Missed opportunities in health sector responses to violence against women and girls: a comparative mixed-methods study in Albania and Brazil

Abstract

Background

Violence against women and girls (VAWG) is a global public health crisis, affecting one in three women worldwide. Survivors of VAWG access health services more frequently due to the direct and indirect consequences of violence. Despite the health system’s potential lifesaving role, these visits often result in missed opportunities.

Methods

The Missed Opportunities to Respond to Violence Against Women and Girls in the Health Sector (MISSOP) study investigated the nature, scale and determinants of missed opportunities in responding to VAWG within primary care and emergency departments in Tirana, Albania and Belo Horizonte, Brazil. Using a triangulated mixed-methods design with an intersectional systems thinking lens, we built a retrospective cohort of women affected by VAWG, analysed their health service use and conducted focused ethnography through observations and interviews with health professionals and survivors to understand why missed opportunities occur.

Results

Missed opportunities emerged as a discontinuum of care. In both settings, failures occurred across the continuum, ranging from access, detection, care and referral to statistics. In each municipality, 42% of women had not accessed any public healthcare facility in the 5 years investigated. Among the 58% who accessed public healthcare services, missed detection rates ranged from 68% in Belo Horizonte to 100% in Tirana’s primary care system.

These gaps were shaped by a complex interplay of factors, the biomedical orientation of health systems and by intersecting systems of discrimination, such as racism, sexism and classism, that shaped provider attitudes and institutional responses. Although protocols for responding to VAWG existed in both settings, they were poorly implemented or unknown to providers.

Conclusion

Despite contextual differences, both health systems showed a similar pattern of systemic neglect. By conceptualising missed opportunities as a reinforcing cycle, our study introduces a novel framework to understand and address institutional failures. This approach highlights the complexity of VAWG as a health system challenge and identifies leverage points for structural and cultural reform.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Health systems play a key role in responding to violence against women and girls (VAWG), but evidence shows that many survivors remain undetected or not cared for comprehensively. Few studies have examined the nature and scale of missed opportunities in the health system’s response to VAWG.

WHAT THIS STUDY ADDS

• This study introduces and operationalises the continuum of missed opportunities in health system responses to VAWG, revealing their frequency, forms, and shared determinants across two distinct contexts. It shows how structural discrimination and gender norms interact with institutional design, rather than acting as separate determinants, reinforcing cycles of invisibility and neglect within health systems.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• It underscores the need for integrated, survivor-centred responses within health systems and shows that addressing missed opportunities requires structural reforms that transcend local contexts. Our findings, as well as a novel framework can contribute to strengthen health systems and multisectoral policies and interventions to respond to VAWG.

Introduction

Violence against women and girls (VAWG) has reached epidemic proportions, with one in three women globally experiencing violence in their lifetime.¹ VAWG includes various forms of abuse, including physical, sexual, economic and psychological violence perpetrated against women and girls because of their gender.² Research has documented the profound impact of VAWG on individuals, communities and societies, reinforcing the urgent need for a comprehensive, multisectoral response.^{3 4} In 2013, the WHO declared VAWG as a public health emergency.⁵

Health systems have a critical role to play in early detection and intervention, which are essential to prevent escalation and reduce both immediate and long-term health consequences.^{6 7} Survivors of VAWG visit outpatient and emergency departments more frequently due to the acute and sometimes severe nature of consequences from violence (ie, injuries, mental health issues) and they identify healthcare providers as professionals they can trust to disclose abuse.⁸

Yet, despite this potential, the health sector continues to play a limited role in addressing VAWG.^{6 9 10} Most countries do not have a health policy to respond to VAWG and even where policies exist, the health system fails to translate these into practice.⁹ Every time a woman or girl suffering from VAWG attends a health service and is not detected, treated adequately or referred to other specialised services, it constitutes a missed opportunity.

Few studies have examined how often missed opportunities occur in the health sector’s response to VAWG—or why they happen.^{11 12} In the USA, a study showed that only 30% of the survivors of intimate partner violence who accessed health facilities were screened for violence, with just 5.8%, resulting in a positive screen.¹² In Kenya, over 30% of the women seeking care after sexual violence did not get HIV preventive treatment, despite it being the standard of care.¹¹ These missed opportunities reveal a range of individual, institutional and societal determinants.^{2 13}

Our study conceptualises missed opportunities in the health system’s response to VAWG, examining their frequency, underlying mechanisms, and implications for strengthening care. We investigated these using a mixed-methods design informed by intersectional systems thinking in two countries, Brazil and Albania—two middle-income countries with longstanding health-sector policies on VAWG.

Methods

This study was conducted as part of the MISSOP (Missed Opportunities to Respond to Violence Against Women and Girls in the Health Sector) project, which aimed to investigate the scale, nature and determinants of missed opportunities in the health sector response to VAWG in Albania and Brazil. Given the societal and political relevance of the topic, the research teams in both countries engaged local authorities and civil society throughout the study to refine objectives and plan data collection. This section also outlines the steps taken with regard to the safety and ethical treatment of the participants and researchers, given the sensitivity of working with the theme of VAWG and VAWG survivors.

