DEVELOPING AN APPROPRIATE HEALTH SECTOR RESPONSE TO GENDER-BASED VIOLENCE

Report of a Workshop Jointly Hosted by
The National Department of Health and
South African Gender Based Violence and Health Initiative
Farm Inn, Pretoria, 26 - 27 March 2001

June 2001

Prepared by: Rachel Jewkes, Tanya Jacobs, Loveday Penn – Kekana , and Naomi Webster

SA Gender Based Violence and Health Initiative

The South African Gender-based Violence and Health Initiative

MEDICAL RESEARCH COUNCIL

Private Bag X385
PRETORIA
0001

Tel: (012) 339 8527
Fax: (012) 339 8582

CONTENTS

  1. Executive Summary

  2. Introduction

  3. Gender based violence as a public health issue – Naeema Abrahams, Medical Research Council (MRC)

  4. Developing a vision for a health sector response to gender-based violence – Dr Rachel Jewkes, MRC

  5. Provincial Overview

  6. Workshop Discussions

  7. Conclusion

  8. Recommendations

  9. Participants List

EXECUTIVE SUMMARY

  1. INTRODUCTION

The Women’s Health and Gender Directorate and the Gender Focal Point of the National Department of Health and the South African Gender-Based Violence & Health Initiative co-hosted a two-day workshop to initiate a process of developing an appropriate health sector response to gender-based violence. It was held from the 26-27th March 2001 with 43 participants from all provinces, national government as well as NGO stakeholders.

  1. OBJECTIVES OF THE WORKSHOP:

The objectives of the workshop were to:

Gender-based violence as a public health issue

Gender-based violence is extremely common in South Africa. Research findings indicate that in the general population 25% of women have experienced physical violence from an intimate partner and as many a 1 in 2 health service users many have previously experienced this. In addition to injury, disability and death, gender-based violence is associated with an increased risk of a range of physical and mental health problems including, HIV, STDs, pregnancy loss, depression and anxiety disorders, substance use, chronic pain, miscarriage, teenage pregnancy and antepartum haemorrhage. Managing the health consequences of gender-based violence costs the South African health sector millions of rands each year.

Developing a vision for a health sector response to gender-based violence

A health sector response to gender-based violence must be comprehensive, client-centred, coordinated and enable the provision of high quality care to women irrespective of location of the health facility. The health sector response will differ somewhat depending of whether a woman is presenting after rape, is presenting after intimate partner violence either acute or chronic in nature, or depending on whether the response is required in the context of HIV prevention and counselling. It is most important that women are treated with kindness and sensitivity by health care workers and that they are given a simple message that they are not to blame for the abuse and that no woman deserves to be beaten. In order to do this these health care workers need to have a basic understanding of gender issues, gender-based violence and its consequences, the dynamics of abusive relationships and have good consultation skills. Many health workers require health sector management to help them to address issues of gender-based violence in their own lives before they can appropriately respond to patients.

Health workers also need the competency to undertake forensic examinations and document appropriately, to ask women about domestic violence, to assess safety and to provide counselling, prophylaxis and referral to other agencies for further support. In order to do this further training is required for staff to enable them to ask women about gender-based violence and respond appropriately and for those who will be undertaking forensic examinations.

Feedback from the Provinces

A report on activities in each province around gender-based violence was received. These indicated that in every province there was a range of activities which included protocol development, training for particular grades of staff to enable them to response to gender-based violence, delivery of services mainly to women after rape, advocacy campaigns, joint working or partnerships with NGOs and some providences has model victim-friendly or victim-empowering services.

Workshop discussions

Overall policy framework:

The workshop agreed that the overall gender-based violence framework for the health sector should include the following components:

Integration of gender-based violence into programmes:

The workshop perceived that gender-based violence probably had an impact on almost all Programmes of the Department of Health. Integration would require extensive advocacy within the Departments of Health to raise awareness of the issue and knowledge of how it impacts on the work of a specific programme so that managerial commitment for mainstreaming could be gained. The SAGBVHI was seen as having an important role in supporting this work.

Training:

The most important groups of staff who need competency in understanding gender-based violence and managing patients are nurses and doctors. The workshop identified both in-service training and integration of gender-based violence into the curriculum of Universities and Colleges as priorities. Three main types of training were identified: basic sensitisation; competency in identifying women who have experienced intimate partner violence; and competency in medico-legal rape examination and victim support. Several models for in-service training courses for nurses and doctors and for College-based training have been developed by SAGBVHI partners together with the Department of Health in various provinces.

Rape protocol:

The workshop discussed the Western Cape’s rape protocol and agreed that it provided a useful point of departure for developing a national rape policy, protocol and guidelines. Several other provinces also have policies. Developing a national policy is a priority for ensuring high quality services.

Medico-legal issues:

The workshop argued that a national human resources plan was needed for training sexual assault specialists and that the goal should be that only trained and accredited staff would undertake examinations. Processes are needed to agree curricula, extend training, set standards and accreditation processes. The workshop identified the availability of crime kits as a common problem and recognised that there was no information on the quality and service provided by forensic laboratories. Improving relationship with police, especially in rural areas was important.

IEC and health promotion:

Recognising that changes in clinical practice are facilitated by information materials for health workers and for patients, a range of information materials and posters were identified which would be useful for health facilities. Integration of gender-based violence issues into work of or funded through the Departments of Health on HIV was identified as a priority. It was recommended that strong relationships be built between HIV/AIDS Directorates and Gender Focal Points, with the goal of ensuring that work on HIV prevention was made gender-sensitive.

Conclusion

The workshop was recognised as an important step in the process of developing a more systematic health sector response to gender-based violence and partnership between different parts of the health sector. The activities recommended were recognised to have short, medium and long term time frames and to require action from through out the sector. The South Africa Gender-based Violence and Health Initiative is committed to supporting this process with research and technical expertise.

WORKSHOP REPORT

  1. INTRODUCTION

The Women’s Health and Genetics Directorate and the Gender Focal Point of the National Department of Health, and the South African Gender-Based Violence & Health Initiative (SAGBVHI) co-hosted a two-day workshop to initiate a process of developing an appropriate health sector response to gender-based violence. It was held from the 26-27th March 2001 with 43 participants from all provinces, national government as well as NGO stakeholders.

  1. OBJECTIVES OF THE WORKSHOP

The Objectives of the workshop were to:

Esther Maluleke, Director of Gender Focal Point of the National Department of Health, welcomed participants on behalf the Department of Health. She emphasised that the workshop, jointly organized by SAGBVHI and the Department of Health demonstrates that the health sector is committed to addressing gender-based violence.

Nicola Christofides, chairperson of SAGBVHI, introduced the international human rights framework and definition of gender- based violence. Within international treaties and conventions such as the Beijing Platform for Action and Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), gender-based violence is understood as violence directed against women which is a manifestation of unequal power relations between men and women.

