CRY! OUR BELOVED COUNTRY!

AN EXPLORATORY RESEARCH STUDY

The Scope of Strengthening Child

Protection Systems and Programmes
in Hospitals in India

NATIONAL CHILD RIGHTS AND YOU (CRY) RESEARCH FELLOWSHIP

2014

EDWINA PEREIRA

1
 CONTENTS

THE HIPPOCRATIC OATH ........................................................................................ 3

ACKNOWLEDGEMENTS ........................................................................................... 4

CHAPTER 1 Introduction…..………………………………………………………6

CHAPTER 2 Review of Literature……...………………………………………...24

CHAPTER 3 Methodology………………………………………………………..44

CHAPTER 4 Analysis…………………………………………………………….50

CHAPTER 5 Key Findings………………………………………………………73

CHAPTER 6 Recommendations………………………………………………….77

CHAPTER 7 Conclusion………………………………………………………..102

ANNEXURES 1-5………………………..………………………………………..103

Tools for Children's FGD; Questionnaire; Survey Form

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 THE HIPPOCRATIC OATH1

The Hippocratic Oath (Ορκος) is definitely the most widely known of

Greek medical texts which requires a new physician to swear to uphold a
number of professional ethical standards. The original version contains a
promise not to indulge in sexual contact with patients.

The Original Version

I swear by Apollo the healer, by Aesculapius, by Health and all the powers of healing,
and call to witness all the gods and goddesses that I may keep this Oath and Promise
to the best of my ability and judgement.
I will pay the same respect to my master in the Science as to my parents and share my
life with him and pay all my debts to him. I will regard his sons as my brothers and
teach them the Science, if they desire to learn it, without fee or contract. I will hand
on precepts, lectures and all other learning to my sons, to those of my master and to
those pupils duly apprenticed and sworn, and to none other.
I will use my power to help the sick to the best of my ability and judgement; I will
abstain from harming or wronging any man by it.
I will not give a fatal draught to anyone if I am asked, nor will I suggest any such
thing. Neither will I give a woman means to procure an abortion.
I will be chaste and religious in my life and in my practice.
I will not cut, even for the stone, but I will leave such procedures to the practitioners
of that craft.
Whenever I go into a house, I will go to help the sick and never with the intention of
doing harm or injury. I will not abuse my position to indulge in sexual contacts with
the bodies of women or of men, whether they be freemen or slaves.
Whatever I see or hear, professionally or privately, which ought not to be divulged, I
will keep secret and tell no one.
If, therefore, I observe this Oath and do not violate it, may I prosper both in my life
and in my profession, earning good repute among all men for my time. If I transgress
and forswear this oath, may my lot be otherwise.
Translated by J Chadwick and WN Mann, 1950.

1 http://www.nlm.nih.gov/hmd/greek/greek_oath.html/20140705

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 ACKNOWLEDGEMENTS

Protection is a Child’s Right. The Alma Ata Declaration of “Health for All
by 2000 AD” focused on child survival and included a target of reducing
IMR to 60 per 1000 live births. The United Nations Convention for the
Rights of the Child in 1989 spelt out the child’s Right to protection. The
Millennium Development Goals, in terms of child Rights, slipped back on
child protection by focusing only on child survival. I read many beautifully
written, well intentioned documents related to realizing the child’s Right
to protection. I acknowledge them for being there to guide me in this
research.
Child Rights and You (CRY) leadership and the research team have hand
held us through the one year, sharing with us their inputs, supporting us
for undertaking this research. In particular, Ms. Puja Marwaha, CEO, CRY,
Ms. Vijaylakshmi Arora Director - Policy, Research Advocacy and
Documentation, Ms. Leena, Mr. Santosh Morey Ms. Anuja Ms. Thangamma
Ms Chhaya and Mr. Keith have gone out of their way in supporting us
while we undertook this journey of discovery. Their true commitment to
the child was evident in their very interactions and actions thereof.
Research mentors , Dr. V. S. Shastri, Professor, Faculty of Law, National
Law University, Jodhpur, Dr. Awadhendra Sharan, Faculty, Centre for the
Study of Developing Societies(CSDS), New Delhi, Ms. Aarti Dhar, Senior
Assistant Editor, The Hindu gave me technical research inputs that shifted
my stance from a facilitating expert and activist for child protection to an
open minded researcher going into the research with zero knowledge and
learning from the process.
I acknowledge how much I have learnt from the children of the Child
Parliaments in my focus group interactions to reinforce the need for
setting up child protection systems and policies. I thank International

4
Services Association, INSA-India, the organization I work in, that gave me
time off to venture into this journey of discovery and supported me
through out to complete it. Ms Santa Sylvia from Asha Forum Bangalore,
Ms Lakshmi in particular and Indian Social Institute helped me with data
entry and analysis using SPSS which was a rich learning experience,
which I do acknowledge.

The openness with which discussions on setting up child protection

systems and programs happened at the Ministry of Health and Family
Welfare in New Delhi and in the Department of Health and Family Welfare
in Bangalore is hereby acknowledged. Due thanks to Dr Rakesh Kumar
and Dr Ramesh respectively for the valuable time spent. I thank Dr Pooja
Gujjar for the role of coordinating the data collection in one of the
hospitals in Bangalore. I acknowledge, but will not name the hospitals,
and experts who were part of the research data collection because of the
sensitivity of data collected related to sexual abuse. I thank Dr Shaiba
Saldanha from ENFOLD and Mr. Sonykutty George, UNICEF for their
insights into working with child protection systems in hospitals in
Bangalore.

Last but not least, I thank my family and friends for standing by me
patiently as I kept mulling over solutions to the challenges I faced in data
collection and while writing this report. This would not have been
possible without the intervention of God Almighty giving me this
opportunity to venture into an area few have traversed in India.

EDWINA PEREIRA
20.08.2014
Bangalore

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 CHAPTER 1

INTRODUCTION
BACKGROUND INFORMATION

“The history of humanity is founded on the abuse of children”2

In yester years, children in India lived in nested joint families where the
surrounding community lived in close proximities to a child. This did not
necessarily protect children from child abuse. Child marriages,
clitorectomy, child killing were rampant. Children were not viewed with
the same lens as adults3. Today, child abuse is a known reality in India.
Yet, a general lack of sensitivity to child abuse in India may be one of the
reasons that health leaders, professionals and citizens of this country did
not perceive the need for child protection systems in hospitals in India. I
found this out when I introduced the topic during the course of this
research. I did not have to even explain why I chose the topic. “We did not
think about it!” was an echo I got used to.

As per the Indian view, the child is parental property, who is subject to
discipline as parents find appropriate. Battering of children in India is not
seen as detrimental to the child. The oft used parenting proverb is, “Spare
the rod and spoil the child”. Since 1988, attention focused on child abuse
in India, with the beginning of discussions, media awareness, and national

2
deMause , Lloyd (1998),The History of Child Abuse , The Journal of Psychohistory 25 (3) Winter
http://www.psychohistory.com/htm/05_history.html/20141204

3
deMause , Lloyd (1998),The History of Child Abuse , The Journal of Psychohistory 25 (3) Winter
http://www.psychohistory.com/htm/05_history.html/20141205

6
 seminars. Definitions of child abuse in India were only recently
operationalized.

Who is a child? Conflicting laws add to the confusion surrounding this

question. As far as the clinical aspect is concerned, for obtaining medical
care in a Government health facility in India, a child is defined as one who
is less than 12 years of age. A request from Indian Academy of Pediatrics
to increase the age limit up to 18 years is still under consideration by the
Government of India4. So if, a 15 year working old girl is found to be
sexually abused and brought to a hospital, does the hospital treat her as
an adult or a child? Thankfully, several recent judgments have brushed
away the webs of confusion and reinforced that a child is a person below
18 years of age (Juvenile Justice Act, 2000). The newly enacted Protection
of Child Sexual Offences Act, 2012 was further clarified that a person
below 18 years of age is a child. But how equipped are hospitals to glean
this difference?

The choices, we, as citizens, families and as a country make in how we

protect children do affect the very nature of childhood.

The original Hippocratic Oath had a section that read, “I will not abuse my
position to indulge in sexual contacts with the bodies of women or of men”.
Child sexual abuse or exploitation was not included but alluded to in this
section of the oath. The fiduciary relationship between health care givers
and the patients ethically mandates standards of care which inherently
disallows sexual relationship with patients. Further, this relationship and
oath compels them to protect children in their care. Children who are
admitted to hospitals with a history of sexual abuse, notwithstanding the
fact that the medical professionals can through their physical examination
and work identify when a child is abused. Do they then have a

4
http://www.childlineindia.org.in/Child-Sexual-Abuse-Medical-Procedures-and-
Protocols.htm/20131104

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responsibility to participate in protecting the child? While men and
women have the power to report such abuse, children do not have a
language for sharing sexual abuse, especially when the abuser is a person
the child trusts. Most child protection programmes focus on empowering
the child. Is child protection only a child’s responsibility? What is the role
of adults in protecting the child through systems building? What about
children who are further vulnerable when they are ill? This makes it
imperative to explore child protection systems and programs in hospitals
to find out to what extent do those giving care and the managements
include the child’s right to protection.

STRUCTURE OF THE RESEARCH STUDY REPORT

This study seeks to explore the scope of strengthening child protection

systems and programs in hospitals in India. It begins with an introduction
in Chapter 1 which includes background information, need for the study,
hypothesis, general and specific objectives and definitions. The researcher
has spent much time sourcing out a wealth of review of literature related
to child abuse in hospital setting in India and developing and developed
countries, responses of hospitals to child abuse, curriculum of health care
personnel related to child protection, child protection policies and
programs in hospitals, critique of models for child protection systems and
programs in hospitals . This is Chapter 2. Chapter 3 is the research
methodology which is then explained with a view to describe the
sampling technique, data collection methods, and challenges and target
population. Analysis follows in Chapter 4 with key findings described.
Based on the data analysis and several discussions that happened with
stakeholders Chapter 5 summarises Key Findings from the Analysis
Chapter 6 details the Recommendations, which includes Models for Child
Protection, a suggested training curriculum outline, a sample child
protection policy and guidelines. Chapter 7 highlights the researcher’s
conclusions.

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 CHAPTER 2

NEED FOR THE STUDY

Every Child has a Fundamental Right to Protection
The 1989 UN Charter, to which India is a signatory, guarantees every child
the Right to Survival, Protection, Development and Participation. Since its
adoption in 1989 after more than 60 years of advocacy, the United
Nations Convention on the Rights of the Child was ratified more quickly
and by more governments (all except Somalia, South Sudan and the US)
than any other human rights instrument. This Convention is also the only
international human rights treaty that expressly gives non-governmental
organisations (NGOs) a role in monitoring its implementation (under
Article 45a). The basic premise of the Convention is that children (all
human beings below the age of 18) are born with fundamental freedoms
and the inherent rights of all human beings. Many governments have
enacted legislation, created mechanisms and put into place a range of
creative measures to ensure the protection and realization of the rights of
those under the age of 18. Each government, including India is expected to
mandatorily report back on children's rights in their country.

With 42% of India's population being children5, their interests require

urgent priority. UNICEF defines a child as a person below 18 years. With
more than one-third of its population below 18 years, India has the
largest child population in the world; a huge 440 million.

5
http://wcd.nic.in/childwelfare/BudgetingChildProtection.pdf/20131104

9
 Protecting children is both a public and private responsibility
When it comes to protecting children, the family (including kin) plays a
central role, particularly during the child’s earliest days. Children are an
integral part of a broader community. Their ongoing deepening of
relationships, engagement, and roles take on increased significance in the
health and development of a society. Therefore, protecting children is
both a private and a public responsibility. Globally, the recognition that
childhood confers a special status upon children deepens the recognition
that children are vulnerable and need protection. The way this protection
should be provided and is provided, however, is not universal. Cultural
beliefs about how to protect children differ with everyday realities. Child
protection responsibilities and strategies are different based on
geography, political and social history, religion, wealth and social
structure. There is no one best way to protect children. For a wide
variety of reasons, children are not always sufficiently protected. Serious
choices are involved and every society stands to do better when the
choices it makes are grounded in the Rights of children.
India fails to protect its children once again! 6
In India’s own planning and implementation, child protection has
received poor investment. A review of budgetary allocation over the
years highlights the neglect of vulnerable children - street children,
orphans, migrant children, trafficked and sexually abused children in
Indian policy and financial statements. Ever since child budget analysis
was undertaken in India, the share of child protection in the Union Budget
dipped even lower (0.04%7). Allocation made for child protection is
negligible when compared to the number of children falling out of the
safety and protective net. On an average, between 2000 A.D. and 2005
A.D., of every 100 rupees spent by the Union Government only 3 paise was
spent on child protection. In the 2013-2014 Union budgets, the budgets

6
HAQ: Centre For Child Rights, Budget For Children 2013-14, New Delhi, 2014, p.2

7
ibid

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 for child protection showed a miniscule increase of 1 paise.8! When a
children’s right to protection is not met, every other right is at stake.

Hospitals and Child Protection

From a hospital perspective, children find their way into hospitals from
the time of conception. India has the world’s largest number of sexually
abused children, with a child below 16 raped every 155th minute, a child
below 10 every 13th hour, and at least one in every 10 children sexually
abused at any point in time. A National Study undertaken by the Ministry
of Women and Child Development9 highlights that:
 53.22% children reported having faced one or more forms of sexual
abuse
 21.90% child respondents reported facing severe forms of sexual
abuse and 50.76% other forms of sexual abuse. Out of the child
respondents, 5.69% reported being sexually assaulted.
 7. 50% abuses are persons known to the child or in a position of trust
and responsibility.
 Most children did not report the matter to anyone. Most
organizations, including hospitals do not include these issues in
their interventions.

The need for health care institutions to put into place risk management
strategies for child protection cannot be understated. UNICEF strongly
states that, “Correctly identifying risks and taking steps to minimise them
in an organization is essential to the development of effective child
protection policies and procedures”.
Even in health care settings examples of risks include:
 failure to properly screen job applicants may lead to a child abuser
working for a hospital in close contact with children,

8 HAQ: Centre For Child Rights, Budget For Children 2013-14, New Delhi, 2014, p.2 ( for more
information on services under the ICPS connect to
www.wcd.nic.in/icpsmon/pdf/icps/final_icps.pdf 20141104

9 wcd.nic.in/childabuse.pdf/20131101

11
 failure to provide safety environment (leaving child alone during a
procedure that exposes the body of a child, or just leaving a child alone
with a health care staff etc.) may lead to hospital staff, attendees and
other patients sexually abusing children
 privacy activities that may result in loss of evidence in a child
admitted after being sexually abused,
 failure to keep a child’s records securely locked up may result in
them being lost and/or getting into the wrong hands (e.g. other children
who may then tease the child media who may distort facts and invade the
child’s privacy or an adult who uses sensitive information to emotionally
blackmail a child)
 failure of medical professionals using child friendly methods to
minimise damage cause to children who are sexually abused.
 Failure of hospitals to report sexual abuse of a child admitted in
their care will lead to the hospital management being charged for failure
to report the abuse which includes 6 months imprisonment. (POCSO,
2012 Art 21)

The recent Prevention of Child Sexual Offenses Act, 2012 is a clearer legal
instrument for responses to sexual abuses of a child. POCSO, 2012
broadened the scope of sexual offences against children viz., penetrative
sexual assault; non penetrative sexual assault; aggravated forms, sexual
harassment, using the child for pornographic purposes. Key features
include the following:

 Gender neutral
 Applicable to all children below 18 years
 Provisions for a special court
 Laid down procedures to be followed in the police station
during medical examination and in the court
 Provision of interpreters and translators at state costs
 Support person
 In camera proceedings
12
  Identity protection by police and courts
 No exposure of child to the accused
 Mandatory reporting protocols(includes - media and hotels)

“Section 20, POCSO Act vests the responsibility of reporting (any

person including) on "personnel of ....hospital" if they come across
"any material or object which is sexually exploitative of the child
(including pornographic, sexually related or making obscene
representation of a child or children) through any medium". Failure
to report will attract punishment in the form of imprisonment or fine
or both. It is not clear whether the hospital administration can be
held responsible for the failure on the part of their employee to
report. A plain reading of the provision suggests that the obligation
is on individual health care personnel who have the knowledge
about the abuse to report. The heads of the hospital can be charged
under Section 21(2), if the alleged perpetrator was a subordinate
under their control.” Summarized by Swagata Raha, Centre of Child
and Law, NSLIU, 2014 for this research.

Nurturing, empowering and protecting children are fundamental moral

and professional obligation which all humans share. The recognition of
this unavoidable obligation in the light that children are holders of human
rights, is leading professions to accept their duty of care to children.
Among health care personnel, doctors, nurses and midwives are
especially well placed to enhance the protection and empowerment of
children and families given the range of acute and primary care settings in
which they work, and their trusted and respected role in the community.

For child protection, especially from sexual abuse there is a need for the
intimate dialogue with adults. In this context, the parents and teachers
may be the ones the child trusts best. However, when parents and
teachers are not equipped to handle such information, doctors and nurses
with their exhaustive training on communication; training and counseling

13
 have the edge over them at the basic level. Further, in contrast to a school
or a children’s home set-up, a hospital is a place where evidence of
suspected or child sexual abuse is practically collected. Hence, hospitals
need to have guidelines, protocols and child friendly, protection
environments. A child protection policy encompasses these needs. Most
health care institutions that the researcher visited in over 100 towns and
cities within India do not have a child protection policy. The silence
related to sexual abuse, the pedagogical attitude of society compound the
vulnerability of children to further abuse.

This study does not, however, negate the value that parents and teachers
add to child protection. The hospital complements the child protection
services and hence, this study is limited to exploring the scope of them
developing child protection systems and programmes.