Study design and theoretical approach

We conducted a comparative case study,¹⁴ employing a triangulation mixed methods design.^{15 16} This enabled in-depth, context-specific analysis of missed opportunities in the health system’s response to VAWG as well as cross-case comparison between Tirana and Belo Horizonte. Following Flick’s understandings of triangulation, quantitative and qualitative data were collected and analysed concurrently, with equal weight given to each strand. The two strands informed one another throughout the research process, from design through to joint interpretation.¹⁷

The research was guided by a theoretical framework that was initially developed after a literature review and then inductively adapted throughout the study. Building on the existing health system readiness framework to respond to VAWG^{6 13} and previous studies that looked at missed opportunities,^{11 12 18} we developed a comprehensive approach to understanding missed opportunities to respond to VAWG.

This framework (figure 1) captures a reinforcing feedback loop, where each missed opportunity weakens the next point of potential intervention—creating a continuous cycle with no clear beginning or end. Like the cycle of VAWG itself—where periods of tension, violence and reconciliation entrap survivors in repeated attempts to leave and subsequent returns⁶—the system’s failure to guarantee access, detect, care, refer or produce statistics reproduces conditions for further harm, entrenching invisibility and institutional neglect that results in a discontinuum of care.

Figure 1. Definition of missed opportunities to respond to VAWG in the MISSOP study (a discontinuum of care). MISSOP, Missed Opportunities to Respond to Violence Against Women and Girls in the Health Sector; VAWG, violence against women and girls.

To strengthen this, we applied an intersectional systems thinking lens, combining two complementary analytical approaches. Intersectionality, developed by Black feminist scholars, considers how overlapping systems of oppression—such as racism, classism and sexism—structure lived experiences and institutional responses.¹⁹ Systems thinking is used across fields to understand and intervene in complex adaptive systems; it treats health systems as shaped by dynamic interactions, feedback loops, and non-linear processes.²⁰ Together, these lenses allowed us to conceptualise the health system not as a static delivery mechanism but as a complex adaptive and socially embedded system whose responses to VAWG are shaped by broader power relations and structural inequalities.

Study setting

We purposively selected two middle-income country contexts with existing policy frameworks for addressing VAWG in the health system: Albania and Brazil. This selection aimed to capture diversity in geographic, cultural as well as differences in healthcare and political systems (see table 1). Additionally, our research team had pre-existing, well-established relationships with local communities and relevant stakeholders, facilitating access and collaboration in the two selected municipalities, Tirana and Belo Horizonte.

Table 1. Overview of context and public policies in Tirana, Albania and Belo Horizonte, Brazil for violence against women and girls.

Domain	Tirana, Albania	Belo Horizonte, Brazil
Total population	758 216 (2025)46	2 315 560 (2022)47
Estimate physical or sexual IPV prevalence in a lifetime (age 15–49), 48	13% (2018)	24% (2017)
Gender inequality index (2021)49	0.144	0.390
Public health system organisation	45 primary health centres; 2 emergency departments in second-level public hospitals; 10 emergency departments in private hospitals and clinics50	153 primary health centres; 9 emergency departments. Services provided in the public health system are free at the point of care.51
VAWG response	Law No. 9669 (2006)—measures against family violence, aiming to prevent and reduce domestic violence and protect victims.52 Decision No. 327 (2021)—established the coordinated community response to VAWG, structured around Local Referral Mechanisms (LRMs) in each municipality.53 LRM in Tirana was established in 2012.	Lei Maria da Penha (Law No. 11.340/2006)—established an intersectoral network for prevention and response to domestic violence, including the health sector.54 National Policy to Combat Violence Against Women (2011)—which aims to combat violence against women through intersectoral actions that encompass prevention, assistance, combat and guarantee of rights.55 In Belo Horizonte, the multisectoral protocol for the response to VAWG was launched in 2024.56
VAWG response in the health system	Several protocols, guidelines, and standard operating procedures exist (2011–2021), including specific protocols for cases of sexual violence. Health professionals are mandated to report suspected cases of VAWG directly to the police. Training on VAWG topics is insufficient and non-mandatory for health professionals.57	Several national laws and policies define the public health system’s role in the response to VAWG, within Brazil’s universal health system (SUS). Health professionals in public and private health facilities have been requested to notify VAWG cases for epidemiological purposes since 2006, with notification becoming mandatory in 2011. In 2019, legislation introduced a further requirement, obliging health services to report suspected cases to the police within 24 hours.58 Belo Horizonte has had a municipal protocol for health providers to respond to VAWG since 2015.59 At the Federal level a guide for the care of survivors of VAWG in primary healthcare services was released in 2025.60 Training on VAWG during education and in-service is insufficient.61

IPV, Intimate Partner Violence; MISSOP, Missed Opportunities to Respond to Violence Against Women and Girls in the Health Sector; VAWG, violence against women and girls.

