Chikkaballapur, Bengaluru, Karnataka: Twenty-eight-year-old Amruta smiled as she showed us the grainy photo of her two sons that she had set as the wallpaper on her phone.

Three years earlier, Amruta was pregnant with her second child. Her second marriage was failing; her in-laws and her husband tortured her, did not allow her to step out of the house or use the phone, while her natal family refused to help.

Frustrated and losing the will to live, she consumed poison, and was admitted to the government hospital. That was where she met counsellor Nagalakshmi N., at the Muktha centre in Chikkaballapur district hospital.

In her, Amruta found a sympathetic well-wisher and a support system. Nagalakshmi referred her to a government shelter where Amruta stayed for five months. She gradually found the courage to file for divorce, earn a living, and make an independent life for herself and her sons.

“It is difficult to meet the needs of my children with my measly salary, but I cannot imagine ever living with my in-laws again,” Amruta said. She works as a mechanic, earning Rs 10,000 a month.

She credits her new life to Nagalakshmi, who works as an Antiretroviral Therapy (ART) counsellor at the hospital and as counsellor for the Muktha centre that addresses violence against women. “I could help her connect to a shelter, thanks to the Muktha training we received; I didn’t even know how to help [domestic violence survivors] before,” Nagalakshmi told IndiaSpend. Muktha centres were started under the Karnataka National Health Mission (KNHM) in 2020.

Studies across the world have found that women who face violence are more likely to attempt suicide than those who do not. Indian women, 15-39 years, account for 36% of suicides in the world in that age-group. The National Family Health Survey-5 shows three in 10 Indian women (18-49 years), face spousal violence, and yet very few seek support to end it.

Despite the high numbers, domestic violence is not addressed as the public health crisis it is, activists say. Some hospitals across India are slowly changing that by integrating women-centric care into health services, so that survivors of violence are identified, counselled and enabled to find treatment and support.

Why the healthcare system is ideal to help survivors of violence

Women crowding the gynaecology out-patient department at Gosha Hospital, Bengaluru.

Health systems have a strategic role in responding to survivors of violence, because the first need of survivors is treatment for their injuries. Early intervention by health professionals in identifying survivors and providing psycho-social counselling can prevent severe health consequences, experts say. However, doctors say, without training, health professionals end up treating only the medical complaints, and miss the opportunity to provide holistic care.

The World Health Organization (WHO) has recognised domestic violence as a health concern and issued guidelines outlining the responsibilities of doctors and other health providers in responding to survivors of violence. India’s National Health Policy 2017 also recognises the need to reduce gender-based violence as it is a determinant of health, and recommends providing “healthcare free and with dignity” to survivors of violence.

Given that three in 10 married Indian women (29.3%) from the age of 15 to 49 have experienced spousal violence (NFHS-5) and only 14% of the women facing violence are likely to seek help (NFHS-5), the role of hospitals in responding to gender-based violence is crucial.

The Dilaasa crisis intervention centre, at the KB Bhabha Municipal Hospital, is India’s first hospital-based crisis centre. It was set up by Mumbai-based non-profit Centre for Enquiry into Health and Allied Themes (CEHAT) and the Municipal Corporation of Greater Mumbai (MCGM) in 2000. It provides feminist counselling along with needs-based referrals for legal services and shelters, facilitating a multi-sectoral response to domestic violence. In 2005, Dilaasa was integrated in 11 MCGM hospitals under the National Urban Health Mission, with 6,000 beds covering 75% of Mumbai’s population.

Over the years, various studies, including by The Lancet commission on violence against women and girls, have recognised the Dilaasa model as an evidence-based scalable model for health-sector response to survivors of violence in low- and middle-income countries.

CEHAT has also facilitated the replication of the Dilaasa model in other states like Kerala, Haryana, Meghayala, Goa, Tamil Nadu and Karnataka. Each of the states used technical support and training from CEHAT while adapting the model to suit their needs.

The Muktha model

Hemlata P., doctor and nodal officer for Muktha at the Gosha Hospital, speaking to a patient. Doctors, nurses and support staff at the hospital have been trained to look for signs of violence and gently prod patients about it.

In December 2020, in collaboration with CEHAT, the KNHM initiated a health system-based response to violence against women and children through ‘Muktha’ centres. Trained healthcare personnel including doctors, nurses and counsellors are expected to identify survivors of violence and provide psycho-social support and need-based referral to police, legal and shelter services.