Child Sexual Abuse from the perspective of public health, violence

and child maltreatment.

According to the World Health Organisation (WHO), violence is a

public health issue. Preventing violence against children is a health
agenda of the World Health Organisation (WHO)10. Child abuse,
including sexual abuse comes under the ambit of ‘violence’. The
ongoing WHO Global Campaign for Violence Prevention, and its
contribution to follow up on the UN Secretary General's Study on
Violence against Children, describes the need for prevention of
violence against children as:
 Violence directly affects millions of individuals worldwide every year.
WHO estimates are cited in the UN Secretary General's Study on
Violence against Children. This states that the prevalence of forced
sexual intercourse and other forms of sexual violence involving touch,

10

http://www.who.int/violence_injury_prevention/violence/activities/child_maltreatment/en/2014071
0

14
 among boys and girls under 18, is 73 million (or 7%) and 150 million
(or 14%), respectively. Abused children will end up in hospitals, who
need to be equipped to deal with it and care for children.
 Violence against infants and younger children is a major risk factor for
psychiatric disorders and suicide, and has lifelong sequelae including
depression, anxiety disorders, smoking, alcohol and drug abuse.
Preventing violence against children therefore, contributes to
preventing a much broader range of non-communicable diseases.
 Violence against children is highlighted in the World report on violence
and health11 . It is an integral part of W.H.O.'s Global Campaign for
Violence Prevention. The WHA Resolution 56.24 Implementing the
recommendations of the World report on violence and health is best
implemented in countries through hospitals.

Child maltreatment is defined by WHO as “all forms of physical and

or emotional ill-treatment, sexual abuse, neglect or negligent treatment
or commercial or other exploitation, resulting in actual or potential
harm of a child’s health, survival, development or dignity, in the
context of a relationship of responsibility, trust or power.”12 The WHO
1999 Consultation on Child Abuse Prevention distinguishes types of
Child Maltreatment viz., physical abuse, sexual abuse, and neglect.
When a child comes in with physical and sexual abuse, the possibility
of injury is great. Injuries are most likely to be recorded, by and large
in a hospital setting. However, the curriculum of doctors and nurses do
not include the preparation of health care professionals to recognize
injuries related to sexual abuse and then manage the injury and the
consequences of injury on the child both medically, and from a legal-
ethical perspective. Those injuries that result in death could conceal as

11
http://www.who.int/violence_injury_prevention/violence/world_report/en/ (see chapters 2 and 3 on
youth violence and child abuse and neglect)20140709

12
http://whqlibdoc.who.int/publications/2006/9241594365_eng.pdf/20141110

15
 much as they reveal about an injury problem.13. Of grave concern is the
fact that official statistics tend to underreport the true burden of
injuries resulting from child abuse.
The epidemiological model (Figure 2) highlights the need for child
protection systems building and programs in hospitals. At all levels of
agent vector and host, taking in the physical environment and legal-social
environment, hospitals need to strengthen child protection systems and
programs, to ensure their risk management and the child’s right to
protection.

Figure 2 LEGAL SOCIAL

ENVIRONMENT
Failure to report child
sexual abuse =
imprisonment of
management of
hospitals

Poor enforcement

No training for health

personnel on child HOST
protection A child who is ill

In spite of POCSO, A child admitted

AGENT 2012 no defined roles with signs and
Perpetrator of abuse for child protection in symptoms of
recruited in health hospitalVECTOR
settings sexual abuse
settings. No/poor child protection
Visitor to hospital policies, systems or A child reporting
abusing children in programs to health care staff
the wards of injury due to
A patient abusing sexual abuse at
children home/school/
PHYSICAL Hospital/
ENVIRONMENT community

No child protection A pregnant child

behavior protocols
displayed nor enforced
for staff, visitors and
others in contact with
the hospitalized child

?child friendly care

interactions

13 No enforcement of
http://teach-vip.edc.org/mod/resource/view.php?id=47 20131030
child protection systems

16
 Need For a Systems Approach to Child Protection
Historically, analysis and programming in child protection have focused
on particular issues or specific groups of vulnerable children. Issues that
have received attention in recent years include violence against children,
alternative care, justice for children, children affected by armed forces
and groups, trafficking, child labour, child soldiers or war victims and
child separation. While the result of vertical, issue-focused programming
can be very effective in serving the specific cohort of children targeted,
the approaches used have serious limitations. Many children have
multiple child protection problems and, while fragmented child
protection responses may deal with one of these problems, they rarely
provide a comprehensive solution. At the same time opportunities are lost
to provide more comprehensive and effective support. Focusing on issues
alone can result in ineffective programming, which is neither sustainable
nor truly able to reach all children who are in need of protection. In many
countries including South Africa, where violence is a normative
experience, the government has integrated violence prevention as part of
their primary health strategy14. There is a need for strengthening systems
for child protection, by and large.

HYPOTHESIS: Health care institutions need competency building on

Child Protection policy and systems.

RESEARCH STUDY GOALS AND OBJECTIVES

To construct a replicable model program for child protection in health
care settings in India through exploring the scope of them developing and
implementing child protection systems and practices

14
Leby, Leibowitz,’The psychosocial impacts of violence on children, Soul city literature review, rough
draft as found in http://www.soulcity.org.za/projects/soul-buddyz/soul-buddyz-series-4/literature-
review/the-psychosocial-impact-of-violence-on-children

17
 OBJECTIVES:
a. To describe the existing gaps, strengths, opportunities and threats
of hospitals to respond to child protection at preparatory, early
intervention and response levels.
b. To identify from children their inputs for child protection in
hospitals
c. To construct a model program for child protection policies,
systems including M&E, roles for HCIs
d. To develop a need based generic curriculum for HCIs to adopt a
model program for child protection in their institutions

DEFINITION OF TERMS
‘Child abuse’ or ‘maltreatment’ constitutes ‘all forms of physical and/or
emotional ill-treatment, sexual abuse, neglect or negligent treatment or
commercial or other exploitation, resulting in actual or potential harm to
the child’s health, survival, development or dignity in the context of a
relationship of responsibility, trust or power15

Child Abuse Prevention/Professional Preparation16

In respect to nurturing and protecting children, the hospitals will be able
to:
• Describe, support and advocate for the Rights of children
• Demonstrate an understanding of the need to support and promote a
child’s wellbeing through empowering primary care givers and all HCI staff
to develop trusting relationships and empowerment-based approaches
• Advocate the importance of having a preventive primary health care
approach to child nurturing, protection and wellbeing
• Respect and work within understandings of cultural and family diversity
irrespective of caste creed and sex.

15
WHO ibid

16
Adapted from http://w3.unisa.edu.au/childprotection/documents/ ppcn&mcurriculummaterials. pdf
professionals protecting children, nurturing and protecting children: a public health approach 20140811 .
Adaptations were to broaden the scope to health care personnel and from Australian context to Indian.

18
 Develop curriculum and include training on child protection for HCIs staff
 Develop child protection policies and systems (structures) within hospitals
and review them periodically.
 Reporting process drills (similar to fire drills) for a child admitted with
sexual abuse.
 Hospital based research on gaps, strengths and interventions used for child
protection
• Demonstrate engagement in critical reflection on child wellbeing and a
commitment to lifelong learning in this area.

Child Abuse Early Intervention

In respect to nurturing and protecting children, hospitals will be able to:
• Recognise risk and protective factors for child abuse and neglect
• Identify strategies and opportunities to strengthen protective factors and
reduce risk factors for child abuse and neglect at individual family, health
institution and community levels
• Demonstrate an understanding of the legal and ethical context for
physician’s, nursing or midwifery practice, responsibilities and reporting in
child protection in India
• Showcase communication skills to build rapport with children and families
to enable sharing of information, enable disclosure and challenge
inappropriate behaviour
• Demonstrate the ability to work in partnership with children and families
and provide timely and appropriate information to children and families in
a respectful and confidential manner
• Explain and use referral services for comprehensive care of children in
need of protection and restoration/healing

Child Abuse Response

In respect to nurturing and protecting children, the HCIs will be able to:
• Integrate a child protection audit and an assessment of child and family
wellbeing into a health care assessment

19
 • Plan and provide health care that takes account of child protection and
wellbeing
• Collaborate effectively with stakeholders, multi-agency/interdisciplinary
teams of health, education and social service sectors and organisations in
the provision of health care related to child protection and wellbeing
• Recognise and act ‘in the best interest of the child’ when children are at
significant risk of child abuse and neglect
• Answer questions correctly of the processes of identifying, responding and
reporting of risk of or actual child abuse or neglect

Child Parliament: A group of children who work in a parliamentary

system to address their challenges of child protection through electing a
Prime Minister who selects other ministers based on their needs.

Child protection
Child Protection is a broad term to describe philosophies, policies,
standards, guidelines and procedures that are used to protect children
from both intentional and unintentional harm. In the context of this
research study, it applies particularly to the duty of health care
institutions, particularly hospitals and individuals associated with them -
towards protecting children in their care17.

Child Protection policy: ‘A statement of intent that demonstrates a

commitment to safeguard children from harm and makes clear to all what
is required in relation to the protection of children. It helps to create a
safe and positive environment for children and to show that the
organization (in this case hospital) is taking its duty and responsibility of
care seriously.’18

17
Adapted from UNICEF’s definition

18
UNICEF www.unicef.org 20131030

20
 Health Care Institution: An allopathic hospital with more than 100 beds
capacity which includes a pediatric ward in Bangalore city.

Violence19: According to the World report on violence and

health (WRVH), violence is: "the intentional use of physical force or
power, threatened or actual, against oneself, another person, or against
a group or community that either results in or has a high likelihood of
resulting in injury, death, psychological harm, maldevelopment, or
deprivation."

Understanding the Systems Approach

A system accomplishes its work through functions, structures, and
capacities. As a system, the child protection system also exhibits a nested
structure: children are raised in the context of a family, which has a duty
to protect their children. The family itself is nested within family system,
which is nested within a local community (itself a system) and the wider
social/societal system20 . Sometimes, the nested structure of children,
families, and communities is portrayed as a series of concentric circles.21

19
http://www.who.int/violenceprevention/approach/definition/en/20140708

20
Ibid (Stevens,2008; Mulroy, 2004)
21 Ibid (UNICEF EAPRO, 2009).

21
 The nested, interdependent nature of children, families, and communities
is a key element of the ecological perspective and must be recognised as
an important aspect when designing a child protection system in
hospitals.22

When thinking about a systems approach to child protection, it is

important to remember the highly interactive nature between the system
and its context. In some socio-cultural contexts, the formal system
structures may not be considered necessary or appropriate because
parents, extended family members, and other members of the community
protect children through largely informal mechanisms. In other contexts,
more elaborate system structures are needed to coordinate the various
actors who have been assigned responsibilities within that system.
Regardless, a systems approach is not prescriptive. Child protection
systems work best when symmetry exists between the system’s goals, its
structures, functions, and capacities and the normative context in which it
operates. Children are effectively protected by such systems when both
the system and the normative context in which it is embedded place
highest priority for assuring children are free from violence, abuse,
exploitation, and other forms of maltreatment.

In brief, several elements of all systems apply to the development of child

protection systems. These elements include the following:
 A collection of components or parts that are organized around a common
purpose or goal (protecting children from abuse, neglect and
exploitation)—this goal provides the glue that holds the system together.
 All systems reflect a nested structure—in the case of child protection,
children are embedded in families or kin, which live in communities,
which exist within a wider societal system.
 Given the nested nature of systems, specific attention needs to be paid to
coordinating the interaction of these subsystems such that the work of

22 Opcit Bronfenbrenner22(1979)

22
 each system is mutually reinforcing to the purpose, goals, and boundaries
of related systems.
 All systems accomplish their work through a specific set of functions,
structures, and capacities.

In addition, the context in which the system operates determines the

characteristics of functions, structures, and capacities . All change within a
system framework is bi-directional—changes to any system, for whatever
reason, will change the context and changes in the context will alter the
system.
 Well-functioning systems pay particular attention to nurturing and
sustaining acts of cooperation, coordination, and collaboration among all
levels of stakeholders, including those managing key activities as well as
those performing key functions.
 Systems will achieve their desired outcomes when they design,
implement, and sustain an effective and efficient process of care in which
stakeholders are held accountable for both their individual performance
as well as the performance of the overall system.
 Effective governance structures in any system must be flexible and robust
in the face of uncertainty, change, and diversity.

In conclusion, the fact is that children are abused. Yet, not much is so
far systematized within health care institutions to protect children.
There is a need to study the scope of health care institutions in India
strengthening child protection systems and programmes.

23
 CHAPTER 2

REVIEW OF LITERATURE:
The aim of this study is to explore the scope, understanding and
capacity of hospitals in India to strengthen child protection in their
settings, identify workable comprehensive models for child
protection systems and programs and develop a curriculum to
enable competency to be built. The researcher undertook
extensive research in order to explore the need for child protection
systems and programs building in hospitals in India, practical
culture sensitive child protection systems in hospitals across the
world, curriculum and models for child protection. Some data was
reviewed online. Most data were received from hospitals with
systems in place through email requests sent out by the
researcher. The researcher also visited the libraries of Health
related colleges, National Health University in India. CRY, NGOs
and UNICEF also shared data and studies. The researcher heard
from several experts that this research study is a rather new area
for India. Hence, she went in for an exhaustive Review of Literature
to guide hospitals and health care institutions that embark on their
journey for protecting children.

RESEARCH STUDIES RELATED TO THE NEED FOR CHILD

PROTECTION SYSTEMS BUILDING IN HOSPITALS IN INDIA:

a. In 2014, Sujatha undertook a study on Sexual Offence Cases

brought to KIMS Hospital, Bangalore23. She observed that health

23
http://hdl.handle.net/123456789/9439 /20140811

24
 services for victims of sexual offence are recognized as a
particularly neglected area of the health sector worldwide. This
study aimed to find out the profile of sexual offences in South
Bangalore and to describe the characteristics of victims and
accused of sexual assault which were brought to KIMS Hospital,
Bangalore over a period of one and half years. 47.5% of the
incidents occurred in the evening and midnight time, and the place
of incident in 37.5% cases was the accused house. 80% of
survivors presented with rupture of hymen. 48.6% cases
presented with recent tears of hymen, 31.4% cases presented with
old tears of hymen. 11.4% cases presented with genital injuries in
the form of bruising of vulva. The male survivor presented with the
extra genital injuries in the form of multiple abrasions without any
genital injuries. The study concluded that the numbers in the
present study represented the tip of iceberg phenomenon. “Still
vast majority of cases go unreported.” The researcher, having gone
through this study, found evidence of child sexual abuse happening
through people the child trusts. Is staff in hospitals able to detect
sexual abuse in the course of their medical care? When they do come
into the hospitals setting, are the staff equipped to deal with it in
child friendly processes, was a lingering question this research
sought to research.
b. K.S Gujjar undertook a study in 2013 to evaluate the effectiveness
of structured teaching programme regarding child rights and
selected legal aspects among teachers at selected Government
schools in Bengaluru24. Findings revealed that Pre test knowledge
assessment was 37.5% of teachers had inadequate knowledge,
45% had moderate knowledge and 17.5% had adequate
knowledge of child Rights. The overall mean percentage score was
49.5% in pre test. Inferences drawn by the researcher is that
teachers with poor knowledge of child rights will not be able to teach

24
http://hdl.handle.net/123456789/7899/20140810

25
 children about it. This increases vulnerability of children to sexual
abuse in any setting, since their capacity to identify abuse is weak.

c. Karuna B. undertook a study in 201225 among rural and urban

mothers in a town close to Bangalore city , Kolar on the knowledge
of mothers about child abuse. The findings evidenced that there is
a significant difference in knowledge scores of rural and urban
mothers. She concluded that the majority of mothers both in rural
and urban had only moderate knowledge. The findings of this
study were similar to a study undertaken by B. A. Abraham in
200626. These studies inference that parents also do not equip a
child to recognise and deal with child rights and child abuse. Have
hospital staffs made any commitments, then to child protection?
Have they created child protection systems and programs?

d. Sowmini Varghese’s study on sibling abuse in 201327 highlighted

that child abuse did happen between siblings. Did parents know
about the abuse? Do hospitals know how to deal with sibling abuse
when treating children who are injured through abuse? When
neither parents nor teachers are able to teach children about child
Rights and their Right to protection, can hospitals step in, at least for
ascertaining that children entering their care are protected?

e. Study undertaken by the Ministry of Women and Child

Development : Sujatha’s study of 2014 echoed findings of the
Indian Ministry of Women and Child Development research on
child abuse in 200728 which covered 13 states, a sample size of
12447 children (51.9% of them were boys, 25.4% S/Cs; 29.2%

25
http://hdl.handle.net/123456789/8055/20140520/20140812

26
http://hdl.handle.net/123456789/3099/20140520/20140812

27
http://hdl.handle.net/123456789/9059/20140811

28
wcd.nic.in/childabuse.pdf/20131101

26
 ;Backward classes, 15.1% STs, 2324 young adults and 2449
stakeholders. The study researched different forms of child abuse:
physical, sexual, emotional abuse, girl child neglect.
Key findings across different kinds of abuse were that it is the
young children, in the 5-12 year group, who are most at risk of
abuse and exploitation.

The findings of the 2007 MWCD study on Child Sexual Abuse

were:
 53.22% children reported having faced one of more forms of
sexual abuse.
 21.90% child respondents facing severe forms of sexual abuse and
50.76% other forms of sexual abuse.
 Out of the children respondents, 5.69% reported being sexually
assaulted.
 Children on street, children at work and children in institutional
care reported the highest incidence of sexual assault.
 50% abusers are persons known to the child or in a position of
trust and responsibility.
 Most children did not report the matter to anyone.

