SGBV Report 2011-2017

UNTREATED VIOLENCE: Breaking down the barriers to sexual violence care in Harare, Zimbabwe 2011-2017 REPORT

1 Médecins Sans Frontières Charter

Médecins Sans Frontières (MSF) is a private international association. The association is made up mainly of doctors and health sector workers and is also open to all other professions which might help in achieving its aims. All of its members agree to honour the following principles:

Médecins Sans Frontières provides assistance to populations in distress, to victims of natural or man-made disasters and to victims of armed conflict. They do so irrespective of race, religion, creed or political convictions.

Médecins Sans Frontières observes neutrality and impartiality in the name of universal medical ethics and the right to humanitarian assistance and claims full and unhindered freedom in the exercise of its functions.

Members undertake to respect their professional code of ethics and to maintain complete independence from all political, economic, or religious powers.

As volunteers, members understand the risks and dangers of the missions they carry out and make no claim for themselves or their assigns for any form of compensation other than that which the association might be able to afford them.

“In my picture there is also hope for the future. Can you see the house and the dog that I will have one day? I painted myself happily running in a beautiful garden. Like a bird I will fly high and fulfill my dreams. Hopefully with time the pain in my heart will subside and the rest of the picture will take over my life”

“If you find some happiness inside yourself, you’ll start finding it in lot of other places too”

Gladiola Motana Cover photo credit: Charmaine Chitate

This project was implemented by MSF in collaboration with the City of Harare and it summarizes the key findings and lessons learned after seven years of the project.

Photos inside: MSF Zimbabwe and Charmaine Chitate

2 SGBV Report 2011-2017

FOREWORD

Violence often blights people’s lives for decades, leading to alcohol and drug addiction, depression, suicide, school dropout, unemployment and recurrent relationship difficulties. The costs of violence are enormous for the survivors, their families, communities and the nation as a whole. Sexual and gender based violence represent one of the most prevalent forms of violence amongst women and children.

37% of women worldwide and 46% in Africa have experienced physical and/or sexual violence in their lifetime. In Zimbabwe, 27% of women aged between 15 - 49 years have experienced sexual violence.

In 2011 Médecins Sans Frontières (MSF) in collaboration with Harare City Health services opened a sexual and gender based violence (SGBV) clinic in Edith Opperman Polyclinic, Mbare, which offers comprehensive care to the survivors of sexual violence. During the last seven years, SGBV services have been scaled to 9 polyclinics in Harare (Glenview, Budiriro, Kuwadzana, Mabvuku, Hatcliff, Highfields, Rujeko, Warren Park and Rutsanana). More than 120 nurses have been trained on SGBV management and more than 70 nurses were attached to the clinic for on-the-job practical training.

Between 2011 and 2017 more than 8200 survivors of sexual violence received care, 2 out of 3 survivors were children and in most cases the perpetrators were known by the child and the family.

The MSF SGBV programme in Mbare would not have achieved the successes outlined in this report without the continuous efforts and dedication of Harare City Health staff, partners and MSF staff working towards one goal: making a positive difference in the life of the sexual violence survivor.

Most importantly thanks are due to the many survivors of sexual violence and their families testifying their experiences and trusting in the care we are providing.

“Many who live with violence day in and day out assume that it is an intrinsic part of the human condition. But this is not so. Violence can be prevented. Governments, communities and individuals can make a difference.”

Nelson Mandela, World Health Organization’s 2002 World report on violence and health.

Dr Daniela Garone, MD, Infectious Diseases and DTM&H Country Medical Coordinator, MSF Zimbabwe. Dr Clemence Duri Acting Director, Harare City Health Services, Harare.

3 CONTENTS

Foreword 3

I have a Future 6

Executive Summary 7

Chapter 1 Sexual Violence in Zimbabwe 8 The Legal Framework for Sexual Assault in Zimbabwe 10 10 Mbare Suburb 11 Perception Study Prior and after the Opening of SGBV clinic, Mbare12-13

Chapter 2 Model of Care for Survivors of Sexual and Gender Based Violence 14 Nurse - Based Care 15 Basic Principles of SGBV Care Programme 16 14 Health Promotion 17 Health Promotion Messages 18 Collaboration with other Partners to Disseminate Information on SGBV 20 Social Work 21 Decentralization of Sexual Violence Services to other Polyclinics 23 Decentralization Strategy 25 21 Advocacy 26

Chapter 3 SGBV Programme Outcome 28 Scaling up Access to SGBV Services 29 Sex and Age Distributions 29 Types of Aggressors 34 Mitigations of Medical Consequences of Sexual Violence 38 28 Scaling up Legal and Social Support 40 Knowledge, Attitudes, Practices and Perceptions Study (2015) 42 Knowledge on SGBV 42 Perceptions on SGBV 43 Patterns of Assistance Seeking Behaviour 44 Role of Decentralization in Increasing Access to SGBV Services 46

