Society for Women’s Action and Training Initiatives (SWATI and Gujarat Institute for Development Research (GIDR) are organizing a national seminar ‘Violence Against Women a Public Health Concern: Approaches for Rural health Sector Response’ on January 23-24 in Gandhinagar, Gujarat. It aims to brings together data from research and evidence from practical experience of public hospital based programs that cater to a predominantly rural population.
Over two days, researchers, practitioners and policy makers discuss and deliberate on the various approaches that a rural health sector response model needs to integrate and recognize the importance as well as differing needs of rural women. It will specifically explore the particulars of a rural health sector response and the potential role that ASHA workers can play in supporting primary prevention and the manner in which violence is linked to the health outcomes.
A concept note prepared for the seminar:
“If this [domestic violence] were an infectious disease, we would have a treatment center in every neighborhood. There is a huge disconnect between the prevalence of domestic violence and what is done in the health system says.” — Black MC, “Intimate partner violence and adverse health consequences: Implications for clinicians”, American Journal of Lifestyle Medicine, 2011).
Intimate Partner Violence (IPV) affects women’s physical and mental health through direct pathways, such as injury, and indirect pathways, such as a prolonged stress response that leads to chronic health problems. Influence of abuse on women can persist long after the violence has stopped. The more severe the abuse, the greater its impact on a woman’s physical and mental health, and the impact over time appears to be cumulative (Heise L, Garcia MC “Violence by intimate partners”, Krug EG (ed) World report on violence and health. Geneva: World Health Organization, 2002).
Public hospitals and associated health care professionals are uniquely placed to intervene and prevent further violence against women.
According to India’s National Family National Family Health survey (NFHS -4) , 2015-16 , 29% ever married women (31% in rural areas and 26% in urban areas) reported to have experienced one or multiple forms of spousal violence (physical, sexual and emotional), according to the International Institute for Population Sciences (IIPS) & Macro International, National Family Health Survey-4 2015–2016, India factsheet, Mumbai, 2017.
In rural areas of India, where 68% of India’s population lives, there is an urgent need for evolving systematic rural health system response to Gender Based Violence (GBV) because rural women victims suffer more from ‘isolation’ compared to urban women. They lack social /familial support, \have limited mobility, lack information and the prevailing social and cultural norms stress family and traditional gender roles.
Society for Women’s Action and Training Initiatives (SWATI) has been working on developing a rural health sector response model to domestic violence. In 2012 SWATI set up the first crisis intervention and support cell – Mahila Sahayta Kendra (hereafter referred to as Cell) in Radhanpur block of Patan district with a formal permission from Gujarat government. The Cell to be run jointly by the hospital and SWATI staff; is perhaps the first formal, rural health system initiative in the country that has been jointly undertaken by the health department of Government of Gujarat and an NGO specifically working on issues of violence against women and health.
Patan district was selected because it is predominantly rural and remote district (with 80% of population living in rural areas as against only 57% in Gujarat State as a whole) and because of SWATI’s strong field presence in the area. It took SWATI almost three years to establish the Cell in Radhanpur hospital. In 2016 two other referral hospitals – General Hospital, Siddhpur, and the Medical College and Hospital at Dharpur were established.
It has been SWATI’s experience that the challenges in rural areas are different and require an approach different than the one adopted by urban models. The rural model must actively involve the multi-layered and differentially located public health system to ensure women’s access to violence prevention and support cell located in the hospital.
In urban areas where facilities tend to be concentrated in a relatively compact setting or are easy to access (transport) it is relatively easier for women to access the services compared to rural areas where distant location of various services, and poor transport system makes access much more difficult for women.
Thus, healthcare providers from village till district level such as ASHA, the health care providers from sub-centre, the Primary Health Centre (PHC) and the Community Health Centre (CHC) need to be part of an upward referral system(grassroots – up), that refers women to the hospital where ‘a violence prevention and support cell’ is located.
This model thus has several components – some common to models such as Dilaasa (a joint initiative of the Brihanmumbai Municipal Corporation [BMC] and CEHAT located in Bhabha Hospital, Bandra [West], in the western suburb of Mumbai, Mahrashtra) and some that specifically respond to the needs of rural areas.
Subsequent to the Delhi rape case of 2012, the government acknowledged the need for a multi-sectoral response to GBV and sexual assault; including sensitization of health care providers to Violence against Women (VaW) as a health issue. Subsequent to which One Stop Crisis Centres (OSCCs) have been set-up in over 170 districts spread across 32 states in India. A large number of the OSCC are located in district level tertiary care hospitals.
Equally significantly, in 2015 the issue of Violence against Women was included in the training module for the Accredited Social Health activist-ASHA and a handbook titled “Mobilizing for Action on Violence against Women-A handbook for ASHA” has been developed. Thus the health system has now recognized the important role that primary health care providers can play in supporting women survivors in seeking help.
This policy decision has added legitimacy to SWATI’s initiative of developing a grassroots upward referral chain that facilitates referral of VaW survivors at the community level. Adding to SWATI’s work some recent studies in India have explored the role of ASHA in identification of VaW.
Notable among these is a study by Population Council, titled ‘Feasibility of screening and referring women experiencing marital violence by engaging frontline workers: Evidence from rural Bihar’. In addition, initiatives by Civil Society Organisations at various levels of the health system provide us with valuable insights in to exploring the specifics of a rural health sector response.