Dilaasa, which means reassurance in Hindi, is a health system practice which was developed in Mumbai designed to respond to the needs of women facing domestic and sexual violence. It grew out of a realization that large numbers of women experiencing domestic violence are reaching health systems but receive treatment for their physical complaints only. They are not even recorded as cases of domestic violence.

The Municipal Corporation of Greater Mumbai (MCGM) was one of the first organisations to recognise violence as a health issue and how it impacted on women’s health. The Dilaasa Model was a direct response to this need, and was set up in a public hospital of Mumbai in 2000 as a joint initiative between MCGM and the Centre for Enquiry into Health and Allied Themes (CEHAT) [1].

The Dilaasa Model essentially follows the principles of Feminist Counselling which means that domestic violence is understood as a result of patriarchal structures. Dilaasa aims to make women survivors feel that they were not responsible for the violence that they had faced and addresses their fears, anxieties and needs. At its core the Dilaasa Model seeks to ensure the safety of the woman and to help her heal from abuse and take control of her life. Dilaasa also provides emergency shelter and legal counselling which makes it a fully comprehensive service.

As part of the Dilaasa Model, hospital staff – both medical and paramedical – are trained to be sensitive and responsive to the issue of domestic violence, filling a major gap in the public health system.

In 2003, Dilaasa was recognized by UNDP as one of the best practices in gender mainstreaming [2] in health and has since sparked the interest of other public hospitals – training health workers and capacity-building on how a health system should respond to VAW were in high demand.  In response MCGM launched a training centre in 2005 to create a cadre of trained professionals who can lead the replication of the Dilaasa Model in other hospitals – 50 Health Care Practitioners took part. By 2008, Dilaasa had extended its services in two more hospitals in Mumbai¹ and by 2009 it had been recognized by the WHO as a model for health systems response to VAW in LMICs in 2009.

From 2005 to 2012 the Dilaasa Model was replicated in Mumbai, Bangalore, Haryana, and Kerala and during an external evaluation of Dilaasa conducted in 2010 it was further affirmed to be an effective model and recommended its upscaling.

By 2015 Dilaasa had been set up in 11 hospitals all designed and planned using WHO’s health system’s building blocks – a useful system to allow health policymakers, managers, providers, and funders to set up services to respond to the immediate emotional/psychological and physical health needs, safety concerns, and support for survivors of violence.

Leadership and governance

India’s Eleventh Five Year Plan [3], which was published in 2008, had already recognized violence as a public health problem and committed to gender equity through a range of connected policies⁸. Against this backdrop, the National Urban Health Mission (NUHM) was born to deliver essential public health needs and they envisaged VAW as a main component of their work.

In December 2012, India witnessed a brutal rape and murder of a young woman in the National Capital. The incident highlighted health systems’ inefficiency in examining cases of sexual violence. The Ministry of Health and Family Welfare cognizant of its system’s inadequacy roped in CEHAT to formulate a standard protocol for dealing with the specific health needs of women who had experienced sexual violence. The Health Secretary visited Mumbai in January 2014 and approved, the proposed CEHAT’s Dilaasa model for NUHM and by the 8^th March 2015, Dilaasa had been inaugurated in 11 public hospitals in Mumbai.

NUHM prepared the budget in tandem with CEHAT, which was divided into a one-time infrastructure cost,  and a recurring service delivery cost. The infrastructure cost included civil work and furniture, while service delivery cost included salaries of human resources, office expense, and yearly training of health care providers⁷. The Health Care Systems were then responsible for providing space for the functioning of Dilaasa and training the Health Care Providers (HCPs). CEHAT was delegated as a technical partner to support in counselling and assisting hospitals for carrying out training. Upscaling Dilaasa was focused on training the existing staff as Trainers of Trainer (ToT) to ensure sustainability, accountability, and monitoring. To ensure the successful integration of Dilaasa without the hospital a Nodal Officer was appointed, essentially a Senior Medical Officer from the hospital to establish an in-house monitoring committee with Heads from key departments like Gynecology, Medicine, Surgery, ENT, Nursing, etc.