Chapter 4 Challenges 48 No Increase in Uptake of SGBV Services for Specific Groups of Survivors 49 First Entry Point of Reporting Sexual Violence 49 Decentralization 53 Delays in Launch and Roll-Out of SGBV Services due to HR Challenges 54 Provincial Roll-Out of SGBV Services throughout Zimbabwe 54 Voice to Survivors of Sexual Violence 57 Concept Artists Against SGBV in Solidarity with Survivors 57 Income Generating Initiatives 57 56 Conclusion 58

4 SGBV Report 2011-2017

TABLES AND GRAPHS

Table 1: Perceptions Study Results 2010 12

Table 2: Flowchart of care for survivors of sexual violence 17

Table 3: Survivors of sexual violence reporting within 72 hours and 120 hours in 18 Mbare clinic

Table 4: Health Promotion Strategy 20

Table 5: Percentage of survivors according to origin coming to Mbare clinic 24 from 2011 - 2017

Table 6: Proportion of different types of sexual assault per age group reported in Mbare 32 clinic from 2011 - 2017 (out of 8200 survivors)

Table 7: The definitions of different crimes utilized in this study are outlined and 33 the difference in relation to Zimbabwean law is also described

Table 8: Types of aggressors per age group reported in Mbare clinic from 2011 - 2017 35 (out of 8200 survivors)

Table 9: Percentage and age group of survivors reporting within 72 hours in 36 Mbare clinic from 2011 - 2017

Table 10: Overall percentage reporting within 72 hours according to referral system in 37 Mbare clinic from 2011 - 2017 Table 11: List of main service providers for psychological, social and legal support for 41 survivors of sexual violence within Harare (not exclusive)

Table 12: To show what information had been received on rape 43

Table 13: To show assistance seeking behaviour: If someone in your family was raped, what would you do? 45

Table 14: Referral pathway to report sexual violence in Mbare clinic from 2011 - 2017 50

Graph 1: Number of new visits per quarter in Mbare clinic from 2011 - 2017 29

Graph 2: Proportion of gender/age groups reported from 2011 - 2017 in Mbare clinic 32

Graph 3: Percentage of reporting time within 72 hours and 120 hours from 2011 - 2017 36 in Mbare clinic

Graph 4: Perceptions of SGBV in 2010 and 2015 44

Graph 5: Number of survivors accessing SGBV services in decentralized sites 46 from 2015 - 2017

5 I HAVE A FUTURE

When my parents passed away, I was left in who always had been kind to me. Together the care of my grandmother. I can remember we reported the matter to the police and they the whispers at my mother’s funeral that it was referred me to MSF for medical treatment. My fortunate the old lady was still alive, so I had case was dropped from the courts due to what a close relative that would take care of me. they called ‘lack of merit’. I still believe that I won. If I had not gathered the courage to run Little did they know within few weeks my away and speak out, I would still be one of the grandmother would be spreading rumours many wives of the prophet. May be already that I was possessed by evil spirits. I was with children, though I am a child myself. only fifteen, but everyone believed her. Why, otherwise, would an old woman say something At least now I have a chance of a brighter so evil about her own daughter’s child? Then future. I am going to school and my ambition under the guise of this story, she married me is to become a hair dresser and to open a pre- off to a prophet who she claimed would be able school. I now have a more positive image of to exorcise my demons. What she wanted from myself and am able to write that I love myself. all this was the bride price and to get rid of me This is not as easy as it looks. It has taken as a responsibility that she did not want. time and counseling, to start feeling positive about myself. I believe my future is bright and Everything inside of me refused to succumb I wanted to use bright colours to show that ‘I to this arrangement. After a few days at the have a Future’. prophet’s house, I ran away to my paternal aunt Photo credit: Charmaine Chitate

6 SGBV Report 2011-2017

EXECUTIVE SUMMARY

Definition of sexual violence (WHO 2002): “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work.”

