MRC policy briefs to government

Evaluation of medico-legal services in Gauteng: Implications for the development of best practices in the after-care of rape survivors

Shahnaaz Suffla¹, Mohamed Seedat², Anabela Nascimento<sup>2

1</sup>Institute for Counselling,University of the Western Cape.
Tel.:+27 21 959-2732;email:ssuffla@iafrica.com
² MRC-UNISA Crime,Violence and Injury Lead Programme.Tel.:+27 11 857-1142;
Fax:+27 11 857-1770;email:Seedama@unisa.ac.za.

View the policy brief in pdf format (204 kb)

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.

Findings
The findings 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 resources,
• inadequate training,
• disparities across clinics, and
• weak inter-sectoral collaboration.

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 agents.

Recommendations
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 sensitive treatment.
• 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 referral procedures.
• 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 and nationally.
• 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).

Priority action steps*
These 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 ongoing training.
• 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).

References

1. Hirschowitz R, Worku S, Orkin M. Quantitative research findings on rape in South Africa. Pretoria: Statistics South Africa, 2000.
2. Jewkes R, Abrahams N, Wood K. Rape. Pretoria: Crime Prevention Research Resources Centre, 2000.
3. 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.
4. Human Rights Watch. South Africa: Violence against women and the medico-
   legal system, 1997. http://www.hrw.org/reports/1997/safrica/Safrica.htm
5. Department of Health. Audit of clinical medico-legal services in Gauteng. Unpublished manuscript, Department of Health, Johannesburg, 1998.
6. 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.
7. Nel J, Kruger J. From policy to practice: Exploring victim empowerment initiatives in South Africa. Pretoria: Council for Industrial and Scientific
   Research, 1999.

*The Directorate 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.