The definition of violence against women used in the workshop was:

" any act of gender-based violence that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life".

Declaration on the Elimination of Violence Against Women (General Assembly, UN,1993)

The aim of the initiative is to maximise the utilisation of resources and skills and strengthen collective effort to improve the health sector's response to gender based violence in South Africa.

The workshop represented the first major activity of SAGBVHI, which was formed in 2000 as a partnership of 15 organizations and individuals working on gender-based violence and health issues. Through building partnerships between government, researchers and other stakeholders SAGBVHI aims to use research to strengthen the development of the health sector response to gender-based violence, advocate for the importance of addressing the issue in the health sector and promote training interventions to address gender-based violence. SAGBVHI aims to define a research agenda around gender-based violence and the health sector. It will use seed funds to ensure that part of this agenda can be addressed and promote research capacity development in the field.

The workshop represents the first step in a process of reflection on the health sector response by SAGBVHI. Research findings and activities within provinces will also be reviewed annually at a conference on gender-based violence and health and Parliamentary hearings will be jointly hosted with the Portfolio Committee on Health.

  1. GENDER-BASED VIOLENCE AS A PUBLIC HEALTH ISSUE

Naeema Abrahams provided an overview of gender - based violence as a public health issue.

Introduction

Gender violence is the world’s most widespread form of human rights violation. It is found in all types of societies, social classes, races, ages and ethnic groups. Research conducted in more than 50 countries has shown that between 10% and 50% of women reported having been hit or physically harmed by a partner on at least one occasion (Heise et al., 1999).

Recently studies highlighting gender violence as a public health issue have been completed in South Africa. The MRC Three Provinces Study (Mpumalanga, Eastern Cape and Northern Province) found that 25% of the women had experienced physical violence by a partner at some time in their lives (Jewkes et al in press). One in 10 of the women experienced this violence within the last year. Similarly, a study of women attending a community health centre in Cape Town found that 1 in 2 of the women had a history of domestic violence (Jacobs 1999).

Physical Violence

Physical violence is often the most visible form of abuse and perhaps easiest recognised. The physical injuries inflicted most commonly range from minor cuts and bruises to the murder of women by their intimate partners. The latter is the most extreme manifestation and consequence of gender violence. Worldwide, it is estimated that between 40 - 70% of the female murders are committed by intimate partners often within the context of an abusive relationship. A pilot study conducted in South Africa estimated that one woman in every six days is a victim of intimate femicide (Vetten 1995).

Sexual violence

Recently the media has reported increasing numbers of rape homicides. A review of such cases admitted to the Salt River Mortuary found a rape fatality rate of 1.2% (Martin 1999). In other words 12 deaths for every 1000 rapes reported to the police, which is 12 times higher than the rate found in the USA (Marchbanks et al 1990). In a country where it is estimated that 10% of the population is HIV positive, the true fatality associated with rape is more likely to be much higher.

South Africa has the highest number of rapes reported to police compared to its female population than any other country. This is in an environment in which many women experience secondary victimisation at the services and from a society which discourages reporting of rapes. The MRC study found that 2 in every 100 women reported that they have been raped in the previous year (Jewkes and Abrahams, forthcoming). In Cape Town a study nearly 16% of men reported that they had raped or attempted to rape an intimate partner within the last 10 years (Abrahams etc al 1999).

Psychological abuse

Very often women state that the emotional abuse they suffer at the hands of their partners is far worse than the physical abuse. In Mpumalanga, the Three Province Study found that 50% of women had experienced some form of psychological abuse. A range of controlling behaviors by the male partner were reported, including not being given money to run the homes when the husband had money to spend, being evicted from the home, prevented from visiting family and prevented from working (Jewkes et al 1999). The study of men in Cape Town reported the use of similar emotional tactics such as deliberate humiliation, belittling of women partners, damaging the women’s valuables and the use of threats of physical violence (Abrahams et al 1999).

The health consequences of gender violence

Violence against women is associated with a greater risk of experiencing a wide range of health problems (Heise et al, 1999). The direct consequences such as injuries are most visible but the indirect health consequences are just as important since they increase the risk to ill health in the future, for example through increasing likelihood of unsafe sexual practices or abuse of alcohol and drugs. The impact of the abuse can persist long after the abuse has stopped. The longer the abuse continues and the more severe the abuse, the greater the impact is on the women’s mental and physical health. An overview of the health consequences of abuse is presented in Figure1.

Figure 1: Health consequences of violence against women.

 

Associations with HIV/AIDS

The high incidence of HIV infection in South Africa has added a new dimension to gender violence. Women have very little power in sexual relations and men often use violence or threats of violence and other coercive tactics to dictate when and how sex will take place. Women are often beaten if they refuse to have sex or if they want to end a relationship or when suspected of having affairs. In addition men have multiple partners and women fear being abandoned or losing social standing if they assert their rights. Further more the studies have shown that fear of violence influences whether women disclose their HIV status.

Forced sex is also a major problem. Research has found that more than a quarter of young women report that their first sexual encounter was forced (Buga et al, 1996 ). Girls who find themselves in these situations are less likely to use contraception and to negotiate condom use. In a study in Cape Town these adolescent girls who had forced initial sexual encounters were very much more likely to have a teenage pregnancy (Risk Ratio of 14.0) (Jewkes et al, 2001). Rape has severe health consequences and the risk pathways of rape is presented in Figure 2.

Problems in pregnancies and gynaecological symptoms

Blows to the abdomen during pregnancy are common. In the Three Province Study 9% of the women in the Eastern Cape were beaten during pregnancy and 1 in 10 of the women said their male partners prevented them from attending antenatal care at some stage (Jewkes et al 1999). Violence also leads to adverse pregnancy outcomes and has been associated with later entry into prenatal care, increase smoking and substance abuse, vaginal and cervical infections, premature labour, miscarriage and abortions and low birth-weight and injury of the newborn

A history of sexual violence has been associated with vaginal bleeding, vaginal discharge, painful menstruation, sexual dysfunctions, pelvic inflammatory disease, painful intercourse and chronic pelvic pains. Abused women are more likely to have STDs including HIV (Heise et al 1999).

Psychological problems

Some of them the common psychological problems associated with gender violence are depression, anxiety, low self esteem, sleep and eating disorders, suicidal behaviour, alcohol and drug misuse and Post Traumatic Stress Disorder (PTSD) and suicide. As a result of this, violence also affects women’s health indirectly, for example by impacting on their ability to work, take care of her children and to participate fully in society (Heise et al 1999).