Sexual violence is a global concern with 37% of sexual violence (33%). A baseline study on of women worldwide (46% in Africa) having the perceptions of SGBV (2010) confirmed experienced either physical and/or sexual that the knowledge of the Mbare population on violence in their lifetime. In Zimbabwe, 14% of SGBV, the need for seeking medical treatment women aged 15 - 49 years reported that they and accessible service providers were limited. have experienced sexual violence at some point in their lives. And 8% experienced sexual The vast majority of sexual violence acts are violence in the past twelve months. However, committed against women, children or other only 20% of women who experienced sexual men by known perpetrators who are supposed violence sought help. (Zimbabwe Demographic to be in the positions of trust and provide and Health survey, ZDHS 2010 - 2015). It is security in their homes and in their society. acknowledged but not well documented that men suffer from sexual violence in Zimbabwe This report aims to give insight to the (Research and Advocacy Unit). operational set up of the SGBV clinic that provides comprehensive nurse-based medical Médecins Sans Frontières in collaboration with care, psychosocial and legal support 7 days Harare City Health services opened in 2011 a a week, for the victims of sexual violence. It sexual and gender based violence (SGBV) outlines the main achievements, challenges clinic located in Edith Opperman Polyclinic and innovative activities interwoven with the in Mbare. Mbare is a high density suburb of specific characteristics of survivors of sexual Harare characterized by a high prevalence of violence. HIV (14% in Zimbabwe) and a high prevalence

A soccer tournament advocating “ Kickout Sexual Violence” in Zimbabwe. Photo credit: MSF Zimbabwe Chapter 1 Sexual violence in Zimbabwe

In Zimbabwe, 27% of women aged 15 - 49 years reported that they have experienced sexual violence at some point in their lives; 49% of the survivors had their first experience of sexual violence between 15 -19 years of age and 9% prior to 14 years of age, reflecting the vulnerability of adolescent girls to sexual violence. Approximately 22% reported that their first sexual intercourse was against their will. Only 20% of women who experienced sexual violence sought help. (Source: Zimbabwe Demographic and Health survey ZDHS 2010 - 2011). Photo credit: Charmaine Chitate

A mural on a building in Mbare advocating against child abuse. SGBV Report 2011-2017

Almost one third of females (33%) and 1 in and perpetrators once convicted, receive 10 males (9%) aged 18 to 24 years reported lengthy jail terms. The community sees rape experiencing sexual violence in childhood. of a minor as a serious offence, for which (Source:National Baseline Survey on the Life perpetrators should be punished. Rape of an Experiences of Adolescents NSBLEA, 2011). adolescent is viewed as more acceptable and The vast majority of sexual violence acts are the survivor is often blamed or married to the committed by men against women, children alleged perpetrator. or other men. In the majority of cases, the perpetrator is well known to the survivor Adult rape more often leads to stigmatisation (boyfriend, husband, family member, relatives in the community, the breakdown of marriages and/or known civilians). A variety of religious, and apportion of blame. If the survivor has traditional and cultural practices and beliefs been raped by her husband it is being more contribute directly to an increased risk of SGBV accepted as a part of a woman’s fault rather reinforcing gender stereotypes and point to the than as a crime that should be punished. subordination of women and children by men. Sodomy is illegal and homosexuality is highly stigmatized. Adults of both sexes are therefore Rape is seen as serious offence in Zimbabwe less likely to report if they are raped. TRADITIONAL PRACTICES IMPACTING ON SEXUAL VIOLENCE

Lobola : Groom paying bride price Chiramu: Young girls having their breasts fondled by the husbands of their sisters and aunts Inheritance of a husband or wife: By sister or brother of a deceased marital partner Virgin Cure: Having sex with a virgin as a cure for HIV/AIDS Ritual Rape: Usually linked with religion, magical, super natural for wealth accumulation or power etc Kuzvarira (Girl Pledging): When a girl is given to another family in return of a favour that her family is in need of e.g. food or money Kuripa Ngozi: A girl is given to another family to calm an avenging spirit that would harm people in her family or extended family Coerced Sex: Forced sex Forced Marriage: Forcing a girl/woman to marry without her consent Sex Work : Someone willingly taking sex work as type of job for survival Transactional Sex: Engaging in sexual activities for monetory or material gains

Sharon (19) felt desolated after her boyfriend deserted her when she was found to be HIV +ve. An MSF counsellor helped her come to terms with the rejection. A mural on a building in Mbare advocating against child abuse. 9 THE LEGAL FRAMEWORK FOR SEXUAL ASSAULT IN ZIMBABWE National legislation is coupled with a national governed by the common law except for a few MBARE SUBURB ‘Protocol on the Multi - Sectorial Management which were statutory. After July 2006 all the of Sexual Abuse in Zimbabwe’ (2003) and sexual offences were codified among others by outlines the roles and responsibilities of all the Criminal Law (Codification and Reform Act), stakeholders involved in handling sexual Chapter 9:23 under sexual crimes and crimes violence survivors to create the Victim Friendly against morality. The Criminal Procedure System (VFS). The multi-stakeholders in the and Evidence Act Chapter 9:07 (amended in VFS are the police, Ministry of Justice, Ministry 1997) provided the legal framework for the of Health and Child Care, Ministry of Women establishment of the Victim Friendly Court Affairs and Gender, Department of Social (VFC) system. Services, NGOs. The Victim Friendly Unit was initiated by the In 2012, the Zimbabwean protocol for Government and children’s activists in the management of sexual violence changed, early 1990s. The unit is composed of the to specify that it is no longer necessary for police, lawyers (wherever available) and survivors to report to the police before seeking the community at every police station in medical care. the country where survivors or witnesses who are minors can be supported to give Prior to 2006, most sexual offences were evidence.