The study calls for a comprehensive response to build child safe

environments where no child experiences abuse. Hospitals are one
such place. More so, when children do not have access to child rights
education. In fact in other countries, there is a child protective risk
management system in hospitals.

f. R.N. Srivastav, during the Asia Pacific Conference on Child

Abuse and Neglect in Delhi in 2011 highlighted, “Although the IAP
(Indian Academy of Paediatrics) has largely been occupied with
problems of the sick child, preventive pediatrics, and academic
activities, it has been concerned with the wider issues that affect
child welfare and development. In 1996, IAP adopted

27
 “Comprehensive Child Care” as its motto, and thereafter a Child
Abuse, Neglect and Child Labour Group was established to address
these problems29. In 2007, IAP organized a series of training
workshops on Child Abuse and Neglect issues and also brought out
guidelines on pediatricians’ response to child abuse and neglect.
Several pediatricians were providing voluntary services in rural
and underprivileged communities. Child abuse and neglect issues
were regularly deliberated at IAP its national and regional
conferences”.

CHILD PROTECTIVE SYSTEMS BUILDING IN DEVELOPING

COUNTRIES
a. A paper presentation of experiences in Tanzania30 studied
looks at violence among children as an entry point for
strengthening child protective systems building. Over 29% girls
and 13% boys reported sexual violence. A Multi-Sector Task Force
for Violence against Children was formed with:

 Ministry of Community Development, Gender and

Children (Minister)
 Ministry of Health and Social Welfare (Minister)
 Prime Minister’s Office Regional and Local
Government (Deputy Minister)
 Ministry of Home Affairs/ Tanzania Police Force
(Police Commissioner)
 Ministry of Education and Vocational Training
(Minister)
 Ministry of Constitutional and Legal Affairs (P.S.)
 Tanzania Commission for HIV and AIDS (Executive
Director)

29
http://medind.nic.in/ibv/t12/i1/ibvt12i1p11.pdf/20140612

30
( not able to find source)

28
  Tanzania Child Rights Forum – Civil Society

In Tanzania, as in India, the perpetrators of child sexual abuse

were known people the child trusted. Health care providers
received skills training on case management using the Gender
Based Violence Medical Management Guidelines (launched in
December 2011). All children exposed to all forms of sexual
violence and abuses receive emergency care and free treatment.
All public health facilities and clinics become key sites for health
education on negative impact of violence to build early warning
systems to protect children and women.

b. Recognizing the meager evidence base on system

strengthening in Africa and the nascent nature of Child Protection
systems strengthening work in general, a working paper was
developed by multiple stakeholders in May 2012 to consolidate
what the learning about child protection systems strengthening in
sub-Saharan Africa were and to suggest a way forward. The
working paper was designed to focus on concrete actions for
systems strengthening. The paper suggested that a specific path or
trajectory that child protection system strengthening takes is
country specific. “It is an outcome of a full range of social, cultural,
economic and political factors. System strengthening is
evolutionary. At the same time, it requires strategic attention to
successes and good practices established at all levels in order to
capitalize them for moving the system strengthening agenda
forward”. Based on the learning from what is happening in other
developing countries the paper emphasized the following:
 Motivated leadership and positive governance
(or champions of change) enable positive action on system
work. A political space that is conducive is the key point for

29
 any sustainability in system work31. The paper cites the
following examples: “in Ghana, the national policy
directives for children include the departments and
agencies of the ministries of health, education, and social
welfare and community development32. In Côte d’Ivoire, the
Government used the publication of the national mapping
and analysis of child protection as a way to engage the
health, education, and labour sectors in discussions of the
findings and ways in which collective and systematic action
could be carried out. Sierra Leone has initiated similar
processes of cross-sector discussions on system
strengthening strategies. In Tanzania, research data on the
very high prevalence of school-based violence helped put
the issue of violence as a national priority for action.
Children revealed that sexual, physical and emotional
violence are common features for children growing up in
Tanzania, and that the perpetrators are often close or well
known to the victims.”
 Establishing effective partnerships and
coordination mechanisms can then serve as an entry
point for system strengthening. Some examples cited in the
paper include the use of coordinating groups to create the
national protocols for gender-based violence in Sierra
Leone, for domestic violence in Ghana and for overseeing
the development of social protection situation analysis and
framework in Niger.

The paper emphasizes the importance of looking at the

participation of populations and children to the process of
creating a political space. They gave examples from the Central

31
Stella Nkrumah-Ababio (2012). Regional Advisor on Child Protection and Child Focus, West Africa,
World Vision International. Personal Communication.
32
Republic of Ghana, Ministry of Women and Children’s Affairs, undated document./20140814

30
African Republic, where the use of children consultations was
pivotal to allow the creation of a political and policy dialogue
between children, child focused organizations, and policy makers.
In Ethiopia, the participation of children and populations to local
processes of creating a political space for Child Protective system
strengthening is an encompassing approach In Senegal, a National
Child Protection Strategy was developed in 2011 with key
contributions from civil society organizations and children
themselves.

The paper opines the need to be strategic to promote policy

change or law revision at a time of broader sector reforms.
This emphasizes the need for a systems approach when
designing a child protection programmes for hospitals in India.
This was effective in Guinea Bissau for instance, with the inclusion
of children’s vulnerabilities in the range of threats to human
development and the mainstreaming of child protection issues in
broad sector reforms (Education, Health, Justice and Social
Security).

The paper asserted that the Child Protection Workforce is an

inclusive term and means all categories of people who work on
behalf of vulnerable children and families i.e. A range of providers
and actors, both informal and traditional viz., family and kinship
networks, community volunteers as well as formal workers who
are employed. They may be unpaid volunteers working in the
informal system as well as paid employees working in
governmental and non-governmental organizations including
hospitals, schools, prisons, community centers and other
community programs. It includes people who work at the national,
regional, district and local levels .

31
 The above papers share deep insights on how and why a system
approach to child protection is needed in India’s health care
institutions and other places caring for children also.

RELATED STUDIES FROM DEVELOPED COUNTRIES

a. Crisp and Lister33 stressed that health care workers were
recognized as having a key role in the protection and care of
children in Scotland, particularly in respect of identification and
detection of child abuse. Nurses, especially health visitors in
Scotland, are often the first professionals to suspect that child
abuse has taken place. The aim of this study was to explore
nurses' understanding of their professional responsibilities in
relation to child protection, and the potential for nurses to be
involved in the protection of children from abuse. One of the key
findings was that there was lack of consensus among interviewees
about the nursing role in child protection issues, particularly with
respect to the extent to which nurses should actively seek to
detect cases of child abuse. An emphasis on identification and
detection was not easily accepted by many nurses, and was
perceived by some to be a change from their more traditional role
of supporting families, as well as being potentially in conflict with
some public health responsibilities.

In spite of the perception of some nurses that there was a sharp

divide between child protection work and public health
interventions, many of the child protection roles that were
identified by nurses, such as supporting families, parenting
education and service development, are clearly within the ambit of
contemporary notions of public health. Furthermore, the study
concluded, it was clear that there is a role in child protection for a
much wider group of nurses than health visitors.

33
Crisp BR, Lister PG.,( 2004 ) Adv Nurs. Child protection and public health: nurses' responsibilities, Sep;47(6):656-63.
(b.crisp@socsci.gla.ac.uk http://www.ncbi.nlm.nih.gov/pubmed/15324435/20130810

32
 b. Rowse undertook a qualitative study34 to explore the
experiences of nurses working in a hospital paediatric department,
who had direct involvement in child protection cases, to discover
their support needs and suggest developments in training and
support. The study was inspired by an awareness of increasing
anxiety amongst nurses involved in child protection cases.

Results highlighted that involvement in child protection had a

lasting impact; nurses needed procedural information from a
knowledgeable supporter during a case; and, they needed
individualized support. The personal qualities of the ‘Named Nurse
for Safeguarding Children’ were crucial. The study concluded that
involvement in child protection cases has lasting effects for
individuals. The emotions generated can lead to interagency and
inter-professional communication difficulties and affect the future
management of child protection by individuals. Seeking support
could be hampered by individuals' fear of ridicule or of making a
mistake. This study has implications for the training of children's
nurses in child protection procedures, and the provision of
appropriate effective support for individuals. The long-term effects
of involvement are previously unreported by nurses.

c. Appleton undertook a study35 that set out to examine how

Primary Care Organisations (PCOs) in England manage, organise
and deliver their safeguarding children responsibilities. Keeping in
mind changing organisational configurations across primary care,
a wealth of policy directives and a climate of extensive media
attention around child protection, her paper focussed on how PCOs

34
Rowse V, (2009 ) Support needs of children's nurses involved in child protection cases, J Nurs
Manag. Sep;17(6):659-66.

35
Appleton JV, (2012)Delivering safeguarding children services in primary care: responding to
national child protection policy, Prim Health Care Res Dev. Jan;13(1):60-71.
(Epub 2011 Sep 1. http://www.ncbi.nlm.nih.gov/pubmed/21880177.)/20131030

33
 respond to national policy and deliver safeguarding children
services.

The findings outlined how and to what extent PCOs respond to the
national policy and organise and deliver their child protection
services. The paper highlighted some of the key challenges facing
PCOs, in particular, safeguarding moving off the primary care
agenda, child protection staff recruitment difficulties, a
proliferation and overload of policy, resource implications for
additional staff training, challenges to collaborative working, high
referral thresholds to social care services and cutbacks in public
health nursing services. This paper concluded by offering some
suggestions about how child protection services could be
improved as primary care. But it faces another major
reorganization with the demise of Primary Care Trusts in April
2013.

d. Hanafin’s paper36 argued that children who were deemed to

be 'at-risk' needed specialist intervention and that the Irish public
health nurse (PHN) could not provide this intervention. It further
argued that a failure to acknowledge and act on this was placing
children at further risk and it suggested that the mismatch
between actual and perceived (or expected) roles led to practices
which undermined rather than supported child protection. The
evidence suggested that the PHN fulfilled a range of prescribed
roles but that there was a perception or expectation among other
service providers that she was also fulfilling additional roles. The
paper concluded by suggesting some possible solutions to this
discontinuity with a view to improving child protection services.

36 Hanafin S, (1998) Deconstructing the role of the public health nurse in child protection. J Adv Nurs. Jul;28(1):178-84
(http://www.ncbi.nlm.nih.gov/pubmed/9687146) 20131104

34
 CHILDREN and RIGHTS ?
In the 19th century in West 41st Street ,
New York, a nurse, Etta Wheeler
constantly heard the cries of a child in
agony from one of the homes on her
way to work. On the pretext of seeking
help for another neighbour, she
entered the house and saw the
malnourished child badly, abused,
bruised and beaten. She however, had
no power legally to rescue the child out
of the abusive situation. Finally, the
Prevention of Cruelty to Animals
Law was used to find a legal recourse
and her step mother, The 10 year old
Mary Ellen testified in court on the
April 10, 1874. Mary McCormack , the
step mother was jailed (Her father had
died) for one year. That year, the New
York Society for the Prevention of
Cruelty to Children was founded, the
first organization of its kind.
e.

f. In the U.K a study37 undertaken to strengthen child protection

services and acute care identified three main types of social work
delivery models:

 hospital-based social work team which take referrals and

manage early stages of case work
 smaller hospital liaison teams comprising social work staff
designated to work with trusts but not necessarily based in
hospital full-time
 Community-based teams providing services to the whole
local authority area and receiving referrals from all local agencies.

The study found that both in-hospital and community-based

arrangements can be effective for joint working with respect to
child maltreatment. Within any staffing arrangement, however,
success relied on visible, tangible investment in collaborative

37
http://www.scie.org.uk/publications/ataglance/ataglance63.asp/20131108

35
 working. Child protection needed to be explicit priority at all
organizational levels. They also recommended that culture should
enable staff to understand what this means for their day-to-day
work. The study also identified several likely success factors
specific to each model.

REVIEW OF LITERATURE RELATED TO THE SYSTEMS

APPROACH
a. UNICEF proposed a two-stage approach helps draw the
distinction between what a system is in general versus what a child
protection system does or could do. Our review found enormous
variation in what stakeholders perceived as appropriate activities
for a child protection system and in the degree to which
responsibility for such activities were shared with other
community and governmental entities. Ultimately, how these
choices are defined and resolved are of central interest to those
constructing a specific child protection system. Every family,
community, and nation has a child protection system in place that
reflects the underlying cultural value base and diversity within
that context. As such, a particular child protection system
manifests a combination of cultural norms, standards of behaviour,
history, resources, and external influences that over time reflect
the choices participants have made regarding their system. The
goal was not to define these decisions but rather to highlight the
key components that will be found in any child protection system
and to encourage a robust and transparent conversation among
key stakeholders as to how the definition of these components will
impact child protection.

b. UNICEF’s Global Child Protection Strategy38, adopted in

2008, provides tips on child protection system strengthening
strategies for strengthening culture sensitive community based
38
unrol.org/files/CP/20140730

36
 mechanisms within a national child protection framework that
protect children across the range of thematic areas. “The strategy
suggested two priority actions:

(i) to identify the minimum package of services - a range of

services on a continuum from prevention to response that are
shared across sectors (social welfare, education, health justice &
security) and that includes the private sector, community NGO’s
and can be modified for emergency situations and

(ii) develop and apply an analytic tool for assessing existing

system components and processes.39 The UNICEF strategy has
catalyzed an enormous amount of work on Child Protection
systems, much of it in the early implementation stage. At the
country level, stakeholders are grappling with an array of new
concepts of issues, from very basic definitions (“what is child
protection?”) to the difficulties in determining what it really means
in practice to establish a child focused, community based, and
nationally owned system.” These challenges are relevant to the
scope of developing child protection systems and programs in
hospitals in India too.

c. In Hong Kong40, where reporting of child abuse is not

mandated and the primary care system is not well developed,
children who are suspected victims of abuse are often brought to
public hospitals where they are treated in conjunction with other
children who are experiencing acute medical problems. One study
examined the effects of a group of medical practitioners at the
Tuen Mun hospital in Hong Kong who organized and developed a

39
UNICEF. (2008). Summary of Highlights: UNICEF Global child protection systems mapping
workshop. Bucharest, Romania./20140814
40
Lee, A. C. W., et al. (2006). The impact of a management protocol on the outcomes of child abuse in
hospitalized children in Hong Kong. Child Abuse & Neglect, 30(8).

37
 protocol for the investigation of child abuse to strengthen the
clinical management of abused children. Their protocol included
three components:
i. a designated group of medical professionals and social workers
to coordinate and manage all cases of child abuse in the hospital,
ii. early communication between the medical staff and community
professionals such as child protection workers and the police who
investigate suspected cases of abuse, and
iii. a focus on physical and medical history and de-emphasis of
clinical interventions.
Similar approaches could be adopted by hospitals in India too.

d. Paralleling examples of error in the fields of medicine with

those found in child protection, Munro41 contrasts the traditional
approach of examining errors in these fields with a systems
approach. Traditional investigations into child protection
problems, often concluded with the determination of “human
error,” lead to the development of tools, manuals, and closer
scrutiny of frontline workers but do not necessarily improve
outcomes. The systems approach, Munro argued, uses human
error as a starting point, leading investigators to examine the
entire system within which a person is operating. A systems
approach looks at the caseworker as “part of a constant stream of
activity, often spread across groups, and located within an
organizational culture that limits their activities, sets up rewards
and punishments, provides resources, and defines goals that are
sometimes inconsistent.” The paper proposes using a systems
approach as the first step to finding better solutions to problems
encountered in child protection.

41
Munro, E. (2005). Improving Practice: Child protection as a systems approach. London: LSE Research
Articles Online. Available at: http://eprints.lse.ac.uk/archive/00000359.20140729

38
 e. UNICEF’s internally called “Bucharest paper,” was developed
following a meeting in Bucharest titled “Global Child Protection
Systems Mapping Workshop.42 Those attending this workshop
were charged with three tasks:
i. develop a diagram of service types falling within the purview of a
child protection system,
ii. Agree on the key elements and supporting capacities that are
needed to successfully implement these service types and
iii. Reach consensus on the list of outcomes to which a child
protection system should contribute.
At the end, the participants at the Bucharest meeting concluded
that a common understanding of child protection systems does not
yet exist within the field at large. The Bucharest paper made this
researcher question whether there is a need to develop a common
understanding of what is child abuse is and what a child protection
system for hospitals is?

The review of literature and several anecdotal sharing deepened

the understanding of the scope of setting up child protection
systems and programs in hospitals for the researcher. In
conclusion key learning included:
 There is a priority to first accord the family and community
as the first line for child protection. Hence, it is critical for the
hospital staff to fully assess endogenous child protection practices
within families and communities
 Within hospitals, social dialogue and policy definitions need
to lend clarity on concepts of child safety and protection as it fits
with a child rights framework. The definition of children,
childhood and adulthood is culture-bound. Developing a
normative framework or child protection policy must be reflective

42
UNICEF. (2009). UNICEF Global Child Protection Systems Mapping Workshop: Summary Highlights. New
York City: UNICEF./20140210

39
of the local culture and the universal child rights approach. This
must take a fully participatory approach inclusive of children and
adults in order to negotiate what it is children need and want
within the context of the family and community real and desired
needs. Child Safety and protection within the home, school and
community needs to be fully contextualized through participation.
 Build on existing traditional and informal protection
mechanisms
There are many traditional and informal structures to protect and
support and their families. There is evidence that children and
families are reluctant to report sexual abuse they experienced to
the formal authorities .Ways to empower children to speak up is
part of his or her restoration and resilience building, which
counselors and nursing staff in a hospital team are trained to do.

