Illustration: Pariplab Chakraborty
This story was supported by the Pulitzer Center.
Bengaluru, India: In May this year, 21-year-old Mina* walked into Hajee Sir Ismail Sait Gosha Hospital, a government-run maternity facility in Bengaluru, Karnataka, desperately seeking an abortion. Mina had been sexually assaulted. She was evasive about the details, but Hemalatha P., the gynaecologist attending to her, suspected the involvement of an intimate partner.
“She didn’t want to lodge a complaint. She wanted to protect the family honour,” Hemalatha said.
Hemalatha informed her that an abortion wouldn’t be possible. India allows termination of pregnancies up to 24 weeks – and Mina was almost 30 weeks pregnant.
Mina’s assault is not an isolated incident. Almost one in three (31%) women in India have faced physical or sexual violence, according to the National Family Health Survey (NFHS). Gender-based violence is a more common cause of ill health among women than traffic accidents and malaria combined. However, this epidemic of violence goes largely unaddressed. Almost 86% of the women who have faced gender-based violence did not seek any help and 77% never told anyone about it.
The Indian government recognises gender-based violence as a criminal justice issue, but largely ignores that it is also, in the words of the World Health Organisation, “a public health crisis”. Emotional abuse, physical abuse, and neglect are all bad for the brain, and trauma expert Dr Gabor Maté argues that being too “nice” and overly accommodating of others can actually be harmful to one’s health.
India has dedicated national programmes for a long list of medical conditions: HIV-AIDS, tuberculosis, malaria, cancer, diabetes, cardio-vascular diseases, fluorosis, iodine deficiencies, blindness, and palliative care among others. Despite how pervasive it is, gender-based violence hasn’t received similar attention as a health concern. Numerous studies, as well as a previous article by the reporters, have found that gender-based violence impacts the physical and mental health of survivors, as well as their sexual and reproductive health. Yet, it was only after a national outpouring of anger in 2012 over the sexual assault and death of a young woman in Delhi, that the health ministry introduced a protocol for care for survivors of sexual violence. Only nine out of 28 states and eight union territories have implemented it so far.
“Not all health providers are trained in the protocol, and the government’s commitment varies because health is a state subject,” said Avni Amin, unit head, Rights and Equality through the Life Course, Department of Sexual and Reproductive Health and Research at the WHO. Given the huge gaps in guidance, policy, and funding for tackling gender-based violence, healthcare providers are often unable to respond to cases like Mina’s. There is no national protocol for domestic violence survivors even now.
In a staggering 80% of the cases of gender-based violence reported in the NFHS, the perpetrator was a current or former partner. A study conducted in two tertiary hospitals in Bihar found that while healthcare providers could recognise signs and symptoms of intimate partner violence, more than half did not have information on care pathways and support for the survivors.
“The health systems have really not woken up to the fact that they are the first port of call,” said Sangeeta Rege, director of the Centre for Enquiry Into Health and Allied Themes (CEHAT).
“They occupy an important position to early-identify signs and symptoms and can provide a therapeutic response to build a survivor’s capacity to be able to access another service.”
CEHAT, in collaboration with Mumbai’s municipal corporation, pioneered Dilaasa – India’s first hospital-based crisis centre for survivors of gender-based violence in Mumbai in 2001. In the absence of a national policy, localised initiatives like Dilaasa have been filling the void. State governments in Maharashtra, Kerala, Tamil Nadu, Gujarat, Meghalaya and Karnataka have, with the support of nonprofits, started healthcare-based crisis centres that aim to provide survivors easy access to healthcare and support.
Hemalatha, the gynaecologist, was trained under one such programme called Muktha. Started in 2021, it is supported by Karnataka’s National Health Mission and covers five hospitals in Bengaluru and Chikkaballapur districts. While it doesn’t have funding for dedicated counsellors, Muktha facilitated the training of around 400 existing staffers – including 129 doctors and 227 nurses – to identify survivors of gender-based violence, provide them with first-line counselling, and refer them to other services.
