, Women and Adolescents 2010). Public Sector Response to Gender-based Violence in Vietnam 3
  4. 4. AIDSTAR-One | CASE STUDY SERIESincluding divorced couples or common law couples training and established a counseling center with(Huong 2008). two professional, full-time counselors. UNFPA and the Reproductive and Family Health Institute,Vietnam’s policies have evolved to reflect the funded by the Swedish Cooperation, have projectsrapidly changing social and economic situation in targeting both survivors and abusers in otherVietnam, especially after 1986 when the country provinces. All of these programs are generally smallopened its markets and began to dismantle its in scale, scattered across the country, and focusedcentrally managed economy. However, the laws primarily on physical violence (UNFPA 2007).in and of themselves are not sufficient to beginthe process of change; each ministry involved in Many hospitals will keep GBV survivors for five toimplementing a policy must issue a decree before seven days, but after that there is no safe placedeveloping guidelines and funding implementation for women to go. The first shelter for survivors ofat all levels of state authority (UNFPA 2007). violence, established in Hanoi in March 2007 by theWhile several decrees and strategy documents Center for Women’s Development, houses up tohave been issued, many are not backed by line- 20 women and their children for a maximum of fouritem budgets, staff training, or mechanisms to weeks.ensure the accountability of those responsible forimplementation. As a result, implementation ofthese laws is nascent. Nevertheless, these laws The Improving Health Caremark a shift in the perception of GBV; once aprivate matter, it has become a public issue. Response to Gender-based Violence ProjectGender-based Violence Hanoi Department of Health Services (HDH) data show that a significant number of womenServices in Vietnam seek services for “in-house accidents” at several hospitals under its supervision. Statistics fromSome services for GBV do exist in Vietnam. DGGH from 1997 to 2001 indicate 14,035 accidentYears before the law on domestic violence was cases, with 28 percent caused by interpersonaldrafted, several government agencies and local conflicts; of these, women comprised 44 percentand international nongovernmental organizations of survivors. Of the 57 accidents registered inmobilized to address GBV and by late 2010 the obstetrics and gynecology department, oversupported three nationwide GBV counseling half (31) were rape cases. Twenty-six accidentshotlines and 11 counseling and “trusted” addresses during pregnancy were reported in the same periodin the Hanoi area. One of these organizations, (Population Council 2002). At the time, clinicsthe Center for Creative Initiatives in Health and and hospitals did not routinely screen clients forPopulation (CCIHP), is conducting research GBV. When health care providers did identifythrough support from the Ford Foundation to build cases of GBV, there was no obligation to recordcommunity capacity to address GBV and gender the violence, give advice to survivors, or routinelynorms in the town of Cua Lo in Nghe An Province. notify the police or commune officials. There wereCCIHP adapted training manuals produced by the no standard service protocols or guidelines forU.K.-based organization Respect4 for community providers who wanted to give specialized care to4 Respect is the U.K. membership association for domestic violence per- GBV victims, and no referral networks for servicespetrator programs and associated support services: after the women were discharged.4 AIDSTAR-One | January 2012
  5. 5. AIDSTAR-One | CASE STUDY SERIESHDH managers decided to address GBV. In 2002, hospital directors were committed to implementingwith technical assistance from the Center for the project. In phase II (2005–2009), the model wasStudies and Applied Sciences in Gender, Family, also implemented at Dong Anh General HospitalWomen and Adolescents and the Population (DAGH), in suburban Hanoi, and additional healthCouncil, and financial support from the Ford centers.Foundation, HDH piloted the Improving HealthCare Response to Gender-based Violence project.HDH played a central role in developing guidelines Service Delivery Modeland provided project management, supervision,and technical support to the hospitals involved. At A major project goal was to establish routinethis time, neither the Gender Equality Law nor the screening of female patients for GBV and to shiftLDVPC had been approved, though both became providers’ perspective so that they would seelaw during the course of the project. screening not as a project activity but as part of