Concern as Doctors Without Borders’ rape crisis support leaves North West
The exit of Doctors without Borders’ (MSF) rape crisis support in the North West province during the Covid-19 pandemic arguably could not come at a worse time. Is the North West’s Department of Health ready to take over these services?
Traffic at a main intersection leading to Paardekraal, a township outside Rustenburg, is quieter than usual given South Africa’s ongoing Covid-19 restrictions. But on a late winter’s day, a cluster of people who are gathered on the pavement refuse to be silent.
It is an impromptu protest, but an important one. They are responding to the news that on that morning the body of a young woman was found dumped in the township. The protestors believe she was also sexually assaulted.
The protestors shout and sing from behind their masks. They wave placards for the muted traffic, for passersby and a handful of police who watch on. In the thick of the protest, is a Medicins San Frontieres (MSF)/ Doctors without Borders minibus. It is with the PA system inside the humanitarian medical organisation’s vehicle that protestors are calling out their demands: for the killing of women and children to stop and for the police to act.
“We have to be here to support the community. People are complaining that such things keep happening, but the police aren’t doing anything for them,” says Molefe Motsilenyane, who works for MSF as a psychological first-aider and a driver. He and his colleagues join in the protests, dancing and chanting.
For Nwabisa Thwesha, organising a gathering in lockdown risks the police clamping down on them, but she and the other angry protesters do not care. Thwesha lives in Paardekraal and says the violence and killing of women and children is unacceptable and unabated.
“We can’t blame Covid for this, this GBV (gender-based violence) stuff was happening long before. Every few days you hear these stories. It’s like the bushes are eating us women and still women are not being taken seriously till we must come here to protest,” she says, waving her hand towards open veld and shrubs on the outskirts of Paardekraal. At night, without electricity, proper pathways and the reality of high crime in the area, she says these become terrains of terror, especially if you’re a woman.
For five years MSF has had a strong presence in the Bojanala district, building infrastructure and support networks for rape and domestic abuse survivors. They set up their operations off the back of a study they conducted and published in 2015. The study findings were damning, showing that among the 800 women in the district surveyed at the time, one in four women reported having been raped. Access to care and resources for care were also found to be pitiful.
The MSF services in the Bojanala district have been centred on the establishment of four Kgomotso Care Centres (KCCs). Each care centre is equipped to give a rape victim medical, emotional and psychological support. Besides having a registered counsellor and social worker on hand, there is also a forensic nurse to collect evidence that will stand up in court. They also help facilitate the reporting of the crime to the police if the victim wants to.
Community outreach also became an important pillar over the past five years. It includes the likes of support for patient transport, helping to raise awareness about gender-based violence, conducting surveys for reports and deeper investigation into rape and violence in the community, and strengthening referral pathways that include those that lead back to the KCCs.
Now, though, MSF is leaving the province.
It is in line with the MSF’s model of operations worldwide. The organisation responds to emergencies, helps fill a gap in medical healthcare while partnering with local authorities. Sometimes they build infrastructure, like in Bojanala, and employ local teams to staff their projects or deploy staff from their international offices. The aim is always to build up something, make it sustainable, and then to hand it over to the local authority.
The Bojanala exit has come in a year of Covid-19. It has meant that, even in winding down, MSF has had to change gears. Their resources have been diverted to set up screening and testing. At one point they employed a nurse on a temporary contract to do the swab testing that was not happening in the district.
Kgaladi Mphahlele is a professional nurse and was part of the MSF response team until the end of September. These MSF teams have been stationed outside clinics and hospitals, screening, sanitising and collecting information for tracking purposes in recent months. MSF also set up portable hand washing stations at taxi ranks throughout the district.
Months into South Africa’s Covid-19 lockdown, however, much of this has been vandalised. Mphahlele points this out on a spot-check visit to the taxi rank. It is also noticeable that mask wearing is not being enforced and taxis do not operate with windows open.
Mphahlele says the North West has never been ready for a worst-case scenario of Covid-19 – they just got lucky with low infection rates.
“There was all this talk about getting field hospitals ready in lockdown, but we only have the mine hospitals that were handed over to DoH (health department) and we don’t know what equipment or staff they have there. Complaints from healthcare workers who don’t have PPE and the PPE corruption is our daily bread here. Thank goodness our numbers in the province are low, we are not ready for a big outbreak in the province,” says Mphahlele.
The Bojanala district is platinum-mining country. Concerns were that returning miners would cause localised spikes in infections. By early winter the mines did record increases, but by spring the number of new infections had dropped again.
Mphahlele’s biggest concern is that Covid-19 lockdown restrictions have disrupted regular services for reproductive health and termination of pregnancy. In the early months of lockdown, there were reduced services and some facilities closed for weeks at a time. MSF had to increase their assistance to transport patients to facilities and to arrange appointments at the few sites where treatment was still available.