The impact on children

The impact on children is also profound since children who come from homes in which they witnessed abuse are more likely to become perpetrators or victims of violence themselves. They are more likely to experience behavioral problems which impacts on their development and their performance at school, they may also live in the constant fear of violence, they could be injured during an incident and they could also often run away from home. It is possible that mothers project their own anxiety onto their children’s health problems and may even bring them to the health centres more often for minor ailments. Gender violence may also be the under-lying cause of child neglect, particularly if an abused woman is depressed or abusing alcohol it may affect her ability to care for her children (Heise et al 1999).

The financial burden

In Canada the annual health related cost was estimated to be $ 1 500 million. The Three Province Study very roughly estimated the cost of treating just injuries alone as R 29 million a year in the Three Provinces (Jewkes 2000). The full costs are much higher as abused women use health services more often than other women and the costs of care for the indirect health problems arising form the abuse also need to be considered.

Conclusion

Gender violence is very common in South Africa and has a major impact on the morbidity and the mortality of women and children. It also is responsible for substantial economic costs to the health sector. The health sector has a major role to play in assisting women who experience violence, managing its health consequences and participating in the overall struggle to stop the abuse of women.

References

Heise L, Ellsberg M, Gottemoeller M. (1999) Ending violence against women. Population Reports Volume XXVII, Number 4, Population Information program, Center for Communication Programs, The John Hopkins University, School of Public Health.

Jewkes R, Penn-Kekana L, Levin J (in press) Risk factors for domestic violence: findings from a South African cross-sectional study. Social Science and Medicine.

Jacobs T (1999) Breaking the silence: a survey of women attending Mitchell’s Plain Day Hospital. Prevalence of abuse and acceptability of screening by health care workers. MPhil thesis. University of the Western Cape.

Vetten L (1995) “Man shoots wife”. A pilot study detailing intimate femicide in Gauteng, South Africa. People Opposing Women Abuse, Johannesburg.

Marchbanks PA, Kung-Jong L, Marcy JA (1990) Risk of injury from resisting rape. Am J Epidemiology 132(3),540-549.

Martin L (1999) Violence against women: an analysis of the epidemiology and patterns of injury in rape homicide in Cape Town and in rape in Johannesburg. Unpublished MMed Forensic Pathology Thesis, University of Cape Town.

Abrahams N, Jewkes R, Laubscher R (1999) “ I do not believe in democracy in the home”. Men on relationships with and abuse of women. Medical Research Council Technical Report, Medical Research Council, Tygerberg.

Jewkes R, Abrahams N (in press) The Epidemiology of rape and sexual coercion in South Africa: an overview. Social science and Medicine.

Jewkes R, Penn-Kekana L, Levin J, Ratsaka M, Schrieber M. (1999) “He must give me money he mustn’t beat me”. Violence against women in three South African Provinces. Medical Research Council Technical Report, Medical Research Council, Pretoria.

Jewkes R, Vundule C, Maforah F, Jordaan E.(2001) Relationship dynamics and adolescent pregnancy in South Africa. Social Science and Medicine 5, 733-744.

Buga GAB, Amoko DHA, Ncayiyana D. (1996) Sexual behaviour, contraceptive practices and reproductive health among school adolescents in rural Transkei. South African Medical Journal 86,523-527.

Jewkes R (2000) Violence against women in South Africa. International Clinical Psychopathology 15 (suppl 3), 37-45.

  1. DEVELOPING A VISION FOR A HEALTH SECTOR RESPONSE TO GENDER-BASED VIOLENCE

Rachel Jewkes provided an overall vision for a South African health sector response to gender-based violence as a framework to facilitate further discussion in the working groups.

Key features of the vision

A health sector response to gender-based violence must be comprehensive, client (or woman) centred, enable the provision of high quality care even in rural areas and it should be coordinated through the sector as a whole. Processes of monitoring and evaluation need to run through out so that the effectiveness of each part can be assessed and any necessary changes made as it is rolled out across the country.

A health sector response needs to be designed to ensure that at the point of service use, patients or clients received the best possible standard of care. In trying to understand what this entails and what is needed for the health sector to be able to provide it, it is perhaps helpful to focus on some common clinical scenarios.

Scenario One: a woman comes to the services after she has been raped

In this situation a woman needs:

Each of these needs of the women place a series of demands on health workers, which require particular attitudes and competencies to meet. In turn particular actions are needed from health sector management to ensure health workers are able to respond appropriately.

Responding with kindness and sensitivity

Health workers need sensitisation to issues of gender and gender-based violence, including knowledge of their health consequences, the dynamics of abusive relationships, the impact of abuse on women, and gender issues. They need to have convey attitudes of respect for women, be non-judgmental and understand the need for separation of professional and personal issues.

In order to do this in-service training of clinical staff and front-line support staff is needed. Curricula for basic training of nurses and undergraduate medical training need to be revised accordingly. Health service management needs training to understand the issues and re-orientation to indicate that these attitudes and values are core elements of good practice. Core values need to be emphasised in recruitment of health professionals and the practices of disciplinary procedures.

Undertaking a competent rape examination and collecting evidence

Health workers need clarity on which staff should and should not examine rape survivors, so that evidence is not lost by inappropriate staff examining patients. Designated staff need to be identified and trained in examination, collection of specimens and documentation. A private room with adequate equipment needs to be available for rape examinations in all facilities where these examinations will take place. In order to do this staff need training on rape and the sensitivities of examination. A decision needs to be made on the future of forensic nursing. Provinces need to identify funding and appropriate management structures for forensic nursing. Provincial protocols need to be agreed for management of rape.

Rape examiners need ready access to crime kits and good relations with the police to ensure that they respond quickly when informed of women who have been raped attending health settings and recognise the need to deliver evidence to the laboratories in good condition. Efficient and well equipped labs are needed with effective processes for delivery of results. In order to have these health sector management needs to recognise the importance of health facility’s role in rape, good relationships with police need to be built at a district and facility level. Laboratories need to be efficiently run and report results timeously.

Counselling, testing and prophylaxis

Health workers examining women who have been raped need to develop competence in offering and undertaking pregnancy and HIV tests and providing prophylaxis against pregnancy (or abortion advice) and STDs (including HIV starter packs). Health facilities need to stock pregnancy tests, HIV tests, emergency contraceptives, antibiotics for STD prophylaxis and HIV starter packs. If health workers are to become good at discussing very sensitive issues at a time of extreme distress for their patients they will need a basic foundation in communication skills in undergraduate medical and nursing training.

Referral to the police and NGOs

Health workers need to understand that rape survivors need further support, beyond their initial visit to a health facility and help with a decision whether or not to lay charges. Local knowledge of sources of support for rape survivors is needed and good intersectoral networks. Management support at a facility level and district level for intersectoral collaboration is critical. Intersectoral bridges are needed between different providers of gender-based violence services and information on sources of referral is needed in health facilities. This might be in the form of posters and leaflets for the general public and staff.

