Women queue outside of a Malawian health facility for healthcare for their children. Moving rape crisis centres out of central hospitals in Malawi and into clinics closer to communities might increase the number of people who use them, experts say.
The air is still and scalding at Blantyre’s Queen Elizabeth Central Hospital. Nurses are stifling yawns and scrolling through their phones, watching their Friday tick slowly away.
The arrival of three women in the doorway breaks the stillness like a thunderclap. Joyce, 20, is sobbing, her arms slumped over the shoulders of her elder sister and mother as the group of women shuffles inside the clinic.
Joyce has been sexually assaulted, her companions explain in a panic to the nurse manning the front desk. In an instant, the sleepy office around them flies into motion.
A nurse gently escorts Joyce and her companions into an examination room, where she’ll be offered HIV testing. If she tests negative for the virus, she’ll be given post-exposure prophylaxis or Pep. The one-month trio of daily antiretroviral medication can reduce the risk of HIV infection by about 80%, shows 2016 research published in the journal Clinical Infectious Diseases. It has to be taken within 72 hours after exposure to HIV whether through rape or even if a condom breaks during consensual sex. The sooner it’s taken, the more effective it is.
Outside the room, a police officer reaches for a notebook, preparing to take Joyce’s statement – if she wants to give one – after the medical examination is finished.
“We try to establish where the victim is coming from… and if there is any [ongoing] threat to them, especially if the perpetrator is a family member,” says Sergeant Isaac Chinzeti, the police prosecutor stationed at the centre. Next, Joyce will be taken down the passage to speak to a trained trauma therapist from a local rape counselling NGO called Fountain of Life.
This isn’t your typical hospital trauma unit. Instead, it’s part of a network of facilities called Chikwanekwanesset up by the Malawian government to support victims of sexual violence. The name means “everything under one roof” in the local Chichewa language and that’s exactly what the 22 centres are meant to provide – all the medical, legal, and social services that victims are entitled to follow a physical or sexual assault in one place.
Before they came into existence, legal, medical, and trauma support services for rape survivors were provided in different places, often far from each other – if at all. Victims who approached police stations sometimes weren’t even told they should also have an examination done by a medical professional, a 2018 study in the journal BMC Pediatrics describes
The complicated nature of the process, and the distances between the victim’s home, the police station, and the hospital, often caused victims to give up early in the process.
The Blantyre one-stop centre, which was the country’s first, opened in 2012 and is built on a model that United Nations data shows has been piloted in at least 30 countries, including South Africa.
From the United Kingdom to Laos, the idea behind places like these is simple: If victims can have all their immediate needs met in one place in the days or hours after an assault, they’re more likely to receive the support they need to heal, prevent pregnancy or HIV infection and to feel empowered to take legal action against their attackers if they choose to do so.
The logic behind the centres may be simple but making them work in practice is another story.
In South Africa, the country’s National Prosecuting Authority (NPA) introduced the country’s one-stop Thuthuzela Care Centres (TCCs) in 2000. Today, the NPA and multiple government departments are responsible for TCCs. It’s much the same in Malawi where at least three ministries play a role in running the Chikwanekwanes. Staff from two UN agencies — the United Nations Children’s Fund and the UN Population Fund — train the centres’ staff.
And in both countries, this arrangement has sometimes complicated how the centres are resourced.
“The centre does not have an own pool of funding from government as an entity for its operations,” says the Queen Elizabeth centre’s child protection officer, John Manyumba. “This is why we are facing a lot of challenges in the delivery of our services.”
In South Africa, most of the country’s 55 centres have relied on non-profits to provide psychosocial services, including extra social workers. This was largely funded by the international financing mechanism, the Global Fund to Fight Aids, TB and Malaria. This funding helped allow some centres to run 24-hours and offer better HIV prevention services, 2017 research published by the Networking HIV/AIDS Community of South Africa (Nacosa) organisation shows.
But Global Fund support ended in March and many organisations interviewed by Nacosa as part of the study didn’t have a plan to cover the shortfall — and didn’t know if government would be stepping up to fill the gap.
“Despite South Africa’s alarming levels of gender-based violence”, researchers wrote, “NGOs and community-based organisations working in the sector find themselves in deep financial crisis.”
In Malawi, Queen Elizabeth Central Hospital’s one-stop centre was also partly funded by international donors and more than five years since it opened, it and other centres are still battling to get patients in the door — and convictions to follow.
Statistics from the hospital’s centre’s records indicate that between May 2014 and December 2018, it saw less than 50 patients a month. Unicef’s Chief of Child Protection in Malawi, Afrooz Kaviani Johnson, she says she knows that the number of victims being reached by the current system is just a drop in the ocean.
“The problem in Malawi is that very few people seek services following an experience of abuse,” Johnson explains.
The next step, she says, is for one-stop centres to move out of hospitals and into clinics where community health care workers could help recognise symptoms of sexual abuse in patients.
Meanwhile, one-stop facilities are also battling to get victims’ cases successfully to trial, says the Queen Elizabeth centre’s child protection officer, John Manyumba.
Technically, police prosecutors and child protection officers like Manyumba should remind clients of their court dates and accompany them to trial. But this rarely happens because centres don’t have transport — something that has also plagued TCCs in South Africa.
And in many cases, victims do not want to press charges because abusers are close to or members of their family, shows research by the local human rights NGO, the Centre for Human Rights, Education, Advice and Assistance (CHREAA).
On top of that, it can take as long as a year for sexual assault trials to conclude, admits CHREAA paralegal officer Lisa Tembo.
“As a result, many victims give up [trying] to access justice”.
Despite their limitations, for many victims in Malawi, the Chikwanekwanes are a radical change from what came before.
Back at Queen Elizabeth Central Hospital, Joyce finishes her medical examination and is given a referral to return for counselling next Monday. In the meantime, the police have opened a case file for her. She will be taking her attacker to court.
About an hour after she first arrived at the centre, Joyce walks back out the front doors. This time, her mother and sister walk beside her, but she doesn’t lean on them anymore. For now anyway, she doesn’t need to.