 Strategically plan, coordinate, monitor and evaluate the

formal and informal community processes and systems at the
response level
There are many good practice models that have been shown to be
effective in addressing children’s needs and rights within the local
community context. The District Child Protection Unit was
established under the Integrated Child Protection Scheme, a
financial instrument to the Juvenile Justice (Care and Protection)
Act 2000. There is a District Child Protection Society comprising of
government and non government levels. 1098 is the Child helpline
number. Hospitals do not need to start from scratch. Yet, since this
comes under the umbrella of the Ministry of Women and Child
Development , and not health there needs to be inter ministerial or
departmental coordination for strengthening child protection
systems building in hospitals.

 Strengthen service models

A Hospital’s Child Protection Plan refers to a range of responses

including preparation, prevention, response and participation.

40
 These responses may be called different things and have different
structures. The responses may include a range of integrated case
management practices such as curriculum development for health
related personnel, systematic assessment strategies, case planning,
treatment, and follow up. In their discussion of health systems,
Begun, Zimmerman, and Dooley 43talk about how relationships
among agents in complex systems are “massively entangled,”
altering and being altered by other actors in the system. Specific
processes are shaped by formal and informal laws, policies and
practices. Included are measures that ensure equal access,
protection and participation of all children.

43 Begun, Zimmerman, and Dooley (2003)

41
 CHAPTER 2 a

EMERGING ADVANCEMENTS IN
CHILD PROTECTION IN HOSPITALS

In India, the Ministry of Health and Family Welfare in January 2014

published protocols for hospitals to develop a response system for
children admitted with suspected or real sexual abuse. The book
entitled “GUIDELINES & PROTOCOLS -Medico-legal care for
survivors/victims of Sexual Violence” 44 has a chapter on page 18
on guidelines for responding to children.

In India, cases taken up on child sexual abuse is on the increase. A

6 year old child from a school in Bangalore catalysed a bandh with
people demanding stronger child protection systems in schools.
The time is ripe for systems building where ever there are children
under the care of adults45.

44
For a copy, write to dwinapereira@gmail.com

45
www.newindianexpress.com/...6-Year-Olds-Gangrape/.../article2354515/20140212

42
 In Chicago, major efforts were focused on the development of child
abuse as a recognized medical subspecialty which now is
certified as a new board subspecialty.46

In the U.K., 47work on the system known as ‘Child Protection –

Information’ began in early 2013 and it will start to be introduced
to NHS hospitals in 2015. Doctors and nurses using the system, in
emergency departments or urgent care centres will be able to see
if the children they treat:

 are subject of a child protection plan or child welfare authority

 Have frequently attended emergency departments or urgent care
centres They are working on improving liaison between acute
paediatric and child protection services48

46
http://pediatrics.uchicago.edu/SectionDetail.aspx?section=1025/20140224

47
https://www.gov.uk/government/news/new-child-abuse-alert-system-for-hospitals-
announced/20131211

48
http://www.scie.org.uk/publications/ataglance/ataglance63.asp/20131210

43
 CHAPTER 3

METHODOLOGY
This research study is exploratory in nature. The researcher had not
found any hospital in her experience in India that had either child
protection policies developed nor programs. Discussions with UNICEF
elicited no knowledge of any hospital in India with a formal child
protection system in place. The extensive literature review and feedback
from the research mentors enabled the creation of the research design.
This exploratory research study is formative , with the purpose of gaining
new insights, finding out new ideas about the scope of setting up child
protection systems and programs in hospitals in India.

THE SETTING:
The research was conducted among decision makers in the health care
systems, hospitals and clinics, mostly in Bangalore. However, part of the
exploration was undertaken in the Ministry of Health and Family Welfare,
New Delhi and in organizations including the World Health Oganisation in
Geneva, Switzerland.

THE UNIVERSE: Health care institutions in India.

THE SAMPLE POPULATION: The sample population included decision

makers, medical and nursing staff who were working in hospitals or the
health care system primarily in Bangalore, India. Children from child
parliaments facilitated by an NGO, International Services Association,
INSA-India in Bangalore were also part of the study. A total of 423
hospitals listed in the Yellow pages in Bangalore city formed the largest
population.

44
 THE METHOD:
a. Focus Group Discussions with children

Firstly, the researcher developed and used a child appropriate guided tool
to undertake a focus group discussion with children in Child Parliaments
facilitated by an NGO viz., INSA-India (www.theinsaindia.org). The
researcher sought informed consent from the Principal/Director of the
schools/ children’s homes first. After which, she sought informed consent
of the children. Child parliament members are well aware of the terms
child abuse, since for the past three years they were engaged in child
protection activities. While three were in a school setting, one was in a
children’s home for children living with HIV infection. The assumption
made was that children do visit hospitals for treatments, or medical
reviews and their input into the design of the research could strengthen
the research meaningfully.
b. Observation Study:
The research question here was how visible child protection in hospitals
is. The researcher spent more than one hour in four tertiary hospitals in
Bangalore city and visited the pediatric Outpatient departments, wards,
the corridors outside the PICU / NICU and emergency to find out if there
were any child protection messages displayed and the care given to
children in general.
c. Survey Questionnaires: The researcher first visited the Department of
Health and Family Welfare, in order to obtain the complete list of
hospitals and clinics in Bangalore city with postal information. When the
government officials approached informed her that they have a list of only
government concerns under their jurisdiction, she enquired about the
registration to run a clinic or hospital. She was directed to the Medical
Council to no avail. Ultimately with advice of the Department of Health
and Family Welfare, she used the data from the Yellow Pages Directory
online. The number of clinics and hospitals listed were only 423. The
questionnaire was mailed by post to 423 hospitals along with a return

45
 stamped envelope for receiving their replies. Quantitative data related to
the need for child protection systems and programs, as well as their
interest in developing such systems and programs was the content of the
15- item questionnaire posted to them. An stamped return post
enveloped was enclosed with each .
d. In depth interviews:
The in depth interviews were undertaken with 15 decision makers of
health in the government, private doctors , members of NGOs, a parent
and a school headmistress. The in-depth interviews hoped to capture
qualitative data related to the following key research questions
- Is it necessary to have child protection systems and programs in
hospitals? Do they know of any hospital with a child protection policy
in India?
- Why does your hospital have/not have child protection policies in
place with programs?
- If a hospital has to develop child protection policies and systems, what
is the process? Who are the decision makers for this? Where are such
decisions made?
- Are there any other policies that protect children in hospitals?
- What child protection programs are possible even without a child
protection policy?
- Is staff of hospitals equipped to prevent and deal with child abuse and
exploitation? What are the training needs?
- In what way can you help strengthen child protection systems in
hospitals?
e. Focus group discussions in four hospitals in Bangalore
From March till August 2014, the researcher tried through different ways
to organize for focus group discussions in four tertiary hospitals in
Bangalore city. However, even though the Hospital Ethics Clearance was
given in one of the hospitals, it was subject to consent of the management.
The researcher did not hear from the management despite reminders in
writing. In one government child hospital, a member of the Ethics
Clearance Board suggested that since the study was educative, to

46
 undertake learning needs assessment with the doctors and nurses using a
Questionnaire. Hence, the researcher modified the approach to use
questionnaires in one tertiary government child health hospital which
was used for 40 doctors and nurses.
f. Questionnaires
Questionnaires contained the same key questions as the In Depth
Interviews. It also contained a perception tool of what abuse was
according to the respondents. The respondents were 40 doctors and
nurses of a tertiary government Child Hospital in Bangalore. The
questionnaires were administered as part of a training session for the
staff with support of the management who appointed a child protection
point person to coordinate this.

KEY DATA COLLECTED:

In brief, the data collection planned and collected were as follows:

S.NO METHOD TOTAL NO DONE

PLANNED
a. FGDs with children 5 4

b. Observation study 4 4

c. Survey Questionnaire 100 423

posted
d. IDIs with stakeholders 10 15
in 4 hospitals/health
e. FGDs in 4 hospitals 4 0

f. Questionnaire 40 40

Survey with 423 hospitals in Bangalore listed in Yellow pages:

Of the 423 letters with self addressed stamped return envelops, only 7
were returned with answers to the questions raised. 41 were returned

47
 unopened with addressee not known (9.6%). Only 7 responded by
returning by post the questionnaire to the researcher. One did not
complete the questionnaire but added a letter saying, “Since this is an
Ophthalmic Out Patient Clinic, there is no chance for child abuse”. Hence,
only 6 survey replies were analysed.

FGDs with children:

4 FGDs were undertaken in the following schools/child parliaments using

the adapted story centred outline tool submitted to CRY during the
January meeting. The FGD was undertaken in child parliaments facilitated
by INSA-India in :

a. St Antony’s school , Gowripalya

b. Binny High school, Binnypet
c. Binny Middle school, Binnypet
d. Snehagram Children’s Home

“Making hospitals child safe is a definitely needed,” said one Principal

during the discussions for eliciting her consent. She went on to described
a recent incident where a child was touched on her breasts by the doctor.
The child told her mother, who shouted at the doctor. The neighbouring
community joined in the protest. The clinic was closed for 6 months. “But
what happens after 6 months?” she asked. The focus group discussions
enabled the researcher to further modify her tools for the in depth
interviews and the questionnaires that followed.

In Depth Interviews brought in qualitative data for the researcher on the

scope of child protection risk management in hospitals. The following
were interviewed:

i. Additional Secretary, Ministry of Health and Family Welfare, Nirman

Bhavan
ii. HOD Pediatrics at a tertiary private hospital
iii. Unit Head, Pediatrics department in a tertiary mission hospital.

48
 iv. Commissioner of the State Commission for the Protection of Child
Rights in one state
v. Medical Superintendent of a tertiary government hospital
vi. HOD Paediatrics, at a tertiary government child Hospital.
vii. Director, NGO, Bangalore
viii. Nursing superintendent of a mission hospital, Bangalore
ix. A nurse in an NGO in Bangalore running a home for children from the
streets.
x. Technical officer, Department of Violence and Injury, WHO, Geneva:
xi. Program Executive, Women in Church and Society, World Council of
Churches, Geneva
xii. Program Officer, HIV Workplace Programs, ILO, Geneva
xiii. Joint Director of a Department of Health and Family Welfare.
xiv. Director of a National Health University
xv. Parent who experienced abuse in a hospital setting as a child

Unstructured exploratory discussions on the need for child protection

systems and programs in hospitals were also done with the Director for
Child Protection Unit in the Department of Women and Child
Development, UNICEF Child Protection representative, Paediatricians,
Childline nodal organization representative , several NGOs and schools.
The purpose was to garner qualitative information related to the study.

DATA ENTRY:
The researcher used SPSS and excel to enter the data and for finer
analysis outputs. In conclusion, the methodology was in itself a learning
process for the researcher.

49
 Chapter 4

DATA ANALYSIS
This Chapter focuses on the analysis of data gathered in exploring
the scope of setting up child protection systems and programs in
hospitals in India. The Observation study was undertaken first to
find out how visible child protection in hospital settings is. The
researcher did not find any poster or chart related to child
protection viz., behaviour protocols, child helpline numbers or
how precious children are and how their care is important in any
of the emergency or paediatric wards of the four tertiary hospitals
in Bangalore during her visit. In one government child hospital, a
number of the child help line was pasted as a sticker in the
administrative secretary’s of the paediatric Head of the
Department’s chamber. All the four hospitals had gone through an
incomplete program of the Collaborative Child Response Unit49
where selected medical and nursing personnel of the hospitals
were trained on child friendly protocols for responding to children
who were sexually abused ( 2012-2013).

This chapter describes the analysis of

 Focus Group discussions with the children on child protection in
hospitals,
 Survey undertaken with 423 hospitals in Bangalore,
 Questionnaire administered to medical and nursing staff of one
hospital
 In Depth Interviews of key stakeholders ,

49
CCRU was piloted by ENFOLD with support from UNICEF. “CCRU is a Hospital based multidisciplinary
team approach to child abuse, intended to provide sensitive and comprehensive care for the targets
of child sexual abuse, while maintaining the dignity and best interests of the child at all times.” The
project was closed midway due to funding challenges. (http://www.enfoldindia.org/hospital-based-
multidisciplinary-child-protection-systems/20141125).

50
ANALYSIS OF THE FOCUS GROUP DISCUSSIONS WITH
CHILDREN

All children in the four focus group discussions were in agreement

that doctors and nurses must take care of them when they go to
the hospitals.

They had personally not experienced sexual abuse in hospitals.

However, they had experienced hospital personnel being rude to
them, not keeping their problems secret and embarrassing them,
and being injected without any preparation. They all agreed that
hospitals also should have rules about how to take care of children
and how to protect them. The writing of one group of children and
their ideas for strengthening child protection are depicted below.

ANALYSIS OF THE SURVEY ON HOSPITALS IN BANGALORE

Given below is the analysis of 6 questionnaires. One of the seven

was left blank with a letter written to say that since it is an

51
ophthalmic OPD there was no need for child protection systems or
programs.

Do you have any systems in place in the hospital to protect

them from abuse

Yes
50% of the hospitals
Not sure
No reported that they
have systems in place
to protect children
from abuse. Whilst
33.3

50
16.7% were not sure,
33.3% reported that
16.7
they did not have any
system to protect
children from abuse.

Do you agree that child abuse is a matter for hospitals to work

out

Yes
Not sure

16.7

83.3

83.3% of the hospitals

Do you agree that most staff in your hospital know about child
agreed that child abuse is a
abuse
matter for hospitals to work
Yes
Not sure
out.

67.7% of the hospitals stated

33.3
that the hospitals’ staff knew
about child abuse.
66.7

52
 Do you agree that we need to develop culture sensitive child
protection programs in hospitals

Yes
Not sure

16.7

83.3

83.3% hospitals stated

that there is a need for
hospitals to develop
child protection
policies and
Do you agree that perpetuators of child sexual abuse are
programmes.
people the child trusts, are known members of family and
friends mostly

Yes
Further, 83.3% of them
Not sure
understand that a
16.7
perpetuator of child
sexual abuse is a
person the child trusts.
83.3

Does your hospital have a child protection policy

Yes
Not sure
No

33.3

50

16.7

50% of the hospitals reported that they do not have child

53
protection policies and systems in place according to respondents
of the survey conducted. 33.3% of them stated they have a child
protection policy, but were not able to share a copy with us. 16.7%
were not sure of whether there was a child protection policy in
place. The graph depicts a potential for peer learning from other
hospitals on child protection systems building since 83.3% of the
hospitals state that it is necessary for child protection policies and
programmes.
Do you think it is necessary for a hospital to have a child
protection policy and programs

Yes
Not sure

16.7

83.3
50% of the hospitals that
responded to the survey
form stated they were
interested in setting up a
risk management system
for child protection in their
Would you be interested in setting up a risk management
hospital. The rest were not
program for child protection in your hospital sure .
Yes
Not sure
Instead of a child
protection policy 33.3% of
the hospitals indicated they
have alternative systems
50 50 viz., they ensure a
guardian/parent
accompanies the child at
all times.

54
Would you like to participate in developing a culture sensitive
child protection model in Indian hospitals

Not answered
Yes
Not sure

16.7 16.7

66.7% of the respondents

were willing to
participate in developing
a culture sensitive child
protection model in
Indian hospitals. An
equal number of 16.7%
66.7 were either not sure or
did not answer the
question.

Considering 33.3% of the

hospitals have had to
deal with a child who was
brought to the hospital
after being sexually
have you had to deal with sexually abused children brought to
abused, 66.7% of the
your hospital
hospitals that responded
Yes
No
to the survey reported
that there is a need for
culture sensitive child
33.3
protection models to be
developed for hospitals
66.7 in India.
Only 50% of the hospitals
have protocols for
apprehending the
perpetrator of child sexual
abuse.
Does your hospital have protocols to deal with enabling the
perpetuators of child sexual abuse to be apprehended

Yes
No

50 50

55
Analysis of the Questionnaire

The Questionnaire was divided into two parts. The first part of
their perception of what child abuse was. The second part took
their inputs on strengthening child protection in hospitals. The
questionnaire was administered to 26 doctors and 14 nurses in
one tertiary government children’s hospital. This hospital had a
comprehensive child response unit program which included
setting up of a child protection point persons, staff education on
how to respond to children who were admitted with sexual abuse.

A child being teased by other children in the hospital 15% of the

respondents stated that
Not answered
Extremely Serious
a child being teased by
Quite Serious
Less Serious
other children in the
5 2.5

15
Not Serious
hospital was extremely
serious while 55% of
them said it was quite
22.5

serious. 5% of them
feel this is not serious.
55 22.5% felt this is ‘less
serious’
However, 47.5% of the
respondents felt ‘a
child being bullied by
other children in a
A child being bullied by other children in the hospital hospital was extremely
serious and 45% of
them felt it was quite
Not answered
Extremely Serious

serious. There is a 5%
Quite Serious
Not Serious

of staff that feel this is

5 2.5

not serious.

47.5
The findings show that
perception of abuse is
45

different between staff

of the same hospital,
which calls for a
uniform understanding
of child abuse that staff
needs training on.

56
Hospital staff making the child stand in the corner for an hour

Hospital staff making a

child stand in the
Not answered
Extremely Serious

corner was considered

Quite Serious
Less Serious
2.5 2.5 2.5
‘extremely serious’ by
Not Serious

17.5
75% of the staff while
2.5 % of them said it
was not serious and an
75 equal number of staff
did not answer the
question.

Hospital staff beating a

child with a stick
leaving red marks was
Hospital staff beating a child with a stick, leaving red marks considered extremely
serious by 92.5% of the
staff whereas if it was a
Extremely Serious
Quite Serious

parent that was

Less Serious
Not Serious
2.5
2.5
beating the child with a
stick leaving red
marks, only 62.5%
respondents
considered it
extremely serious and
30% of them
considered it ‘quite
serious’.