Five district hospitals under the NHM--the Chikkaballapur District Hospital, the Bengaluru-based Bowring & Lady Curzon Hospital, Government HSIS Gosha Hospital, Jayanagar General Hospital and KC General Hospital--were selected as sites for the implementation of the project. Initially meant for one year, the project was later extended for three years till December 2025, information from CEHAT shows. As of February 2023, the Muktha centres in the five hospitals have responded to 2,763 survivors of violence, data provided to IndiaSpend by CEHAT show.

The genesis of the Muktha centres came from Gelathi, the special treatment cells started by the Women and Children Welfare Department, Legal Services Authority and the police in 2015. These centres, until 2020, provided counselling, legal, health and police assistance under one roof.

In 2020, Arundhati Chandrashekhar, who was the secretary of the department of Women and Child Development in Karnataka, visited Dilaasa centres in Mumbai and wanted to replicate the model in Karnataka. As the Mission Director of NHM, Karnataka, she, in tandem with state officials, and the chief secretary, signed a Memorandum of Understanding (MOU) with CEHAT for establishing Muktha centres in hospitals in Karnataka.

The training of trainers started in March 2020 and continued via video conferencing platforms while the Covid-19 lockdown was in place.

The key lay in identifying women facing violence right in the wards or the outpatient departments (OPDs). The signs of violence are both overt and subtle, experts say. Doctors and nurses were trained to look for symptoms of violence such as chronic anaemia, repeated abortions, depression, constant headaches and body ache, sudden weight loss, tuberculosis, fainting spells, breathlessness, white discharge, infertility as well as signs of falls, fractures, burns and attempts of suicide. Once they notice any of these signs, they then discreetly check with the patient to find out if she faces violence at home. The doctors take down their details in the Muktha register and refer the patient to the Muktha counsellor.

The Chikballapur district hospital, 60 km from Bengaluru, is a 400-bedded tertiary care hospital for the whole district and peripheral areas. While working in the casualty department in the hospital, Uma J.C., senior medical officer, would see at least three-four cases of women every day who had consumed poison, attempted self-harm, or had injuries or vague symptoms that did not correlate with any medical conditions.

She used to treat the medical symptoms and leave it at that. Now, her role begins with observing the symptoms and looking for root causes. If she suspects domestic violence, she gently asks her patient if she is facing any problem. “The patient generally just smiles but once alone in another room, she confesses that she faces violence at home,” said Uma, who is also the nodal officer for the Muktha centre at the hospital. “Now we know what kind of help she can get and where she can go.”

The counsellors who get the referrals from doctors are trained in providing survivor-centred counselling and in offering support based on the survivor’s needs. Their working template, they say, is ‘LIVES’: Listen, Inquire about needs and concerns, Validate, Enhance safety and Support.

In Chikballapur hospital, six counsellors from departments including psychiatry, special newborn care units, integrated child transmission and family planning, are trained in providing counselling and maintaining documentation. The counsellors are given Muktha centre duties on a rotational basis. While based in their own department rooms, they meet the survivors referred to them, note down their history, provide with psycho-social support and based on each survivor’s needs, refer the patient to other services like one-stop centres, police and legal services.

“Violence should not be tolerated, my intention is to empower women,” said Nagalakshmi, the ART counsellor mentioned earlier, who has referred the most number of cases to Muktha centres.

Nagalakshmi showed us the register she maintains with detailed notes, police FIR [First Information Report] copies and photos. The counsellor said that she and her colleagues are able to use the gender-based violence lens in their primary department. “A lot of the domestic violence cases that we get are due to sexual discord between the couple, so I am able to handle them,” she said.

The centres are an example of how public hospitals can support survivors of violence by using existing infrastructure and workforce--the state did not hire any new counsellors but instead, trained existing NHM counsellors in providing psycho-social counselling.

The project also focussed on creating master trainers within the hospitals, who could then train other health staff and conduct refresher training. Under the project, 200 doctors, 358 nurses and 168 support staff were trained in identifying and supporting survivors of violence against women, as per data from CEHAT.

The data, and the challenges

An analysis of the data of Mukhta centres [accessed by IndiaSpend] from January to December 2022 shows that out of 759 cases, 73% were of physical violence and 27% were of sexual violence. Almost 40% of survivors were below 18, and their cases were falling under the ambit of Protection of Children from Sexual Offences (POCSO) Act. Almost one in three survivors (31%) were between the ages of 18 and 25.

The Casualty Department, and the Obstetrics and Gynaecology departments, refer the most number of survivors to the centres. Physical injuries (46%) and suicidal ideation (38%) remain the most common symptoms found in the women; these are also the most direct signs of violence.

CEHAT coordinator Sangeeta Rege finds the Muktha model impressive. “The work that they could do despite the pandemic shows how championing at the top--in this case, Dr Arundhati Chandrashekar [the former head of the National Health Mission, Karnataka]--could stimulate the system to overcome challenges,” she said.

