policy briefs to government
BRIEF NO 4 DECEMBER 2001
medico-legal services in Gauteng: Implications for the development of
best practices in the after-care of rape survivors
Suffla1, Mohamed Seedat2, Anabela Nascimento2
1Institute for Counselling,University of the Western Cape.
Tel.:+27 21 959-2732;email:firstname.lastname@example.org
2 MRC-UNISA Crime,Violence and Injury Lead Programme.Tel.:+27
Fax:+27 11 857-1770;email:Seedama@unisa.ac.za.
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brief in pdf format (204
The subject of rape
against women in South Africa continues to receive considerable attention.1-3 There is an emerging and urgent emphasis on the need to prevent the secondary
victimisation of rape survivors within the criminal justice system, through
the provision of quality services to survivors of sexual assault.
The trauma associated
with sexual violence is often accompanied by chronic health system problems
of difficult access and inconsistent quality of care.4-6 In addition,
health and social services in many low-income contexts suffer from a long-standing
and serious lack of co-ordination and fragmentation, rendering them ineffective.
Over-utilisation of certain services, inaccessibility of others, services
that do not provide for diversity of language, culture and worldview, and
lack of long-term planning of new services are some of the difficulties that
have contributed to the ineffectiveness of services to victims of violence
in South Africa.7
Other difficulties are
related to issues such as transportation, level of education, proximity to
health care providers, health literacy, skills in negotiating sometimes difficult
and complex health systems, and poverty. The provision of responsive, holistic,
and effective person-centred and service-oriented health services for victims
of violence is therefore needed in order to undermine the depredation of violence
on them, to ensure the secondary prevention of injury and trauma, and thereby
to improve health.
This brief focuses on
findings and recommendations emerging from an evaluation of medico-legal services
in Gauteng. This included an assessment of the structure (resources), process
(activities) and outcome (effectiveness) of after-care services for adult
rape survivors at 26 medico-legal centres in Gauteng. The evaluation focused
on the availability, accessibility, quantity, effectiveness and acceptability
of the services. The views of various service agents involved in the care
and management of rape survivors were ascertained. The aim was to determine
the current status of medico-legal services in Gauteng against the Health
Department's stated objectives and various other stakeholders' views of how
the service can and should function, serving to inform the development of
quality services based on the principles of best practice, as well as the
development of standardised evaluation tools to assess the quality of care
at medico-legal clinics.
In-depth focus group discussions
were conducted with service providers from the medico-legal centres, district
and regional managers and members of the South African Police Services (SAPS).
Individual interviews were conducted with the Director and Deputy-Director
of Medico-Legal Services for the Gauteng Provincial Health Department, and
with social workers/counsellors who provide psychosocial services to rape
survivors. Information related to structure and process was supplemented by
the scrutiny of relevant documentation. A detailed case review of 10 selected
medico-legal clinics was conducted. Feedback of findings was provided to relevant
stakeholders, including the Directorate of Medico-Legal Services.
suggest that the current system of service provision at medico-legal clinics
in Gauteng remains flawed in many respects. Although the medico-legal system
is increasingly engaged in developing and improving service, reform efforts
have not been consistently applied across the province. Consequently, minimum
standards of care are not being met.
Leading concerns affecting the quality of care provided to rape survivors were:
- problems of access,
- charges of insensitive
treatment of rape survivors,
- incompetent documentation
of medico-legal evidence,
- lack of human and financial
- inadequate training,
- disparities across
- weak inter-sectoral
The challenges to effective
service delivery identified appear to predominate in
historically disadvantaged communities, with poor black women receiving the
most inadequate service.
This evaluation also served
to highlight best practices currently being implemented at service
sites. These included:
- the availability of
protocols across the province,
- environmental design
and improved admission procedures affording greater
privacy to rape survivors,
- an increased number
of referrals to social service agencies,
- increased utilisation
of volunteers to assist in the functioning of medico-legal clinics, and
- implementation of procedures
to improve intersectoral collaboration and coordination between service
In line with
the above, recommended broad strategies for improving the
functioning of the medico-legal system and its related service components
are outlined below.
At the level of structure:
- The establishment of
victim-centred, quality-driven one-stop centres.
- Enhanced accessibility
of service sites: 24-hour service, access for disabled, access to same-language
personnel, transport facilities, access to information.
- Training and supervision
of all relevant stakeholders. Topics to include: clarification
of stakeholder roles and frames of activity, use and implementation of protocol,
J88 form (crucial document recording medico-legal evidence that may be used
to obtain a conviction in rape cases) and crime kit (additional tool used
for the collection of medico-legal evidence, containing slides, swabs, test
tubes and other equipment to collect samples of blood, hair, semen, vaginal
fluid and fingernail scrapings), gender sensitivity, the consequences of
rape for survivors, stress management, court appearance,etc.