Retrospective cohort: data collection and analysis

We employed a retrospective cohort study design through database linkage²¹ to trace the healthcare journeys of survivors and victims across multiple health system touchpoints and quantify missed opportunities for detection, treatment, referral and statistics. Data linkage was conducted using both probabilistic and deterministic methods to connect individual cases with health records from multiple databases, ensuring a comprehensive reconstruction of health system interactions.²²

In Tirana, we constructed a retrospective cohort of survivors of VAWG, who had received support from the Counselling Line for Women and Girls (CLWG) between 2018 and 2022. We included all the women above 18 who had an ID number in the records. The CLWG is a non-governmental organisation (NGO) offering support to VAWG survivors, based in Tirana and part of the research team. For each survivor, we manually traced health records from the four main Tirana hospitals and primary healthcare (PHC) facilities covering the same period. To protect participants’ confidentiality, names were never shared with the research team. The CLWG assigned each woman a temporary individual code, which was used throughout the analysis. Only national ID numbers, without any nominal identifiers, were shared with healthcare service providers to enable manual tracing of health records across the four main Tirana hospitals and PHC facilities. Researchers worked exclusively with coded, de-identified data at all stages of analysis.

In Belo Horizonte, we built a retrospective cohort of women aged 10 to 49 years who were victims of femicide registered in the prosecutors database between 2016 and 2020. We employed probabilistic linkage to connect these cases with records from five national health datasets: the Mortality Information System (SIM), the National System of Notifiable Events (SINAN), the Live Birth Information System (SINASC), the Hospital Information System (SIH), and the Ambulatory Information System (SIA). Deterministic linkage was used to integrate cases with medical records from PHC and emergency care units (UPA) using the SISREDE information system. Data linkage was conducted under formal data-sharing agreements: probabilistic linkage was performed in a secure environment at the Ministry of Health, and deterministic linkage with medical records was carried out by the Municipal Health Secretariat of Belo Horizonte. The research team worked exclusively with a fully deidentified database following linkage, with no access to nominal or individually identifying information at any stage. A detailed description of these systems can be found in Melo et al²¹ and these processes are detailed in Vitral Pinto et al.²³

Descriptive analyses were performed to examine survivor characteristics, the nature of healthcare visits and to reconstruct healthcare interactions and conduct a detailed analysis of missed opportunities for detection, treatment and referral within the healthcare system.

Focused ethnography: data collection and analysis

To investigate the determinants of missed opportunities in the health sector’s response to VAWG, we employed focused ethnography,²⁴ combining semistructured interviews and participatory observation. The depth and scope of ethnographic data collection differed between the two sites, reflecting differences in research team capacity, access and the stage of the study in each context. In Belo Horizonte, where the research team was establishing new relationships with health facilities and staff, participatory observation was essential to build rapport, understand institutional dynamics and contextualise interview data. The larger and more diverse urban context of Belo Horizonte, with 153 primary health centres serving a population of over 2.3 million and the availability of a larger, multidisciplinary research team also made sustained ethnographic observation both feasible and analytically necessary in a way that was not possible in Tirana.

We conducted semistructured interviews in Tirana with a purposive sample of healthcare professionals (n=11—3 men, 8 women), covering roles such as family doctors, psychologists, gynaecologists, forensic doctors and municipal specialists and survivors of VAWG (n=9—all women). All interviews with professionals were conducted at their place of work and with survivors at the offices of the CLWG, a trusted partner organisation where survivor participants were already receiving psychosocial support. This setting provided a safe and familiar environment, minimising potential distress. Counselling was available to survivor participants both before and after the interview. Interviews were carried out by two experienced qualitative researchers, both Albanian women with a social work background, trained in trauma-informed interviewing and in the WHO ethical guidelines for conducting research with survivors of VAWG.

In Belo Horizonte, we conducted in-depth interviews with a purposive sample of healthcare professionals (n=62—7 men, 55 women), three survivors of VAWG and two activists from social movements, resulting in a total of 70 in-depth interviews. Participants were recruited through the primary health centres and interviewed in confidential, designated safe spaces within the same facilities. Psychosocial support was available to survivor participants both before and after the interview, either at the health centre or through the specialised centre for survivors of VAWG in Belo Horizonte. Seven Brazilian women researchers conducted the interviews, each in the same primary health unit where they had previously conducted participatory observation and established rapport with participants. The average duration of the interviews was 43 min. The research team comprised political scientists, anthropologists and public health researchers, all with extensive experience in qualitative research and VAWG, and all trained in trauma-informed principles and ethical guidelines for conducting research with survivors of violence. The team was coordinated by a psychologist who provided ongoing methodological and emotional support to the group. The team met weekly to discuss emerging findings, align analytical approaches and reflexively refine the interview process throughout data collection.

The interview guides were pilot tested in each setting with individuals that were then not included in the study. All interviews were audio-recorded, anonymised using unique identifiers and transcribed verbatim.

Thematic analysis was guided by a collaboratively developed analytical framework, with initial codes agreed across country teams based on the conceptual framework, the jointly developed intersectional systems thinking lens and preliminary readings of the data.²⁵ Researchers in each context then led the coding and analysis for their setting, applying the shared framework while allowing for the development of emergent, context-specific themes. Once within-case analyses were completed, we conducted a comparative case analysis between Tirana and Belo Horizonte to identify convergences and divergences across the two settings. A reflexive approach underpinned the process, with attention to researcher positionality and the coconstruction of meaning across study sites.

Ethical considerations

Participation in the study was entirely voluntary, and participants were fully informed of their right to withdraw at any time without consequence. Written informed consent was obtained from all participants prior to data collection. Confidentiality and anonymity were strictly protected throughout all stages of the study.