their daily routine and professional duty. HDHHDH staff visited GBV service sites in Thailand and assumed that making screening routine would makethe United States and adapted approaches used the practice sustainable after the project periodthere to develop an appropriate model for Vietnam. (though this proved not to be the case).The first phase was implemented from 2002 to2004 in DGGH and two health centers serving The project model had three components:large populations in the outer suburbs of Hanoi. screening, referrals, and community outreach andHDH chose these sites assuming that in-house support.accidents in the catchment areas near the hospitalwas higher than in urban catchment areas, the work Integrating GBV screening into healthwould be easier to implement in less congested services: All medical and nursing staff insuburban hospitals and communities, and the emergency rooms, obstetrics/gynecology and surgery departments, maternal and child health and family planning, mobile teams, and other “Before they [health care staff] just professional staff and managers were trained cared about the symptoms and in basic knowledge about GBV, consequences therapeutic methods. Now they of violence, recognizing GBV, talking to clients, working with survivors, and collaborating with the ask questions to find out relations community to support GBV survivors. Staff were between symptoms and violence. trained to use a short, three-question screening If a woman came frequently to the tool asking clients whether they have experienced hospital for gynecological treatment physical, emotional, or sexual violence, or rape. The training also discussed the issues that underlie or for an abortion, health staff GBV in Vietnam, including gender, the unequal would ask if she had been sexually power between men and women, the pressure of coerced. Before, they would gender roles, and the causes of GBV. consider the phenomenon as a All female clients over age 15 in hospital emergency normal thing.” rooms, treatment departments, or general –Doctor, Dong Anh General Hospital examination departments were to be screened for GBV. Females under age 15 would be screened Public Sector Response to Gender-based Violence in Vietnam 5
  6. 6. AIDSTAR-One | CASE STUDY SERIESonly if they had signs or symptoms of physical or transmitted infection (STI) services are easy tosexual violence. Women who experienced GBV access and free, subsidized by an HIV preventionwould receive emergency treatment, if needed, and project underway at the hospitals. However,a referral to the Women’s Counseling Center for counselors said that many women were reluctant toHealth or also, during phase II, to the Dong Anh test for HIV; only 282 women accepted referrals toCounseling Center. the voluntary counseling and testing site at DGGH and only 15 at DAGH (fewer than 10 percent atFree counseling services: Two trained nurses each facility).worked full-time at DGGH’s counseling center,which is on the third floor of the hospital building. Community outreach and support:In DAGH (phase II), a medical doctor who is also The Population Council trained hospital andan HIV counselor in the Voluntary Counseling and counseling center staff as master trainers. TheseTesting Center, was the primary GBV counselor at trainers visited communities monthly to providethe Dong Anh Counseling Center, which is located communication sessions on GBV and genderin a separate building on the hospital grounds. To equality to members of mass organizations, like theavoid stigma and protect clients’ privacy, the names Farmers’ Union and Students’ Union, or interestedof the counseling centers do not mention GBV. community members. In phase II, “Clubs for Family Happiness” were established for female survivors inBoth centers receive GBV referrals from the several communes, and members of the Women’shospitals, mass organizations, and the police, and Union were invited to participate in helping toreceive walk-in clients from the community who decrease stigma. In some communes, communityhear about the service through mass media or members established two different clubs—one forfriends. Counseling centers keep detailed case survivors of violence, and one for GBV preventionreports on each survivor and take photos of a volunteers. Both clubs provided information on GBVwoman’s injuries in case she decides to press and referrals to counseling centers and trustedcharges. The counselors provide one-on-one addresses. The project provided transportationcounseling and refer women to other services funds and helped the volunteer clubs provideincluding reproductive health, the counseling support to GBV survivors and intervene whenhotline