Parent beating a child

parent beating a child with a stick, leaving red marks on the
skin with their hands was
Extremely Serious
considered as
Quite Serious
Less Serious
extremely serious by
7.5
lesser proportion of
staff, 47.5%.

This depicts the need

to clarify to staff of
30

hospitals what child

62.5

abuse is. With POCSO,

2012 in force, there is
potential for staff to be
able to track injuries a
child receives
repeatedly. Reporting
of child physical abuse
becomes a possibility.

57
 Parent beating a child with their hands

Extremely Serious
Quite Serious
Less Serious
Not Serious
7.5

17.5

A child being sold by

parents was
47.5

considered as
27.5
‘extremely serious’ by
77.5% of the
respondents while
7.5% felt it was ‘not
Child being sold by parents serious’.
Extremely Serious
The need to sensitise
Quite Serious
Less Serious hospital staff on
government protocols
Not Serious
7.5

10
and the right of a child
5
to a family is
77.5
highlighted through
this.

Child being raped by a hospital care-giver

Not answered
Extremely Serious
Not Serious

2.5 5

92.5

A child being raped by a hospital care giver was considered as

‘extremely serious’ by 92.5% of the respondents. 5% of the
respondents did not answer this question and 2.5% of the
respondents felt that a child being raped by a hospital care-
giver was ‘not serious’.
The responses throw light on the need to explain child abuse
and its seriousness to staff of hospitals.

58
A 2 year-old child being touched by an adult attender on the
genitals

Extremely Serious
Quite Serious
Less Serious
Not Serious
5
2.5

7.5
85% of the respondents found a 2
year old child being touched on
the genitals by an adult attender
to be extremely serious while 5%
of them found it to be not serious.
85 Another 5% found a 12 year old
being touched on the genitals as
not serious while 87.5% differed
and felt it was extremely serious.

The concept of child’s rights and

‘good and bad touch’ needs to be
clarified to the staff of the
hospital.

A 12 year-old child being touched by an adult on the genitals

Extremely Serious
Quite Serious
Not Serious

5
7.5

87.5

59
Have you heard of child protection policies and programs in If so, do you know any hospital in India that has them?
hospitals?

Not answered Not answered

Yes Yes
No No

42.5
35 45

60

12.5

Do you think that hospitals need to have child protection

policies? why?

Not answered
Yes
No

60% of the Doctors and

2.5 5

nurses in one tertiary

child care hospital had
heard of child
92.5 protection policies and
programs and 45% of
them knew of a
hospital in India that
has them. However,
none of them could
provide the name of a
hospital with child
Does you hospital have a child protection policy?
protection policies and
programs.
Not answered
Yes
No
Dont know
92. 5 % of them felt
10 that hospitals need to
have child protection
policies. In fact 35% of
30

25
them reported that
their hospital had a
child protection policy.
35 The above reflects a
need to strengthen
child protection
through policy
development.

60
 Why does your hospital have/not have a child protection
policy?

Not answered
Ego
Fear
Didnt think of it
7.5 Dont know
Lack of
7.5 knowledge

5
Most of the
respondents did not
answer the
10
57.5
question related to
why the hospital
does not have a
child protection
policy, or any other
related policy.
However, 10% of
the staff mentioned
that fear could be a
reason for the
hospital not having
a child protection
Do you have any other policy in which child protection is policy, 5% that they
included?
did not think of it.
Not answered
No
Dont know
No other policy in
5
the hospital
12.5
includes child
protection
according to 100%
of the respondents.
82.5

This is a gap for

child protection
risk management.

61
 Describe steps for that your hospital would take to develop a
child protection policy/program
77.5% of the respondents
Not answered
Management
did not answer the
question. 17.5% said the
makes it
Consultations with

management will take of

experts
2.5 2.5
Government
Protocols

17.5 it. A mere 2.5% of the

respondents said that
government protocols
77.5 and experts could help as
steps for their hospital to
develop child protection
policy/programme.

This was reinforced by

the next questions as to
Who could help your hospital to have a child protection policy
who could help. While
57.5% did not answer the
Not answered
NGOs
question, 17% said the
Others
Government government could help
17.5 and 20% that NGOs could
help.
5

57.5
Challenges they are likely
20
to face while developing
child protection policies
and programmes elicited
no response from 72.5%
of the respondent. The
reputation of the hospital
What are some of the challenges(name at least three) you are
likely to face when developing child protection policies and fear were mentioned
Not answered
by 15% and 12.5% of the
Sensitivity
Reputation of
respondents respectively.
Hospital

The above analysis elicits

15

the need for sensitizing

the management on the
12.5

72.5 need for child protection

policies and systems.
This could be undertaken
by the Government and
NGOs.

62
WHAT ARE THE STEPS TO MAKE YOUR HOSPITAL CHILD SAFE

The respondents gave many suggestions to make the hospital child

safe, even without a child protection policy. 62.5% of the
respondents said that placing complaint boxes and facilitating
children to voice their complaints was possible. 60% of the staff
said training of staff on child protection can make a hospital child
safe. 50% of the respondents suggested screening of staff on
recruitment, child protection behaviour protocols/pledge/code.
Other suggestions the respondents agreed about were, having a
child protection committee (45%), research related to child
protection actions (47.5%), putting up notices on whom to contact
when there is a case of child abuse, (55%) and reporting staff who
63
are abusing children to the management (57.5%). The findings find
scope for beginning child protection related programmes without
a child protection policy in place too.

ANALYSIS OF THE IN DEPTH INTERVIEWS UNDERTAKEN

In Depth Interviews were undertaken to garner quantitative and

qualitative information for exploring the scope of hospitals to set
up child protection systems and programmes. A range of
stakeholders which included the government authorities,
management of hospitals, staff, parent, international organisation
violence point persons were interviewed using a guided interview
tool.

While 80% of the respondents of the In Depth Interviews had

heard of child protection policies and programmes in hospitals,
73.3% felt it was needed in hospitals settings in India. Only 6.7% of
them said that they have a child protection policy in their hospital.
On further probing, all of them were part of the Comprehensive
Child Response Unit of ENFOLD where a response protocol and
staff training was done in the past year. Neither were the
preparatory actions nor the preventive actions for child protection
included in the protocol. It was not a policy actually.
64
 Why

60

50

40
Percent

30 60

20

10
13.3 13.3
6.7 6.7
0
Not answered Prevent CSA Respond to Not thought of May be
child abused
Why

While 60% of the respondents did admit that the child protection
policy and programmes could prevent child sexual abuse, 13.3%
had not thought of it earlier. 13.3% said it could improve the
response hospitals have when a child is admitted with
history/suspected sexual abuse.

Why does your hospital have/not have a child protection

policy?

60

50

40
Percent

30
53.3

20
33.3

10

6.7 6.7
0
Not answered Not thought of No Gvernment Not applicable
Order
Why does your hospital have/not have a child protection
policy?
65
53.3% felt that child protection policies in hospitals are not
applicable to them since they do not work in a hospital. 33.3 % of
them had not thought of it earlier, till the researcher had posed the
question. 6.7% said there was no Government Order for such a
child protection policy and a similar number did not answer the
question at all.

What are three most important next steps for your hospital to
be child safe

60

50

40
Percent

30 60

20

10
13.3 13.3
6.7 6.7
0
Not answered Attendant with children Guidelines
Nurse accompany children Training on CP
What are three most important next steps for your hospital to
be child safe

60% of the respondents felt training on child protection for

staff could help make the hospital child safe. 13.3% said that
nurse must accompany all children, while 6.7% felt the
attendant accompany a child. Only 6.7% said guidelines
help.

66
 Generally, what is the process for a policy to be developed in
your hospital

40

30
Percent

20 40

33.3

10

13.3

6.7 6.7

0
Not answered Management Government Other Dont know
makes it order
The In Generally,
Depth Interviews
what is theprobed
processinto
for athe process
policy of how a in
to be developed child
your hospital
protection policy could be made. 40% of them said the
management is responsible for any policy development. 6.7% said
a government order could help. Other ways shared by 6.7% of
them was that there are other standards like the National
Accreditation Board for hospitals, who could include child
protection more deeply. Present NABH standards do not include all
the elements of a child protection policy. There are words like
“child friendly” that are all. One of the ways shared by the
Department of Women and Child Development to get a
Government Order was if the National Commission or State
Commission for the Protection of Child Rights issues an order to
them. They will then share this with the Principal Secretary of the
DWCD who will get the signing authorities (Chief Secretary) to sign
it. An interview with the Chairperson of the State commission
elicited that it could be done, but his priority was for more beds
allocated for poor children in private hospitals too.

67
 Who is involved in passing the policy

40

30
Percent

20

33.3

10 20 20

13.3

6.7 6.7

0
Not Principal E.R.C Management CBCI Government
answered Secretary
Who is involved in passing the policy

In each of the hospitals, whether private or government, it is the

administrative system in place is followed for the development of
child protection policies. The Catholic Bishops Conference of India
(CBCI) is the administrative head of the hospitals under them. The
Principal Secretary of the Ministry of Health and Family Welfare
has the power to call for a core group of government
representatives, NGOs and specialists to be able to prepare child
protection policies and programmes for government set ups. They
also have the power through a government order to get the
Cabinet Secretary to sign the order. Since health is a state subject,
it would be practical to get the Principal Health Secretary to give
the order. In private hospitals, the management can initiate this,
after it is passed through the Ethics Review process.

68
 Describe steps for that your hospital would take to develop a
child protection policy

40

30
Percent

20

33.3

26.7

10 20

6.7 6.7 6.7

0
Not Get Admin Do Training Others Not thought Government
answered Approval of
Describe steps for that your hospital wouldAdministrative
take to develop aapproval
child protection policy
seemed to be a
significant step to
Who is involved in passing the policy
develop a child
protection policy in
40 hospitals. Training of
staff was seen as an
30
important step by 26.7%
of them. Government
orders could be a step
Percent

20

33.3
said 6.7% of them.
“There is a need to train
10 20 20
management. Stronger
13.3

6.7 6.7
advocacy that child
0 abuse is a health agenda
Not Principal E.R.C Management CBCI Government
answered Secretary
Who is involved in passing the policy
is needed” said a
representative of an
apex health institution.
“Abusers are clever”
“Abusers are powerful”
were comments shared.
“Enlighten abusers on
God’s love for children”
69
was shared by one
respondent.
 What are some of the challenges ( name at least three) you are
likely to face when developing child protection policies

60

50

40
Percent

30
53.3

20

10 20
13.3 13.3

0
Ego Sensitivity Reputation of Others
hospital
What are some of the challenges ( name at least three) you
The moreare
the researcher
likely probed
to face when what came
developing childout from respondents
protection policies
across the sectors they worked in was that child protection
policies and programmes could harm the reputation of the
hospital. 53.3% of those interviewed actually voiced it. In one
hospital, the research was cleared by the Ethics Review Committee
but needed the management approval for a go-ahead. The subject
being a sensitive one, this researcher has in no place mentioned
the names of the hospitals nor the persons from whom data was
gathered. 20% mentioned how sensitive the subject was. Ego was
mentioned by 13.3% of them. The power of abusers and the clever
tactics used could bring disrepute to the hospitals was shared
across the sectors from which respondents were. Most did not
mind some programmes related to child protection without the
child protection policy. The commitment of hospitals to the Rights
of children over the reputation of the hospitals to employing staff
who could be abusers was a conflict. The challenges envisaged will

70
need to be addressed when putting into place child protection
systems (policies) for sustainable child protection actions. “Prove
it to me, that it is needed,” said one interviewee when asked
whether curriculum building for child protection could be
introduced as part of the curriculum of health personnel.
Ironically, the researcher obtained research from the library of a
University on the need for child protection training for health
personnel.

All respondents agreed that some child protection actions could

happen in hospital settings even without a government order or
child protection policy. However, sustainability of such actions is
questionable without the child protection policy or Government
Order. Education to all staff on child protection, staff taking a
behaviour protocols pledge for child protection, placing charts on

71
walls visibly for behaviour protocols on child protection were seen
as practical ways by 93.3% of them. Using complaint boxes
(86.7%), Notice boards with contact numbers to call in case of
abuse (67.7%) reporting staff who are abusing children (67.7%)
having a child protection committee in house (66.7%), researching
child sexual abuse with ethics clearance (53.3%). Screening staff at
the time of recruitment was seen as possible by some (53.3%).
However, the rest felt it was not practical since there was no data
base of child abusers. In the government set up, at the time of
recruitment a police clearance is in place.

72
 Chapter 5

KEY FINDINGS
Child Protection is not seen as a health agenda in health care
settings
Out of 426 questionnaires sent out, only 7 were returned and 6
completely filled. Most of the discussions at the questionnaire and
in-depth interview time elicited that there was no need for such a
study since its relationship with hospitals was a grey area. The
researcher had to explain and describe how hospitals are at risk by
not having a child protection system in place in most of the
discussions preceding the interviews. Greater advocacy
highlighting child abuse and maltreatment as a health agenda is
required.

Child Protection systems building have less priority in

hospital setting at preparatory, prevention and response
levels.

A key finding from this exploratory study is that presently,

curriculum developers in India for the health sciences do not see
preventing and dealing with children who are sexually abused to
be part of the curriculum of doctors and nurse professionals.
Further, there is no inclusion of this in the present curriculum that
doctors and nurses go through.

Survivors of child sexual abuse who report the abuse “are often
alienated and ostracized by their own families and by the whole

73
 community, if they go public with allegations of abuse”50. Reasons
when one delves deeper elicit that it is the entrenched over
centuries culture where notions of shame result in the blaming of
victims rather than perpetrators. Sexual abuse, particularly child
sexual abuse has been systemically under-reported in India due to
deeply entrenched cultural taboos which obscure the reality that it
exists. There is a rampant problem of minority girls being abused
by members of their own community. The wall of silence
perpetuates further abuse.

The findings of the research study complement this culture of

shame in India. In such a shameful scenario, preparation of health
personnel to prevent and take care of survivors of child sexual
abuse, including mandatory reporting by doctors who identify and
treat children sexually abused could protect children from years of
abuse. Yet, neither in the curriculum of doctors or nurses is there
any mention of how to identify and care for survivors of child
sexual abuse.

Further, the study also elicits the differing viewpoints of staff of

hospitals related to child abuse. There is no common consensus on
which abuse is considered severe. Unless perceptions of health
professionals on what is child abuse are uniform, there will be
chaotic responses that may not consistently be in the best interest
of children. If a curriculum exists on what is abuse and how health
professionals respond to it in the daily process of their work, the
Rights of a child would be better protected.

This is even more urgent with POCSO Act, 2012 including hospitals
and its role in their guidelines.

50
http://www.theguardian.com/society/2014/aug/29/-sp-untold-story-culture-of-shame-ruzwana-bashir
20141124

74
There is a need for a generic curriculum on Child Protection
that incorporates government and legal protocols.

The findings also elicited that staff and Ethics Review Committees
in hospitals are open to staff training on child protection. Staff and
leadership of hospitals are not averse to caring for children who
are sexually abused. They however, fear that when there are child
protection policies, there is a chance for the hospital staff to be
‘caught’ abusing children, which could harm the reputation of the
hospital. They affirm that they recruit qualified staff that could be
vulnerable to ‘false accusations’ from the public using their
services. Hospitals and the staff would be in a better position to
take care of the specialized needs of children needing care when
there are no child protection policies, they believe. They firmly
believe that children have a right to be protected. They further
shared that the child protection system that exists in the developed
countries does not align with Indian culture. “The culture of touch
is different in India and the child does need positive touches to
bloom” was a common statement across varied data collected.

The research study could not go deeper on culture specific

detailing of the curriculum, but left it open for staff of hospitals to
work out what touches are permitted and not permitted within a
hospital setting. However, there is a need for staff in hospitals
to be trained on Child Protection as a beginning step. There is
a dire need for children in hospitals to be trained on child
protection (at least ‘good touch’ and bad touch’) in order to
strengthen their participation in child protection programmes that
are hospital based is also needed. Using simple cartoon pamphlets
or the existing audio visual equipment in hospitals, child friendly
education could be a regular part of the hospital respecting the
Right of a child’s protection.

75
Poor culture of child protection systems exist in hospitals too.

Across sectors, child protection is poor priority. The education

sector is waking up to the need to put systems in place presently,
after a spate of newspaper articles highlighting child abuse by staff
of schools on little children. A key finding of this study is that
hospitals have not yet. There is no government order or guidelines
for hospitals to develop child protection policies, have a child
protection committee in place and regularly mainstream child
protection systems monitoring and actions in hospitals. In fact a
key finding of the in depth interviews was that most had not
thought about it before the interview. Presently there exists a
government developed protocol for responding to survivors of
child sexual abuse. But none of the hospitals in the study knew
about it. Stronger advocacy with decision makers,
management is needed for strengthening child protection
systems in hospitals.

Key findings from undertaking this research is that setting up

child protection systems, guidelines, programmes, does not
need to be newly invented. Existing protocols and guidelines
exist, which could be adapted for use in hospitals. A child
protection generic curriculum, guidelines existing with
POCSO, 2012 and the MWCD, basic programmes and enough
review of literature is adapted and included in this study, for
hospitals to begin at once to include a child protection system.

76
 Chapter 6

RECOMMENDATIONS
Key recommendations based on this exploratory study encourages
health care settings to
a. Develop a model for child protection in health care settings
(Recom 1)
b. Train staff using a generic child protection curriculum (Recom 2)
c. Link to existing resources for child protection (Recom 3)
d. Guidelines for strengthening child protection in hospitals (Recom
4)
e. Develop child protection policy for the hospital /or health care
institution to sustain the child protection system (Recom 5)
f. A greater advocacy platform is required to ensure health care
settings develop a child protection system that upholds the rights
of children.