Given the sensitive nature of VAWG research, additional safeguarding mechanisms were implemented in accordance with WHO ethical recommendations for conducting research on violence against women.²⁶ These included: conducting interviews in safe, private and familiar settings; ensuring psychosocial support was available to survivor participants before and after interviews through trained counsellors from partner organisations; using trauma-informed approaches across all data collection; and applying strict data protection protocols, including the use of unique participant codes and secure data storage with access limited to authorised team members

Ethical approval was obtained from review boards in Albania (4161/2), Brazil (CEP/Fiocruz Minas—CAAE: 53271621.7.0000.5091; CEP/Secretaria Municipal de Saúde de Belo Horizonte—CAAE: 53271621.7.3001.5140; Comissão Nacional de Ética em Pesquisa/CONEP—CAAE: 53271621.7.0000.5091) and Switzerland (AO_2022-00053).

Results

Our study found that missed opportunities occur across the continuum of care in both settings, with striking similarities in the quantity of missed opportunities as well as in the underlying mechanisms. We constructed two retrospective cohorts of women and girls in Tirana and Belo Horizonte to examine their trajectories through the public health system over a 5-year period (table 2).

Table 2. Cohort characteristics.

Indicator	Tirana, Albania	Belo Horizonte, Brazil
Number of girls and women in the cohort	68	52
Average age	38.8 years	31.8 years*
Race/ethnicity (as captured in the health records)	Not available	19.2% (10/52) Black 36.5% (19/52) Brown (Parda) 44.2% (23/52) White
Living in the capital city	100% (68/68)	86.5% (n=45/52)

^*The cohort in Belo Horizonte included only women and girls aged 10–49 years.

In both contexts, we found missed opportunities in primary health as well as in emergency and hospital settings. The quantified indicators for each missed opportunity are outlined in table 3.

Table 3. Quantitative results—missed opportunities in Tirana and Belo Horizonte.

Domain	Indicator	Indicator definition	Tirana, Albania	Belo Horizonte, Brazil
Missed access	Missed access to a minimum one public healthcare facility	% of women who had not accessed any public healthcare facility (primary, emergency or hospital)	42.7% (n=29/68)	42% (n=22/52)
	Missed access to primary healthcare	% of women who had not accessed primary healthcare facilities	48.5% (n=35/68)	63% (n=33/52)
	Missed access to emergency/hospital services	% of women who had not accessed emergency or hospital services	80.9% (n=55/68)	63% (n=33/52)
Missed detection	Missed detection in PHC	% of women who accessed PHC and had no registry of VAWG in the medical records	100% (n=35/35)	68% (n=13/19)
	Average number of visits to primary healthcare per woman	Average number of visits to PHC per woman who had accessed	3.3 visits	Average: 14 visits Mean: 6 visits
	Missed detection in emergency/hospital services	% of women who accessed emergency or hospital and had no registry of VAWG in the medical records	96.8% (n=30/31)	79% (n=16/19)*
	Average number of visits to emergency/hospital services per woman	Number of visits to emergency or hospital facility per woman who had accessed	1.2 visits	2.3 hospitalisations
Missed statistic	Missed notification in PHC	% of women who accessed PHC and had no notification of VAWG	Not applicable	100% (n=19/19)
	Missed notification emergency/hospital services	% of women who accessed emergency or hospital services and had no notification of VAWG	Not applicable	58% (n=11/19)
	Missed cause of death statistic	% of women killed by femicide and who had a different cause of death from aggression in the mortality database	Not applicable	11.5% (n=6/52)

PHC, primary healthcare; VAWG, violence against women and girls.

Despite the high frequency of health service visits by survivors, detection and notification remained almost absent pointing to systemic neglect embedded in health system structures and norms rather than individual provider oversight. The common mechanisms leading to these missed opportunities across both study sites are outlined in figure 2.

Figure 2. Common determinants of missed opportunities in Tirana and Belo Horizonte. VAWG, violence against women and girls.

To allow for in-depth, context-specific analysis, findings are presented separately for each case study, triangulating quantitative and qualitative data within each setting. Cross-case comparison is addressed in the Discussion.

Case study 1: Tirana, Albania

Quantitative and qualitative data reveal that Tirana’s health system’s response to VAWG is largely absent across both primary and hospital care. Systemic factors shape these missed opportunities, such as the biomedical design of health services, which—as interviewees noted—prioritises clinical interventions over holistic, socioecological approaches. Social and gender norms further shape these missed opportunities, as these influence the attitudes and interactions of health providers with survivors of VAWG. Statements such as, If violence occurs here, I can confidently say that it’s the woman’s fault (16—male doctor, Tirana) illustrate how victim-blaming and minimisation of women’s experiences undermine empathetic care and discourage disclosure.

The lack of VAWG training further aggravates the discontinuum of care. Neither preservice education nor in-service programmes address how to respond to such cases. While some providers attended workshops or short courses, most received no training, leaving major knowledge gaps on care and legal obligations. Several physicians were unaware of the existence of a national standard operating procedure (SOP) for health professionals since 2011, leaving providers ill-prepared to identify, manage or refer survivors effectively.