or shelter in Hanoi, and community-based violence occurred in their communities. Theorganizations that provide support (e.g., the survivors’ club introduced dancing, drama, games,Women’s Union). Women who come on their own painting, and puppets to help women expressto the counseling centers may be referred to the their emotions and discuss solutions. Gradually,hospital if medical care and treatment services are management of the clubs shifted from projectneeded. Women are encouraged to return to the staff to club members, who continued to organizecounseling centers any time for social support or performances in their communities. These clubsreferrals to other resources and services. provide a safe environment for women to share their problems, support each other, learn how toIn phase II, counselors started advising women solve family conflicts, and make safety plans.who experienced sexual violence and those whosepartners refused to use a condom to visit the Figure 1 is a diagram of the hospital- andVoluntary Counseling and Testing Center for HIV community-based service model, adapted from thetesting and counseling (HTC). The HIV and sexually government manual (Population Council 2002).6 AIDSTAR-One | January 2012
  7. 7. AIDSTAR-One | CASE STUDY SERIESResults strengthened providers’ counseling skills and improved their ability to interact with GBV survivors.A 2005 assessment by the Population Council The evaluation showed that as the servicesand HDH indicated significant positive changes became known in the catchment areas, DGGHin providers’ awareness and attitudes regarding and the Women’s Counseling Center for Healthgender equality and factors contributing to were overwhelmed with clients. However, doctorsviolence during phase I (Mai 2006). Findings maintained that they were too busy and often failedalso indicated more proactive screening, to screen every female client, conduct follow-upassessment, and documentation of GBV cases, and care with GBV clients, and fully document casesimproved support to GBV survivors. The training of GBV. The responsibility for screening shifted toFigure 1. Hospital- and community-based service model Flow of GBV Survivors at Duc Giang General Hospital Departments Emergency room Examine and Classify Come by themselves Health stations Women’s Counseling Center for Health Examination/Treatment/Consulting/Record keeping Follow-up Return Follow-up Victims of home GBV Community; Support; Organizations; Government; Assistance addresses: police, court, Women’s Union, Linh Tam counseling hotline by the Center for Applied Studies in Gender and Adolescence, shelter by the Center for Women and Development, legal aid service of Hanoi. Public Sector Response to Gender-based Violence in Vietnam 7
  8. 8. AIDSTAR-One | CASE STUDY SERIESnursing staff; in some cases, women were asked tofill out the forms themselves because of providers’ “Before, most clients of theheavy workload. As a result of this shift, the number counseling centers were referredof women being adequately screened declined. by hospitals. Now many clients areThe evaluation also identified problems in the introduced by ex-clients. They werecommunity component stemming from insufficient given my phone number and calledcollaboration by HDH. In phase II (2005–2009),HDH increased communication and outreach me to ask for counseling. Beforeactivities to local commune authorities and provided clients came to us only when theirgender equity and GBV training to authorities to situations were serious. Now theyincrease their support for GBV community outreach come to us even when nothingactivities. The project added communicationsessions for men (mostly male farmers through the is serious yet, and they are moreFarmers’ Union) and adolescents in schools, and eager to ask for counseling andorganized several large social events to strengthen information.”outreach to the community. –Counselor, Dong AnhOutside funding and technical assistance ended General Hospitalin September 2009. Maintaining GBV screeningservices at DGGH and DAGH and community Increasing community awareness ofreferrals and outreach activities are now the GBV: Community awareness about counselingresponsibility of the respective hospitals, commune services increased significantly during phase II.authorities, and HDH. In 2010, the Ministry of During phase I, about half (383, or 48 percent) ofHealth endorsed the project model for all health the 797 clients visiting the the Women’s Counselingfacilities in Vietnam. Center for Health were either referred by other organizations or came on their own. In phase II, only 460 (12 percent) of the 3,982 clients seen atWhat Worked Well the Women’s Counseling