Tapiwa (26) was stripped, beaten and raped by two men on the way home to her four year old son. Left naked, she walked to the highway and flagged a vehicle to take her to the nearest police station. MSF trained nurse Margaret Chigwamba explains the nature of medical care she needs.

10 SGBV Report 2011-2017

MBARE SUBURB Photo credit: MSF Zimbabwe

Trading centres (larger markets and flea markets for second hand clothes) and transport hubs convoke mobile population, especially young people coming from out of Harare looking for work opportunities. Overcrowded large hostels, music scene and bar spots are multiple.

Mbare is the first suburb of Harare 2011 after the grant from Ministry of (1907), capital city of Zimbabwe and one Health and Child Care (MOHCC) and of the most populated and poorest areas City of Harare. Initially the clinic was with economic and social conditions operating in the premises of EO polyclinic that create an environment conducive before the construction of its new building to sexual violence. Mbare has been the within the same compound. It always has first place to settle for people migrating to been operating as a standalone clinic the city looking for growing opportunities. with MSF staff in conjunction with Harare The estimated population is between City Health. 84,168 and 142,195 habitants with the Living conditions in Mbare are majority of the population without formal generally poor with overcrowding, employment. frequent cuts in the supply of water and electricity, poor roads, poor lighting The sexual and gender based violence and lack of basic infrastructure. clinic is located in Edith Opperman Tapiwa (26) was stripped, beaten and raped by two men on the way home to her four year old son. Left Access to education and health care Polyclinic (EO) situated in Mbare and naked, she walked to the highway and flagged a vehicle to take her to the nearest police station. MSF is not free and is unaffordable for started to be operational in September trained nurse Margaret Chigwamba explains the nature of medical care she needs. some.

11 PERCEPTION STUDY PRIOR AND AFTER THE OPENING OF SGBV CLINIC, MBARE

Prior to the opening of the clinic, MSF in collaboration with the “University of Zimbabwe Centre

PERCEPTION STUDY for Applied Social Services” conducted a perception study to assess the knowledge and perceptions of SGBV in Mbare.

The prior implementation of knowledge, attitude and perecptions (KAP) study identified that there was a lack of knowledge about the importance of seeking medical care after rape and on the urgency to do this within 72 hours. It also identified the need for

Table 1: Perception Study Results 2010 Information participants have received about rape and other sexual abuse in 2010

Had received some sort of information on rape

MEDICAL Seek help within 72 hours

Prevention of HIV and STI is possible

Prevention of pregnancy is possible

Medical help can be given even if you don’t seek legal help

Counseling can be provided

LEGAL

Information received related to special place for victim friendly support

SOCIAL

There are organizations that can support you to find the help you need

KNOWLEDGE

Knew that there is a time limit in which to seek medical help

Knew that time limit is 72 hours

KNOWLEDGE ON SERVICE PROVIDERS

MSF Edith Opperman

ARC

FST

Other, specify

12 SGBV Report 2011-2017

PERCEPTION STUDY PRIOR AND AFTER THE OPENING OF SGBV CLINIC, MBARE

comprehensive services (medical, psychological and social) for survivors of sexual violence in the Mbare community and to expand the services to the local clinics in Harare so that survivors have access to comprehensive care close to their home. Mbare district offered sole opportunity to develop a Model of Care for victims of sexual violence in urban Zimbabwe, due to the high prevalence of rape (30% in Harare, ZDHS 2010 - 2011), high prevalence of HIV (14%) associated with a high risk of HIV transmission during rape; the low uptake of SGBV services (only 2% of women who

Information participants have received about rape and other sexual abuse in 2010

2010

71%

19%

22%

12%

12%

24%

5% t

3% There are organizations that can support you to find the help you need

70%

11%

Nil

Nil

Nil

Nil

13 Chapter 2 Model of care for survivors of sexual and gender based violence

The model of care in Mbare has evolved over time from a centralized-vertical approach in the SGBV clinic at Edith Opperman Clinic to a more integrated approach into the outpatient department in the Harare polyclinics.

Nurse Mafoti during an examination of a survivor

The Mbare program started based on the principles of respect for individual patient’s right and with the ultimate goal of reducing morbidity and mortality related to sexual abuse by scaling-up a patient centre-approach to ensure access to quality, timing (<72 hrs) and comprehensive medical, legal and psychosocial support for survivors of sexual abuse in Mbare community.

