Scaling up the health system response to violence against women: lessons from hospital interventions in Maharashtra, India

Evaluation and Lessons Learned
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01 Background

Violence against women (VAW) is a major public health concern, a manifestation of gender inequality and a human rights violation. Intimate partner violence is the most common form of violence experienced by women. Violence has significant and long-lasting impacts on women’s physical health, including sexual, reproductive and mental health. Women who have experienced violence are more likely to seek health care than non-abused women. Health-care providers (HCPs) are well-placed to identify women who have experienced violence and to provide appropriate clinical care and referrals.

In India, in the fifth round of the National Family Health Survey (2019–2020), physical and sexual violence declined in most states, compared to the fourth round (2015–2016). However, Maharashtra is one of the five states that registered an increase in such violence, from 21% to 25% between the two surveys. Among women who have experienced violence, only 14% explicitly sought any formal or informal help. Despite the significant health burden, the health system response to VAW in India remains ad hoc and fragmented, comprising of different models of service delivery on a small scale, delivered mostly by non-governmental organizations (NGOs). The training of HCPs is a common element of the different models. There is little documentation, however, of whether the training content and approaches are acceptable to HCPs, whether they are feasible, sustainable and effective, and of which models of service delivery can provide a woman-centred response in line with World Health Organization (WHO) recommendations.

In an effort to address these gaps, the Centre for Health and Enquiry into Allied Themes [CEHAT], the Government Medical College and Hospital, Miraj-Sangli, and the Government Medical College and Hospital, Aurangabad, worked with the WHO's Department of Sexual and Reproductive Health and Research and the Human Reproduction Programme (HRP) to run a mixed-methods pilot study of the implementation of WHO guidelines for responding to VAW.

One of the aims of the study was to refine and validate approaches to roll out the WHO clinical and policy guidelines and tools, with a particular focus on domestic violence, including spousal or intimate partner violence. The specific objectives involved:

  • Assessing the needs and priorities of HCPs and managers in responding to VAW

  • Adapting and implementing the training, and assessing improvements in the knowledge, attitudes and practices/skills of the providers

  • Assessing the relevance of the training approaches in meeting the needs of HCPs and identifying the barriers and facilitators for them to deliver care to women subjected to violence

The findings of this study will contribute to:

  1. operationalizing the health system response to VAW, as mandated by India’s National Health Policy (2017), with respect to the feasibility, acceptability and sustainability of integrating the response into existing health services;

  2. identifying the basic elements of a health system response to domestic violence, which can feed into the development of a national protocol or training materials for HCPs (currently missing) as a complement to the national guidelines on medico-legal care for survivors of sexual violence;

  3. implementing a global plan of action to strengthen the role of the health system within a national multi-sectoral response to address interpersonal violence, in particular against women and girls, and against children, that has been endorsed by WHO Member States, including India.