Center for Health were referred by DGGH clinics (Budiharsana and TungExpanding providers’ awareness of GBV: 2009). At DAGH, between January 2007 and MayBy the project’s end, providers’ perceptions of 2009, less than half (146) of the 363 women whoGBV had changed; they saw violence as not only visited the counseling center were hospital referrals;a purely medical issue, but also a social and public the majority (217, or 60 percent) were referred byhealth issue (Budiharsana and Tung 2009). This other organizations or came on their own.5 Thischange was due in part to culturally appropriate suggests that the GBV services met a significanttraining and monitoring tools, periodic retraining, need within the community and that word wasand consistent support from HDH and hospital spread within the community allowing women tomanagement, but also to the discussions of gender access these services without having to go throughand inequality that were included in the training. the hospital.Many staff members said that the GBV projecttransformed their lives. 5 Ratio before 2007 is unknown.8 AIDSTAR-One | January 2012
  9. 9. AIDSTAR-One | CASE STUDY SERIESTraining expertise: Local HDH master trainers joint mechanism to document GBV cases in thetook over all of the project-related training. Key staff event that a woman decides to press charges.and counselors provided training and technical The education sector is the least involved in GBVassistance to projects undertaken by local Women’s issues, and is not linked to any of the community-or Farmers’ Unions in the adjacent communes. based activities that the project supported.Model for domestic violence law: The Limited impact on HIV prevention: Thereproject’s most far-reaching outcome occurred was little opportunity to amend the training toin mid-2009. In a first step for implementing the include content on how GBV increases women’s2007 law on domestic violence, the Ministry of vulnerability to HIV and other STIs. The modelHealth used the project model to develop a circular does not include routine referral to services for(guidance) that requires all Vietnamese hospitals STIs and HTC for GBV clients; only women whomto integrate screening for GBV into health check- counselors considered at risk for HIV were referredups (Circular No. 16/2009/TT-BYT). The guidance to the HIV testing center—mostly women who hadmandates that project training materials and experienced sexual violence. Women were notscreening tools be used countrywide. This guidance screened on other risk factors such as being sexrepresents a true, policy-based commitment by the workers or people who inject drugs. As a result,health sector to address GBV. very few women received HTC at DGGH. At the Dong Anh Counseling Center, the staff trained for GBV counseling were HTC counselors, so theChallenges proportion of women receiving HTC was greater than at DGGH. Missed opportunities to provide HTCThe Improving Health Care Response to Gender- were due in part to the nature of project funding: thebased Violence project experienced many project was funded as a GBV project, not a GBVchallenges. It was able to address some of those and HIV project, so HTC was not integrated intochallenges because an assessment was built in and the training or services. This omission is especiallyHDH committed full-time staff, albeit funded by the troubling because data collected during the projectproject, for supervision, support, and monitoring. showed that many women were subject to multipleMany of the challenges relate to structural issues forms of GBV (see Table 1).that could not be addressed without a concomitantstrategy for multi-sectoral policy advocacy. Economic constraints: Economic restructuring by the Government of Vietnam has reduced centralLimited response to GBV across sectors: funding to public sector health services, whichOutside the health sector, referrals for GBV clients are increasingly under pressure to charge fees toare limited. Police respond to conflicts resulting in cover the majority of costs for salaries, operatingserious physical violence but not to cases involving expenses, and service provision. GBV services atmental violence or sexual coercion. Because DGGH and DAGH are free, and providers are notcivil laws only recognize serious physical harm compensated through hospital operating budgetsas a crime, there is little motivation for police to or by Ministry of Health subsidies to the hospitals.respond to complaints that do not result in short- When the incentives provided by the project ended,term disability or visible injury. Hospitals, commune anecdotal reports from project staff indicate thathealth clinics, and police have not established a the number of women being screened decreased, Public Sector Response to Gender-based Violence in Vietnam 9