14 SGBV Report 2011-2017

NURSE - BASED CARE

MSF has globally promoted nurse-based allowed to do e.g. filling in the request letter care and task shifting as a way to extend for Termination of Pregnancy for Magistrate’s access to health care in countries with authorization. serious shortages of staff like in Zimbabwe. The opening of the clinic every day The Mbare clinic was the first clinic providing including weekends and public holidays, the a nurse-based comprehensive package availability of an emergency phone number of SGBV services. Referral networking after opening hours and the provision of with medical doctors and hospitals is care to both adults and children were also however required for severe cases and/or innovative as initially none of the other clinics for administrative tasks that nurses are not provided similar services.

15 BASIC PRINCIPLES OF SGBV CARE PROGRAMME PRINCIPLES OF SGBV PROGRAMME Establish a patient centred approach that Health promotion is one of the key places patients at the centre of their components for a succesful SGBV treatment respecting their human rights program to increase awareness and and ensure human protection promoting access to comprehensive care

BASIC PRINCIPLES OF SGBV PROGRAMME

Understanding SGBV perceptions Identify legal processes and point including culturally framed beliefs among of services needed to provide local population will help to identify the comprehensive care. patterns of health seeking behaviours, Establish services that are accesible to knowledge and barriers that can patients 24 hours/day, 7 days a week determine program effectiveness and access to care. Peer volunteers carrying the community door- to- door awareness campaign on “MEDICAL TREATMENT AFTER RAPE IS EMERGENCY” and create awareness on access to treatment at the 24 hours (phone attendance and counseling) centre in Edith Opperman clinic. Zimbabwe Model of Care Nurse led model 7 days a week

Free Health Psycho-social

Multi-sectoral response Community victim “Victim friendly programe”

Legal Justice Social and affidavit Protection

Medical affidavit is a standardized certificate documenting the medical findings and the details of the sexual assault that is sent to legal authorities as an objective evidence admitted in court. Decentralization of Sexual Violence clinics Training and mentoring (MoHCC nurses) 16 SGBV Report 2011-2017

Table 2 : Flowchart of care for survivor of sexual violence

Receive the survivor of sexual Medical treatment according violence. to time of presentation Immediately start psychological Take clinical and event history including psycho-social support. care, fill in medical affidavit Assess urgent medical needs and make a follow up plan

Receive the survivor of sexual Medical treatment according HEALTHviolence. PROMOTION to time of presentation Immediately start psychological Take clinical and event history including psycho-social support. care, fill in medical affidavit HealthAssess promotion urgent medical is needs one of the key components in the project to increaseand make a follow up plan awareness on SGBV through promoting the 72 hours strategy and as part of advocacy.

Peer volunteers carrying the community door- to- door awareness campaign on “MEDICAL TREATMENT AFTER RAPE IS EMERGENCY” and create awareness on access to treatment at the 24 hours (phone attendance and counseling) centre in Edith Opperman clinic.

17 Table 3 : Survivors of sexual violence reporting within 72 hours and 120 hours in Mbare Clinic

Target Group < 72 hours < 120 hours > 120 hours

Post - exposure pro- All survivors with HIV - phylaxis for HIV (PEP) negative status

Emergency contraception to prevent unwanted Females of reproductive pregnancy (ECP) age

Determining if client Determination of was already pregnant pregnancy before sexual assault

Survivors with court order Termination of for TOP referred to tertiary pregnancy (ToP) government hospitals

All survivors except Prophylaxis and treatment for sexually transmitted non sexual intercourse, suspect case infections (STI’s) If not vaccinated Hep B vaccine prophylaxis according to national protocol Survivors with physical Tetanus vaccine pro - injuries as per risk & - phylaxis pre-exposure vaccination

Survivors with minor Wound care physical injuries

Refer to tertiary Severe injuries level care providers

HEALTH PROMOTION MESSAGES

The Health Promotion (HP) messages focus message has proved to be effective as the on the benefits of prompt medical care after number of survivors accessing medical care sexual violence available to survivors without within 72 hours increased (34% in 2012 vs. a police report and where services can be 44% in 2016). accessed.The content of the HP messages evaluated from ‘Rape is a painful experience’, Though information on “seeking medical and ‘Rape is not your Fault’ at the start of attention first” is one of the key HP the project to ‘Medical treatment After Rape messages, the majority of the survivors are is an Emergency’, from late 2013. A more still coming through the police even if they straight forward message was necessary knew the clinic beforehand (more than 93%). to emphasize on the importance of seeking Expanding HP programs to cover police medical care as early as possible to mitigate forces is critical to reduce unnecessary the consequences of sexual assault.This delays in referring survivors to care.

