1. Providing Protection Services for Survivors of Sexual Abuse in Malawi Dr Neil Kennedy - Assoc Prof Paediatrics, College of Medicine, University of Malawi Dr Yabwile Mulambia – Paediatric registrar, College of Medicine, University of Malawi Prof Geraldine MacDonald - QUB

2. MALAWI Blantyre

3. Malawi Population 15.9 million 52% less than 18yrs 1 million orphans 11% HIV prevalence Falling under-5 mortality 3

4. 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 4

5. Response to CSA in Malawi Advocacy  Legal / policy framework  – CSA guidelines 2005 – UNCRC – 2010 Act Provision of services for survivors 

6. February 2009 – disjointed service Police Station Victim Support Unit Hospital QECH Social Services  No psychological support 6

7. February 2009 - problems 1.Poor recognition and facilities for CSA at QECH 2.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 rate 6.No coordinated service for victims

8. 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

9. 9 Home visit by: SWO CCPW VSU

10. One-Stop Centre

11. One-Stop Centre Services 11 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

12. OSC services - approved but not evaluated

13. 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

14. 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

15. 228 Survivors of CSA All consented to follow up 59 lost to follow up 62 withdrew consent 25 In-depth interview 107 questionnaire 107 participants re-consented at 3 months

16. 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 Guidelines WHO guidelines

17. Adequately handled Cases (indicator) At presentation (%) N= 107 By 3months (%) Health (Examination / PEP HIV test 0 + 3 months) 10082 Social (Initial assessment, home visit by 3 months) 80.229 Psychological (Support offered to all clients) 8412 more than one visit Justice (Investigation, referral to court) 95.353.8

18. 18% of survivors received all services as required 27% (29 / 107) - perpetrator convicted

19. 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…” 19

20. Perceptions of quality 73.8% (79/107) satisfied with the service 26.2% (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) 20

21. “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”

22. 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.

23. 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

24. An opportunity exists to break the cycle of abuse DON’T TELLTELL Shame Fear Stigma No use

25. DON’T TELLTELL Shame Fear Stigma No use Fear of HIV Justice

26. 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

27. 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

28. Acknowledgments UKaid UNICEF Association of Physicians Members of the one-stop-centre team Parents and children willing to share their story 28