  10. 10. AIDSTAR-One | CASE STUDY SERIES TABLE 1. REPORTED GBV CASES IN Ford Foundation, which HDH estimated would cost PROJECT PHASES I (2002–2004) AND II an additional U.S.$5,000 per year per hospital (2005–2009)* beyond the current staffing commitment. As of July 2010, DGGH still retained one of the two Duc Giang Phase I Phase II full-time counselors and was committed to paying (n = 797) (n = 3,982) the counselor’s salary for at least the next year, Physical violence 529 979 but was unable to cover community outreach Emotional violence 502 944 activities or long-term recurrent costs for the Sexual violence 35 183 Women’s Counseling Center for Health. In Dong Economic deprivation 56 142 Anh, GBV services were combined with the HTC Dong Anh Phase II site to compensate for a lost staff position in the (n = 363) GBV clinic; outreach activities were curtailed. Physical violence 145 Fortunately, a few community-based activities Emotional violence 344 initiated through the project may continue through Sexual violence 15 local Women’s Union or Farmers’ Union budgets. Economic deprivation 22*Women may have reported more than one type of violence. Data pro- Future funding: For want of approximatelyvided by the Hanoi Department of Health. $5,000 per year per hospital, it is difficult to predict the extent to which GBV screening, counseling,and given the economic pressures on hospitals referrals, and community outreach will continueand health care providers, the number of womenscreened could further diminish. “After 8 years involved in this proj-The Ministry of Health circular mandates GBV ect, I found my own awareness onscreening but does not specify how screening willbe funded, and costs for counseling, referrals, and GBV has significantly changed. Wecommunity outreach and events to raise awareness struggled hard to change our opin-about GBV are not included in the guidance. ions and then I found humanitarianIt is possible that hospital administrations may equality in the intervention on GBV.use their own budget to reimburse staff for GBVscreening and counseling. However, the quality I would feel very sorry if this proj-and level of GBV services could vary widely ect model could not find resourcesacross Vietnam, depending on the extent to which to continue. After all the efforts wehospital administrators prioritize GBV services.DGGH and DAGH administrators indicate that took to write down our experiencesthey are committed to continuing the services, but and lessons learned into these pro-maintaining the level of services depends on a tocols and manuals, I feel it wouldfunding mechanism from the Ministry of Health. be a big waste not to use them fur-Staffing: HDH, which has administrative ther in health services.”management responsibility for hospital and clinic –Vice Director of Duc Giangfunding, has been unable to fully fund the levelof services and staff positions supported by the General Hospital10 AIDSTAR-One | January 2012
  11. 11. AIDSTAR-One | CASE STUDY SERIESat both hospitals. Addressing GBV represents a Health circular is a promising indicator of thelong-term effort to change cultural and community government’s commitment to reducing GBV, butnorms. The best outcome would be that the this support is only one of many steps that mustMinistry of Health circular represents the first step be taken before the social and cultural factors thatin implementing existing legislation on GBV and influence GBV begin to change. The Vietnamesegender equity, and that additional guidance on political system does not accommodate citizen-funding, staffing, and training will be forthcoming. based advocacy groups, but committed government officials can and do influence ministry policy choices and funding decisions at the provincial,Recommendations municipal, and commune levels.Link HIV and GBV in service provision: Vietnam has made enviable progress on the thirdHospitals should integrate routine referral for HTC goal of the Millennium Challenge7 by reducinginto their GBV counseling and referral services. poverty and increasing girls’ level of access toThis will require a long-term strategy to ensure that education, but it will fall short on increasing genderbudgets are available at all levels for integrated equality if efforts to address GBV remain limited.HTC and GBV services, and that staff receive With proper strategic planning and advocacysufficient training to provide good services. In the skills, HDH leaders and their nongovernmentalcase of Vietnam, the government has not adopted organization partners are in an excellent