injury control
An evaluation of Medico-Legal Services in Gauteng: Implications for the Development of Best Practices in the After-Care of Rape Survivors

Scope and Aims
The scope of the evaluation project included an assessment of the structure, process and outcome of after-care services for adult rape survivors at 26 medico-legal centres in Gauteng. The evaluation framework included a focus on issues related to the availability, accessibility, quantity, effectiveness and acceptability of the services.  The current component of the evaluation project granted attention to the views of various service agents involved in the care and management of rape survivors.   

The aim of the evaluation was to ascertain the current status of medico-legal services in Gauteng against the Health Department’s stated objectives and various other stakeholders’ views of how the service can and should function. It is anticipated that the evaluation will serve to inform the development of quality services based on the principles of best practice, as well as the development of standardized evaluation tools to assess the quality of care at medico-legal clinics.

Methodology
A multi-method approach was designed to evaluate the medico-legal clinics. In-depth focus group discussions were conducted with service providers from the different medico-legal centres, district and regional managers and members of the South African Police Services (SAPS).  Individual interviews were conducted with the Director and Deputy-Director of Medico-Legal Services for the Gauteng Provincial Health Department, and with social workers/counsellors who provide counseling services to rape survivors. Information related to structure and process was also supplemented by the scrutiny of relevant documentation. A detailed case review of selected medico-legal clinics (10 in total) was conducted. The guiding questions that were used in conducting the analysis related to the key components of the evaluation, as outlined above.

Finally, in line with the aim to develop a culture of learning and reflexivity in the organisation, feedback of findings was provided to relevant stakeholders, including the Directorate of Medico-Legal Services.  Feedback of findings at a consultative workshop with management level stakeholders resulted in the formulation of priority action steps to address current challenges facing the medico-legal system.  The findings of the evaluation have been, and will be, disseminated through various mediums, including workshops, meetings, conferences, seminars, the media and a report publicising the findings to relevant stakeholders.

Findings
The findings of the current evaluation suggest that the current system of service provision at medico-legal clinics in Gauteng remains flawed in many respects.  Although the medico-legal system is increasingly engaged in developing and improving service provision at district and regional levels, these reform efforts have not been consistently applied across the province. Consequently, minimum standards of care are not being met, with problems of access; charges of insensitive treatment of rape survivors; incompetent documentation of medico-legal evidence; lack of human and financial resources; inadequate training; disparities across clinics and weak inter-sectorial collaboration being the leading concerns affecting the quality of care provided to rape survivors.  The identified challenges to effective service delivery appear to predominate in historically disadvantaged communities, with poor black women receiving the most inadequate service. However, the evaluation also served to highlight best practices currently being implemented at service sites.  These included the availability of protocols across the province; environmental design and improved admission procedures to afford greater privacy to rape survivors; an increased number of referrals to social service agencies; the increased utilisation of volunteers to assist in the functioning of medico-legal clinics and the implementation of procedures to improve inter-sectorial collaboration and co-ordination between service agents.     

We offer a range of recommended strategies for improving the functioning of the medico-legal system and its related service components.  Of these, priority action steps to address the identified concerns include:

• The establishment of Violence Information, Training and Treatment Centres (ViTICs) at district level across the province.  Their role and functions need to be made explicit.  The success of these centres implies political support, and increased human and financial resources. The establishment of ViTICs presents as an urgent requisite.
• The imperative to address concerns related to the issue of service specialisation versus service generalisation so that an appropriate balance is achieved between access to services and quality of care.
• The acceleration of training, and increased human and financial resources to support the implementation of ongoing training.  Since training has now been decentralised to the district level, the required allocation of resources is to be the responsibility of the districts.
• Providing input to the task team attending to the revision of the J88 form, as well as in-depth training to relevant service providers in the use of the J88 form.
• Mechanisms and protocols to ensure that crime kits are available, accessible and collected timeously.
• Increased psychosocial support services for rape survivors.  This implies that linkages with the Department of Welfare, NGOs, CBOs and other relevant agencies be established and be strengthened.  
• The provision of support to service providers to assist them in dealing with their own traumatisation and stress.
• Initiating formal interaction and strengthening the relationship with the Department of Justice in order to facilitate the development of a standardised protocol that would inform and ease the entry and involvement of medical officers into the system.
• Closer collaboration with the SAPS.
• Closer collaboration with the private sector.
• An adequately functioning communication system between management and workers to ensure that all stakeholders are kept informed of developments within the system. This will further serve to clarify and address misperceptions, myths and anxieties about service providers’ roles and functions (e.g., filling of J88 form)