With higher officials onboard, the local leadership by nodal officers ensured that the public health system found ways to support women facing violence despite various hurdles, she said.

Senior Medical Officer Uma J.C. examining a patient who has consumed poison, in the casualty department of Chikballapur hospital.

The challenge for the counsellors is that their Muktha centre work is additional to their duties and, despite rotation, they are unable to dedicate time for follow-ups. Uma, the senior medical officer at Chikballapur hospital, says conducting more training and identifying more patients is often challenging because of transfers of staff and a shortage of staff. “There were four trained nursing officers [for Mukhta centres] and only two are left; out of five trained doctors, only three are left,” Uma said.

Another challenge is that Muktha centres come under the Health Department while the One Stop Centres are under the Women and Child Development Department and often, there is no coordination between the two. “My concern is that we refer a lot of cases to Sakhi One Stop Centres, but we do not hear back from them about what action was taken, and so we are in the dark,” said Nagalakshmi.

We have reached out to Naveen Bhat, NHM Director, Karnataka for his comment on these challenges, and will update the story when he responds.

Despite these challenges, most nodal officers have found novel ways to keep the work going. At HSIS Gosha Hospital, a busy 100-bedded maternity hospital in Bengaluru, nodal officer Asha Nadager works as a nursing officer and also works full-time as a Muktha counsellor. This was because they wanted a full-time resource to attend the centre, and the existing counsellors could not do that.

Of the 30-35 cases the centre sees every month, 15-20 cases are sexual assault victims brought in by the police for medical examination and psycho-social counselling, and the rest are identified from the outpatient and inpatient departments, Nadager said.

Asha Nadager, a nursing officer, is trained in crisis counselling and is responsible for psycho-social counselling at the Muktha centre at Gosha Hospital.

The counsellors are trained to be non-judgemental and not to blame the victim. “I try to be very gentle with the survivors because they have suffered and they need moral support,” Nadager said. “We counsel the survivor so that one day, she can come back and take action to stop the violence.”

The nursing officers keep an eye out for patients who deliver babies and have no one to attend to them, who seem depressed, have repeated abortions or miscarriages, have many girl children, etc., and probe to see if there is any sign of violence. If yes, they register the case in the Muktha register and notify a nurse, said Nadager.

“In many cases we counsel the mothers-in-law too, because they make demands of the women,” said Hemlata P., nodal officer for Muktha at the hospital. She said that initially there was resistance among doctors and counsellors who thought this work does not come under their mandate, but it has slowly changed into acceptance through sensitisation. “Now, they identify cases and tell us that there is a Muktha case in the ward and ask if we can intervene.”

The security and house-keeping staff at the hospitals are also trained to identify women who would need counselling, as for instance underage girls who are pregnant, and to intimate Nadager on WhatsApp with the details of the case. The centre at Gosha is open 24 hours, all days of the week, with work divided among the full-time counsellor and another nursing officer who handles the night shift.

At K C General Hospital, Malleshwaram, one of the oldest and busiest hospitals in the city, the Muktha centre operations are far more complex given the size of the hospital--500-bedded, with a large intensive care unit, surgical units and regular OPD and IPD [Inpatient Department], and footfall of hundreds of patients daily. Half of the Muktha cases come from the police, and the rest from the hospital, especially from the Casualty and Gynaecology and Obstetrics departments. If the doctors notice a patient showing symptoms of violence, she is referred to the Muktha centre and a support staff usually accompanies the woman to the centre.

“We had a case of a woman who came with repeated pelvic inflammatory disease. Because of the training, we enquired if she faced violence and realised her husband had been having sex forcefully. We then sent her to the Muktha centre for counselling,” said Veena P.T., Senior Specialist Obstetrician and Gynaecologist. However, staff shortage remains the single biggest issue. Almost all the nodal officers and counsellors we spoke to talked of the need for having dedicated counsellors for Muktha centres.

Arundhati Chandrashekar, who was the NHM director when Muktha centres were set-up, and who now works as Treasury Commissioner, said using existing NHM counsellors to do this work was intentional. “We wanted to integrate Muktha work with overall health services,” Chandrashekar told IndiaSpend, adding that their plan is to sensitise every health worker about domestic violence, and not to make it a separate department.

“There will never be a perfect model,” said Rege from CEHAT. She said when they started the Muktha centres, using the existing counsellors to do the work felt like a good idea, but now the resistance from the counsellors and their department heads shows that it may not work well, as there is a high case-load from their own primary department and providing counselling is an intensive job.