The following sections describe the above recommendations in detail.

The review of literature chapter describes the Tanzania study and

outlines in detail how in several developing countries, systems were
developed which included Ministries, departments and health care
settings all with the vision of child friendly protection services for
children. Further, a few models are described below which could be used
based on the findings of this study.
Key recommendations need to be addressed looking at three angles of the
findings viz., the human aspect of addressing fear and perception of a
child without a voice; secondly the institutional aspect of hospitals
wanting to keep things simple, their inability to deal with complexities of

77
child protection and fear of the reputation of the hospital and thirdly
societal concerns – the patriarchal attitude of looking at a child as a
property for whom whatever is done is good.

RECOMMENDATION 1: SUGGESTIVE MODELS FOR CHILD

PROTECTION IN HOSPITALS

Based the analysis and findings, the simplest model for strengthening
child protection in hospitals is the one displayed above. While child
protection policies may take its own red-tape course, the key actions
under
 Training staff about child protection so that there is a uniform
understanding of what abuse is, how to recognise child abuse,
what to do when one finds a child is abused, who and how to
report it, and government protocols and laws related to child
protection.
 Safe working practices which could work could include the
formation of a child protection committee with child protection
focus staff. An interdisciplinary team of five which could be
headed by a Paediatrician and consist also of a lawyer and social
worker would help. Other actions are as the respondents said:

78
  Safer recruitment would include checking out the history of child
abuse at previous places the applicant has worked in.

 The Child Protection Policy and system can take the following
standards:
1. Policy 6. Inclusion
2. Procedures 7. Participation
3. Risk Reduction 8. Learning Opportunity
4. Code of Conduct 9. Code of Conduct
5. Local Circumstances 10. Monitoring

OTHER MODELS
Understanding the child protection system planning parameters
In building a child protection system, hospitals will benefit from
considering the following planning parameters.

a. Understand the networks a child is part of viz., formal systems

(e.g., legal, education, health, mental health) and informal systems
((e.g., family, kin, and community). Hospitals must clarify what
their boundary would be and link with the support systems
existing, based on child protection protocols of the government.
The boundary between a child protection system and other formal
systems or informal systems is an important feature of the child
protection system. The boundary has implications for how one
goes defines functions, capacities, and the process of care,

79
 governance, and accountability. For example all hospitals will
choose to include
 recruitment guidelines to check child abuse history of all
staff, volunteers and management
 training and capacity building of staff to recognise and
respond to child abuse
 Have an active child protection committee in place.
 put up behaviour protocols for child protection visibly on
their walls
 encourage children to distinguish good and bad touch and
use a complaint box to share about abuse
 have guidelines in place that they follow to respond in a
child friendly environment to care for an abused child
 Have regular monitoring and evaluation of the child
protection system.
However, the boundary of what a hospital could take up or not will
determine how they program their child protection system. Not all
hospitals will have the services of a counsellor equipped to deal with child
sexual abuse survivors. Referrals may be then put in place. Not all
hospitals would have laboratory facilities to collect evidence of sexual
abuse and ability to keep the chain of evidentiary findings. Children could
then be referred to a tertiary hospital that can undertake comprehensive
care. Not all hospitals could take care of physical injuries (e.g. fractures)
that a child who is sexually abused needs. If they choose to render such
service, they will need to train staff in house, or obtain the budgets,
human resources, equipment and materials to do so. Further, if hospitals
do not have a child protection policy, then staff within hospitals is not
given a mandate to take decisions on the extent of involvement of care
with children who are survivors of sexual abuse. Nor would staff have the
required guidelines to report abuse within a hospital scenario. The
findings from the in-depth interviews on what a hospital could still do,
without a child protection policy elicited this limitation.

80
b. It is important to create a goal for the child protection system (For
example create an environment in the hospital where all children are
protected from abuse or promoting the well-being of children). Building
the system is shaped around the goals of the child protection system. The
impact of the child protection system on the status of children is a central
force that affects how the system evolves through time. It is important to
review whether the child protection system is protecting only the
“reputation” of the hospital by silencing the abuse or protecting children.
Where there is a gap between the goals of the system and whether
children are being protected there must be added efforts within the
system to bring what the system accomplishes into line with system goals.

c. For a system of child protection to work, extensive understanding of

what child abuse is, what the protocols to be followed are,
development of child protection policies by the hospital is
important. The findings of one in two (53.3%) of the in depth
interviewees expressing that child protection policy and system
development would ‘harm’ hospitals is an extension of the culture of
shame associated with sexual abuse. The reputation of a hospital is not
dependent on the care they render to children who are abused. The
reputation does not depend on whether they act on a complaint of child
abuse in house. However, the hospitals, as per the findings, would rather
promote silence related to sexual abuse, for fear of their reputation,
rather than see it as a means to reduce further abuse of children. This
researcher has not studied too much about the culture of shame to make
deeper connections to it.

d. Creation of child protection committees with point persons in each

department where children are cared for help sustain the focus on
the Right of children to protection. External forces and emergencies
could have significant impacts on the capacity of any child protection
system. While designing the child protection system, it is suggestive to be
better prepared to manage externalities and emergencies. External forces

81
 and emergencies may lead to stronger systems building and
implementation in the long run, provided the actors involved respond in a
cooperative manner.

e. With respect to the process, all child protection systems must have a
means to identify children whose protection rights are violated. The
normative framework (child protection policy) must establish a boundary
about who is in need of protection, the process of care and clarify the
myriad ways children and families may come to the hospital. The process
of care also incorporates admission and assessment strategies, case
planning, treatment, and follow up, referral with the specific processes
shaped by whether the underlying services are child protection
promotion, prevention, or response. Further, when hospital staff is
trained on child protection, their capacity to identify child abuse and
perception of its severity will be consistent across cadres of staff. This
could prevent ‘harm’ to the child and hospital.

f. Because the hospital serves children coming from diverse circumstances

presenting equally diverse protection needs, it needs a service continuum
matched to this diversity. The holistic view of children, families, and
communities that is one hallmark of the systems approach to child
protection expands response to protection needs. It does this by adding
promotion and prevention as points along the health service continuum.
This depends on how other systems with potentially overlapping
mandates are structured in relationship to the child protection system.

g. When a hospital has a child protection system in place, it has to maintain

a level of capacity appropriate with what the system requires. Capacity
refers to funding, human resources and infrastructure. A sound child
protection system has the means to compel the use of resources towards
the goals of the system. Child protection relies on hospital staff and
management who are suitably equipped to carry out the work. The
hospital must link children, families to communities, states, and formal

82
 and informal organisations working for child protection. Hospitals can
make specific choices to reflect local preferences, customs, pre-existing
structures, laws, and the will of their staff /management who take on the
challenge of protecting children.

h. Within a highly appropriate approach to supporting child protection

systems in hospitals the most important question is: Are children being
protected in a manner consistent with their rights? If not, then the focus
shifts to why not and how the existing system could be strengthened so as
to fulfil those goal oriented expectations. The existing public health
system could be extended to strengthen child protection systems in
house.
The public health approach51
The public health approach consists of four steps:
a. To define the problem through the participatory child
appraisals, systematic collection of information about the
magnitude, scope, characteristics and consequences of violence.
b. To establish why sexual abuse occurs using research
similar to the study in the Chapter 2 Review done by Sujatha52,
to determine the causes and correlates of child sexual abuse, the
factors that increase or decrease the risk for violence, and the
factors that could be modified through interventions.
c. To find out what works to prevent sexual abuse of
children by designing, implementing and evaluating
interventions.
d. To implement effective and promising interventions
in hospitals and public health settings. Monitoring and
Evaluations could gauge the effects of these interventions on
risk factors , their impact and cost-effectiveness.

51
http://www.who.int/violenceprevention/approach/public_health/en/

52
opcit

83
 Programmes for the primary prevention of violence based on
the public health approach are designed to expose a broad
segment of a population to prevention measures and to reduce
and prevent violence at a population-level. Since the primary
care givers of children are the family and community,
prevention of child abuse through the public health system is
relevant.

It is important to understand child protection systems

components and actors 53
Practically, child protection systems are nested within other
systems.54That is, a given system (e.g., the child protection system)
is embedded within its boundaries to other systems (e.g., foster
care, child protective services reporting, case management). The
nested quality of systems may vary by discipline, but the central

53
Adapted from Wulczn, Fred, Daro Deborah et al,UNICEF, Adapting a Systems Approach to Child
Protection: Key concepts and considerations, UNICEF,Jan 2010, New York
54 Mizikaci, F. (2006). A systems approach to program evaluation model for quality in higher

education.Quality Assurance in Education, 14 (1), p. 37.

84
 idea remains: subsystems exist at various levels and are embedded
within the larger system environment. 55For example, educational
systems are structured, such that the classroom is nested within
individual schools, which are nested in a larger educational
system56 . Similarly, health systems, too, tend to include various
levels of care that fit one inside the other57.

S.NO COMPONENTS ACTORS

Child Family Community State Natio

Relationship between system nal
components and actors

Informal hospital institution Formal hospital

institution
Structures Physical
structures

Governance

Functions Management

Enforcement

Human Resources

Capacities Service delivery

Promotion
Response
Identification,
reporting
Referrel,
investigation
Assessment,
treatment,
followup
Commodities

Research and
Information

Monitoring and
Evaluation

55 Mulroy, E. A. (2004). Theoretical perspectives on the social environment to guide management

and community practice: An organization-in-environment approach. Administration in Social
Work, 28(1), p. 77.
56 Bowen, G. L. (2004). "Social organization and schools: A General Systems Theory perspective."

In P.Allen-Meares, Social Work Services in Schools (4th ed.). Boston: Allyn and Bacon
57 Bennett, S. & Eichler, R. (2006). Taking Forward the Health Systems Agenda: Report on a

Consultation Developing the Health Systems Action Network. Washington, D.C.: USAID.

85
It is important to note that systems do “things” in accordance with
their purpose and goals. The child protection system developed by
a hospital must hence adhere to government and international
protocols for child protection. However, this researcher did not
find any formal system approach to child protection in hospitals. A
formal approach which delineates the actors at each level (child,
family, community, etc.) will play a vital role in shaping what the
system would look like in its totality. It is recommended that
hospitals develop child protection system not in isolation (or a
vertical programme) but design that it meshes and links with the
actors at various levels. The strength of the system depends on
effective interaction across various system levels. For example, the
juvenile justice and child welfare systems clearly share a
boundary. The hospital needs to align with these boundaries. The
referral management of a ‘child at risk’ is different from the
management of a ‘child in conflict with law’. The child at risk for
child abuse and exploitation is seen by the Child Welfare
committee while the child in conflict with law will follow the
juvenile justice system. In fact, the efficacy of the child protection
system is often connected to whether children are protected,
empowered and live with dignity. Given the nested, interacting
nature of systems, hospitals need to promote an integration of
Child Rights and values across systems. That is, the work of each
system has to be mutually reinforcing with respect to the purpose,
goals, and boundaries of the other systems.

Alternatively,
With specific respect to hospital based child protection systems,
system functions recommended fall into one of two categories:
those related to case decision making (e.g., assessments, gate-
keeping, investigation, placement, etc.) and those designed to
support system performance (e.g., capacity building, research and

86
evaluation, allocation of resources, cross-sector coordination, etc )
Hospitals may choose to develop their system. What is first needed
is their commitment to the Rights of a child to protection.

87
 RECOMMENDATION 2
CURRICULUM OUTLINE FOR CHILD PROTECTION IN
HOSPITALS

Minimum
S.NO
Subject Name of the topic Hours
Code
(Overview)
a. Advocacy for The Child: Situational 1/2
Analysis of child protection and role of
hospitals
b. Rights of a Child 1/2

c. Understanding child abuse 3

d. Legal Framework for child protection 1

and role of hospitals
e. Developing and implementing Child 2
Protection policy in hospitals

f. Child Protection system building 1/2

g. Protocols for responding to children 2

admitted with sexual abuse
h. Basic Skills for Child Protection 2

i. Documenting, Monitoring and 1/2

Evaluating child protection system in
the hospitals
Total 12

88
 Recommendation 3
LINK TO
RESOURCES

89
 Key resources found as part of the study are also listed :
S.No Name Address Contact For what
1. Christopher Department of Email:miktonc@who.int Resources on child
Mikton, PhD Violence and Injury protection
Technical Prevention and
Officer, Disability
Prevention of NCDs and Mental
Violence Health
World Health
Organization
20 Avenue Appia
CH-1211 Geneva 27
Switzerland
2. Dr Fulata World Council of fmm@wcc-coe.org Resources on faith
Lusungu Moyo, Churches, based sources
PHD 150 Route de
Program Ferney,
executive PO Box 2100, CH -
Women in 1211 Geneva 2,
Church and Switzerland, Direct
Society Phone

3. Mohammed ILO afsar@ilo.org Resources for ILO Rec.

Afsar International 182 onchild labour
Labour Office (ILO)
4 route des
Morillons
1211 Geneva 22
Switzerland

4. Dr. Rakesh Ministry of Health secyhfw@nic.in, ash- Advocacy building and

Kumar etc. and Family Welfare mohfw@nic.in, guidelines for
Nirman Bhavan rkumar92@hotmail.com, response protocols
New Delhi - 110001 anuradha-
gupta@outlook.com
5. Mr Sonykutty UNICEF Email: newdelhi@unicef. Technical expert in
George 73 Lodi Estate ,New org child protection
Delhi 110 003, India sogeorge@unicef.org programs
Tel: 91 11 2469-0401,
2469-1410
Fax: 011 2462-7521,
2469-1410
6. Dr Shaiba Enfold Proactive +91 99000 94251 For facilitating child
Saldanha Health Trust info@enfoldindia.org protection training ,
399, Second floor, advocacy and systems
18th main road, 6th building in hospitals
block
Koramangala
Bangalore 560 091
India

7. Edwina Pereira INSA-India insaind@gmail.com For facilitating child

Florence 24 Benson Road, protection training ,
Jasmine David Benson Town advocacy and systems
Agatha Shekar Bangalore building in hospitals
Charlet Vijay
John Paul

90
8. Mr Vasudev 4606, 6th Floor, 080 4113 8285 For facilitating child
Sharma High Point IV, Near- kcronodalcrt@gmail.co protection training ,
Dr Padmini Bangalore Golf m advocacy and systems
Club Palace Road crtsimha@gmail.com building in hospitals
Bengaluru, padmini@grot.org
Karnataka 560001

9. Dr Rajeev Seth Chairperson, Child 011 - 26565190 For IAPs guidelines on

Abuse, Neglect & Mobile: 09811509460 Child Abuse Neglect
Child Labour Group Email: Sethrajeev@Gmail and Child labour
E/10 Green Park .Com
(Main)
New Delhi 110016

10. Dr Uma Secretary, Child 011 - 42331185 For IAPs guidelines on

Agrawal Abuse, Neglect & Mobile: 09811041605 Child Abuse Neglect
Child Labour Group Email: Umaarp@Yahoo.C and Child labour
G-15, Pushkar om
Enclave
Panchim Vihar
New Delhi 110063

11. Dr. Swagata Centre for Child and swagataraha@gmail.com For legal consultations
Raha the Law (CCL) ccl@nls.ac.in and facilitation related
National Law School Tele/Fax: 080-23160528 to child protection
Of India University
Nagarbhavi,
Bangalore 560 072,

12. Childline BOSCO - Yuvodaya Toll free 1098 For rescue and
91, 'B' Street, 6th email boscoban@gmail.c counselling
Fr George Cross, om or
Gandhinagar, hrbosco12@gmail.com
Bangalore 560009 Tel No. +918022253392,
Karnataka, +918022424138
India

13. APSA APSA 1098 For rescue and

24 Annasandrapalya 080 5232749 couselling
Ms Sheela Vimanapura
Devaraj Bangalore 560017
14. Childline - CRT See serial no 9 for 1098 For rescue and
details counselline

Parenting Project Group

Leaders: Cathy Ward (Cathy.Ward.SA@gmail.com – Safety and Violence Initiative,
University of Cape Town), Theresa Kilbane (tkilbane@unicef.org – UNICEF), and
Christopher Mikton (miktonc@who.int – WHO);

91
 RECOMMENDATION 4
GENERIC GUIDELINES
Guidelines for Managing Child Abuse and Neglect Cases58

NAME OF THE HOSPITAL

ADDRESS
CONTACT DETAILS

THE FOLLOWING GUIDELINES ARE RECOMMENDED WHEN:

A parent or guardian or police brings a child to the Emergency Room or Paediatric
Outpatient Clinic and the physician suspects that the child sustained non-accidental
injuries, caloric deprivation, sexual abuse, or serious medical neglect, the following
guidelines are recommended. There is a separate protocol for victims of rape.

1. HOSPITALIZE THE CHILD:

The objective of hospitalization is to protect the child until we can ascertain that the
child’s home or place of stay is safe based on other completing evaluations. The extent of
injuries is not relevant to this requirement. The child's need for protection
supersedes any other consideration. Even if the child has no medical insurance, the
child should be admitted.

The reason that the hospital lead staff can give to the parent for hospitalization is that
"the child’s condition/ injuries need to be studied" or "further tests are needed." The
Emergency Room is not the place to evaluate or manage such cases. It is not helpful to
mention the possibility of non-accidental trauma or underfeeding, at this time. If it
becomes difficult to persuade the parents of the need for admission, contact the child's
own pediatrician, if there is one, or the Chief Resident for assistance. If the parents refuse
hospitalization, the child can be placed in protective custody by the local police. This is
rarely necessary and should not be routine procedure.

