HORIZONTAL DELIVERY OF SERVICES

Almost all of the models that were viewed as horizontal integration included referral outside of the health sector and therefore these are presented together in this section.

Interventions to improve the delivery of post-rape care in South Africa were implemented in two rural hospitals without further expansion. In the first intervention, a nurse-driven model of post- rape care was implemented by a research unit in 2005, consisting of the establishment of a sexual violence advisory committee, development of a hospital rape management policy, running of a training workshop, assigning a designated room for examination, and running community awareness campaigns (54, 266). Prior to the intervention, a review of the service found that it was of poor quality and fragmented, while there were considerable improvements in the delivery of clinical care as well as trauma counselling, and referrals after implementation of the

45 intervention. In addition, efficiency improved by providing all rape-related treatments in one room and 54% of survivors reported seeing six or more providers compared to 86% in the past. Nurses were able to provide high-quality care, however many nurses were reluctant to conduct forensic examinations as there was a lack of clarity on their ability to testify in court. Moreover, rape survivors provided more positive feedback on the services, staff attitudes, and counselling after implementation of the intervention. A second phase of the intervention occurred in 2006 when the hospital employed a forensic nurse, who was supported by a nurse employed by the project (55). In addition, a lay counsellor and para-legal officer were appointed. In the second hospital, a NGO-led intervention established separate rooms for clinicians, police and counsellors to deliver care for rape survivors, and they provided staff including victim advocates who offered on-going support to survivors (266). The programme was found to improve adherence levels for PEP through intensive counselling plus a household-level follow-up. Between 2007 and 2009, 55% of 765 clients were given PEP compared to rates of 20% to 35% reported elsewhere in the country at the time. However, follow-ups at the household-level are resource intensive for many LMIC, and more costly to implement.

In El Salvador, Guatemala, Honduras, and Nicaragua, national guidelines on sexual violence made provision for comprehensive care but a review in late 2008 on the availability and implementation of the guidelines found that only 18% of facilities had them available and that comprehensive services were not fully implemented (267). Sixty eight percent of facilities had pregnancy tests, 59% had emergency contraception, 38% provided PEP and 3% had hepatitis B vaccine available. In addition, 62% provided psychosocial support either by referral or on-site while only 26% of facilities provided legal assistance again through referral or on-site (267). There was no reliable information on the number of survivors managed and a review of four patient files per facility found poor quality of documentation, lack of standardized forms, and inadequate information. The comprehensive care programme that was implemented in six municipalities in Guatemala was further described in another publication (268). The project included 1) medical and psychological care, and active case finding, 2) prevention of sexual violence through education and awareness, and 3) advocacy and networking. A unique feature of this programme was that a social worker actively searched for survivors who did not attend

46 their second visit. Challenges included the low number of survivors accessing care, high loss to follow-up thereafter, and the need for legal guidance to be included in the services.

In Mexico and Kenya, models for post-rape care were first tested in a few locations before being expanded more widely in the country (2, 269). In Mexico, the integrated model that began launched in 2000 included the detection of violence, provision of medical care and counselling, information registration, and referral for social and legal services (2). As part of the implementation of the model, health care providers and justice staff were trained and later a national certification course and policy were developed in 2009. In Kenya, a standard of care, protocols and algorithm were initially launched in 2003, while a national guideline was later published, user fees waived in 2005, and an evidence collection kit developed (269). The model included having a coordinator in each District Health Management Team liaising with police to improve referrals although it was later noted that there were still problems with referrals from smaller health facilities and within the hospitals themselves. Other challenges included the lack of coordination between programmes, the fact that clinicians were uncomfortable about testifying in court, the shortage of counsellors, increasing workloads for others, while counsellors themselves had concerns related to confidentiality.