position toa provider-initiated testing and counseling strategy promote GBV as a public health and developmentin primary health settings,6 so GBV counselors may issue with decision makers at all levels ofnot be allowed to test for HIV. Until such a strategy implemented, GBV counselors should receive Include males in efforts to reduce GBV:training on the link between HIV and GBV and on Deeply held beliefs about gender roles andpre- and post-test counseling, and should provide relations underlie GBV. Interventions that addressreferrals to HTC sites (as well as sites for STI and gender roles and expectations for men and womenreproductive health services) within the hospital or are necessary to break the cycle of violence. Futurein the community. GBV programs must include activities to reach menEstablish a broad advocacy base: Donors and boys to begin changing norms that perpetrateand foundations should consider funding advocacy gender inequality and for HDH, nongovernmental organizations, Integrate GBV screening across services:and local government staff countrywide to expand Ministries of health, the U.S. President’s Emergencythe base of knowledge and strengthen advocacy Plan for AIDS Relief, and other donors shouldon GBV. This will increase the capacity and popular support programs to incorporate GBV screeningsupport for developing long-term, multi-sectoral and referral into all of their clinic-based services; instrategies for addressing GBV. The Ministry of addition, community-based services should be able6 The U.S. Centers for Disease Control and Prevention (CDC) HTC to provide referrals to GBV services. Women andguidelines will be revised in 2012. CDC is providing technical assistance men who are at risk for HIV may be at higher riskto the government of Vietnam on inclusion of both couples testing andcounseling and provider-initiated testing and counseling. Currently, pro-vider-initiated testing and counseling is limited to tuberculosis, preven- 7 “Promote gender equality and empower women by eliminating gendertion of mother-to-child transmission of HIV, and STI settings in Vietnam disparity in primary and secondary education, preferably by 2005, and in(funded through the U.S. President’s Emergency Plan for AIDS Relief). all levels of education no later than 2015” (United Nations 2010, 20). Public Sector Response to Gender-based Violence in Vietnam 11
  12. 12. AIDSTAR-One | CASE STUDY SERIESfor GBV, and current HIV programs are not reachingsome of the most vulnerable—male and female sex Future Programmingworkers, women who inject drugs, and partners of Government policies that support gender equalitymen who inject drugs. Research on how to motivate and address domestic violence reflect hard-wondoctors and nurses to screen for GBV without gains by advocates working on behalf of survivors.payment would help inform program interventions However, the commitment to implement theseand identify what kinds of non-monetary incentives policies—through dedicated funding for training,would sustain their engagement to provide implementation, and monitoring—remains elusive.compassionate and competent care. Further, there needs to be a broader effort to lookIncorporate quality assurance: Integrating a at GBV throughout society. While social norms areGBV approach should include a quality assurance changing, there are still very few options for GBVprocess to ensure quality counseling. This could survivors to find safe places and the counseling andinclude annual refresher training for health care support they need. GBV remains predominantlyproviders and counselors to maintain skills in how a woman’s issue, though men and boys alsobest to interact with GBV survivors, and developing experience violence. Future GBV projects anda small cadre of health workers who only screen services need to work from the planning stages toand care for patients (children and adults) who strengthen the capacity of mass organizations likeexperience trauma, rape, and GBV. the Women’s Union and Student’s Union, as well as individual community members and families toFoster donor-government collaboration: understand and challenge the gender norms thatDonor collaboration with the government on perpetuate GBV.providing GBV services should be based more on a“partnership framework” approach where the local The training supported through the project had agovernment begins to take on the cost of continuing profound impact on many providers and governmentthe services at some early point in the project so partners because it provided opportunities to thinkthat by the end of the project period the entire cost critically, for the first time, about gender equality,is sustained by the local health department/public gender norms, and GBV. Programs should ensuresector budget. In Hanoi, there was hope that the that such training, along with information andgovernment would continue to support the services guidance for providers, communities, and thosewhich, according to HDH estimates, is U.S.$5,000 experiencing violence, is supported in futureper year per hospital to maintain the pre-2010 level projects. gof services annually.12 AIDSTAR-One | January 2012
