How India’s Public Health System Can Reach Rural Women Suffering Domestic Abuse

The key is identifying gender-based violence in villages early, together with counselling services at the lowest levels and support by ASHAs.

PATAN, Gujarat, India — Hetal [name changed] was in her late thirties and pregnant with her fifth child when she was persuaded by an Accredited Social Health Activist (ASHA) to visit a counsellor at the Mahila Sahayata Kendra (MSK), or Women’s Help Centre, inside the Radhanpur Sub-District Hospital in Patan, Gujarat. ASHAs work at the grassroots to provide maternal and child health services in India’s villages and urban slums.

Hetal was suffering from severe anaemia and hypertension and was malnourished. She was also shy and barely spoke. The ASHA observed Hetal had been subjected to verbal abuse by her in-laws and husband and that they didn’t care for her health. Even when she suffered fits of breathlessness and couldn’t move because her hands and feet were swollen, they dismissed her agony.

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After the ASHA took her to the hospital, the doctors requested the husband or a family member join Hetal for follow-up checks. But her family didn’t care for such summons by a doctor, recalls Jashodaben Bhil, a counsellor at MSK. The doctors told Bhil that Hetal needed immediate attention or that she could die before or during childbirth.  

Counsellors like Bhil and ASHAs at the grassroots of the public health system in Patan have been detecting, supporting and enabling survivors of violence to access other services since they were trained to do so by an initiative of the Gujarat-based nonprofit Society for Women’s Action and Training Initiatives (SWATI). 

The impetus is that, while the WHO has described violence against women as a public health concern, India’s response has been rooted in criminal justice. The country doesn’t have a national policy to tackle domestic violence as a public health issue. For Hetal, that means India’s laws offer an avenue of redress by lodging a complaint with the police against her husband but don't necessarily attend to her rehabilitation.

Nearly 30% of India’s women suffer gender-based violence. “Cruelty by husband” has been the highest-ranked category in relation to violence against women in the National Crime Records Bureau—even though an estimated 75% of domestic violence survivors have never registered a case.

In 2012, SWATI set up the MSK at the Radhanpur Sub-District Hospital together with the state’s Department of Health and Family Welfare. Over the years, their model has evolved to integrate ground-level insights to create an “upward referral chain” that ensures women’s access to healthcare and support located in the hospital at different levels, explains Poonam Kathuria, Director of SWATI. 

According to Sanjida Arora of the Mumbai-based nonprofit Center for Enquiry into Health and Allied Themes (CEHAT), the criminal justice system doesn’t meet survivors’ expectations. 

“It's very important to set up a response mechanism at the level of the health facility, which is an early point of contact for the women facing violence, whereas the criminal justice system comes into the picture at a very later stage,” Arora says.  

CEHAT along with other civil society organisations and experts have created a draft protocol that focuses on treating domestic violence as a public health concern. Arora says they are working with states and the Center to push for an implementation plan to include the health sector response to domestic violence. You can read a draft version of the plan here.  

At the outset, MSKs’ services and interventions for survivors were offered at the secondary and tertiary level i.e. at the sub-district, district, and city hospitals, including the Radhanpur Sub-District Hospital, GMERS Medical College and Siddhpur District Hospital in Patan. After training 400 ASHAs, the referrals to the sub-district hospitals increased by around 13% between 2016 and 2020. 

However, distressed survivors had to travel great distances to receive counselling and referral services, and they were reluctant to do so, Kathuria says. The expenses they would incur on the way didn’t help either.

Almost 80% of Patan’s residents are in villages. More than 65% of India’s population lives in such rural areas. Surveys have found that the women in these places are far removed from public hospitals as well as lack social and financial support, mobility, and the agency to make their own decisions. 

Hetal, for instance, couldn’t visit the hospital without her husband or the ASHA. When her family members refused to bring her for follow-up visits, the ASHA, Bhil and the doctor resorted to contacting the head of the village council and the police. They put social pressure on the in-laws, reminding them that their neglect could endanger Hetal’s life. 

As Bhil points out, it took a village for the husband to see that he needed to bring her to the doctor. 

When this reporter met Hetal, her husband was with her and she was reluctant to share her experiences. 

Kathuria notes that reaching the communities is essential. While India’s public health system works towards this, support systems for survivors don’t. 

For instance, there is one ASHA for every 1,000 people in rural areas focussing on maternal and child health, along with antenatal care staff, immunisation workers and so on. Sub-centres cater to more than five villages or 5,000 people each, whereas primary health centres cater to upwards of 30,000 people. Sub-district, district and teaching hospitals that function as secondary and tertiary hospitals cater to millions and are home to specialised departments. 

Initially, survivors like Hetal were being treated and counselled only at the district hospital. That needed to change. The “upward referral chain” meant survivors—especially those in rural India—could be treated and counselled at all levels.

But then the COVID-19 pandemic began, prompting the government to transform secondary and tertiary hospitals into COVID centres, and shutting off healthcare access to survivors. In response, the counsellors began to visit the sub-centres on rotation.  

