The overall national health policy in Malawi aims to raise the health status of all Malawians by reducing the incidence of illness and death through developing a sound delivery system capable of promoting health; preventing, reducing and curing disease; protecting life and fostering general well-being and increased productivity. Since violence against women and children threatens life, well-being and decreases productivity this policy provides over- arching support for addressing violence issues. The many health sector and child protection policy documents, guidelines and protocols vary in their target audiences, level of detail and focus area as regards to violence against women and children. Included in this analysis are 7 health policies and one from policing services.
HIV/AIDS Policy (2003) Chapter 5 the Protection, Participation and Empowerment of Vulnerable Populations outlines policy in relation to women and girls (section 5.2) and specifies a commitment to protect women and girls from violence and sexual abuse. It states that government, through the NAC undertakes to: (1) protect the rights of women to have control over and to decide responsibly, free of discrimination or coercive violence, on matters related to their sexuality, including sexual and reproductive health and (2) ensure that women and girls are protected against violence, including sexual violence, rape and other forms of coerced sex, as well as against traditional practices that may negatively affect their health. This document also includes an appendix with proposals for legislative reform to improve the rights of people living with HIV and reduce the risk of HIV in vulnerable populations. It proposes changes to criminal laws including the decriminalization of same sex practices and prostitution; the revision of the Penal Code to remove the defence of genuine belief in higher age in order to protect children from sexual abuse and to make marital sexual abuse a criminal offence;
HIV Counselling and Testing Guidelines are not a single unified document. Malawi has separate guidelines for Voluntary Counselling and Testing (VCT) (2003), for Prevention of Mother-to-Child-Transmission (PMTCT) (second edition 2008) and for Provider-Initiated Testing and Counselling in Clinical settings (PITC) the guidance is captured in the 2011 Guidelines for the Clinical Management of HIV in Children and Adults. Couples
143
Counselling and Testing Training Manuals are based on generic Centre for Disease Control (CDC) couples counselling and testing training modules. They have information on counselling skills, on follow up counselling and state that disclosure may lead to violence in a minority of cases. They veer deliberately away from HIV couples counselling being seen as marital or violence counselling but include an annex with questions to help counsellors screen for intimate partner violence and how HIV Testing and Counselling (HTC) counsellors can identify it although information on what to do next is lacking.
Sexual Abuse Guidelines (2005) provide a practical handbook with a focus on health care workers. The guidelines focus on sexual assault in adults (primarily women) and children. They aim to provide the information on managing survivors, set standards for the provision of health care and forensic evidence to survivors of sexual assault and provide guidance on the establishment of services for survivors. They provide a lay summary of the duty of care of HCWs in relation to violence. There are practical suggestions on dealing with survivors, including history taking, examination, treatment and follow up. The appendices have flowcharts, checklists and examination records. The guidelines are being updated to include a focus on One Stop Centres (see section 5.2.3).
Malawi Police Service Community Policing Services Victim Support and Child Protection Guidelines (no date on this document) provide guidance on the support and care of survivors of GBV, HIV and AIDs related abuses and other human rights violations. These were developed as guiding instruments to victim support unit (VSU) officers and other interested parties on how to: provide care and support to survivors of GBV, HIV and AIDs related abuses, and other human rights violations; to minimize further trauma and distress to survivors and maximize efficiency.
Management of Sexually Transmitted Infections using Syndromic Management Approach (third edition 2007) states that one objective of STI services should be to prevent and provide support to survivors of domestic violence and abuse. They affirm the guiding principle that all individuals have the right to a sexual life that is free of discrimination, coercion or violence. There is a section in these guidelines that explains how health care worker attitudes can be a barrier to good STI services. This is not extended to reporting of violence. The guidelines have a distinct policy (Policy 3.6) on sexual and domestic violence that states that ‘All victims of domestic and sexual violence shall have access to legal entitlement under the course of the law, HIV testing, counselling and other support services’.
144
The guidelines give no further practical guidance on how this can be achieved and no mention of screening for or reporting of either violence or any suggested referral points.
National Sexual and Reproductive Health and Rights (SRHR) Policy (2009) builds on international agreements and development frameworks. It has ‘harmful practices and domestic violence’ as one of ten policy themes and gives an overall stated goal of reducing the incidence of these. Harmful practices include domestic and sexual violence as well as wife inheritance, initiation, dry sex, death rituals and genital mutilation. It does not spell out the details of the SRHR standards and guidelines, but states its close relationship to the HIV Policy, the Gender Policy, the STI and Family planning guidance. The SRH policy aims to reduce domestic violence and mentions strengthening human resource capacity to provide screening, treatment and follow-up care for victims of violence, including provision of Post Exposure Prophylaxis ( PEP). It also encourages research on the magnitude of domestic violence. The policy outlines roles and responsibilities within each Ministry in the government with respect to Sexual Reproductive Health and Rights (SRHR) and clarifies the importance of multi-sectoral working. With respect to violence the responsibilities are:
Ministry of Health – disseminate relevant guidelines and standards
Ministry of Education – empower boys and girls to make informed decisions about their SRHR
Ministry of Information and Tourism – raise community awareness of SRHR services including harmful practices/domestic violence
Ministry of Local Government and Rural Development – assist community dispel misconceptions and eliminate harmful practices
Ministry of Women and Child Development – support empowerment of women to make informed sexual choices; support advocacy against harmful practices that affect women and girls reproductive health; GBV prevention
Ministry of Youth Development and Sports – raise awareness on cultural practice that expose youth, especially girls, to HIV
Parliamentary Committee on Health – supports enactment of appropriate legislation including age of marriage and on violence against women.
Pre-service Education Family Planning Reference Guide (2010) has been developed to assist pre-service health institutions in Malawi in creating, updating, or adapting the family planning content of their curricula and individual courses. Included in this document are
145
materials that institutions and individual tutors can use to develop technically accurate and pedagogically sound lessons on family planning. This document includes a comprehensive unit (unit 2) on gender-sensitive family planning service with training exercises and sessions on gender-based violence and its impact on family planning choices417.
Guidelines for Provision of Comprehensive services for survivors of physical and sexual violence (One-Stop Centres) in Malawi (2012). These have recently been finalised and provide a detailed operational manual for future establishment of One Stop Centres focusing on the sexual abuse of women and children. They build on the 2005 Sexual Abuse Guidelines They outline steps for examination, treatment and support for women and children presenting to the centres and provide guidance on documentation and reporting418.