Expert witness

Finally, rape examiners need to be able to competently present evidence in court. To do this they need to understand the importance of their evidence and value their role. They need training to provide the skills and knowledge to present evidence competently and stand up under cross-examination. The court system also needs to be sensitive to the competing demands of expert witnesses. Collaboration between health and justice sectors is needed to streamline the court processes.

Scenario Two: a woman attends a health facility with a problem and gender-based violence is the underlying cause

In this situation a woman needs:

In order be able to ask about gender-based violence and then set in process a chain of appropriate responses, health workers need reorientation to understand the importance of investigating underlying causes of ill-health.

Learning to ASK

Health workers need to understand the links between gender-based violence and many presenting problems they see in the course of their work. They need to develop competencies in sensitive but direct questioning about whether there was an injury, who caused the injury or whether the patient is experiencing violence. They need to understand that violence is often denied and that support should still be given and understand that asking may well be an intervention in itself.

In order to do this in-service training is needed for clinical staff and front-line support staff. Medical and nursing training curricula changes are needed to emphasise the importance of exploring risk factors and include competency in asking about abuse appropriately. Training for health service management is needed on gender issues so that health workers have time to spend with a patient once she has disclosed. It is necessary to build an understanding that addressing gender-based violence for abused women is a process, often a long process, and that overnight results should not be expected.

No woman deserves to be beaten

Health workers need to develop attitudes towards violence and abused women which support women’s right not to experience any form of gender-based violence. Skills need to be developed in providing basic supportive messages that no woman deserves to be abused and an outline of the law on gender-based violence. In order to do this in-service training is needed for clinical and front-line support staff, and medical and nursing undergraduate training curricula need to be revised. Accessible information for health care settings needs to be produced and disseminated in the form of posters or leaflets, directed at health workers to remind them to ask as well as at women.

Assessing safety

Intimate partner violence is the only form of violence an adult experiences where the chances are the victim will have to go home to her assailant. This brings with it a special set of safety concerns which are quite unique. Health care workers need to understand the safety concerns related to gender-based violence. They need to be able to assess risk of suicide and homicide and in the case of maternity service, of pregnancy loss. They need to protect confidentiality of information, understand how to secure privacy in discussions and how to refer to police and psychiatric services if necessary.

In order to do this health workers need training in how to assess safety, the special risks of this area and necessary precautions. This needs to be both in-service and undergraduate training. Referral networks need to be developed for psychiatric emergencies and referral to the police. Management support is needed for the importance of privacy, and areas where private discussions can be held need to be identified. Managers need to treat breeches of security and confidentiality seriously.

Referral

Health workers need to understand the need for abused women to have access to further support and perhaps the law, and to develop good intersectoral relationships to facilitate referral to the police, social workers and NGOs. Managers need to give staff opportunities to meet with representatives from different sectors to discuss and share understanding of the potential, and limitations, of each other’s role.

Scenario three: gender-based violence in HIV prevention and counselling

Gender-based violence also critically impacts on health care in the area of motivation for safer sexual practices and counselling around HIV risk. High quality care requires :

Mainstreaming gender issues in HIV prevention

Health workers need to address gender inequity and gender-based violence in life skills, peer education programmes and other sexual health training programmes. To do this, gender and HIV issues need to be included in medical and nursing training curricula and sexual health trainers need to be familiarised with gender issues. Funders and commissioners of HIV prevention activities need to have a similar understanding of gender issues so that these are specified in their briefs and influence funding decisions. Information, education and communication (IEC) materials need to be used creatively to address gender issues as part of overall efforts to reduce HIV.

Addressing gender in HIV counselling

Health workers need to be sensitized to issues of gender and gender-based violence. This should include, gender-based violence as a risk factor for HIV infection, as a barrier to adoption of safer sexual practices before and after diagnosis, as a risk after disclosure, and as a feature of the lives of women living with HIV and preparing for dying. To do this the curricula for training HIV counselors needs to address gender and violence issues and support is needed from managers and donors for the extra time which addressing issues of violence may entail.

Health workers also experience abuse

Health workers may also be women who experience violence in their personal lives. Similarly, male health workers may also beat their wives. Managers of health services need to recognize that gender-based violence may impact on the attendance and performance at work of their staff. Health workers need information on how they can get help with abuse in their lives and should be encouraged to join support programmes. Managers need to be sensitive to the likelihood that some male health sector employees abuse their partners and that this will influence their suitability for certain types of work. They may also want help to stop being violent. Managers need to be sensitive to questions of the gender-based violence in employment and how to raise the issue with staff. They need to be prepared to support staff who try to get help for these personal issues. Human resources departments need to work with DENOSA and the Unions to investigate appropriate models of support for workers.

Conclusions

In developing an appropriate health sector response to gender-based violence it is important to understand that isolated interventions may be of limited success, systems-wide change is needed – impacting on all corners of the health sector. The process needs to be guided by research, which can help describe problems, define and refine interventions and provide an understanding of the degree of effectiveness and conditions for maximal impact. Intersectoral collaboration will be vital to success and creative partnerships between the public sector, NGOs and research organizations.

  1. FEEDBACK FROM PROVINCES

In preparation for the workshop, all provinces were asked to complete a short form indicating activities under way in their provinces related to gender-based violence. The information supplied is listed below.

Eastern Cape

Policy and programme Training Service Delivery other activities Key stakeholders in addressing gender violence Partnerships with other organizations
Medico-legal services, Victim referral centers, and Victim Empowerment Programmes Forensic speciality and trauma support, Psychiatric nurses and district surgeons in violence referral centres and hospitals. Gender-based violence training for PHC nurses in Two districts. Roll out is planned. Medico-legal services, trauma support by Departments of Health, Justice, Welfare, NGOs and CBOs Developing training materials for health workers and communities. Advocacy campaigns to encourage enforcement of DV legislation. Depts. of Welfare, Justice, OSW, Youth commission, NGO's and CBOs UNITRA, District surgeons, Welfare, ECNOVAW, Masimanyane WSC

FREE STATE

Policy and programme Training Service Delivery other activities Key stakeholders addressing gender violence Partnerships with other organization
Victim support and victim friendly rooms in hospitals and clinics.

Tshepong victim support centre at National Hospital.

 In-service training for medical officers in forensic and trauma support Clinical Forensic services for sexual offenses at national hospital. Complex Addendum to J88 Monthly meeting by intersectoral management team.

Provincial victim empowerment programme meeting.