  13. 13. AIDSTAR-One | CASE STUDY SERIESRESOURCES Mai, L.T.P. 2006. The Role of Health Providers in Assessment and Treatment of Gender BasedCenter for Creative Initiatives in Health and Violence: Evidence from an Intervention in Hanoi,Population, Hanoi, Vietnam: Vietnam. Unpublished paper.Center for Studies and Applied Sciences in Gender, Ministry of Health. 2009. Viet Nam HIV EstimatesFamily, Women and Adolescents, Hanoi, Vietnam: and Projections 2007–2012. Hanoi, Vietnam: Health International. Nguyen, T.D. 2006. Prevalence of Male IntimateREFERENCES Partner Abuse in Vietnam. Violence Against Women 12(8):732–739.Budiharsana M.P., and M.Q. Tung. 2009.Final Project Evaluation Report: Improving Population Council. 2002. Project on Improvingthe Health Care Response to Gender-based the Health Care Response to Gender-basedViolence – Phase II. Hanoi: Population Council. Violence: Training for Heath Providers on Gender-Available at Based Violence. Training Manual. Hanoi, Vietnam:HealthCareRespGBVVietnam.pdf (accessed Population Council (accessed January 2011)January 2011) Socialist Republic of Vietnam. 1998. Ordinance onCenter for Studies and Applied Sciences in Gender, the Organization and Activities of Reconciliation atFamily, Women and Adolescents. Interview with the the Grassroots. Available at July 7, 2010. en/Lists/Vn%20bn%20php%20lut/View_Detail. aspx?ItemID=1238 (accessed June 2011)Gardsbane, D., V. Song Ha, K. Taylor, and K.Chanthavysouk. 2010. Gender-Based Violence: United Nations. 2010. The Millennium DevelopmentIssue Paper. Hanoi: United Nations. Goals Report. New York: United Nations. Available at, H.M. 2008. Vietnamese Legislation on Products/Progress2010/MDG_Report_2010_En.pdfCombating Domestic Violence. Social Sciences (accessed January 2011)Information Review 2(4). Available at UN Population Fund. 2007. Gender-based Violence(accessed October 2010) Programming Review. Available at http://vietnam. (accessedJonzon, R., N.D. Vung, K.C. Ringsberg, and G. September 2010)Krantz. 2007. Violence Against Women in IntimateRelationships: Explanations and Suggestions for Vu, M.L., T.H. Vu, H.M. Nguyen, and J. Clement.Interventions as Perceived by Healthcare Workers, 1999. Gender-based Violence: The Case ofLocal Leaders, and Trusted Community Members Vietnam. The World Bank Policy Research Reportin a Northern District of Vietnam. Scandinavian on Gender and Development. Washington, DC:Journal of Public Health 35(6):640–647. World Bank. Public Sector Response to Gender-based Violence in Vietnam 13
  14. 14. AIDSTAR-One | CASE STUDY SERIESACKNOWLEDGMENTS case study. Thanks also to the PEPFAR Gender Technical Working Group for their support andThe authors would like to express their deepest careful review of this case study.gratitude to staff at the Hanoi Department of Healthand at the Duc Giang and Dong Anh GeneralHospitals involved in the Improving Health Care RECOMMENDED CITATIONResponse to Gender-based Violence projectfor generously sharing their experiences and Spratt, Kai, and Thi Thu Trang. 2012. Public Sectorenthusiasm for integrating a GBV response into Response to Gender-based Violence in Vietnam.their clinic services. The authors thank the Center Case Study Series. Arlington, VA: USAID’s AIDSfor Creative Initiatives in Health and Population Support and Technical Assistance Resources,for their invaluable insights, expert collaboration, AIDSTAR-One, Task Order 1.and extensive logistical support. The authorsexpress their sincere thanks to the U.S. President’s Please visit forEmergency Plan for AIDS Relief (PEPFAR) team additional AIDSTAR-One case studies and otherin Vietnam for allowing them to conduct this HIV- and AIDS-related resources.14 AIDSTAR-One | January 2012
  15. 15. AIDSTAR-One’s Case Studies provide insight into innovative HIV programs and approachesaround the world. These engaging case studies are designed for HIV program planners andimplementers, documenting the steps from idea to intervention and from research to practice.Please sign up at to receive notification of HIV-related resources,including additional case studies focused on emerging issues in HIV prevention, treatment,testing and counseling, care and support, gender integration and more.