We do not have an official protocol… Theoretically, I know I should keep notes and refer cases, but I don’t remember the details (14 Female Doctor, Tirana).

Missed access

While most survivors accessed health services, many faced missed opportunities of access. Our data revealed that 42.7% of women seeking support at the CLWG had not accessed any public primary or hospital health services in the 5 years before contacting the NGO.

The qualitative findings reveal that missed access for many women was a consequence of the VAWG. Many women avoided healthcare during violent relationships due to shame and fear of judgement—especially when violence was repeated and women described feeling responsible for having allowed the violence for so long.

I never went to the hospital or the health centre because I was ashamed. I ended up in this state because I tolerated him too much. He broke my leg and injured my head. (106 Woman Survivor, Tirana).

Many survivors perceived health services as focused solely on physical health further discouraging help seeking, especially during ongoing abuse. Prior negative or unsupportive encounters with providers further deepened their reluctance to seek care.

Survivors who lived with their abusers—intimate partners or family members—often had their movements controlled, including when and how they could seek healthcare. Even when permitted to attend appointments, they were frequently accompanied by the perpetrator or other controlling relatives, limiting their ability to disclose violence or seek support.

Missed detection

Our quantitative data showed that none of the 68 women who visited a primary health facility had VAWG documented in their medical records, and only one of the 31 women who accessed a hospital had a recorded case of VAWG. This detection occurred in the specialised sexual violence centre, after the woman sought care for rape. These missed detection opportunities occurred despite frequent service use, particularly in primary care, where women averaged 3.3 visits in the studied period, increasing to 5.1 for those aged 50 and older.

Qualitative data also showed that VAWG detection in clinical encounters was rare, even when women presented with symptoms that could have indicated violence—such as psychological distress or repeated injuries.

When asked about barriers to detection, health professionals expressed hesitancy to ask about violence. They often perceived VAWG as a private matter and feared that questioning would open a Pandora’s box that they felt unprepared to manage. As a result, many avoided inquiring about violence and remained passive even when it was suspected to not have to deal with the consequences of a positive response.

Detection patterns varied between healthcare settings. In primary care, professionals were more familiar with women’s family and social contexts, but this closeness sometimes discouraged disclosure by the survivors due to fear of confidentiality breaches or retaliation by perpetrators. Hospitals, on the other hand, offered greater anonymity, which survivors sometimes preferred, but providers lacked the time and conditions to explore underlying causes.

We are a university hospital, we are called ‘running hospitals’. They are not centres where women can sit, stay long, seek attention and talk. There is not enough time for them to talk about their social or psychological concerns. (10 Female Doctor).

Discriminatory or dismissive treatment by health providers, particularly towards survivors from ethnic minority backgrounds, such as Roma women, was reported by several interviewees. One survivor from an ethnic minority background described being treated ‘like an animal’.

I went to the hospital when my lip was cut. The police took me to the hospital. But they didn't explain anything to me at all. Even the doctor was mocking me: What’s up, did the third world war start? and he was laughing. (116 Woman Survivor)

These types of experiences further eroded trust in the health system and discouraged disclosure.

Missed care

In Tirana, missed care could not be assessed from medical records, as documentation of violence was almost entirely absent. Within our cohort, only one case had been formally detected—at the hospital’s specialised sexual violence centre (Lilium). In this instance, the survivor received STI prevention, but no further care or follow-up was recorded.

Although Albania’s SOP for health professionals outlines the steps for identifying, treating and referring survivors of VAWG. It mandates documentation, confidentiality and timely referral to ensure survivors receive comprehensive medical, psychological and legal support. Yet, most professionals reported not following it. Survivors described that when they felt the health professionals in primary care suspected situations of VAWG, they would provide informal advice, but not want to get mixed up in the situation.

Interviews with health professionals revealed that missed care was not simply the result of inaction but also the result of systemic invisibility. Some health professionals did attempt to support or refer survivors, but these efforts were typically delivered outside formal procedures and deliberately left undocumented. Providers described avoiding formal reporting to sidestep potential consequences, such as involvement with police or judicial proceedings, confrontation with perpetrators or procedures for which they felt unprepared.

In hospitals, where social workers and psychologists are present, some survivors and professionals described elements of interdisciplinary collaboration. Yet workflows were informal and poorly structured, leaving professionals frustrated:

What stops you is the fact that if that woman does not become part of a support system, then the work we do fades away and it leaves you with a bitter taste at the end because that work done by us is reduced just to a friendly conversation and not like an institutional support, as it should be. (10 Female Gynaecologist)

The introduction of social workers and psychologists in the primary health sector is seen as an opportunity to strengthen the response to VAWG in the health sector, but the specific procedures remain unclear.

Missed referral

While hospital-based professionals occasionally referred survivors to in-house psychologists or social workers, these referrals were informal and dependent on personal networks. A formal, coordinated referral system was absent. Awareness of support services beyond the health sector—such as the Counselling Line for Women and Girls or municipal and civil society services—was limited. Referral was often narrowly interpreted as legal reporting rather than connecting survivors to a broader network of social and protective services.