Hemalatha is a nodal officer for Muktha at Gosha Hospital. After comforting Mina, she advised her to carry on with the pregnancy, informing her that she could hand the baby over to the Child Welfare Committee after the delivery. She cautioned Mina, who was suffering from hypertension, against seeking an abortion elsewhere.
Mina agreed. But things took a turn for the worse soon after. Two weeks after she met Hemalatha, Mina went into labour. Born at just 32 weeks, the baby was preterm.
That wasn’t the only problem.
“This was all sudden. Her family members and neighbours didn’t know she was pregnant,” Hemalatha said.
Mina couldn’t go back home immediately, which left Hemalatha scrambling to find shelter for her as well as the baby.
Funding and lopsided focus
Mina’s only real option was a one-stop centre (OSC) for women affected by violence. Run by the Department of Women and Child Development (WCD), the OSCs aim to provide temporary shelter, medical, legal, and police assistance as well as psychological support for survivors of gender-based violence. These centres remain the only project with at least a tangential focus on healthcare that has been supported by the Nirbhaya Fund, a non-lapsable corpus that was created in the wake of the 2012 Delhi rape case to respond to the gender-based violence crisis.
The Fund is managed by a committee led by the WCD, with members from various ministries and departments – such as Home Affairs and Railways – but none from the Ministry of Health and Family Welfare (MOHFW), a review of publicly available documents shows. Moreover, an analysis of the 42 programmes under the Nirbhaya Fund shows only 41% (Rs 4,923 crore of Rs 12,000 crore) of the appraised fund has been released, of which only 51% (Rs 2,521 crore) has been utilised.
In August 2021, a Parliamentary Standing Committee pulled up the Ministry of Home Affairs for under-utilisation and diversion of Nirbhaya funds.
The Committee took “a very serious note of this and strongly recommends that the Ministry should desist from sanctioning funds for other schemes/projects from Nirbhaya Fund and adhere to the original purpose of Nirbhaya Fund.” It also recommended setting up a central-level committee to oversee and improve the utilisation of the Nirbhaya Fund.
According to an August 2023 Lok Sabha reply, there are 733 OSCs across 35 states and union territories that have assisted more than 700,000 women – on average, each OSC has assisted 964 women since the inception of the scheme in 2015. While the topline numbers paint a positive picture, breaking the numbers down by state reveals a startling disparity in the usefulness of these centres – from around 3,000 women assisted at each OSC in Goa, Andhra Pradesh and Uttar Pradesh to just 15 in West Bengal and 33 in Tripura.
“It’s a decade since Nirbhaya, and of the 700+ centres many are not functional,” Amin from WHO said. We don’t know whether these centres have been evaluated for quality and uptake of services, which is important for accountability, she added.
“So many women have reached the centre, but we don’t really have outcome data,” said Rege, pointing out that OSCs are ill-equipped to provide medical support to survivors of gender-based violence. “[The OSCs] have nobody from the health system. At most, the centre may have an auxiliary nurse or midwife, who does not have a mandate for conducting medical examination in rape or domestic violence in India.”
The Ministry of Health and Family Welfare, and Women and Child Department were contacted over email for a comment on these issues. The article will be updated if there is a response.
After Mina delivered the baby, staff at Gosha Hospital tried contacting the OSC centre, just five kilometres away, but they couldn’t reach the coordinator. Referring to other services or coordinating with other departments isn’t easy or straightforward, doctors and nurses interviewed for this story said. But the team at Gosha used all the resources they could, and within 24 hours arranged shelter for Mina at the OSC and handed over the baby to the Child Welfare Committee.
The 2017 National Health Policy calls for strengthening the health system’s response to gender-based violence and “ensuring that the staff have orientation to gender-sensitivity issues.” But the central and state health departments need to, in Amin’s view, “put their money where their mouth is.” Training and resources required to strengthen the health system response to gender-based violence need to be included in “project implementation plans of the national health mission because otherwise, nothing’s going to move,” she said.
“When it comes from the central government, every state, every district, every taluka, is going to follow it,” explained Rege. “So the mandate really needs to come from the centre.”