The infrastructure

Dilaasa was set up as its own department to ensure its successful integration into the hospital system. It was either set up within the outpatient department or next to the emergency department to ensure maximum visibility and increase accessibility to women. Offering a private and confidential space for the Dilaasa department was key for it to work – it was expected to have two light rooms with doors that can be closed to allow for total privacy during counselling sessions. It must have access to drinking water, clean and safe toilets, washbasin, phone connection, stationery supplies, a secured cabinet for storage of records, and a waiting area. Each room of the department must be equipped with a table, four chairs, and and a table, chair, and computer for the data entry operator. And for the medico-legal examination of sexual violence cases, an enclosed lockable room in the gynecology department must be provided to ensure absolute privacy along with essential drugs, equipment, and other supplies like emergency contraceptives⁶.  After the initial examination two to three days emergency shelter in hospital is arranged for those women who have nowhere to go. This space, in both time and place, helps women regain strength and to discuss with the counsellor on what to do next. Emergency shelter can also be facilitated by the Nodal Officer following the counsellor’s assessment.

The team

The Dilaasa team consists of five staff: two Counsellors, two Auxiliary Nurse Midwives (ANM), and one Data Entry Operator (DEO).  A medical officer is designated as the person in charge of the Dilaasa department to facilitate inter-departmental coordination within the hospital, ongoing training, and administrative support.  Each of the nodal officers and Dilaasa teams were given extensive training. And staff from the 11 hospitals were also trained as trainers so that they can conduct training of staff in their hospitals. Training of trainers included topics such as gender discrimination and violence, identifying signs and symptoms of violence, how to provide first-line psychological support, medico-legal care, and appropriate referrals to Dilaasa. Additionally, regular incremental training on topics like Cyber Crime and VAW, perspective development based on feminist counselling, legal aspect in cases of violence were also given.  In this way the Dilaasa team was dedicated not only to providing services to women facing violence, but also to create an ecosystem to respond to it too.

The service

A standard operating procedure (SoP) was established to ensure a comprehensive duty of care for all survivors and a nodal officer was designated to oversee the whole of the Dilaasa department.  Health Care Professionals (HCPs) were trained to identify abuse based on signs and symptoms, respect survivor’s disclosure of abuse, enquire about history, and provide first-line psychological support through LIVES. Hospitals were oriented with protocols to be followed in cases of violence as stated by the Ministry of Health and Family Welfare (MOHFW). HCPs were also trained to document current and past episodes of violence in the medical paper, refer for Medico-Legal Care (MLC) if relevant, and in cases of sexual violence fill in the MOHFW ‘Proforma For Medicolegal Examination of Survivors/Victims of Sexual Violence. HCPs were also advised that the two-finger test, PV/PS examination, and comment on hymen, should be done only when clinically indicated. They were also advised never to comment on past sexual history.

Hospitals were equally prepared to maintain intake forms, casualty, inpatient papers, copies of medico-legal examination, charts, and registers that collect information about a survivor’s experience of violence. Hospitals were trained to put in place systems for safe and secure storage of relevant documentation that could be of relevance in court cases or for provision of care to the survivor in the future.

Counsellors and ANMs carried out daily ward visits to identify cases of violence. Ward visits helped identify survivors who may not be identified by the doctor or nurse. These visits also serve as a reminder for the staff about Dilaasa. Dilaasa staff are regularly involved in creating awareness on VAW among patients and their relatives, HCPs working in hospital departments, and outreach programs at the community level.

Dilaasa counsellors and ANMs’ were trained in gender-sensitive delivery of care and feminist approaches in counselling using the LIVES framework.

Key elements of the crisis intervention service

Rapport Building
During the first interaction with the female survivor, counsellors introduce Dilaasa and its services on offer, they ensure that there is agreement and consent before initiating any intervention, and communicate to the woman about their practices of privacy and confidentiality. The aim of this first interaction is to build trust and to put women at ease by offering water and refreshments.

Emotional Support
An important message conveyed to women in the first counselling session is that they are not to be blamed for the violence. They validate women’s experiences and uphold the right to self-determination. They discuss the concept of patriarchy in the context of the client’s experience to identify VAW as a manifestation of it. Using principles of feminist intervention, counsellors assist the women in reflecting reasons of inequality, the responsibility of family members to share domestic chores, the right to live a violence-free life, and to speak out against any form of abuse.