A better coordination with social services. Contacts with organizations and the municipality are created personally. We have no official sources of information. There is a lack of institutional and official networking of services. (9 Female Psychologist in a hospital)

Mandatory reporting to the police—legally required in cases of VAWG, even without the consent of the survivors—was a major barrier to intervention and referral. Some providers avoided reporting, fearing women were not ready or it could put women at risk, while others avoided legal involvement altogether. This reluctance was compounded by the absence of a functional coordination mechanism linking health, social and legal sectors, which left providers with few alternatives for safe and supportive referrals.

The lack of institutional follow-up further discouraged action, as professionals rarely received feedback, fostering disillusionment and reluctance to engage in a process that raised survivor expectations without adequate support.

Case study 2: Belo Horizonte, Brazil

In Belo Horizonte, the quantitative and qualitative data show that missed opportunities also occur across all milestones of response, in primary healthcare and emergency units. As in Tirana, systemic determinants influence these gaps. Although professionals frequently described awareness for the VAWG as a societal problem and, in interviews, they often shared examples of attempts to offer support, these efforts remained fragmented and relied largely on individual initiative and creativity.

Missed opportunities were driven by the lack of formal VAWG training and work processes guided by reimbursement indicators like Previne Brasil, which reduced care to biomedical approaches. Social and gender norms within the health system—especially regarding marginalised groups such as Black women, survivors from fragile territories or those using criminalised substances—further reinforced exclusion from care.

I think it really depends on whether the attendant has empathy; sometimes, most of them don't have it. And when they lack empathy, they're not specialists, right? They treat us rudely, like we're crazy, you know? We need support. (Woman survivor)

Missed access

42% of the women who were killed by femicides had no records in the health information systems reviewed—meaning they had not accessed a primary health facility, emergency care (UPA), hospitalisation, or outpatient services in the 5 years prior to their death.

We explored whether and how VAWG influenced access to public health services in our focused ethnography. A direct mechanism was perpetrators’ control over women’s behaviour, including healthcare decisions, leaving survivors unable to seek care autonomously.

(…) the perpetrator does not let the person leave the house, does not let the person do anything, not even take care of their own health. She will be exposing herself even more.” (Women’s Group 1)

We found a crucial enabler for access to primary health facilities in the figure of the community health workers. These are usually women of the community who are employed and integrated in the Family health model of primary care in Brazil (ESF, acronym in Portuguese). Their mission is making the link between the health facility and the community and accompany longitudinally patients and communities over time. In our observations, as well as during the interviews, they played a crucial role in ensuring survivors of VAWG would access care. For example, when a patient missed an appointment, the CHW would follow-up and visit the house of the person. However, these workers are also in a vulnerable position, as explained in the Missed detection section.

Missed detection

Although 58% of the women had accessed health services in the 5 years preceding their deaths, formal detection of violence was extremely rare. Analysis of ICD-10 codes and medical records across primary care, ambulatory and hospital services revealed only six instances in PHC and three in hospitals where violence was recorded as a reason for the visit, reflecting high missed detection rates (68% and 78%, respectively). These findings are striking given the intensity of health service use. In PHC alone, the women averaged 14 visits (median of 6), yet only six (31.6%) had any documentation indicating violence. In other words, for 13 women (68.4%), violence went undetected or undocumented despite repeated contact with the health system.

Our qualitative analysis identified multiple, overlapping factors behind missed detection. Violence is often framed as a private matter—professionals described disclosures of VAWG as emotional venting (desabafos) rather than actionable reports and thus treated them as secrets.

Facility-level dynamics further contributed to missed detection. In ‘violent territories’, normalisation of violence and fear of retaliation—especially where perpetrators were linked to organised crime—discouraged formal detection and documentation.

Community health workers, who are well-positioned to identify risk of VAWG face personal exposure to violence and feared community backlash. This tension undermined detection, even when frontline staff were aware of it.

Regarding violence against women, we cannot get access to the situation; women do not open up, and we are also afraid. For example, if the aggressor decides that we made some report, provided some guidance, or directed someone to an organization, they won't let us work in the territory anymore; they threaten us. We have to change our basic healthcare unit to work, you know? We have to protect our lives too, not just the users’, you understand? That’s why we don't get too involved (Female community health worker).

Survivors themselves also encountered structural barriers to disclosure. Consultations were often rushed or interrupted, and many feared being judged or misunderstood if they described or talked about the VAWG—further contributing to them not asking for support.

Missed care

Family Health Teams (ESF) provide holistic primary care and are supported in Belo Horizonte by specialised professionals such as psychologists, psychiatrists, or nutritionists. Monthly multidisciplinary meetings coordinate care for complex cases, which often involve hidden violence. However, VAWG was rarely named explicitly, instead appearing indirectly as depression, substance abuse or complicated family situations. Responses frequently defaulted to medicalisation, constrained by limited time, staffing and resources.

So we started discussing with the teams why these women are being medicated so much, right? (Male Psychologist)

These meetings also offered important moments of reflection, allowing professionals to question beliefs and improve future care. Community health workers played a particularly important role in these discussions by bringing the social context of cases into focus, helping to bridge the gap between the facility and the realities of survivors’ lives.