In relation to IPV, two models were tested by external organisations in other countries while two models were tested as part of a research project in South Africa. In the first model, a primary care programme for women suffering from domestic violence was implemented in the University Health Centre of São Paulo in 2000 (Brazil) (270). Patients who were identified at the hospital were referred to the programme in the PHC centre, but all women were able to access the services. Trained health care providers, such as nurses, psychologists, social workers or physicians provided counselling in sessions lasting about an hour, and on average three to four meetings occurred. The programme also used a service guide, which listed all referral services in the city although intersectoral service networks were unable to be established (71). In the second model, presented in an article published in 2002, the Women Friendly Hospital Initiative was launched in 30 facilities in Bangladesh (271). It focused on the management of violence against women, quality of care, mother-baby service package, and gender equity. In terms of the management of violence against women, the initiative required that each level of facility should

47 have four personnel trained on the Protocol for Violence against Women, adequate examination and records maintained, and a proper referral system to other agencies or higher levels. The Violence against Women Management Protocol and Standard Operating Procedures were developed with stakeholders, researchers and activists, and these were refined over time. Training modules and six-day lesson plans to train doctors and nurses separately were also developed. Doctors were trained more on medico-legal examination, while nurses were trained on psychosocial counselling because of the lack of psychologists and psychiatrists on site. The authors reported that pre- and post-testing were conducted but no results were presented.

Another model for IPV service delivery was tested, revised and piloted in the Western Cape of South Africa by researchers from a local university (15, 272–274). The first study sought to evaluate a proposed protocol on screening for and managing IPV in two urban and three rural PHC facilities as there were no clinical management guidelines for IPV in South Africa (15). According to the protocol, primary providers were expected to provide all aspects of the service including universal screening, forensic documentation, safety assessment and safety planning, referral to the justice system and local services, and follow-up care. Providers from the facilities were trained to screen for IPV and refer to the study nurse but it was found that they did not do this for a number of reasons: heavy workloads, attitudes of providers – feeling that IPV was a social and not a health problem, the nature of the provider-patient relationship, difficulties of managing IPV in a PHC setting, frustration with survivors not following their advice, concerns regarding privacy and danger if they lived in the same community as the survivor, and possibly provider’s own personal experience with IPV (272). Furthermore, the full assessment by the study nurse took on average between 60 to 90 minutes, which would make it impossible for the primary provider to implement.

Following this work, a revised intersectoral model for IPV care was piloted in a rural sub-district in 2012 (58). In this model, IPV survivors would be identified through targeted case finding and treated clinically by the primary provider before being referred to a dedicated IPV service that was run by one of the social workers employed by the Department of Social Development on one day a month per facility. Here safety assessment and planning, counselling and referral were to be offered. This would be followed by participation in five life-skills group sessions and a

48 community-based support group that would be facilitated and coordinated by the Department of Social Development. On completion of the 11-month intervention period, it was noted that 165 women were given appointments for the IPV service yet only 75 (45%) attended. In the same time period 373 IPV complaints had been reported to the police. Only one life skills session was run at two venues, and no community-support groups were established. Access to the intervention was noted as problematic. The fact that the service was only available once a month with potential indirect costs and loss of income for survivors, fears regarding the removal of children or breach of confidentiality within the small communities, concerns regarding stigma for seeing a social worker or suspicions that they would be forced to follow a legal route (as was the previous focus of services) all resulted in poor attendance. The on-going belief that IPV is a non-health related problem continued, resulting in poor-uptake of the project by providers and it was felt that the social workers lacked organizational and facilitation skills to run the group sessions. It was hoped that referrals would be reduced and survivors treated more holistically by the social worker, but this did not occur. In part this was due to the attitude of providers and their lack of capacity in mental health skills, but health system issues such as high workloads also played a part. Another major challenge resulted from the intersectoral nature of the project. The implementation team, which was made up of members from the Department of Health, SAPS, Social Development, service providers and the university, did not function well. They complained about the lack of consultation and opposed the group components of the intervention stating that it was inappropriate in the local context. They did not communicate sufficiently amongst each other and with service providers on the ground resulting in further resistance to the project at all levels. In summary, the scale and the complexity of the project were underestimated and IPV services were not integrated into routine services. The need to consider contextual factors was an important lesson from the project.