Consequently, there is now some discussion about how to get dedicated counsellors for Muktha Centres. “We are having a dialogue with the NHM Mission director to see if the Muktha centres can be funded under innovations by the NHM, and thus be able to recruit dedicated counsellors so that the progress will be faster,” said Rajani Parthasarthy, Deputy Director, Mental Health, Health and Family Welfare department, Karnataka who is the nodal officer for implementation of Muktha centres in collaboration with CEHAT.

We have reached out to Naveen Bhat, NHM Director, Karnataka for his response on the challenges faced by the Muktha centres, and solutions to these problems, and will update the story when he responds.

Other states, other models

Just one visit to the casualty department of a district hospital in Haryana showed that a lot of women come to the hospital with symptoms of violence, poisoning, physical abuse, fractures, burns etc., said Sonia Trikha, Director General of Health Services, Haryana. Yet, she added, there was no mechanism to follow-up with these patients, and the doctors had no way of knowing what happened to them after discharge.

This is where the idea of providing some kind of psycho-social counselling within the hospital was formed, and the Haryana State Health Systems Resource Centre (HSHRC) started the first ‘Sukoon’ centre in Panchkula district hospital in 2013. Many women visited the centre, found the HSHRC, and the project expanded to three more hospitals in 2014. Sukoon centres are now functional in 12 district hospitals in the state, and have responded to over 10,800 women till December 2022, Trikha said. HSHRC further collaborated with CEHAT in 2017 to build the abilities of doctors, nurses and support staff to address gender-based issues.

“Doctors told us that till then, they also used to ask survivors to compromise with their husbands’ families as they didn’t know any better,” said Trikha.

Police staff were also sensitised to the issues faced by women. Further, counsellors shared their findings with doctors and health officials, which helped in changing the way survivors were treated in the hospital. Trikha said that they made the centres survivor-friendly by adding water dispensers and providing tea for survivors. There are plans to expand the centres to all 22 districts, she said.

District Women Hospital, also known as Lady Harding Hospital, is a 500-bedded maternity hospital and one of the busiest in Maharashtra, with 14,000 deliveries per year. In 2017, with the help of the Women and Child Development department, a One Stop Centre called Sakhi was started in the hospital, near the emergency labour room. Five dedicated personnel including a case worker, administrator, paramedical staff, IT staff and housekeeping provide services to the centre.

From 2017 to January 2023, the centre has provided care to 153 survivors, data provided by Arti Kulwal, Medical Superintendent of the hospital, show. The centre works well because everything from medical treatment and psycho-social help to police intervention and legal formalities are under one roof, said Kulwal. She added that there is a high number of self-referrals to the one-stop centre, which survivors find easy to access as it is situated within the hospital premises. The staff is also able to spread awareness among the community through inpatient and out-patient services. Further, the centre has linkages with police and allied health workers like Anganwadi workers and ASHAs.

Their analysis of survivor data shows that 44% of the survivors were below the age of 18 and 59% of them were unmarried, Kulwal said. Worried about the efficacy of Adolescent Reproductive and Sexual Health (ARSH) education by the government, Kulwal adds that “we need to educate, create awareness and empower girls and women about family planning practices, abortion practices and different Acts like POCSO”.

Costs and scaling up

There is evidence that tackling gender-based violence is important for health. Also, providing a health system response is neither expensive nor resource intensive, data show. Estimates from 2012 show that the cost of setting up and running the Dilaasa centre at Bhabha Hospital in Bandra, Mumbai was approximately Rs 30 lakh, which, for a population of 337,000 women, comes to Rs 19 per woman. The additional cost to the hospital is Rs 14 lakh, that is Rs 9 per woman, as the existing staff of the hospital also manage the crisis centre. In all, the cost to provide holistic care to deal with violence against women is less than Rs 30 per woman.

There is no such estimate for the Muktha programme currently, said Rege from CEHAT.

But there is little push by the Union health ministry to scale the model across all district hospitals, said Rege. Between the fact that health is a state subject--a common refrain from the health ministry--and the fact that states expect the NHM to fund the centres, the opportunity to provide relief to women is lost, she said. We have reached out to Roli Singh, Managing Director, NHM, Ministry of Health and Family Welfare, and will update the story when she responds.

Rege points out that the work of addressing gender-based violence via the healthcare setup can start from anywhere. It can start as a pilot project and scale up, or it can be done using existing budgets and by training existing staff, or by using one-stop-centres for the purpose. She says, “Where there is a will, there is a way.”

(The reporting of this story was supported by CEHAT, Research Centre of Anusandhan Trust. CEHAT has not exercised any editorial control over the story.)

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