In structural adjustment programmes, reforms in the health sector have focused on streamlining and cost-recovery of services. But many victims of gender-based violence do not receive adequate health care until they are critically disabled–by which time both human morbidity and medical costs are unnecessarily high. Because of this gap in health care in the public health sector, much of the responsibility for the care of abused women has been delegated by default to small women’s organizations which have neither the resources nor the capacity to fully meet their needs.

Yet the health sector is uniquely situated to be an open door to aid for the women who have no other contact with authorities who can help them. Health care providers can refer women to other resources, such as legal services, safe houses for battered women, and counselling by gender-sensitive NGOs.

The World Bank has taken action to determine the precise toll of gender violence in the lives of women. The l993 issue of the World Development Report estimated the healthy years of life lost to men and women due to adverse causes. Every year lost due to premature death is counted as one "disability- adjusted life year" (DALY), and every year spent sick or incapacitated is counted as a fraction of a DALY, with the value determined by the severity of the disability.

This analysis indicates that rape and domestic violence are major causes of disability and death among women of reproductive age in both developed and developing countries. They are risk factors for a number of disease conditions such as STDs, depression and injuries.

In developing countries, it is estimated that rape and domestic violence account for 5 per cent of the healthy years of life lost to women of reproductive age. The percentage is even higher where the overall burden of disease faced by women has been reduced. For example, in China, where the disease burden is on the decline, the healthy years lost due to rape and domestic violence has increased to 16 per cent of the total burden. Globally, the health burden from gender violence among women age 15 to 44 is comparable to the burden of other risk factors and diseases such as HIV, tuberculosis, sepsis, childbirth, cancer, and cardiovascular disease (see Table 2).

These percentages are important indicators of the demands on the health care system. The physical and mental consequences of gender violence are usually sustained over an extended period of time and require monitoring and close follow-up if they are to be fully and effectively addressed.

The Fourth World Conference on Women, held in Beijing in 1995, specifically endorsed the concept of integrating relevant services for women into primary health care. This implies that the health sector, particularly the reproductive health and family planning sector, needs to more systematically study and respond to the specific health care requirements of victims of gender violence. The economic arguments for cost-effective health service delivery need to take into account the impact of violence against women on women’s health. As the pressure for integrating and decentralizing services grows, it will be crucial to create policy reforms that respond to women’s specific needs so that appropriate preventive as well as curative programmes are put in place.