Safety Assessment
Counsellors use a series of yes/no questions to assess the severity and frequency of violence, to assess their safety, and to develop a safety plan which is bespoke to her experience. Special attention is given to the safety plans of those women who live with the abuser. Women are encouraged to use informal support or call the police helpline when they face violence. They are informed about procedures to register a formal complaint to prevent future occurrence of violence.

Legal Counselling
Counsellors explain about the advantages of medico-legal examination. The women are informed about the Domestic Violence Act 2005, Section 498A of Indian Penal Code, about the legal aspects of custody, divorce, maintenance, dowry, and ramifications of opting for legal action. Counsellors take assistance and refer cases to legal experts and CEHAT as per each of the women’s specific needs.

Establishing information systems and structures for monitoring and evidence generation

For effective coordination of Dilaasa within all the departments in the hospital, a monitoring committee comprising senior HCPs and the Nodal Officer were set up to ensure good and equal quality of care for all the survivors of violence. A regular review of the hospital’s response to VAW to identify gaps, non-compliance to the SoPs, as well as recognizing good practices, is the mandate of this committee. CEHAT also facilitates capacity building to ensure the quality of documentation and provides support to the team in addressing challenges at the hospital level.  And finally, a monthly practice of Case Presentations was set up to enhance learning through experience shared between each Dilaasa department. These are attended by counselors and ANMs of all Dilaasa departments and facilitated by senior counselors.

Each Dilaasa department also keeps a copy of all the cases which are bought to it, this is called MIS. MIS data includes the profile of health complaints, nature of violence, interventions offered, and pathways to care. This data is then used for monitoring and evidence generation to create awareness about Dilaasa and improve the hospital response. The MIS is routinely monitored by NUHM officials, hospital authorities, and CEHAT.

Multisectoral Co-ordination

No sector can respond in isolation and VAW requires a multi-sectoral response, Dilaasa model implements this approach by coordinating with multiple agencies, these are:

• Police: Counsellors assist a woman if she decides to file a formal complaint with the Police especially when they do not cooperate. They take efforts to build rapport with the Police to help the women facing violence.
• Protection Officer: Protection Officers (PO) are deputed by the government to provide socio-legal guidance as per the Domestic Violence Act, 2005. A woman can file a Domestic Incident Report with the help of a PO to initiate legal proceedings for custody, maintenance, residence, or protection. Counsellors then facilitate meetings between the women with the PO, and prepare them to communicate when the PO does not provide services as per the Act.
• Child Welfare Committee: Counsellors interact with the Child Welfare Committee for girl child survivors especially when they need shelter, and in cases of medical termination of a pregnancy.
• Shelter Homes: Counsellors arrange a stay for women who have no place to live. They inform women about the rules and regulations followed in homes but the decision to reside is taken by the woman.
• Lawyers: Counsellors also help the women in getting a legal representative. In cases of lack of cooperation from legal aid lawyers, counsellors would intervene.
• Other Social Support referrals: Women are given information as per their individual needs such as skill-building courses, organizations providing monetary relief for education and health.

Conclusion

Dilaasa is a powerful and successful model that can be integrated into the hospital system providing comprehensive social and psychological support to women facing violence, empowering them to lead a violence-free and self-reliant life.

References

1. Deosthali, P., Maghnani, P., Malik, S. (2005). Establishing Dilaasa: Documenting the challenges. (vi. 43p). CEHAT

2. MoHFW. (2013). Guidelines and protocols medico-legal care for survivors/victims of sexual violence. Ministry of Health and Family Welfare. New Delhi

3. NHM.  (2015). Ninth Common Review Mission Report. Ministry of Health and Family Welfare. New Delhi.

4. MoFHW. (2015).  Making a Difference Good, Replicable, and Innovative Practices. Ministry of Health and Family Welfare, New Delhi, India
5. WHO. (2010) Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and their Measurement Strategies. WHO. Geneva, Switzerland.
6. CEHAT. (ND) Standard Operating Procedures for Dilaasa Functions. CEHAT. Mumbai. India
7. NUHM. (2014). NUHM PIP, Maharashtra 2014-15. India
8. MCGM and CEHAT. (2011). Hospital-based Crisis Centre for Domestic Violence: The Dilaasa Model. India.

Annex: The Dilaasa Model

Written by Anshit Baxi ( Senior Research Associate), Diana Thomas (Research Associate)