18 SGBV Report 2011-2017

19 Table 4 : Health Promotion Strategy

Objective Component Type HP/Target

Electronic Radio Wide reaching HP activities Print Calendars, flyer, stickers and posters

COLLABORATION & SOCIAL WORK & SOCIAL COLLABORATION (Community and National level) Community communication Exhibition in national events

Target health promotion activities Health promotion talks Clinics, infomal trader’s hostel door to door campaign

Sensitization on SGBV Community health workers, promoters, Trainings and HP messages volunteers,teachers,church and community leaders

Distribution of IEC and health Flyers, quarterly VFU visits Police officers VFU, NGO’s education to partners

Toll free line 116 toll free number Run by Childline

COLLABORATION WITH OTHER PARTNERS TO DISSEMINATE INFORMATION ON SGBV

The success of HP relies on a good co- operation with other partners and standardised messages of all information disseminators to secure consistent messaging. To reach as many people in the community, the project identified different local actors who play an important role in the management of sexual violence or who have access to the target group. Community volunteers, Zimbabwe Red Cross Society Volunteers, volunteers from Childline (toll free lines), key community leaders, teachers, police Call Free Phone officers and church leaders have been trained Helpline on 116 on SGBV to promote access to services within for assistance Mbare. 0732 116116

WILKINS HOSPITAL Open 24 hours everyday POLY CLINICS GLENVIEW 31 Frank Johnson Ave, Eastlea, Harare MABVUKU CITY OF HARARE KUWADZANA DZIVARASEKWA 0732 116 116 CITY HEALTH DEPARTMENT

20 SGBV Report 2011-2017

6 months hostel intervention in Mbare (2014)

A six months door-to-door sensitization campaign on SGBV was conducted in 2014 to intensify health promotion in the Mbare community, engaging in a dialogue to work on people’s beliefs and behavior through discussion and personal contact.

The target of the campaign were the residents of the hostels because of the increased risk for SV due to poor living conditions and low socio- economic status. 20 volunteers of Zimbabwe Red Cross Society Mbare branch were trained and communicated one central message based on ‘medical treatment after rape is an emergency’ using a flip chart and a face-to-face approach with the hostels community members.

A total of 11,485 people were Awareness,case finding, informal trader sensitization interfaced and 97 suspected or campaigns, exhibition and sport tournament have been confirmed SGBV cases were crucial to increase community stakeholder’s involvement reported directly to the volunteers including partners working on legal and social aspects and were further referred for medical, psycho-social, child abuse, and legal assistance. SOCIAL WORK Social work is one of the most complex areas cases have to be referred to the social services. of support to survivors of sexual violence A social worker gives information on where because it involves both an understanding assistance can be provided and accompany of the psychological consequences of rape survivors in protection to the identified as well as an understanding of the family service providers for assistance, to court for dynamics and social environment of the support and up to reunification with the family. survivor. It requires a strong network for linkages to further social, psychological The project works with District Social Services or legal support with service provider in (DSS) for minor survivors as they are their legal the government system and civil society. guardian and any minor can only be taken by a DSS officer with the appropriate court order. All The presence of a MSF employed social worker referrals for adult survivors in need of shelter in the Mbare project was unique and innovative can be done directly to Musasa or other NGOs as it is not common to have an assigned social providing safety shelters for adult women as worker linked to the health clinics, and social it is not necessary to involve social services.

21 Social Workers component:

Two MSF social workers are present in the project (one resident in the clinic and one mobile) to help survivors of sexual and gender based violence and their families to cope with the effect of sexual violence in their lives

SOCIAL WORK & DECENTRALIZATION SOCIAL and to protect and improve their social well-being.

MSF social workers Lynn Njambi and Relative Chitungo work with survivors of SGBV to find solutions to their challenges

Social worker’s main activities:

Counseling of survivor and his/her family

Facilitating places of safety Escorting and supporting survivors to other service providers e.g. hospitals, police and legal/social services, birth certificate, pregnancy support, schooling Escorting and providing psycho-social support to survivors going to court

Conducting family tracing with DSS

Escorting survivors for reunification

Case follow-ups (shelter visits, home visits, phone calls…)

Participating in case conferences, internal and external meetings

The toll free helpline provides information related to social issues and where services are available