   PPASA

GAUTENG

Policy and programme Training Service Delivery other activities Key stakeholders addressing gender violence Partnerships with other organization
Protocols for medico-legal management of all victims in all hospitals, community health centres and district health facilities. Chapter in mental health section of student training. Manuals for PHC course on victims of violence. Guidelines for routine screening written and training for psychiatric community nurses to implement these. Pilot for routine screening at 6 PHC clinics in Alberton from Aug. 1999.60 nurses, social workers and health promoters were trained. Medico-legal departments all received generic training Gauteng welfare department BAC Gauteng CSVR
Lifeline
FAMSA
Ekupholeni
MH service

KWA ZULU NATAL

Policy and programme Training Service Delivery other activities Key stakeholders addressing gender violence
Protocol for the Management of Rape Survivors at PHC Facilities / Provincial Hospitals in KZN. Guidelines for Management of Victims of Rape and other Sexual Offences. Multi-Sectoral Child Abuse and Neglect Protocol Forensic Medicine for Nurses – Introductory Courses x 8  Crisis Intervention in Domestic Violence – regional workshops (ADAW & MC&WH) Violence and Rape – included in formal Sexual and Youth Health courses Management and Disclosure of Violence and Rape Fragmented services/programmes/projects in districts – not well recorded or reported. Pilot projects for child abuse, neglect & violence in 3 regions   Mrs RN Mthethwa – Gender Focal Person
Dr Akoojee – Policy and Forensic
Mrs E Snyman – Maternal, Child and Women’s Health
Mrs G Mthlaluka – Mental Health
NGO’s mentioned under partnerships

CURRENT PARTNERS:

Victims of Violence
Advice Desk for Abused Women
FAMSA
Life Line
Departments of Welfare, Education, SAPS

NORTHERN CAPE

Policy and programme Training Service Delivery other activities Key stakeholders in addressing gender violence
Still busy with national policy Dr Els is training community service doctors. 23 nurses trained.

Training was done by the clinical psychologist for forensic nurses dealing with victims in 5 districts. Counselling is done by NGO's and FAMSA

Provincial Network training workshops on domestic Violence Act Victim empowerment -mental health sub directorate involved

Provincial Network on Violence Against Women
OSW
Child protection Unit
Safety and Security
Forensic Services
FAMSA
NICRO
HIV counsellors

NORTHERN PROVINCE

Policy and programme Training Service Delivery other activities Key stakeholders in addressing gender violence
 

In service training for doctors and nurses in management of survivors/victims Counselling skills

 Medical management of victims of violence by doctors and hospitals

Commission on gender equality is doing awareness raising on violence against women, witchcraft through workshops and performing arts Community outreach during the 16 days of activism Radio slot on Radio Thobela every month

OSW
Justice
NICRO
CGE
Education
Youth Commission
Victim support centre
Child welfare

NORTH WEST

Policy and programme Training Service Delivery other activities Key stakeholders in addressing gender violence

Not yet developed provincially still waiting National {policy} presently using the Justice National Protocols. Intending to develop Provincial Protocols after a research project that is to start in September 2001

Still at the planning stage. Negotiations with The Tshwaragang Legal Advocacy for Violence Against Women to train reproductive health nurses as Counselors of Raped and Battered Women and Children

The division has just been established in Dec 2000. A centre for survivors of violence is soon to be opened in partnership with the Welfare & Justice Department, but the Dept of Health is the one that has made the Budget available. Six {6} multipurpose Youth centres are being piloted in the Province.

A working network formed with the Dept of Psychology in Uniwest to  conduct research on violence against women and also on the psychological impact of CTOP on teenagers VCT the youth centres made available as pilot sites. Women in partnership against AIDS taken by the Women’s health programme but working in partnership with the HIV/AIDS sub-directorate

Department of Health
Department of Social Welfare
Office on the Status of Women
Safety and Liaison

Current Partnerships: University of the North West  {Uniwest}
Provincial Network on No Violence Against Women
Lovelife
Office on the Status of Women

Participants at workshop

WESTERN CAPE

Policy and programme Training Service Delivery other activities Key stakeholders addressing gender violence
Rape Guidelines developed through thorough consultation of role players / stakeholders (including Directorate: Public Prosecutions, NGOs, all regions, Rape Forums; District Surgeons); training in planning phase

District Surgeons system still in operation

’Rape survivors seen at all CHCs, Hospitals

Thuthuzela opened at GF Jooste Hospital as a designated rape centre

Crime kits supplied by police.

 Trauma Training – national funding – programme arranged by Trauma Centre;

Vezimfihlo Training : Pilot project in Helderberg and Malmesbury; province committed to further role out

Foetal Alcohol Syndrome: Training of personnel in Boland Overberg / West Coast Winelands/Southern Cape/Karoo and Metro. Pilot projects in rural regions;

Medical Officer Training : spearheaded by Groote Schuur Medical officers

Rape Guidelines : Manual in  preparation

Gender Awareness Training :  one of the four provincial regions

NGO training: number of actives NGOs in province involved in training programmes

Support from Directorate : HRD : to strengthen monitoring and evaluation and collate training statistics.

 Comfort rooms : Victoria / Hottentots Holland Somerset; partnership of Rape Crisis / SAPS / Health Department

Thuthuzela : GF Jooste Hospital initiated by Directorate: Public Prosecutions and Department of Health

Lay Counsellors : Rape Crisis . Ilitha Labantu / Nicro, Justice Departments strengthen monitoring and evaluation and collate training statistics

Special Courts Mitchell’s Plain / Wynberg; Commitment from Justice Department and Directorate Public Prosecutions to opening additional courts.

Victim Empowerment Programme : Training of 120 lay counsellors

Rape Forums: a number throughout province; comprise of large range of stakeholders in designated areas.

 Provincial Departments
Social Services
South African Police Services
Community Safety
Education
Justice
Directorate Public Prosecutions
Western Cape College of Nursing
NGO’s

CURRENT PARTNERS:
Rape Crisis
Trauma Centre
Ilitha Labantu
Network of Violence against Women
Saartjie Baartman Centre
Nicro
Vezimfihlo
Five-in-Six

  1. WORKSHOP DISCUSSIONS:

OVERALL POLICY FRAMEWORK

The objective is to ensure that gender-based violence is recognised as a public health issue and to ensure that gender-based violence is considered in all policy documents of the following areas, HIV/AIDS, mental health, health promotion, adolescent and child health and maternal and women’s health.

The overall gender-based violence framework for the health sector should include the following components:

The goal of the policy framework is to ensure delivery of high quality service through out the country, including in rural areas. The framework needs to outline a minimum package of services and minimum standards for each service. It needs to ensure that genuine intersectoral collaboration (e.g. all government departments, local authorities, churches, political structures, traditional leaders and private sector) is a feature of implementation. Specific guidelines regarding training and treatment protocols need to be included and systems of monitoring and evaluation need to be included.

The policy framework needs to emphasise the importance of prevention of gender-based violence, recognizing that all health sector actions contribute towards prevention through rolling back the complacency surrounding gender-based violence, challenging the view that it is 'normal' and increasing awareness of its health consequences.

The process of development of a policy needs to take place in tandem with the development of guidelines and protocols. The whole process needs to be driven by the National Department of Health, who should promote equity in skills, knowledge and resources between provinces.

