Background: Health systems have a critical role in a multi-sectoral response to domestic violence against women, but the evidence is skewed to toward high-income countries, and lessons learned are not easily transferred to low-and-middle-income countries due to social, cultural and economic differences. The intervention strengthened the healthcare response to VAW through training for healthcare providers and managers and a care pathway for women experiencing domestic violence. The synthesis aimed to explore what factors promoted or inhibited the translation of HERA’s intended goals into a ‘real world’ set of activities. Methods: Data sources include: qualitative interviews with health care providers and managers and women who disclosed violence; clinic data on cases of domestic violence and referrals; and the Provider Intervention Measure which assessed changes in attitudes and behaviour. Thematic analysis was used to analyse qualitative data and descriptive statistics were used to analyse quantitative data. Results: The intervention increased disclosure of violence from a negligible baseline in clinical settings, but there was little acceptance of further referral for services among women. Although obstacles varied between countries, some Findings were ubiquitous: the impact of the Covid-19 pandemic; poor inter-sectoral coordination; lack of engagement with communities; and a disconnection between what the care pathway could offer and the diverse needs of women. There was inconsistent recording of violence, compounded by multiple documentation systems; uncertainty about role of health care vis-à-vis perpetrators of violence; and poor understanding of VAW as a priority policy issue across sectors. Conclusions: Fundamental research is needed to surface local understandings of how best to support women and children. Community engagement and community health workers have a critical role in building community trust in the health system response. Active leadership, management and institutional support is crucial to implementation.