22 SGBV Report 2011-2017

DECENTRALIZATION OF SEXUAL VIOLENCE SERVICES TO OTHER POLYCLINICS

The purpose of decentralization is to scale-up As such, MSF aims to support the Harare City easy access for survivors of sexual violence Health in the roll-out of decentralization of to services in a timely manner integrated in SGBV services within polyclinics in Harare. nearby health facilities. Distance remains a big challenge as many of the survivors cannot The identification of the sites for decentralization afford money for transport to seek assistance was based on following criteria: in faraway places. Through decentralization, • Areas known as having the highest the accessibility, affordability, acceptability and number of survivors coming to Mbare availability of SGBV services will increase and clinic overcome some of the barriers hindering the • Polyclinics located in high density areas survivors to get medical care. • Areas on long distance of SGBV service providers. The idea of decentralization is also in line with the national protocol on SGBV that emphasizes 9 polyclinics within have been selected within access to health care as the first priority for Harare: Kuwadzana, GlenView, Mabvuku, referrals and to ensure that all survivors of Hatcliffe, Rujeko, Highfield, Budiriro, sexual violence and abuse “receive the free Rutsanana, Warren Park. medical care and support necessary to mitigate the negative health effects that results from their sexual violence and abuse experience.

ZIMBABWE - Harare District - MSF-OCB Harare Urban SGBV Decentralization summary (As at October 17, 2017)

Hatcliffe Polyclinic Mazowe District Decentralization Map Borrowdale Satellite Marlborough Clinic Satellite Clinic Mount Pleasant Satellite Clinic Eastern District Northern Zvimba District District Avondale Clinic Highlands FHS Mabelreign Satellite Clinic Highlands Goromonzi Rujeko Polyclinic Central District Kuwadzana 4 PCC Buisness Greendale Satellite Clinic Belvedere City District FHS Tafara Wilkins Health Mabvuku FHS Caledonia Warren Park FHS Eastlea FHS Hospital PCC Satellite Satellite Polyclinic Kuwadzana Braeside FHS Clinic Clinic Mabvuku Polyclinic Harare Mbare polyclinic Central Polyclinic Arcadia PCC Hospital Mufakose Polyclinic Matapi PCC Mufakose Kambuzuma Beatrice Satellite Clinic Polyclinic Southerton Infectious Mbare Sunningdale Hatfield Budiriro PCC Hospital Hostels Satellite Satellite Satellite Clinic Highfield Clinic Western Triangle Clinic Clinic Budiriro Satellite Clinic Highfields Polyclinic Ruwa Polyclinic Waterfalls Epworth Rutsanana Polyclinic PCC Glen norah Harare Glenview Glenview satellite Urban Satellite Polyclinic clinic Hopley Satellite clinic Clinic Southern District

Western Chegutu District District Seke District

Chitungwiza District

LEGEND City boundary Opening times: SOURCES Zambia Mozambique Hospital Full Decentralization SCALE Polyclinics : 0730 – 1600 Daily (Open on holidays) Health facilities: MSF Environmental Health Dist. limit Roads, waterways : OSM and MSF 1:240,000 1 cm = 2.4 km Clinic (Polyclinic, Satellite and PCC) Administrative boundaries : City of Harare and MSF 0 1 2 4 6 km Partial Decentralization Suburb Primary Care Clinic : 0730 – 1600 Monday to Friday : 0730 – 1300 Saturday Harare Family Health Services (FHS) PROPERTIES Doc name : zwe_act_harare_sgbv_decentral_hltfac_A4L_171017 Urban Pending Decentralization Satellite Clinic : 0730 – 1600 Monday to Friday : 0730 – 1300 Saturday Creation date : 5/16/2018 Zimbabwe Created by : Maternity section : 24 Hours daily (where applicable) MSF GIS(ZWE)=>[email protected] SGBV Partner Print format : A3 Landscape Confidentiality : Public Botswana South Africa This map is for information purposes only and has no political significance. The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by MSF

23 The majority of the survivors come from the southern wards in Harare – Mbare, South, South East, South West and Mabvuku in the east. But survivors come from all over Harare and all over the country. The geographic location of survivors is probably more indicative

DECENTRALIZATION of the available service providers in the area, and the characteristics of reporting for SGBV in each area than any indication of prevalence.

Table 5: Percentage of survivors according to origin coming to Mbare clinic from 2011- 2017 Origin Percentage

Bulawayo Province 0.06%

Central district, city centre 0.8%

East 9.2%

Harare Province 4.5%

Manicaland 0.5%

Mashonaland Central 1.3%

Mashonaland East 11.3%

Mashonaland West 2.9%

Mashonaland East 0.06%

Mashonaland West 0.01%

Masvingo 0.2% Matabeleland North 0.05%

Matabeleland South 0.03%

Mbare 9.2%

Midlands 0.24%

North 3.8%

North East 0.05%

North West 7%

South 16.5%

South East 7.5%

South West 7.2%

West 7.9%

West South West 10%

NOT KNOWN 0.3%

Total 100

24 SGBV Report 2011-2017

DECENTRALIZATION STRATEGY

• Identification of clinics for decentralization health care workers (HCW) on promotion with input from Harare City Health of SGBV messages in the community