Provinces need to develop policy and implementation frameworks addressing issues such as coordination, identifying where the programme should be driven from and human resource. The SAGBVHI should be regarded as a resource and should be able to help Provinces link up with and build upon the resources that have been developed, for example the Western Cape rape policy and guidelines or training materials. It should fundraise to assist this process.

It was suggested that Provincial work would be helped if a situation analysis was conducted (including NGOs, local authorities and provincial departments) in order to describe and define requirements and minimum standards provided in services, gaps and provincial needs and centres of excellence in order to learn lessons and transfer skills.

INTEGRATION OF GENDER BASED VIOLENCE INTO PROGRAMMES

The workshop acknowledged that gender-based violence probably had an impact of some form on almost all the Programmes of the Department of Health. It was perceived as particularly relevant to women’s health (including gynaecology and infertility services); reproductive health including TOP, contraception and maternity services; mental health and substance abuse; health promotion; HIV/AIDS and STD services; medico-legal services; school health; paediatrics; youth and adolescent health; geriatrics; disability and rehabilitation; and chronic care.

Although it was acknowledged that it was a National function rather than Provincial, it was noted that Prison Health and SAMHS were also priority areas especially, in the case of prisons, for rape.

The workshops discussed both mainstreaming gender and gender-based violence. It noted that they are both important and interrelated, but different and the focus of the workshop was on gender-based violence. The first pre-requisites for mainstreaming gender-based violence are an awareness and knowledge of the issue and its health implications. Following this, managerial commitment is essential. In order to build this advocacy is needed with Provincial departments. There was considerable discussion of where responsibilities should be located within the Departments of health. This discussion predominately reflected the views of the interested parties i.e. the National and provincial departments representatives. It was agreed that awareness raising could perhaps be led by the MCHW Directorates in the Provinces working with the Gender Focal Point and in particular the need to involve men was recognized.

Advocacy could be facilited through partnership with NGOs and the SAGBVHI. SAGBVHI could assist in building capacity and developing ideas for taking mainstreaming forward in particular areas.

It was further recommended that government clusters should be utilized at national and provincial level: e.g. justice, correctional services, SAPS, health and welfare. This has the potential for strengthening efforts on gender-based violence, the challenge is to use them it effectively for this purpose.

Who should drive gender-based violence in the Department of Health?

The workshop recommended that a proposal be put to the Minister on the role of the Gender Focal Points versus the Programme Directorates in the area of gender-based violence. It was suggested that the role of the Gender Focal Points should be:

The role for the Programme Directors should be:

The Gender Focal Point in the National Department of Health was identified as having a particular role to:

TRAINING

The workshop discussed two main arenas for training: in-service training and university/college-based courses. Three main types of training were defined according to the intended outcomes:

Basic sensitisation on gender-based violence

What are the priority competencies and areas which need to be covered?

Basic sensitisation on gender-based violence was identified as being essential to enable implementation of more specialised training on the issue, to create a general climate of awareness and sensitivity. Staff who had undergone basic training should be able to:

Training should include:

What are the priority groups for training?

The workshop felt that basic sensitisation on gender-based violence should be a core competence for all grades of staff within the health sector. In particular all medical and nursing staff, social workers, counsellors, clerks, ambulance drivers, security guards, professional allied to medicine, and community health workers or people undertaking health promotion work in communities.

Management were identified as a particularly important group as experience has shown that if district and other line managers do not recognise the importance of the issue they will prevent staff who have been trained from being deployed in a capacity in which they can use their skills.

Where should the training take place?

The workshop recognised that the only way to build sustainable capacity in the long term and to impact on many of these groups was to ensure that gender-based violence was properly addressed during basic training or undergraduate courses. Medical Continuing Professional Development (CPD) courses were also identified as a key avenue.

In-service training is also needed and the top priority groups for this were identified as:

Competency in identifying women who have experience intimate partner violence

What are the priority competencies and areas which need to be covered?

In addition to a basic sensitisation on gender-based violence, staff who have undergone this training should be able to:

In addition to the components identified under general sensitisation, training should include:

Who should be trained?

Where should the training be done?

It was agreed that this needs to be part of post basic training for nursing staff and should be included in post-basic courses for nursing staff in these areas and as part of in-service training. It should be included in undergraduate medical training in the final year, provided as in-service training for medical staff and provided as a Continuing Professional Development (CPD) course.

Competency in medico-legal rape examination

What are the priority competencies and areas which need to be covered?

Staff attaining competency in medico-legal rape examination need to have all the competencies outlined above in the basic sensitisation on gender-based violence course and the training in identifying women who have experienced intimate partner violence. In addition, they should be able to:

Training should include (in addition to that outlined above under basic sensitisation and identification of women experiencing intimate partner violence):

Who should be trained?

Medical staff who are examining women who have been raped need to be trained. Nursing staff who intend to become specialised forensic nurses.

Where should the training be done?

It was agreed that this training should be provided as a post-basic course for nursing and medical staff.

Maximising the benefits from training:

The workshop identified a number of issues which need to be in place to ensure that training and staff resources are most efficiently used. These are as follows:

RAPE PROTOCOL

The working groups discussed the Western Cape Rape Protocol and considered whether it was a useful starting point for developing a nationally recommended rape protocol. A clear need for further policy and protocol development at national level was expressed by all the working groups. It was suggested that the process of developing a national rape protocol needs to be seen in the light of the plans for developing overall policy.

Issues which need to be further addressed in the protocol or accommodated through modifications to the forms:

The discussions at the workshop also noted that consultation with the Department of Justice over revisions to rape policy, protocol and guidelines was essential. Consultation with the SA Law Commission over revisions to the Sexual Offences Legislation were also advised. It was suggested that there should be consultation with SAPS to see if procedures could be changed so that the Police come to the health facility to take a statement after a rape (if the woman presents to the facility first) rather than the woman then having to go to the police.

Taking forward the development of national policy and guidelines on rape

The process of development of national policy and guidelines was discussed. It was suggested that there should be a drafting team and reference group. The drafting team should include a forensic pathologist and gyneacologist, and should consult with other stakeholders including the workshop participants. It was suggested that the reference group include NGOs working on rape, experts, at least one academic hospital, an experienced rape examiner, the Law Commission, the NDPP, National Department of Health and a rural district manager.

It was noted that the new policy and guidelines should be seen to build on what is already in place in provinces and the identified problems of implementation. This could be assisted by a situation analysis of rape management in provinces. Provincial protocols need to be collected by the National Department of Health and compared. It was noted that policies on the provision of PEP for HIV vary considerably.

MEDICO-LEGAL ISSUES

Who should be empowered to conduct medico-legal examinations?