Amin argues that strengthening the health system’s response to violence against women is “not a huge investment, compared to building new buildings outside of the hospitals and staffing them fully, which is what they’re trying to do with Nirbhaya. That’s more expensive, and that’s a wasteful expense…”
Amin said with some support from the Nirbhaya Fund, the health system response can be an integrated component within existing programmes and services (such as HIV-AIDs or reproductive health including maternal care, mental health and emergency or casualty departments), can maximize the use of existing and available resources such as counsellors.
Rege also pointed out that studies around the feasibility of one-stop centres have mostly been conducted only in high-income countries. The 2013 WHO guidelines, using these studies as evidence, described these centres as effective but extremely resource-intensive. So in countries where there isn’t adequate infrastructure and personnel, they may not be the best option, she said. Far more cooperation may be needed from other departments such as health, police, judiciary and so on.
Why women do not seek help
While the questions around cost-efficiency and the effectiveness of their response are significant, the OSCs face an even greater challenge: stigma. These centres often have boards outside that say “rape centre” or “Nirbhaya centre,” which deter many potential beneficiaries from accessing them.
Since Nirbhaya centres are set up as a parallel program–rather than one integrated with the healthcare system–a majority of women needing services are not likely to use them because of the stigma of going to a facility clearly for sexual violence survivors, Amin explained.
“My husband doesn’t let me go anywhere on my own. I don’t even have a phone,” said Pragya [name changed], who lives in a village in Patan district, Gujarat, speaking in hushed tones inside a counselling centre at the GMERS Medical College in Dharpur, Patan. The counselling centre is supported by the Ahmedabad-based Society for Women’s Action and Training Initiative (SWATI), which works to strengthen rural health systems’ response to gender-based violence.
Pragya’s husband was outside the consultation room – a health worker was keeping him at bay while Pragya shared her struggles.
A year after her marriage, when Pragya was pregnant, her husband mixed abortion pills in her food without her consent. It led to a painful miscarriage. He continues to control the finances. Talking to a doctor is often the only time women like Pragya can hope for some privacy. An OSC, which would typically be an independent building unattached to a hospital, would be impossible for someone like her to access.
Pragya’s situation is representative of a widespread reality. Almost half the women surveyed by the NFHS don’t have money that they can decide how to use independently and aren’t allowed to go to a health facility alone.
A counsellor at the Radhanpur District Hospital in Patan said that men preferred to get treatment in private hospitals, but often wouldn’t give women money to even commute to the public hospital. Studies have found that fear of social repercussions, jeopardising family honour and divorce are preventing women from seeking help.
Amin said such attitudes are implicitly present in policy circles too.
“Policymakers and health professionals don’t see women’s health, women’s bodies or women’s minds as being a priority,” she said. “[It] is not an issue of money or lack of resources. It’s a question of just not thinking that women are worth it, and relegating them to a lower status or thinking that they should just bear it.”
These barriers lead to severe underreporting of gender-based violence and deny survivors the care needed to prevent severe ill-health and, in some cases, death.
An analysis of 1,467 autopsies of women at a government hospital in Mumbai found that 12.3% had an underlying history or indication of domestic violence.
Women’s deaths due to gender-based violence may also be masked as natural or accidental deaths, and there needs to be more attention towards why and how they are dying, said Arrpita Paul, country coordinator of the Data Impact programme at Vital Strategies, who co-wrote the analysis.
At least one case of crime against women is reported every 75 seconds, according to data from the National Crime Records Bureau. Almost a third of these cases involved domestic abuse.
Paul said, “I’d say that’s probably just the tip of the iceberg. A lot of cases go unreported.”
“We know that those numbers [from National Crime Records Bureau] are just so vastly grossly underestimating [the scale of violence] because sexual violence and domestic violence are under-reported to the police,” Amin said. Despite that major caveat, these numbers are important because they convey a need for certain services. It is important to similarly document women with sexual violence and domestic violence in the health management information system as that helps determine the need for health services — so women like Pragya and Mina can get the help they need.
This story is part of a reporting project supported by the Pulitzer Center. You can see other stories here.
This article was originally published by Missing Perspectives.