- Ensure that the environment
is user-friendly: e.g. privacy, confidentiality, comfort, professional and
- Resources: comprehensive
audit at clinic level, increased availability (e.g. J88 form, crime kits),
policy to address inequities in service provision across the province.
At the level of process:
- Increased priority
given to the care of rape survivors.
- Reinforcement of the
discourse that recognises the legitimacy of rape survivors' access to the
medico-legal system (e.g. through training).
- Improved processes
in the collection of medico-legal evidence (e.g. through revision of the
J88 form, training).
- District and regional
level mechanisms to ensure record-keeping requirements are consistently
met, and statistics submitted regularly to relevant office.
- Review of data capturing
systems to enhance compilation of data.
- Availability of provincial
and/or national resource directory to facilitate information sharing and
- Ongoing audit of adherence
to minimum standards of care.
- Development of a standardised
evaluation tool to assess quality of care.
- Protocols detailing
roles and duties of different members of the criminal justice system.
- Formal mechanisms to
reinforce intersectoral collaboration (e.g. joint meetings, forums, campaigns).
- Priority given to the
development of best practice models with a view to replicating these provincially
- In-depth research on
the functioning of the police and courts in order to inform the development
of best practices across the criminal justice system.
At the level of outcome:
- Include rape survivors
in routine evaluations of medico-legal system's responsiveness to their
needs (e.g. evaluation/feedback forms, surveys).
findings were discussed at a consultative workshop (September 2001) with representatives
from the Directorate of Medico-Legal Services and the management of medico-legal
services. This resulted in the formulation of a set of priority action steps:
- The establishment of
Violence Information, Training and Treatment Centres (ViTICs) at district
level across the province. Their role and function need to be made explicit.
The success of these centres implies political support and increased human
and financial resources. The establishment of ViTICs is an urgent requisite.
- Need to address the
issue of service specialisation versus service generalisation so that there
is an appropriate balance between access to services and quality of care.
- Acceleration of training,
and increased human and financial resources to support implementation of
- Providing input to
the task team attending to the revision of the J88 form, as well as in-depth
training to relevant service providers in accurate completion of this form.
- Mechanisms and protocols
to ensure that crime kits are available, accessible and collected timeously.
- Increased psychosocial
support services for rape survivors. This implies that linkages with the
Department of Welfare, non-governmental organisations, community-based organisations
and other relevant agencies need to be established and strengthened.
- Provision of support
to service providers to assist them with their own traumatisation and stress.
- Initiating formal interaction
and strengthening the relationship with the Department of Justice to facilitate
development of a standardised protocol to inform and ease entry and
involvement of medical officers into the system.
- Closer collaboration
with the SAPS.
- Closer collaboration
with the private sector.
- An adequately functioning
communication system between management and health care workersto ensure
that all stakeholders are kept informed of developments within the system.
This will further serve to clarify and address misperceptions, myths and
anxieties about service providers' roles and functions (e.g. filling out
the J88 form).
- Hirschowitz R, Worku
S, Orkin M. Quantitative research findings on rape in South Africa. Pretoria:
Statistics South Africa, 2000.
- Jewkes R, Abrahams
N, Wood K. Rape. Pretoria: Crime Prevention Research Resources Centre, 2000.
- Swart L, Gilchrist
A, Butchart A, Seedat M, Martin L. Rape surveillance through district surgeon
offices in Johannesburg, 1996-1998: Findings, evaluation and prevention
implications. South African Journal of Psychology 2000; 30(2): 1-10.
- Human Rights Watch.
South Africa: Violence against women and the medico-
legal system, 1997. http://www.hrw.org/reports/1997/safrica/Safrica.htm
- Department of Health.
Audit of clinical medico-legal services in Gauteng. Unpublished manuscript,
Department of Health, Johannesburg, 1998.
- Moriarty LJ, Earle
JG. An analysis of services for victims of marital rape: A case study. Journal
of Offender Rehabilitation 1999; 29(3/4): 171-181.
- Nel J, Kruger J. From
policy to practice: Exploring victim empowerment initiatives in South Africa.
Pretoria: Council for Industrial and Scientific
has committed to present the report to senior governmental role-players,
and to utilise the evaluation findings and associated recommendations
to advocate for political support, resources and policy revisions in order
to enable changes and improvements within the system, to respond to the
priority action steps outlined above, and ultimately to enhance the quality
of care provided to rape survivors.