Alternatively, the case can be safely evaluated while the child remains in the home in a
few instances (i.e., the offender was a neighbour who is in jail or the perpetuator is no
longer employed). Serious homicidal threats (e.g., "If I have to spend another minute
with that child, I will kill her/him") also require admission and psychiatric consultation.

2. TREAT THE CHILD'S INJURIES:

Once the child is in the hospital, administer medical and surgical care required, based on
a case to case basis. The diagnosis of physical abuse is a paediatric admission, with

58
Source: based on the findings, several documents including POCSO guidelines used for developing the
document.

92
appropriate consultation. An orthopaedic consultation is commonly needed.
Ophthalmologists, neurologists, neurosurgeons are occasionally consulted.

3. OBTAIN NECESSARY LABORATORY TESTS:

Sometimes the x-ray findings change a suspected case into a definite case of non-
accidental trauma. Therefore, every suspected case of child abuse should receive a
radiologic bone survey (termed "trauma survey" at an accredited centre), especially if
under 6 years old. Avoid using incriminating terms (e.g., rule out "battering") on
requisitions. If there are bruises, a history of "easy bruising," or subdermal hematomas,
one should obtain a "bleeding disorder screen" (platelet count, bleeding time, partial
thermoplastics and prothrombin time). If there are visible physical findings, colour
photographs should be obtained before they fade. Photographs may be ordered for chart
documentation.

4. ELICIT DETAILED FACTS CONCERNING THE INJURY:

A complete history should be obtained from the child (if possible) and the
parent/guardian separately by one physician on the ward as to how the injury allegedly
happened. (The place, the exact time, the sequence of events, people present, time lag
before medical attention sought, etc.). The history should be obtained preferably with
one physician interviewing the parent and another staff person present. It is important
that what is said by both the physician and the parents be witnessed.

5. Diagnosis is the pediatrician's job-- not the psychiatrist's or social worker's. Arrange
for the pediatric consultation as soon as possible.

Indications for consultation are:

a. Physical Abuse,
(i.e., unexplained or inadequately explained bruises, swelling fractures, or burns. This
should also include any bruises which are inflicted in the name of discipline.) Check with
figure below for non-accidental injuries and alleged accidental injuries.

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 b. Sexual Abuse
(i.e., child or parents/guardian reports it, bruising around the mouth, breasts, genitals,
anus, sexually transmitted disease, pregnancy in case of an adolescent girl.)

c. Medical Care Neglect

(i.e., noncompliance with therapy or not seeking medical care when the omission is life-
threatening.)

d. Drug or Alcohol Abuse of Young Children

(i.e., caretakers who give children alcohol or dangerous drugs with a physician's orders.)

6. TELL PARENTS THE DIAGNOSIS AND THE NEED TO REPORT IT:

If the parent/guardian is the alleged abuser, directly report abuse tot he child protection
pint person designated by the hospital. If the parents are not the alleged abusers then, in
the privacy of a room, tell the parents the diagnosis. Be emphatic in sharing with the
parents/guardians that child sexual abuse is never the child’s fault. Additionally, tell
them of the need to report it. You could say: "The child's injuries are worrying us
because there is an inadequate explanation for them, "I am obligated by the law (POCSO,
2012) to report all unexplained injuries to children." The doctor (paediatrician) should
do this since the case is reported on the basis of his/her medical finding. In fact, after all
diagnostic studies are completed; the doctor (paediatrician) should share with the
parents/guardian in a kind way the actual case of each specific injury. This convinces the
parents/guardians that we know what actually happened and permits them to turn their
attention to the child’s recovery through treatment. The doctor (paediatrician) should be
willing to discuss the general content of the report, and it may be shown to the parents, if
deemed wise.

The report will go through the medical social worker/child social worker who will link
the paediatrician to the District Child Protection Officer and Special Juvenile Police Unit
depending upon the severity of the abuse and the district of the child's residence. The
doctor (paediatrician) lets the parents /guardians know that the matter will be kept
confidential (not appear in the newspapers). Re-emphasise that everyone's goal is to
help them find better ways of caring for the abused child (not to punish the parents.) If
the parents remain argumentative, they can be advised to seek legal counsel.

7. Indian Laws (POCSO, 2012) require that both a telephone and written report be made
within 36 hours. A phone report should be made as soon as the diagnosis of suspected
child abuse is known.

How to Report:
Section 21 of POCSO, 2012, mandates a report by a doctor when a child comes in with
sexual abuse59. You may use the 24 hour Emergency Response Numbers 1098 for
making referrals. This number may also be called for consultation. Below are the
numbers and designation of departments for reporting child abuse/child sexual abuse

 Child Welfare Committee Chairperson

 District Child Protection Officer

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http://wcd.nic.in/act/POCSO%20-%20Model%20Guidelines.pdf 20141201

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 DCPU Program Officer (institution care)
 DCPU Program Officer (non institutional care)
 SJPU

8. MAINTAIN HELPING APPROACH TO THE PARENTS:

For health personnel, this could be the hardest step. It is normal for the doctor nurses
and other care givers to feel angry with the parents are natural However, expressing this
anger is very damaging to parent cooperation and not in the ‘best interest of the child’.
Repeated interrogation, confrontation and accusation, must be avoided.

The primary physician must communicate to the parents/guardians daily. They become
suspicious quite easily if communication is not optimal. If the child is brought in with
multiple life threatening injuries or DOA, the parent requires an emergency psychiatric
evaluation because he may be psychotic or suicidal.

9. INVOLVE THE PARENTS IN THE CHILD'S HOSPITAL CARE:

The ultimate goal is to have the parents/guardians care for their child adequately
recognising the child’s right to survival, development participation and protection. The
parents/guardians should be encouraged to visit frequently and to take over the care of
their child during these times. It is especially important to include the parents when the
child is going to be hospitalized for 1-2 weeks as in failure-to-thrive evaluations. The
ward staff should offer help, remain supportive, compliment the parents on their efforts,
and in general build their confidence in themselves as parents.

10. COMPLETE AN OFFICIAL WRITTEN REPORT WITHIN 36 HOURS:

The official medical report should be written by a doctor (paediatrician) and contain the
following data:

a. History
- the alleged cause of the injury (with dates and times) or malnutrition.
b. Physical examination
- description of the injury (use non-technical terms like "check instead of "zygoma") or of
the weight gain before and during hospitalization (in the metric system (kgs)
c. Lab tests, i.e., x-rays, blood work
d. Concluding statement on why the above examination/test result represents non-
accidental trauma or severe abuse. Also, any special concern regarding the child's safety
or sexual abuse should be noted. The paediatric ward social worker has reporting forms.
Reporting forms are also available in the Emergency Room.

11. THE SOCIAL ASSESSMENT

The social worker is called in to determines overall family problems, environmental
problems, the state of the marriage, how disturbed the parents are, and how likely they
are to accept therapy. In severe or complex cases, or when the initial social history
information is vague or inconclusive, a psychiatric evaluation is also obtained. (This
helps to uncover the 10% of parents that are very dangerous because they are
sociopathic or psychotic.) The doctor/pediatrician is not usually able to do this.

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The District Child Protection Unit or the SJPU may carry this evaluation concurrent tot he
hospitalisation.

12. AN INTERDISCIPLINARY CONFERENCE involving primary physician, primary nurse,

social worker, and protective services worker should take place within three days of
admission. All evaluations should have been completed and can be discussed. Although
disposition of the case is the responsibility of the DCPU or SJPU to whom referral was
made, hospital staff can benefit from the opportunity to discuss it.

WHEN A CHILD PRESENTS IN ANY HOSPITAL SERVICE OR DEPARTMENT, AND A

PHYSICIAN DETERMINES THAT THE CHILD MAY BE A VICTIM OF NEGLECT OR ABUSE,
THE FOLLOWING ACTIONS SHOULD BE TAKEN:

CHECK LIST FOR SUSPECTED CHILD ABUSE

1. Treat the child's injuries.
2. Document injuries in chart.
3. Whom to notify IN-HOUSE: Pediatric Chief Resident or Senior resident on call. They
should notify the following:
a. Pediatric Chief Resident
b. Attending Physician
c. Family Pediatrician
d. Pediatrics Ward Social Worker
4. Obtain necessary lab tests and photographs.
5. Elicit facts concerning the injuries.
6. Tell parents suspected diagnosis and the need to report - as required by law.
7. Take telephone call within 36 hours. Notify appropriate child protection officers in the
district where the child’s home is.

24-HOUR NUMBER: 1098

Note the name of the person taking the referral and the date.

8. Complete written report within 36 hours, the Pediatrics Social Worker on the Pediatric
Ward has reporting forms. These forms are also available in the Emergency Room. Mail
written report to appropriate address:

9. Send copy of report to ................................................................(confidentiality to be honoured)

Effective from (date), ............................. Hospital is required to obtain a signed statement

from certain new employees which states that the employee has knowledge of the
provisions of which addresses Child Abuse Reporting requirements.
Please read the following statements and sign below.

Section 21(1) of the POCSO Act, 2012 requires mandatory reporting of cases of child sexual
abuse to the law enforcement authorities, and applies to everyone including parents,
doctors and school personnel. Failure to report a suspicion of child abuse is an offence
under the Act. The legislation makes it clear that the reporting obligation exists whether
the information was acquired through the discharge of professional duties or within a
confidential relationship. The obligation to report is unrestricted by any precondition that
the complaint be first reported within the respective departments, services or agencies,
even if the perpetrator is alleged to be an employee of that institution, service or agency.

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 Thus, a person who has knowledge that an offence has been committed under the child can
directly report it to the police or magistrate
I have received a copy of the ............................... Hospital "Guidelines for Managing Child
Abuse and Neglect Cases at ............................................. Hospital." I understand that these
guidelines are also available from the Department of ……………….(e.g. Medical Social
Work), and that I can obtain further information from ............(name) at extension (give
number..................)

________________________________________________________
Signature Date
_________________________________________________________
Print or Type Name

RECOMMENDATION 5

SAMPLE OF A CHILD PROTECTION POLICY FOR HOSPITALS

INTRODUCTION:

This document is the Child Protection Policy for , (insert

hospital’s name) which will be followed by all members of the hospitals and followed and
promoted by those in the position of leadership within the hospitals.
The purpose of the child protection policy is to create an inclusive caring environment
where all children Right to protection and dignity are honoured .
The hospital does not undertake activities with children in the absence of their
parents/carers, but has the opportunity to observe the children’s welfare with their family
present in the hospital. Parents/carers remain responsible for their children’s welfare
throughout all the work undertaken by the hospital.
We know that being a child makes them vulnerable to abuse by other children and adults.
The purpose of this policy is to make sure that the actions of any adult in the context of the
work carried out by the hospital are transparent and safeguard and promote the welfare of
all children.
If any parent or young person/child has any concerns about the conduct of any member of
the hospital, this should be raised in the first instance with ……………………………………….,
(designated child protection contact) (phone no.....)
This document is written in accordance with UNICEF’s Child Protection Policy and in line
with the Government of India’s Child Protection protocols.
Principles upon which the Child Protection Policy is based.

 The rights of a child will always be paramount.

 The child’s right to a family will be promoted.

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 The rights, wishes and feelings of children, young people and their families will be respected
and listened to.
 Those people in positions of responsibility within the hospital will work in accordance with
the interests of children and young people and follow the policy outlined below.
 Those people in positions of responsibility within the hospital will ensure that the same
opportunities are available to everyone and that all differences between individuals will be
treated with respect.

CHILD PROTECTION POLICY

1. Recruitment
Recruitment policies will include checking on the history of the applicant for child abuse in
previous sites he/she worked in.
2. Immediate Action to Ensure Safety
Immediate action may be necessary at any stage in involvement with children and families
to protect a child.
IN ALL CASES IT IS VITAL TO TAKE WHATEVER ACTION IS NEEDED TO SAFEGUARD THE
CHILD/REN ie:

 If emergency medical attention is required, this can be secured by hospital instituted blue
or red codes protocols
 If a child is in immediate danger, the police should be contacted (dial 100 or 1098, the Child
Helpline) as they alone have the power to remove a child immediately if protection is
necessary e.g. from their parents abusive custody via a Protection Order.
3. Recognition of Abuse or Neglect
Abuse or neglect of a child is caused by inflicting harm, or by failing to act to prevent harm.
Children may be abused in a family or in an institutional or community setting: by those
known to them or more rarely by a stranger.
Physical Abuse
Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding,
drowning, suffocating, or otherwise causing physical harm to a child. Physical harm may
also be caused when a parent or carer feigns the symptoms, of, or deliberately causes ill
health to a child whom they are looking after.
Emotional Abuse
Emotional abuse is the persistent emotional ill treatment of a child such as to cause severe
and persistent adverse effects on the child’s emotional development. It may involve
conveying to children that they are worthless or unloved, inadequate, or valued only in so
far as they meet the needs of another person. It may feature age or developmentally
inappropriate expectations being imposed on children. It may involve causing children
frequently to feel frightened or in danger, or the exploitation or corruption of children.
Some level of emotional abuse is involved in all types of ill treatment of a child though it
may occur alone.
Sexual Abuse
Sexual abuse involves forcing or enticing a child or young person to take part in sexual
activities, whether or not the child is aware of what is happening. The activities may
involve physical contact, including penetrative (eg rape or buggery) or non-penetrative
acts. This may include non-penetrative acts. They may include non-contact activities, such
as involving children in looking at, or in the production of, pornographic material, or

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 watching sexual activities, or encouraging children to behave in sexually inappropriate
ways.
Neglect
Neglect is the persistent failure to meet a child’s basic physical and/or psychological needs,
likely to result in the serious impairment of the child’s health or development. It may
involve a parent or carer failing to provide adequate food, shelter and clothing, failing to
protect a child from physical harm or danger, or the failure to ensure access to appropriate
medical care or treatment. It may also include neglect of, or unresponsiveness to, a child’s
basic emotional needs.
Individuals within the hospital need to be alert to the potential abuse of children both
within their families and also from other sources including abuse by members of that
hospital.
The hospital should know how to recognise and act upon indicators of abuse or potential
abuse involving children. There is an expected responsibility for all members of the hospital
to respond to any suspected or actual abuse of a child in accordance with these procedures.
It is good practice to be as open and honest as possible with parents/carers about any
concerns.
However, you must not discuss your concerns with parents/carers in the following
circumstances:

 where sexual abuse is suspected

 where organised or multiple abuse is suspected
 where fictitious illness by proxy (also known as Munchausen Syndrome by proxy) is
suspected
 where contacting parents/carers would place a child, yourself or others at
immediate risk.

4. What to do if children talk to you about abuse or neglect

It is recognised that a child may seek you out to share information about abuse or neglect,
or talk spontaneously individually or in groups when you are present. In care situations
and these situations you must:

 Listen carefully to the child. DO NOT directly question the child.

 Give the child time and attention.
 Allow the child to give a spontaneous account; do not stop a child who is freely recalling
significant events.
 Make an accurate record of the information you have been given taking care to record the
timing, setting and people present, the child’s presentation as well as what was said. Do not
throw this away as it may later be needed as evidence.
 Use the child’s own words where possible.
 Explain that you cannot promise not to speak to others about the information they have
shared.
 Reassure the child that:
o It is NOT the child’s fault
o you are glad they have told you;
o they have not done anything wrong;
o what you are going to do next.

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 Explain that you will need to get help to keep the child safe.
 Do NOT ask the child to repeat his or her account of events to anyone.

5. Consulting about your concern

The purpose of consultation is to discuss your concerns in relation to a child and decide
what action is necessary. You may become concerned about a child who has not spoken to
you, because of your observations of, or information about that child.
It is good practice to ask a child why they are upset or how a cut or bruise was caused, or
respond to a child wanting to talk to you. This practice can help clarify vague concerns and
result in appropriate action.
If you are concerned about a child you must share your concerns. Initially you should talk
to one of the people designated as responsible for child protection within your hospital.
In this hospital this person is ………………… tel: ……………. If one of those people is implicated
in the concerns you should discuss your concerns directly with the Child Protection
Committee or the management in your hospital.
You should consult externally with Child Line or 1098 in the following circumstances:

 when you remain unsure after internal consultation as to whether child protection
concerns exist
 when there is disagreement as to whether child protection concerns exist
 when you are unable to consult promptly or at all with your designated internal
contact for child protection
 when the concerns relate to any member of the organising committee.

Consultation is not the same as making a referral but should enable a decision to be made
as to whether a referral to Child Protective Services (Child Line or 1098 ) should progress.
6. Making a referral
A referral involves giving Child Protection Services (Child Line or 1098 ) about concerns
relating to an individual or family in order that enquiries can be undertaken by the
appropriate agency followed by any necessary action.
In certain cases the level of concern will lead straight to a referral without external
consultation being necessary. Parents/carers should be informed if a referral is being made
except in the circumstances outlined on p 4.
However, inability to inform parents for any reason should not prevent a referral being
made. It would then become a joint decision with Child Protection Services about how and
when the parents should be approached and by whom.
IF YOUR CONCERN IS ABOUT ABUSE OR RISK OF ABUSE FROM SOMEONE NOT KNOWN TO
THE CHILD OR CHILD’S FAMILY, YOU SHOULD MAKE A TELEPHONE REFERRAL DIRECTLY
TO THE 1098, the POLICE AND CONSULT WITH THE PARENTS.
If your concern is about abuse or risk of abuse from a family member or someone known to
the children, you should make a telephone referral to your Child line or 1098
7. Communication guidelines: Information required
Be prepared to give as much of the following information as possible (in emergency
situations all of this information may not be available). Unavailability of some information
should not stop you making a referral.

