SISTEMA DE ESPACIOS PÚBLICOS (PARQUES Y ZONAS VERDES)

The “meso” level refers to referral hospitals (where One Stop Centres are operating), district hospitals and health centres, police, social welfare department and NGOs. One Stop Centres offer opportunities for multi-sectoral linkages as well as for linkages within and between health departments at the referral hospitals they are based in. Interviewees point to the importance of links with the police, with other government bodies such as the social welfare department and with specific non-government agencies that are outlined in policy documents. However, the extent to which these links function effectively at this level with the exception of One Stop Centres is not always clear.

Linkages with the police

The most consistent link mentioned was with the police; however, health care workers felt that this needed to be strengthened.

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“There is need for proper networking between us and the police and these other organisations that deal with violence. In this network if we could give each other feedback, this can help to make this work effective. I would summarise that collaboration, networking and skill acquisition would help very much.” (HCW, FGD, rural )

One-Stop Centres create linkages

The narratives also revealed that services required by survivors were offered in largely disparate locations within and outside the health facility. One Stop Centres offer opportunities for multi-sectoral linkages as well as for linkages within and between health departments at the referral hospitals they are based in. Focusing on specialised centres which function within hospitals is appropriate given the low reporting of cases of violence at health departments. A visible One Stop Centre can contribute to higher reporting and more streamlined referral mechanisms where health workers are aware of the existence of a specialised unit for violence issues. NGO staff however pointed out that lines of communication between One Stop Centres and non-government organisations are not always effective and can exclude NGOs from contributing to work on violence. One staff member of an NGO working on violence gave the following example pointing to the report circulated by the OSC unit:

“The report circulated by the social welfare office at the one stop centre is only circulated to government offices. NGOs are sidelined. This limits participation.” (Male GBV service provider, KII )

It is also important to take into account that the visibility of such a centre could, in some cases, prevent reporting where people are uncomfortable with being seen reporting to a known ‘violence’ unit.

Referral mechanisms

There was some evidence of functioning referral pathways when dealing with child abuse or assisting orphans. The same was not found for the response to IPV among adults. Even health care workers interviewed who had confidently indicated that they refer their clients to Non Governmental Organisations or community based organisations, had little idea of whether any of the services they told their clients to access actually existed. This is illustrated by the following interview where the interviewee was asked how confident she was that such services existed in the communities and admitted referring clients on.

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“We are not sure but we are certain that they will find assistance in the community because in some communities there are child protection workers who care for children and we know they will be assisted. ” (HCW II, hospital)

Outside of the limited network of OSCs the referral mechanisms for rape and domestic violence cases described often relied on informal communication between health workers in different sections and departments. Participants also described problems with follow up. Referral mechanisms for rape and domestic violence cases described often were between police and health care services or vice versa.

“The first thing that the victims of domestic violence go to is police, get report and come to the hospital. The current guidelines are saying that they can come directly to the hospital and they shouldn’t be sent back. We have been sending them back. In fact we didn’t know we are hearing it here for the first time” (HCW FGD, hospital). The potential for Social Welfare Officers as referral point persons

In relation to referral mechanisms for women experiencing violence there was evidence that referral pathways exist between the Social Welfare Officers (SWOs) working in the hospital and various departments. There was some evidence of productive referrals within the health system:

“So what we have started here is a multidisciplinary model with the social worker.... this is somehow the first Malawian child protection officer. His job is this one stop shop and we have a couple of a team of volunteers...from fountains of life rape counselling centre. Again speak to them and police around the area and also including the department of public prosecutions and the people from the juvenile justice court.” (Policy maker, KII)

Social welfare officers mentioned receiving referrals from staff working in the gynaecology department and other general staff. They also described reciprocal referral pathways with staff from Psychiatric wards. SWOs also discussed referring to marriage counsellors beyond the hospital. These were considered to be a useful point of contact. Since they are already providing referrals and making use of linkages beyond the health system, SWOs could be useful point persons in the development of a referral system. However, apart from those SWOs working in the hospital, social workers were generally perceived as ineffective:

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“Also go to social welfare have you put them as part for your interviewees? Just find out from them because they are not effective but they could be. Just find out. They are rubbish you know they are not doing anything...but it doesn’t mean that they are to be ignored. I think you need to find out how best they can be useful and why are they not useful, what is the problem because nobody knows what the problem with those people is.” (Female GBV service provider, KII)