Providing Protection Services for Survivors of Sexual Abuse in Malawi

Dr Neil Kennedy - Assoc Prof Paediatrics, College of Medicine, University of MalawiDr Yabwile Mulambia – Paediatric registrar, College of Medicine, University of MalawiProf Geraldine MacDonald - QUB

MALAWI

Blantyre

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Malawi

• Population 15.9 million

• 52% less than 18yrs

• 1 million orphans

• 11% HIV prevalence

• Falling under-5 mortality

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Child Sexual abuse in Malawi

• School-based survey 2005 – 1 in 4 children had forced

or unwanted sex by 16– 88.4% knew perpetrator

• MoH Welfare monitoring survey 2011– 5% of children 12-18 had

been raped in the previous 12 months

Response to CSA in Malawi• Advocacy • Legal / policy

framework – CSA guidelines 2005– UNCRC– 2010 Act

• Provision of services for survivors

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February 2009 – disjointed service

Police Station

Victim Support Unit

Hospital QECH Social Services

No

psychological support

February 2009 - problems

1. Poor recognition and facilities for CSA at QECH2. Poor communication with police

a) Were we seeing all the referrals?b) Were police following up on reports?c) Did police understand the reports? (particularly if no medical

findings WHICH ARE OFTEN NORMAL) 3. Little or no contact with social services

a) Were children being protected from further abuse?b) Did social services hear about abused children?

4. Lack of psychological victim support 5. Unknown prosecution rate6. No coordinated service for victims

March 2009• Meeting of key stakeholders from:

– Police – Commissioner child protection– Justice – Justice Twea (NJJF)– Social services – Director Social Welfare– Medicine– UNICEF– Partnership to Protect Children

• Establishment Blantyre Child Protection Team• Commitment to build ‘One-Stop Centre’ at QECH

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ONE STOP CENTRE

Police (VSU, CID, Prosecution) Medical Specialist Social worker Counselling

Referral by…

Self Police School

Home visit by:•SWO•CCPW•VSU

One-Stop Centre

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One-Stop Centre Services

• Senior doctors trained in diagnosis of CSA and abuse

• Services for women and children• 24 hours a day PEP / VCT / EC• Specialist child protection social

worker – Ensure place of safety– Coordination with local CCPW

and police• Police victim support• Volunteer led child trauma

counselling

OSC services - approved but not evaluated

Evaluation of OSC services to determine:

• The proportion of children attending that received services in accord with national guidelines.

• The factors that encourage or discourage the use of the service by children and their families

• The perceptions of quality of child protection services amongst service users and providers

Methods

• Investigator administered questionnaire in cohort of families of survivors 3 months after presentation

• In-depth interviews with 25 of these families• IDI with 10 members of staff

• August 2012-June 2013• Consented at presentation and re-consented at 3

months• Data collected in homes of survivors

228 Survivors of CSA

All consented to follow up

59 lost to follow up62 withdrew consent

25 In-depth interview 107 questionnaire

107 participants re-consented at 3

months

MOH guidelines

• Adequately handled case: health

• Medical exam / PEP

• HIV test at 0,3m

Social services and

psychological

• Social services• Home visit at

3m• Psychological

support

Justice

• Police investigation

• Case referred to court

2005 Malawi National GuidelinesWHO guidelines

Adequately handled Cases (indicator)

At presentation (%) N= 107

By 3months (%)

Health (Examination / PEP HIV test 0 + 3 months)

100 82

Social (Initial assessment, home visit by 3 months)

80.2 29

Psychological(Support offered to all clients)

84 12 more than one visit

Justice (Investigation, referral to court)

95.3 53.8

• 18% of survivors received all services as required

• 27% (29 / 107) - perpetrator convicted

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Factors encouraging service use – why do they come?

• Multiple overlapping responses – fear of contracting HIV / need for prophylaxis-19/25– Justice-3/25– counselling -2/25– Pregnancy- 1/25– were referred by the police-1/25– Verification of rape- 5/25

“What we really wanted to find out was the HIV status of the child since there is AIDS…”

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Perceptions of quality

73.8% (79/107) satisfied with the service26.2% (28/107) were not satisfied with the service

– 21- Police• 9 corruption-police• 3 negligence by the police

– 4 -Justice• Sentence too short

– 2 - health services• PEP not provided• Medical exam took too long

– 1- counselling (required more sessions)

“She (Mercy) has been raped by her step-father since 2011. At first she told her aunt, her uncle, then neighbors,

her teacher at school but none helped her…she also reported to the police …who gave a letter to give to her

step-father for him to go to the police…”

“She was raped by 5 men of whom some were children of our neighbours. Its been five months since we first went to court. We were awaiting evidence given by the police.

We went to court that morning and the police didn’t show up. The police officer present used our airtime to call him and he answered saying, “why did not you tell

me all this time I would have prepared, I don’t have transport”. These men still keep threatening the girl”

Provider perceptions

• Offered a good service, but that conviction rates (27%) should be higher.

• Lack of transport funds hinders appropriate social welfare provision.

• Many magistrates, investigators and prosecutors still lack the basic skills to deal appropriately with child survivors of sexual abuse.

Conclusions

• The OSC model is an appropriate means to deliver high quality care to CSA survivors in urban Malawi

• Fear of contracting HIV is driving disclosure

An opportunity exists to break the cycle of abuse

DON’T TELL

TELL

• Shame• Fear

• Stigma• No use

DON’T TELL

TELL

Shame• Fear

• Stigma• No use

• Fear of HIV• Justice

Conclusions

• Corruption amongst police is perceived to reduce prosecution rates.

• Lack of transport reduces the effectiveness of the service.

• Further training of prosecutors and magistrates to handle CSA cases is required

Next steps

• Complete the analysis – harm from OSC?• Highlight availability of PEP to encourage disclosure• Secure sustainable funding for transport /

communication • Roll-out training to reflect community perceptions of

services provided• Specific training for prosecutors / investigators and

magistrates of CSA

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Acknowledgments • UKaid

• UNICEF• Association of Physicians

• Members of the one-stop-centre team

• Parents and children willing to share their story