The quality of care to VAWG varied by type of violence, social markers and provider sensitivity. Black and brown women, in particular, faced disbelief and discriminatory treatment, compounding missed opportunities for meaningful support. These inequities illustrate how systemic and interpersonal factors converge to produce missed care—even when survivors do reach services.

Despite institutional constraints, we also observed individual acts of care marked by the creativity of health professionals, which included interdisciplinary collaboration to care or the establishing of women’s groups at the health facility. Psychologists and mental health teams were particularly crucial in accompanying survivors through long processes of recovery, often helping them reach the tipping point needed to exit situations of violence.

Then I went to another one, also a student, and I was lucky to find this girl. She really identified with my situation. (…) That was the moment when I truly felt welcomed and cared for. (Woman Survivor 2)

Missed referral

As in Tirana, referral in cases of VAWG was difficult to assess quantitatively, but we explored it extensively in qualitative discussions. Providers often lacked knowledge of referral options, limiting referrals to internal pathways such as multidisciplinary teams or social workers. The ability to offer more comprehensive referral pathways varied across health centres and often depended on the initiative of the health centre manager. In some facilities, we encountered managers who had proactively established both formal and informal local networks to improve responses to VAWG.

Referral from the health sector to social services (eg, emergency shelters) is the responsibility of the facility social workers. However, social workers are not always present, leaving survivors in urgent need without access to protection. Even when present, the scarcity of specialised shelters limits effective referral: Belo Horizonte has only one dedicated shelter for VAWG survivors, which is not accepting survivors 24/7. As a result, survivors are sometimes referred to general shelters intended for people experiencing homelessness, where they may once again be exposed to violence due to the mixed gender and precarious conditions.

In interviews and group discussions, responses on where to refer women varied considerably. This highlights the importance of having clearly established referral networks agreed on across stakeholders. Belo Horizonte recently launched a multisectoral protocol through a new network of services to respond to VAWG, introduced at the end of 2024. However, implementation is still in its early stages, and the health sector’s role remains loosely defined within this effort.

Existing response protocols were sometimes misinterpreted, creating barriers to primary care access. For example, survivors of sexual violence are formally directed to specialised services such as one-stop centres. During the study, some survivors were denied support at the PHC level, being told by reception staff to seek help directly from specialised services—undermining access and increasing vulnerability.

Missed statistic

Detection failures also extended to the statistical level. Mortality records (SIM) for six of the 52 femicide cases did not list aggression as the underlying cause of death, distorting national mortality statistics and limiting epidemiological analysis and policy response.

The SINAN system, intended for mandatory epidemiological notification of interpersonal and self-inflicted violence, including VAWG, was underutilised. Among the 19 women who accessed hospital care, only eight had a SINAN notification—five of these notifications occurred only at the time of the death. This pattern suggests that violence was frequently acknowledged only when it was so severe that it could no longer be ignored. In the primary care sector, despite several visits, we found not a single notification.

Interviews with professionals revealed several reasons for under-reporting. Many viewed SINAN as a bureaucratic requirement (long time to needed to complete it) rather than a tool for care. Some feared legal consequences or believed notifications could expose them to judicial involvement, despite no connection between SINAN and judiciary or police. These perceptions contributed to systematic under-reporting and to the invisibility of VAWG in the health system’s decision-making.

I also understand that the care pressure we face is a limiting factor, because while I fill out a notification that will take me 20 minutes, there are another 10 patients in the queue waiting for me. (Male Doctor 12)

Discussion

Our study introduces the concept of missed opportunities to respond to VAWG, providing evidence of their occurrence and the underlying mechanisms in Tirana and Belo Horizonte. Using an intersectional systems thinking approach, we conceptualised the health systems response to VAWG as a discontinuum of care, where each missed opportunity in access, detection, care, referral or statistics weakens the next. Rather than isolated breakdowns, these missed opportunities are systematically connected and mutually reinforcing and affect disproportionately already marginalised women and girls.

Applying this framework in two distinct contexts, we found strikingly similar patterns. Despite differences in geography, culture and health system structures, most women and girls had repeatedly accessed health services in the years studied, yet their experiences of VAWG went largely unaddressed. Mechanisms underpinning missed opportunities across the (dis)continuum of care were consistent with previous research: past negative experiences deter access,^{27 28} institutional constraints limit detection and care^{8 29} and fragmented referral systems prevent continuity of care.^{30 31} The reliance on improvised, individualised responses echoes documented challenges in systems preparedness.⁸ In Belo Horizonte, despite mandatory reporting and legal recognition of femicide, under-recording of women’s deaths due to aggression reflects broader patterns of invisibilisation reported in other settings,^32–34 which contributes to deprioritisation of VAWG in policy and resource allocation, thus reinforcing missed opportunities.

This gap is especially striking given that both Albania and Brazil have had VAWG-specific laws and health sector protocols in place for nearly two decades. However, most professionals were unaware of existing guidelines or uncertain about their responsibilities in implementing them, revealing a disconnect between policy and practice. Studies from other settings, such as Spain,³⁵ United Kingdom,³⁶ New Zealand and more recently the HERA evaluation in four countries (Brazil, Nepal, Palestine and Sri Lanka),³⁷ have similarly shown how protocols alone are insufficient without investment in systems strengthening, supervision and workplace cultures that prioritise VAWG response.