These centres are now called Health and Wellness Centres, under India’s Ayushmann Bharat state-sponsored insurance scheme. HWCs are staffed with permanent community health workers and other staff, allowing them to remain functional on all days of the week. 

In the 22 months between June 2020 and April 2022, straddling the peak of the pandemic and lockdowns in India, MSK in GMERS Dharpur tapped its cadre of 124 ASHAs to build awareness of the counsellors’ visits. ASHAs passed on the details of these visits to survivors, referring them to the nearest HCWs. 

In this period, of the 124 ASHAs, 94 referred women to the counsellors. Each ASHA referred to 10 survivors of violence on average. Of these, 583 women (or 59%) admitted to suffering violence and close to 45% had asked counsellors for help escaping the violence in their homes. As time passed, the counsellors noticed an increase in the percentage of women admitting violence going up from 59% to around 70%. 

According to Kathuria, this is a sign of improvement in ASHAs understanding of the health impact of violence and a recognition of its usefulness for the health outcomes they work towards. 

ASHAs and survivors of violence 

The first survivors to seek help from the MSK were the ASHAs themselves. 

When Geeta [name changed], an ASHA in Patan district was trained by MSK, she came to terms with how deeply domestic violence at home was affecting her health. Her husband had inflicted grievous injuries on her—from public beatings during fits of drunken rage to suffocating her in the bedroom. Yet she had been afraid to approach the police.  

Bhil says that ASHAs were initially unable to identify cases in the field. With training, they started noticing the signs and symptoms: repeated bleeding, white discharge, fevers, stomach aches, insomnia and so forth. 

Avni Amin, a gender-based violence specialist with the WHO, says that training all healthcare providers to identify signs and symptoms of violence survivors can help prevent serious long-term effects on health, and refer them to other services.

Previous stories by this reporter have uncovered how several Indian states are trying to strengthen the health system's response to gender-based violence. 

Geeta admitted she routinely lied to the doctors about the reasons behind her injuries. But after years of counselling, she finally mustered the courage to leave her abusive husband of a decade and sought referrals to services that helped her move on.

Arora of CEHAT explains that survivors need a multi-sectoral response plus a range of services before being able to reach out to the criminal justice system. The dynamics of domestic violence—where an intimate partner is the abuser and also the breadwinner—are complicated. Given the socio-economic conditions of the family, Arora says, “it’s very unlikely that women will take any legal action. But what she wants is better access to the support services, including emotional support, which can be integrated within the health sector.”

SWATI has made these training modules for ASHAs available online and is in touch with other states to expand the programme. 

An important advantage of counsellors visiting the HCW in villages is that ASHAs don’t have to accompany survivors to the MSK. It saves the ASHA her time and travel costs. More importantly, it does not link ASHAs with the MSK. This protects ASHAs from backlash from the community for intervening in cases of domestic violence, Kathuria explains.

Women requiring immediate attention continue to be referred—and even accompanied—to secondary and tertiary hospitals. 

All women who are counselled are given information about helplines, safety and action plans if the violence escalates, guidance on the documents required, and referrals to other services. 

Between 2020 and 2022, around 530 women (91% of those who had the courage to share that they had been suffering violence) visiting the sub-centre for counselling came from their marital homes—where they lived with their in-laws or husbands—but in the same period, 65% of women visiting sub-district and district hospitals say they had returned to their parents' homes. 

Kathuria says those who come from their marital homes may be suffering the initial stages of abuse. But once a woman has returned to her parents' home, the violence has peaked and the worst has happened. 

So identifying survivors at the community level can keep the violence from escalating. Women can also find support and help before they experience extreme distress in the form of dire ill-health or social consequences like desertion and being sent back to the natal family.

Tertiary hospitals also see survivors who have tolerated abuse for a longer time with attempts to take their life or suicidal tendencies, and injuries like burns, cuts and fractures. 

Kathuria says, “By the time a woman comes to a [tertiary] hospital, she has suffered significant abuse by the abuser. She's reached a point of emergency in some ways.” 

However, the survivors who visited the HCWs commonly came with complaints of stress, sleeplessness or worrying, reproductive health disorders like excessive white discharge, menstrual disorders or with signs of high-risk pregnancies. These are health consequences that follow abuse, in place of the love and support rural Indian women should be receiving. 

When asked if spotting survivors of violence was an additional responsibility, and thus a burden on their busy schedule, Mukta Ben, an ASHA worker in Borsan village, says, “Work has reduced, in fact.” In cases where violence is an underlying cause affecting women’s health, addressing it can help ASHAs in their work on improving women’s nutritional levels and health outcomes. 

“If the family is not taking care of a woman, and her health is suffering, then counselling really helps,” she says. 

Bhil adds she has seen ASHA workers welcome the training because it makes their work easier. ASHAs are often on friendly terms with women in villages. These women also trust ASHAs: These grassroots health workers offer home-bound women a connection—and an escape—to the world beyond their threshold, after all.