The workshop felt strongly that quality of care should not be compromised in efforts to extent accessibility of services to women who have been raped. Some form of accreditation process was needed. Rape victims should only be examined by people who are accredited to do so. Accreditation should be dependent on having undergone a recognised specialist course and providing evidence of seeing a certain minimum number of rape survivors each year. The staff who could be accredited included both practicing doctors (GPs, medical officers or specialists) and nurses with a forensic nursing speciality. It was recommended that plans for medico-legal training and provision of services be taken to the Minister and support be gained for this from MINMEC.

It was noted that doctors doing rape examinations should have appropriate attitudes towards women and be enthusiastic about this area of work. They should volunteer for it. The National Department of Health needs to have discussions with the Justice Department about arrangements for expert witnesses so that the time constraints for medical experts can be accommodated.

Training for sexual assault specialists

It was agreed that national human resources plan and provincial plans are needed for training sexual assault specialists. A curriculum task team is needed. This should be driven by the National Department of Health with support from the SAGBVHI and inputs from Human Resources Directorates. A curriculum for nurses has been approved by the South African Nursing Council. Training for doctors needs to be brought in line with this and consultation between the different institutions currently training doctors needs to be organised. Decisions need to be taken about which training institutions train will accredit the training courses. Numbers of people trained needs to be aligned with service needs. Sustainable training targets need to be developed and coverage monitored. Provinces need to develop plans for the management for sexual assault. The national training plan needs to be developed concurrently with provincial plans for implementation.

It was recommended that a quick review be undertaken of the Northern Cape experiences with forensic nurses, an evaluation of one-stop centres and Victim Empowerment Programme experiences. The role of these vertical initiatives in the overall national plans need to be carefully defined.

It was noted that there was a need for a short-term training response as further funds for forensic nurse training had been secured. The workshop noted that there was a plan to train two people from each Province and that contracts with their managers should be signed before they were trained. Guidelines for recruitment should be developed and perhaps one-stop centres would be a good place from which to recruit. The minimum number of training hours and work to maintain competence need to be defined.

Specimen management, the performance of laboratories and relationships with the police

Overall the workshop noted that the quality of laboratories had not been assessed and was not known. A number of problems with the collection and handling of forensic specimens were described. Part of the responsibility in this area lies with Health and part with SAPS, who are responsible for delivery of specimens to laboratories. There were reports of lost and damaged slides and specimens. Crime kits were reported to be often not available in rural police stations and not re-ordered timeously when stocks became low. In many health facilities the police refused to leave crime kits so they were not available for a rape examination until brought to the facility by a police officer. It was suggested that negotiations be held with SAPS as part of the sexual assault policy process so that be either entrusted to accredited rape examiners or kept in a special locked crime kit cupboard provided in health facilities as part of their minimum equipment needed to enable a rape examination to occur.

It was mentioned that the relationship with police is known to be problematic in rural areas. The basis of the problems needs to be investigated and health workers encouraged and supported in building good relationships with police in all areas.

IEC AND HEALTH PROMOTION

Written and visual materials on gender-based violence

The need for some booklets and posters on gender-based violence was generally agreed. The workshop felt that the National Department of Health should lead on this with co-operation between the Health Promotion Directorate and Gender Focal Point. Materials needed to target three groups: women who have been raped; women who have experienced intimate partner violence; and health service providers. Materials should be relevant, researched, tested and are informative. Their tone should be positive and hopeful and take into account issues of diversity of culture and sexual orientation. Materials for women should inform them of their rights and where to access further services. Those for service providers should remind them of protocols and the need to ask women about abuse.

Mainstreaming Gender-Based Violence and Gender Issues in HIV Prevention Work

HIV/AIDS was identified as a top priority area for work integrating gender-based violence. It was recommended that strong relationships be built between HIV/AIDS and the Gender Focal Points to ensure that initiatives on HIV prevention address gender issues and more beyond the gender-insensitive ABC approaches. The workshop felt that all trainers and health promoters working on issues of sexual health need training on gender issues. The gender component of life skills courses in schools needs to be examined and strengthened. Provinces need to ensure that curricula for training HIV counsellors adequately covers gender issues. It was further recommended that the DOH include gender issues in when contracting and awarding tenders and disbursing funds for HIV preventive activities.

  1. CONCLUSION

The workshop was a very important step in the process of developing a more systematic health sector response to gender-based violence and a partnership between different corners of the health sector. It provided important opportunities for communication on the issues both between national and provincial Departments of Health and between Government and the non-governmental sector. Recommendations have been made for activities which must be part of a systematic response, undertaken over short, medium and the longer term time frames. These indicate that action is needed in many parts of the health sector including training institutions. The South African Gender-based Violence and Health Initiative is committed to supporting this process with research and technical expertise.

  1. RECOMMENDATIONS

For the Department of Health:

It is recommended that:

  1. a clear statement be made of the Department of Health’s responsibilities in the area of gender violence.
  2. policy and implementation frameworks, including a minimum package of services and standards and monitoring and evaluation plans, be developed for
  1. a proposal be put to the Minister on the role of Gender Focal Points versus Programme Directorates in the area of gender-based violence as discussed in this workshop
  2. advocacy be undertaken within the Departments of Health to raise awareness and knowledge of gender-based violence and its health implications and so gain managerial commitment as a prerequisite for gender-based violence mainstreaming
  3. in-service training be provided to management and staff to build knowledge of gender-based violence, its health impact and issues related to patient care
  4. key staff be trained in the identification and management of women who have experienced intimate partner violence, including primary health care nurses, trauma and emergency department staff, maternity staff, psychiatric nurses and nurse tutors
  5. a national human resources plan & provincial plan be developed for training sexual assault specialists and a directive issued on the deployment of staff trained in rape examination, including recommended staffing levels
  6. models for de-briefing and supporting staff working on rape be developed
  7. training on gender-based violence be coordinated in each Province by one identified person
  8. a national meeting of representatives of training in the main professions and SAGBVHI to discuss issues which need to be covered in curricula
  9. a national rape policy, protocol and clinical guidelines be developed, building on protocols from the Western Cape and other provinces
  10. standards for accreditation of examiners of rape victims be developed with a view to only accredited staff should be used for this task in future
  11. information materials be developed for women who have been raped, women who have experienced intimate partner abuse, and for health service providers to remind them of protocols and the need to ask about abuse.
  12. the Gender Focal Points prioritise the HIV/AIDS Directorates and sub-directorates for gender mainstreaming and ensure that gender issues are built into initiatives for HIV prevention

For the South African Gender-based Violence and Health Initiative:

It is recommended that:

  1. support be provided to the Departments of Health, especially in more remote provinces, if requested, for advocacy activities which seek to raise awareness of gender-based violence and its health implications within the Departments.
  2. partners be available to assist the Department of Health around training as requested
  3. Initiative partners provide technical assistance in developing courses and curricula, training and evaluation
  4. a situation analysis of the health sector response to gender-based violence nationally be undertaken including training activities, the management of rape victims and relationship with NGOs
  5. a study of specimen management and the performance of forensic laboratories when handling specimens collected during rape examinations be conducted
  6. research be undertaken to evaluate screening initiatives to identify abuse women in health services and understand the costs and benefits to the health sector and to women
  7. research be undertaken on health worker’s own experiences of domestic violence and the implications of this for their clinical practice
  8. research be undertaken on the economic costs of gender-based violence to the health sector
  9. research be undertaken to evaluate and investigate policy on forensic nursing and post-exposure prophylaxis for HIV after rape.
  10. The health sector response should be supported and discussions revisited through an annual conference organized by SAGBVHI.