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  Your name, telephone number, position and request the same of the person to whom
you are speaking.
 Full name and address, telephone number of family, date of birth of child and
siblings.
 Gender, ethnicity, first language, any special needs.
 Names, dates of birth and relationship of household members and any significant
others.
 The names of professionals’ known to be involved with the child/family.
 The nature of the concern; and foundation for them.
 An opinion on whether the child may need urgent action to make them safe.
 Your view of what appears to be the needs of the child and family.
 Whether the consent of a parent with parental responsibility has been given to the
referral being made.
8. Action to be taken following the referral
 Ensure that you keep an accurate record of your concern(s) made at the time.
 Put your concerns in writing to Child Protection Services following the referral
(within 24 hours).
 Accurately record the action agreed or that no further action is to be taken and the
reasons for this decision.
9. Confidentiality
The hospital should ensure that any records made in relation to a referral should be kept
confidentially and in a secure place.
Information in relation to child protection concerns should be shared on a “need to know”
basis. However, the sharing of information is vital to child protection and, therefore, the
issue of confidentiality is secondary to a child’s need for protection.
10. Ensuring staff capacity to deal with child abuse:
A child protection committee of 7 members will be set up in the hospital. Their names,
department and contact numbers are put up on all notice boards of the hospital. Complaint
boxes will be placed in all wards where children are admitted and children adequately
communicated to drop in complaints there, if possible. Regular staff training on child
Rights, recognising child abuse and hospital protocols to deal with promotion, prevention
and responding to abuse will be undertaken under the leadership of the point person
assigned by the Child Protection Committee.
For more guidance and details, consult your Child Protection Committee members, Child
Line 1098; District Child Protection Officer in your area or a local NGO working on Child
Rights.

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 CHAPTER 7
CONCLUSION
“Risk management is defined as a function of administration of a hospital
or other health facility directed toward identification, evaluation, and
correction of potential risks that could lead to injury to patients, staff
members, or visitors and result in property loss or damage.”60 Risk
management is not just an aspect of management control but a
benchmark of good governance. Numerous standards for risk
management practice are produced by hospitals across the word. The
Literature review highlights child protection systems as one of them.

This research study highlights a serious gap in the risk management of

hospitals for child protection. Even when there is evidence of the need for
child protection systems building in hospitals, fear about harming the
reputation of the hospital, and the “I didn’t think about it” attitude makes
hospitals vulnerable for child abuse threats. With the strengthening of
laws like POCSO, 2012 for child protection, hospitals are way backward in
responding to their responsibilities for ensuring child protective
environments through formal systems building. The ostrich head in the
sand attitude on the need for child protective systems building right from
the Ministry of Health and Family Welfare to the small clinics is urgent.

60
Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.

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Further actions are also needed on the following

a. Strengthen advocacy building for child protection in health care

settings
b. Work with state level ministries, health authorities, Integrated
Child Protection Units and Child Rights Commissions to get the
government orders to strengthen child protection in health care
settings.
c. As is now enforced for prevention of sexual harassment in the
workplace, enforce child protection policy and committee (similar
process to the Vishaka guidelines) in hospitals.
d. A 12 hour curriculum on Child Protection to be mainstreamed into
the paediatric undergraduate and post graduate medical, nursing
and allied medical professional courses.
e. Hospitals may choose to develop their own model for child
protection or use the models in Chapter 5, but develop referral
linkages with resources and child protection legal authorities to
follow government protocols.
f. A stronger reporting mechanism for reporting in house child abuse
is urgently required to protect hospitals from disrepute when the
abuse is publicly known. Further, it is the responsibility of
hospitals to report abuse or face legal hurdles and prosecution.

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Key resources for handholding required, apart from the Departments and
Commissions for child protection (in 20 states as of August 2014) are also
attached.

This research was not merely an academic exercise, but a tool and process
for evidence gathering to strengthen child protection in health care
settings. The researcher hopes that this study would be a beginning
advocacy with policy makers to enable a strengthening of systems for
child protection in health care settings. No one wants a VIBYOR to happen
to begin a knee jerk response to child protection. The child deserves
more. It is the child’s Right to Protection.

THE END OF THE BEGINNING

EDWINA PEREIRA
CRY RESEARCH FELLOW 2014

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ANNEXURES

105
 Annexure 1
CONSENT FORMS (FGD children)
Consent form for parents/guardian
I have read the Information Sheet concerning this study and understand what it is about. I have
also read a copy of my child's information sheet and consent form. All my questions have been
answered to my satisfaction. I understand that I am free to request further information at any
stage.
I know that:
1. My child's participation in the study is entirely voluntary;
2. I am free to withdraw my child from the group at any time without any disadvantage to my
child;
3. I understand that the research data from child (children’s group discussion) will be retained in
secure storage for five years, after which time it will be destroyed, and that all personal
information (names and consent forms) will be destroyed at the end of the study;
4. I understand that my child will be part of a group discussion with other children.
5. I understand that my child will not be interviewed without my child's consent;
6. I understand that only the interviewer, his/her supervisor and the person who enters the data
will have access to the personal information of the child.
7. I understand that the results of the project may be published but my anonymity and my child's
anonymity will be preserved;
8. I understand that I have access to the interviewer and his/her supervisor should I need to
discuss this project with him/her or discuss any issues that may arise from this project for myself
or my child.
9. I understand that the research findings will be used in strengthening child protection
meaningfully
I give consent for my child to take part in this project.

………………………………………………. (Date)…..........……..
Signature of parent or guardian

Consent form for Principal/Teacher

I have read the Information Sheet concerning this interview and understand what it is about. I
have also read a copy of the child's information sheet and consent form. All my questions have
been answered to my satisfaction. I understand that I am free to request further information at
any stage.
I know that:
1. The child's participation in the interview is entirely voluntary;
2. I am free to withdraw the child from the interview at any time without any disadvantage to my
child;
3. I understand that the research data on the child (questionnaires) will be retained in secure
storage for five years, after which time it will be destroyed, and that all personal information
(names and consent forms) will be destroyed at the end of the study;
4. I understand that the child will be part of a group discussion with other children.
5. I give my consent for the researcher to notify the Social Workers (names) at our school should
the child disclose personal experiences during or after the discussion of a nature that the
researcher believes may be harmful to the child;
6. I understand that the child will not be interviewed without the child's consent;
7. I understand that only the interviewer, his/her supervisor and the person who enters the data
will have access to the personal information of the child.
8. I understand that the results of the study may be published but my anonymity and the child's
anonymity will be preserved;
9. I understand that I have access to the interviewer and his/her supervisor should I need to
discuss this study with him/her or discuss any issues that may arise from this study for myself or
the child.
10. I understand that the research findings will be used in strengthening child protection
meaningfully

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I give consent for my child to take part in this project.
………………………………………………. (Date)…..........……..
Signature of parent or guardian

Informed consent form for Children

Yes No

I understand why this research is being done and what kind of questions I will be
asked

I understand that my participation is voluntary: If I do not want to answer

questions or if I do not want to take part in the research anymore, I can stop any
time and nobody will be angry

I agree that my answers will be written down in the question sheet

I agree to my answers being used in a report, which will be published

Nobody can find out what I said, because my name will not be recorded or
written down or appear anywhere in the report

I want to take part in meetings with other children about child abuse and talk to
researchers

I understand that the research findings will be used in strengthening child

protection meaningfully

Signature :_________________________________________________

Date: _____________________________________________________

Place: _____________________________________________________

If I have further questions or if I am worried about something, I can always talk

to (Contact person, contact details).

CHILDREN FGD TOOL

Here are is a true story:

Geena [name changed] was admitted to hospital because she had a lot of stomach pain. The
doctors asked her mother some questions and then asked Geena to lie down. He pulled the
screen. Her mother was on the other side. He raised her blouse and started to fondle her breasts,
saying loudly, “Does it pain here? Here?” Geena was stunned and said “No, my stomach hurts”.
She is crying by this time.

I. Have you heard of similar things that happen to children in hospitals? Tell us about it?

II. What do you think Geena should do after this happened?

III. Would that stop further abuse?

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 IV. Who else must help Geena to ensure that further abuse does not happen?

V. What are the other kinds of child abuse that you have known happen in hospitals?

VI. What do you think hospitals should do so that children do not experience abuse?

VII. Draw/list a hospital and tell us what all should be there in hospitals so that children are
better protected against abuse

VIII. In what ways can children participate in making hospitals child-safe?

IX Who do you share experiences of abuse with?

X In which place in the hospital are children more likely to face abuse?

Any other suggestions/comments

ANNEXURE 2 QUESTIONNAIRE POSTED WITH RETURN STAMPED ENVELOP TO

HOSPITALS
CHILD PROTECTION IN HOSPITALS: HOW RELEVANT IS THIS?

Attention: Administrators/Medical Officer in Charge of hospitals:

Dear Sir/Ma’am,
I am CRY Research Fellow who is exploring the scope of setting up child protection systems and
programs in hospitals in India. I invite your assistance developing culture sensitive child
protection models, systems and programs in hospitals through this research. Kindly place a
tick mark in the appropriate column according to your opinions. When complete, submit to
dwinapereira@gmail.com or in the stamped envelop provided herewith.

S.No Questions Yes Not sure No

1. Do you have children coming to your hospital?
2. Do you have any systems in place in the hospital to protect
them from abuse?
3. Do you agree that child abuse is a matter for hospitals to
work out?
4. Do you agree that most staff in your hospital know about
child abuse?
5. Do you agree that managing child protection of children in
the hospital is needed in India?
6. Do you agree that we need to develop culture sensitive child
protection programs in hospitals?
7. Do you agree that perpetuators of child sexual abuse are
people the child trusts, are known members of family and
friends mostly?
8. Does your hospital have a child protection policy?
9. Do you think it is necessary for a hospital to have a child
protection policy and programs?

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 10. Would you be interested in setting up a risk management
program for child protection in your hospital?
11. Instead of a child protection policy, do you have any other
standards for protecting children? If so, please name
it:...............................................................
12. Would you like to participate in developing a culture
sensitive child protection model in Indian hospitals?
13. Have you had to deal with sexually abused children brought
to your hospital?
14. Does your hospital have protocols to deal with enabling the
perpetuators of child sexual abuse to be apprehended?
15. Have you contacted any agency for child protection issues
you have faced ?If so.......name
them...............................................................................................
Please note that your answers will be analysed with confidentiality of source maintained.
Do message me at 9449865413 in case you would like to share more information and
experiences related to child protection in hospitals.

If you are interested in finding how child safe your hospital is and in developing /setting up a
risk management system and program for child protection, kindly complete the following:

Name of the hospital:

Name of the person to contact in your hospital:
Designation:
Contact details of the person to contact in the hospital:
Address
Tel: Email: Web site:
Any other comment: (Kindly note: your name is not asked for)

WHAT DO YOU FEEL WOULD MAKE A GOOD CHILD PROTECTION MODEL FOR HOSPITALS?
DRAW IT HERE?

COMPARED TO HOSPITALS ABROAD, WHAT ARE SOME OF THE HARMS WE MUST AVOID WHEN
DEVELOPING SUCH A CHILD PROTECTION SYSTEM IN OUR HOSPITALS?

IF YOU HAVE A CHILD PROTECTION POLICY, CAN YOU SHARE IT?(ATTACH A COPY)
I thank you for helping me in this research to strengthen protection of children in hospital
setting. This questionnaire is being administered to over 1000 hospitals in Bangalore city.
For further clarifications contact
Edwina Pereira (CRY RESEARCH FELLOW, 2013-2014)
Program director-training
INSA INDIA; 24, Benson Road, Benson Town, Bangalore 560046
Web www.theinsaindia.org
Email dwinapereira@gmail.com

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 Annexure 3

GUIDED TOOL FOR IN DEPTH INTERVIEWS:

a. Have you heard of child protection policies and programs in hospitals?

b. If so, do you know any hospital in India that has them?

c. Do you think that hospitals need to have child protection policies? Why?

d. Does your hospital have a child protection policy?

e. Why does your hospital have/not have a child protection policy?

f. Do you have any other policy in which child protection is included?

g. What are three most important steps for your hospital to be child safe?

S.No Important steps for child protection Why? Is it possible to do?

in your hospital

a. Describe steps for that your hospital would take to develop a child protection
policy/program?

b. Who could help your hospital to have a child protection policy?

c. What are some of the challenges (name at least three) you are likely to face when
developing child protection policies?

d. Do you think it is possible for your hospital to have child protection programs without a
child protection policy? If yes kindly tick mark which ones:

S.No Child Protection Programs Yes No Why? Department

to head this
i. Child Protection staff behaviour
pledge
ii. Education to staff on child
protection
iii. Screening for child protection staff
at recruitment
iv. Placing charts with behaviour
protocols for child protection
visibly in the hospital walls
v. Placing complaint box in all
paediatric and childcare spaces and
encouraging children to voice their
complaints in the box
vi. Reporting staff who are abusing
children to the management
vii. Having a child protection
committee in your hospital
viii. Putting up notices on who to

110
 contact with their numbers in a
case of child abuse by staff
throughout the hospital
ix. Researching what the hospital is
doing when a case of child abuse is
admitted.
x. Any other:
xi.
xii.
xiii.
xiv.
xv.

a. For strengthening child protection policies, systems and programs in your hospital list
down the areas you would like more training on:

Tick where appropriate Who could

As a self As a workshop facilitate
S.No Topic
learning this?(Mention
module who/dept)

Any other topics beyond this list to help develop risk management for child protection in
the hospital

b. What M and E systems could help strengthen this child protection program?
c. In what ways can hospitals enlist the participation of children in child protection: Give us
your ideas?
d. What would be a possible model that would work for your hospital to strengthen risk
management programs for child protection?
e. Any other comments related to setting up risk management programs for child
protection in hospitals

Annexure 4

OBSERVATION TOOL

i. Any placards on behaviour protocols to maintain for child protection

ii. Any CPP [ask for copy if allowed]
iii. Attitude of staff related to children’s rights
iv. Any signs of child abuse during the visit
v. Confidentiality systems
vi. Training facilities for child protection
vii. Books/materials on child rights visible
viii. Ways staff handle children’s privacy
ix. Ways staff handle children’s right to information/consent
x. Openness of hospital to child protection systems building

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 S W

O T

COMMENTS

Annexure 5
QUESTIONNAIRE USED IN HOSPITALS

DESIGNATION.....................................................
A RESEARCH STUDY TO EXPLORE THE SCOPE OF STRENGTHENING CHILD PROTECTION
SERVICES THROUGH POLICY DEVELOPMENT AND ADVOCACY IN HEALTH CARE
INSTITUTIONS AND PROGRAMS IN BANGALORE, INDIA

ABUSE INSIGHTS SURVEY TO BE COMPLETED ANONYMOUSLY

S.No Scenarios Extremely Quite Less Not

Serious Serious Serious Serious

1. A child being teased by other children in the hospital

2. A child being bullied by other children in the hospital
3. Hospital staff making the child stand in the corner for
an hour
4. Hospital staff beating a child with a stick, leaving red
marks
5. Parent beating a child with a stick, leaving red marks
on the skin
6. Parent beating a child with their hands
7. Child being sold by parents
8. Child being raped by a hospital care-giver
9. A 2 year-old child being touched by an adult attender
on the genitals
10. A 12 year-old child being touched by an adult on the
genitals
11. Child being tied to a bed or chair as a form of restraint
12. Child not prepared before an injection given to
her/him
13. Child not prepared /explained simply about
procedures done on him/her
14. A 13 year-old child having to care for eight children
aged 2-5 years
15. A child subjected to research

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Give me more examples of child abuse possibilities in a hospital setting

CHILD PROTECTION RISK MANAGEMENT IN HOSPITALS

h. Have you heard of child protection policies and programs in hospitals?

i. If so, do you know any hospital in India that has them?

j. Do you think that hospitals need to have child protection policies? Why?

k. Does your hospital have a child protection policy?

l. Why does your hospital have/not have a child protection policy?

m. Do you have any other policy in which child protection is included?

n. What are three most important steps for your hospital to be child safe?

S.No Important steps for child protection Why? Is it possible to do?

in your hospital

e. Describe steps for that your hospital would take to develop a child protection
policy/program?

f. Who could help your hospital to have a child protection policy?

g. What are some of the challenges (name at least three) you are likely to face when
developing child protection policies?

113
 h. Do you think it is possible for your hospital to have child protection programs without a
child protection policy? If yes kindly tick mark which ones:

S.No Child Protection Programs Yes No Why? Department

to head this
xvi. Child Protection staff behaviour
pledge
xvii. Education to staff on child
protection
xviii. Screening for child protection staff
at recruitment
xix. Placing charts with behaviour
protocols for child protection
visibly in the hospital walls
xx. Placing complaint box in all
paediatric and childcare spaces and
encouraging children to voice their
complaints in the box
xxi. Reporting staff who are abusing
children to the management
xxii. Having a child protection
committee in your hospital
xxiii. Putting up notices on who to
contact with their numbers in a
case of child abuse by staff
throughout the hospital
xxiv. Researching what the hospital is
doing when a case of child abuse is
admitted.
xxv. Any other:
xxvi.

xxvii.

xxviii.

xxix.

xxx.

f. For strengthening child protection policies, systems and programs in your hospital list down
the areas you would like more training on:

Tick where appropriate Who could

As a self As a workshop facilitate
S.No Topic
learning this?(Mention
module who/dept)

114
 Any other topics beyond this list to help develop risk management for child protection in
the hospital

g. What would be a possible model that would work for your hospital to strengthen risk
management programs for child protection?

h. Any other comments related to setting up risk management programs for child protection in
hospitals

Any other comments

115