“I get desperate phone calls from women who say they are going to get terminations done in places and ways I know are unsafe but they can’t wait for appointments that will only happen weeks later or they have no transport money to get to the facilities; it really makes you worry,” Mphahlele says.
Mphahlele is one of the staff members who is wrapping up their contracts with MSF. “Honestly speaking I don’t know what’s going to happen when MSF leaves Rustenburg,” he says.
The exit plan for the Bojanala district has been in the pipeline for more than a year and the winding down process is expected to be concluded by the first months of next year with a full handover to the North West Department of Health by that time.
In the textbook model of a handover, the facilities, equipment and services become community assets, which the department of health inherits and oversees. MSF staff are redeployed, conclude their contracts, or are retrenched procedurally. Some are also absorbed in department of health structures.
The reality of the handover in the province though has so far been hit and miss – raising questions about the department of health’s capacity and commitment to continue with the KCCs in a model that will still deliver a reasonable service.
North West Department of Health director for media and communications Tebogo Lekgethwane received Spotlight’s interview request and questions. These were confirmed to be circulated to various department heads who have been directly involved in months of discussions. However, no one from the department has responded to Spotlight’s questions.
Lack of communication, commitment and clear decision making by the department goes against a memorandum of agreement signed between MSF and the department five years ago.
Some doors closing
By the end of September, two of the four KCCs had to close their doors without the department of health staff to replace the MSF teams. A month later, only one of these reopened, but MFS says indications are that the services at all four are likely to be interrupted or even closed for the foreseeable future once the non-profit leaves.
For forensic nurse and KCC project medical referent, Cecilia Lamola, the inevitable loss of the facilities to the community is a massive blow.
“We at the KCCs have focused on a programme that has been about preventative measures and supporting a victim in the long run. When the systems are not there, or are not well run then people will be violated like it’s a normal thing. We end up creating a violent community and a violent society,” she says.
She adds evidence that she collected has helped convict perpetrators of rape and abuse.
“When you take evidence and the perpetrator gets arrested and prosecuted, you have played a critical role and given a voice to the justice system,” says Lamola.
She says knowing the community will “not be able to just switch to services run by the department of health when we are gone is heartbreaking – it is something that doesn’t gel with me”.
A concerned resident
For Poppy Makgobatlou, a resident of Bapong, Rustenburg who is a survivor of 29 years of domestic violence and abuse, finding the KCCs in 2017 “saved her life”. She says the team at the KCC helped her “find my self-esteem, to stand up for my dignity – they are my family”.
“Even when I’m not feeling okay I give the people at the KCC a ‘call me back’ and they call and help me. I am going to grieve when they leave. They know how to heal our wounds,” says Makgobatlou.
She adds: “Even if this KCC stays open and falls under the department of health, it won’t be the same. We are at the end of October now and I haven’t seen anyone in training from the department of health. How will they give us the service that we have come to know from MSF?”
Samantha Khan-Gillmore, MSF’s deputy project co-ordinator in the province, says the finalisation of staffing and patient transport still needs to be addressed by the department. There is also the broader matter of forensic nurses’ specialisation not being recognised by pay grade by the DoH. This also leaves the future of the KCCs hanging,” she explains.
“We need enough levels of assurances from the department of health that the model of care is something that can still serve the community properly. It could be rotating the services of a forensic nurse or social worker and being about to work out a referral system for a psychologist. But right now we just don’t have any of those details and time is running out,” she says. “We will continue to exhaust all our efforts to have as smooth a handover as possible, but there will come a point when MSF will have to pull out altogether.”
Sean Christie, MSF communications manager, says their operations in North West ran for nearly double the initial intended lifespan of the project.
“MSF’s DNA is about emergency response, innovating care and being a catalyst. Budgets are renewed on a year on year basis. Something like the projects in the Bojanala District compete against dozens of other initiatives in 67 countries around the world and in places where there is a total gap – absolute zero – in terms of resources or access to care,” he says.
Christie says while MSF never intends to be in one place permanently, their partnership agreements are meant to ensure continuity of service, replicability and the potential to be scaled up.
Christie points out a “disjuncture of service and the uptake of service” in the North West KCCs. It deserves deeper review and reflection by MSF, he says. But it offers up clues to how people seek (or don’t seek) help for rape or in domestic and gender-based violence cases. It speaks also to the shame, stigma and distrust of the systems that are in place.
A key positive though, he says, are the off-shoot projects from MSF’s presence in the province. It is the schools sex education project that is undertaken by youth counsellors. It is also the networks that have been built and a culture of inclusivity that has bought religious leaders and traditional healers into the room.
“An exit plan and a handover are never about a hard stop. And MSF understands that the reality is that public resources are not the same as they are for an organisation with deeper donor pockets,” he says.
“We don’t expect the KCCs to be run in exactly the same way when we leave. But we do want there to be something that remains in place, after all the KCC model is something that started out of a concept of care the department of health themselves envisaged. We just helped to implement that.” DM/MC
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