Key drivers of this systemic discontinuum are gender and social norms that determine the prevalence of VAWG, as well as how institutions miss recognizing VAWG as a public health problem.⁶ Health systems are grounded in biomedical paradigms that marginalise gender-based violence when it is detected as either a private matter or a psychological pathology located within the individual woman.^{37 38} This framing reflects and reinforces patriarchal norms that depoliticise violence, obscuring its structural and relational roots. Feminist scholars have long shown how the medicalisation and privatisation of VAWG work to render it invisible in public policy agendas and how institutional responses often fail to challenge the social axes of power—of gender, race, class and ability—that underpin violence itself.^{39 40} Our findings in both Tirana and Belo Horizonte illustrate how this framing operates in practice: professionals frequently expressed uncertainty about whether VAWG fell within their clinical responsibilities, defaulting to silence or referral rather than engagement. This institutional ambivalence is not incidental; it reflects patriarchal norms embedded in professional training, organisational cultures and policy implementation that systematically deprioritise the health systems response to VAWG.

These institutional failures are not experienced equally. Our analysis shows how intersecting structural inequalities—particularly around race, class and disability—shape these missed opportunities. In Tirana, Roma women and women with disabilities encountered additional barriers rooted in provider bias and assumptions about credibility and deservingness of care, such as the example provided of being treated like an animal. In Belo Horizonte, black and low-income women in peripheral territories were disproportionately underserved, not only because of individual provider attitudes but also because institutional practices, including screening protocols, documentation standards and referral pathways, were designed around a normative patient (generally a white, middle-class, abled woman) who does not reflect their realities. These findings resonate with Carneiro’s and Crenshaw’s arguments that epistemic erasure operates through institutional logics that selectively define whose suffering counts as violence and who deserves care. ^{19 41}

Drawing on Mbembe’s concept of necropolitics,⁴² we interpret these missed opportunities as forms of social abandonment. In Belo Horizonte, the intersection of race, gender and territory created contexts in which women’s deaths were not only unprevented but also rendered socially invisible. As such, the missed opportunities to count some femicides, becomes the endpoint of a system that allows certain populations to suffer and die without institutional response.^43–45

Despite these systemic failures, individual providers in both contexts demonstrated acts of care and compassion, creatively navigating the system to provide formal and informal support. These moments illustrate professional commitment and ethical responsibility, but they also underscore the inadequacy of relying on discretionary acts within systems that fail to guarantee safety or continuity.

Conceptualising missed opportunities as a discontinuum offers more than critique; it helps identify leverage points for intervention. A more integrated, survivor-centred response can be catalysed by small but strategic changes, such as enabling routine screening in primary care that is sensitive to intersecting identities and risks, strengthening community health worker support structures, improving routine information systems to capture the differentiated experiences of women facing violence and using multidisciplinary case discussions more intentionally. Importantly, these discussions should not only serve as spaces for coordination but also embrace their pedagogical dimension—helping providers to identify and respond to signs of violence while critically engaging with the racist and misogynistic stereotypes that perpetuate invisibility. In this way, interventions move beyond fragmented fixes to embed intersectional principles at every level, positioning the health system not only as a site of care but also as a catalyst for social transformation in close coordination with multisectoral actors.

Limitations of the study

The study design aimed to overcome individual method limitations by combining quantitative and qualitative approaches, using triangulation to contextualise gaps in documentation and capture experiences not recorded in administrative systems. Despite this approach, several limitations remain important.

The quantitative figures must be interpreted with caution. In Tirana, reliance on paper records limited both completeness and accessibility. In Belo Horizonte, our analysis focused on women who died by femicide, which represents only the most extreme and tragic outcome of VAWG. The scale of missed opportunities across the wider population is, therefore, likely much greater. Furthermore, the SIA and SIH systems are primarily designed for administrative reimbursement rather than clinical documentation, limiting their utility for identifying VAWG-related cases. The SISREDE system used in primary care similarly lacks a specific field for recording suspected or confirmed VAWG, requiring professionals to document cases in unstructured, ad hoc ways—if at all. These limitations prevented the quantification of missed care and referrals and may have introduced information bias, most likely underestimating the scale of gaps in care.

Our focus on the public health sector excludes interactions with private providers, which may have different dynamics in the health system’s response to VAWG and would require further investigation.

Conclusion

The comparison between Tirana and Belo Horizonte reveals a troubling similarity in how health systems miss opportunities to respond to VAWG. Despite distinct contexts, the underlying dynamics—policy-practice gaps, institutional unpreparedness, stigma and structural discrimination—are shared. This reflects that VAWG is not a culturally specific problem but a systemic issue rooted in common social and institutional logics.

Intersectional systems thinking is key to understanding this. It brings into view how social axes of power, such as race, class and other social markers mediate both experiences of violence and the quality of response. Addressing missed opportunities will require not only better protocols or training but also a structural shift in how violence is recognised, understood and acted on in health systems.

By integrating intersectionality and systems thinking, our study offers both a conceptual advance and a methodological pathway for analysing and transforming health systems’ responses to VAWG.

The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Data availability statement

Data are available upon reasonable request.