For the South African Nursing Council and Nursing training institutions:

It is recommended that:

  1. knowledge of gender-based violence, its health impact and issues related to patient care be included in the curriculum for basic nursing training
  2. post-basic training courses be developed and offered in all provinces on identification and management of women who have experienced intimate partner violence
  3. training courses for forensic nursing be developed, accredited and provided in conjunction with Departments of Forensic Medicine

For the Medical Schools and Health Professions Council:

It is recommended that:

  1. knowledge of gender-based violence, its health impact and issues related to patient care be included in the curriculum for undergraduate medical training
  2. knowledge of gender-based violence, its health impact and issues related to patient care be included in the curriculum for basic training for professions allied to medicine
  3. Continuing Professional Development courses be developed and offered in all provinces on identification and management of women who have experienced intimate partner violence
  4. training courses for medico-legal rape examinations be developed and provided.

  1. LIST OF PARTICIPANTS:

NAME TEL FAX Email
Ms Naeema Abrahams
Gender and Health Group
Medical Research Council		 021 938 0445
0824617542		 021 9380310 naeema.abrahams@mrc.ac.za
Ms Gail Andrews
Director: Women’s Health
Department of Health		 012 312 0189 012 326 2740 andreg@health.gov.za
Ms Matshidiso Baloyi
MCWH
Northern Province Health Department		 015 290 9113 015 2913345 Telefax
015 295 7536		  
Ms N Bengu
Nursing Council of SA		 012 4201056 012 3435400  
Ms Nicola Christofides
Women’s Health Project		 011 489 9927
0827748547		 011 4899922  
Ms Beth Douglas
Directorate: Mental Health
Gauteng Department of Health		 011 3553862 011 3553401 bethd@gpg.gov.za
Dr Tromp Els
Northern Cape DOH		 053 832 6226
083 448 9163		 053 8318014 tromp_els@hotmail.com Or jfe@lantic.net
Ms Elizabeth Dartnall
Snr Programme Development Manager
AMREF		 012 3201332/3
 083 616 0661		 012 3201335 dartnall@iafrica.com
Ms Tanya Jacobs
P O Box 483
EAST LONDON
5200		 043 7271267
0828907022		 043 7352979 tanyaj@iafrica.co
Dr Rachel Jewkes
Director: Gender and Health Group
Medical Research Council		 012 339 8525
0824423655		 012 3398582 rachel.jewkes@mrc.ac.za
Mr Pumzile Kedama
Planned Parenthood Ass of SA		 011 403 7740 011 482 4602  
Ms Ivy Ketse
Free State Health Department		 051-4033859 051-4033851
/403 3129		  
Dr Julia Kim
Gender and Health Programme
Health Systems Development Unit		 013 797 0778 013 7970082 jkim@soft.co.za
Sheila Lapinsky
Prov Administration: Western Cape		 021-4833941 021-4832655 slapinsk@pawc.wcape.gov.za
Ms Carvie Madikane
Sub directorate: MCWH
Northern Cape Health Department		 053-8300665
053-8300600		 053 8324547
053-8315507		  
Ms Vespa Mabitai
Department of Health 		 012 312 0532 012 3235025  
Mr Pierre Smith
National Public Prosecutors Office		 012 3175084 012 323 5686  
Ms Esther Maluleke
Director: Gender Focal Point		 012 312 0979
083 458 4695		 012 3235025  
Emma Matjila
North West Gender Focal Person		 018-3875119
018 /3875103		 018 3878103  
Elizabeth Mathidze (WH)
Gauteng Health Department		 011-3553868
011-3553341		 011-3553338
011-2553332		  
Dr Lorna Martin
Dept of Forensic Pathology
Grootte Schuur Hospital		 021 406 6452 021 4481249  
Ms Mmathari Mashao
Commission on Gender Equality		 011 4037182 011 4035609  
Simangele Mbatha
Mpumalanga Gender Focal Person		 017-8262222
082-3724380		 017-8260044
017-8265395		  
Ms Lollo Mjamba
Ciskei Nursing College		 043 708 2419/8
0834037301		 043 7611158  
Sanna Mohlakoane Mental Health Directorate Mpumalanga Health Department 013-7528085
082-8226046		 013-7524611  
Bella Mohale
Northern Province Gender Focal Point		 015-290-9093 015-2913314  
Ms Ntsoaki Motlhaping (WH) 018-3875231 018-3875332 ntsoaki@nwpg.org.za
Regina N. Mthethwa
Kwa–Zulu Natal Gender Focal Person
Dept of Health		 033-3952804 033-3450792 mthethr@dohho.kznt.gov.za
Dr Elizabeth Musaba
Empilisweni Women and HIV Centre		 043 6425142 043 6425142  
Ms Gloria Nchukane
Eastern Cape Health Department		 040 6093577 040-6350072  
Mr Khomotso Ngwatie
Northern Prov DOH		 015 295 8977
082 734 8993		 015 291 3155  
Ms Susan Nkomo
Office of the Status of Women		 012 3191620 012 321 2573  
Mr.Thobile Nokele
Eastern Cape Special Programmes(including gender)		 040-6093937
0826598626		 040-6350072  
Florah Nxusa
Gauteng Gender Focal Person
Room 1402, 14th Floor		 011-3553183 011-3553358  
Ms Grace Ramadi
SA Nursing Council		 012 420 1059
012 343 0929		 012 3435400  
Ms Ester Snyman
Kwa–Zulu Natal Health Department		 031-3322425 x224 031-3326135 estersay@iafrica.com
Ms Thelma Thulo
Free State Health Department		 051-4301933
051-4033852/6		 051-4483077
051-4303129		  
Ipeleng Tlhankana Gender Focal Person
Northern Cape Health Department		 053-8300718
083-7040424		 053 8300755
053-8334394		  
Dr Shereen Usdin
Soul City		 011 728 7440 (011) 7287442 shereenu@icon.co.za
Ms Lisa Vetten
Centre for the Study of Violence and Reconciliation		 011 403 5650 011 3396785 lvetten@csvr.org.za
Ms Nompumelelo Zungu-Dirwayi
Department of Psychiatry
University of Stellenbosch		 021 9389162 021 9335790 mz@gerga.sun.ac.za

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