• Identification of SGBV room integrated • Training for community workers on in clinic activities with input from Harare establishing and maintaining referral City Health system for the survivors of sexual violence

• Set up of SGBV room with minimum • Sensitization meeting on SGBV for clinic package of material and small staff, local officers from police station and rehabilitation and construction works local partners to develop pathway for the survivors coming to the clinic • Minimum 5 sexual violence focal nurses for each clinic are identified by Harare • 2 weeks of intensified awareness City Health to be trained and mentored campaign in the new decent sites in the management of survivors of sexual supported by MSF violence (5 days theoretical workshop, 2 weeks attachment to Mbare clinic and • Mentoring, support visits for nurses, mentoring on site social workers, district health promoter officers and VFU police stations to ensure • Establishment of a MSF mobile team provision of quality medical/social care composed of a nurse, 1 Health Promoter and community sensitization (HP) and 1 driver to provide training and mentorship support to the decentralized • Minimum one focal trained nurse sites. identified per clinic as trainer for new trainees • Training for District Health Promoter officers (DHPO), health promoters, • Quarterly review meetings with Harare community health workers (CHW) and City Health staff.

A survivor in conversation with Nurse Mafoti at Mbare Edith Opperaman clinic

25

ADVOCACY ADVOCACY

Advocacy is an essential component of the health promotion is the primary strategy, MSF project to raise the profile of rape and the need works also in a broader sense to advocate for for medical care. Though community based SGBV.

Ongoing community outreach of MSF in Mbare. Photo credit: MSF Zimbabwe

• Participation in elaboration and formulation of national protocol and training guideline:

Some of the components MSF lobbied for to be included were nurse-based care, the 72 hours message, decentralization and the social work and are contained in the final version of the National Protocol. Promotion of nurse -based care was done through training and subsequent attachment of Harare City Health nurses as legitimate providers of post rape care to Mbare clinic in preparation for decentralization of SGBV services. The national training guideline on sexual violence • Extensive participation in mass media is currently being used for the provincial roll- campaigns, conducting interviews with out of SGBV services in Zimbabwe. journalists and contributing in getting the theme in the media, organizing official • Participation in meetings as constructive launches of exhibitions and campaigns for forum for raising and discussing medico- partners and media. legal issues / trainings related to SGBV at both Ministerial and community • Close liaison with the office of the public levels e.g. meetings within the Ministry prosecutor and the Victim Friendly of Health and Child Care (MoHCC), Services, Department of Social services, Ministry of Women’s Affairs Gender and legal service providers and many other Community Development (MWAGCD), partners working on SGBV to scale up Justice Service Commission (JSC), the quality of services for the survivors of Victim Friendly Court (VFC), Victim sexual violence. Friendly Service (VFS), Child Protection Committee (CPC). • Establishing and maintenance of a constructive relationship with the police • MSF trainings on SGBV including staff especially the officers in the Victim Friendly from agencies and service providers. Unit for rapid referral for medical care.

26

SGBV Report 2011-2017

A song and video “Emergency” # Speak Out Against Rape” was produced by Celebrity Advocates Edith Weutonga, BaShupi, Selmor Mtukudzi and Ras Caleb in different languages spoken in Zimbabwe. The messages were directed to the survivors and their families to speak out and also to the perpetrators. “Seeking treatment after rape is an emergency. Speak out, Emergency” “ Don’t force me, talk to me. Don’t rush me. Be Gentle;” “A real man doesn’t use force. We say no to rape”

27 Chapter 3 SGBV Programme Outcome

A total of 8200 new survivors received free medical, psychological, legal and social support in Mbare SGBV clinic by the end of the first quarter of 2017. During the first year of the project, there was a steady increase in the number of survivors coming to the clinic per month from 31 in 2011 to 113 in 2014. SGBV Report 2011-2017

SCALING UP ACCESS TO SGBV SERVICES

Intensified HP activities conducted in the Most of the cases are recorded in the first and community by MSF and other partners resulted last quarter of the year, whilst a reduction in in a change in health-seeking behavior linked cases is noted in the second quarter. This to increased awareness of the need for and is attributed to the many public holidays, availability of medical care after sexual festivities and school holidays in which the violence. As the majority of the survivors came festive atmosphere leads to more abuse while through the police and the numbers increased, in quarter 2 the festive season has finished and there was also an increased awareness among school age minors (those who are in school) the police about the urgency of medical rape return to school. after care. Graph 1: Number of new visit per quarter in Mbare clinic from 2011-2017

Number of survivors consulted in Mbare clinic 1600

1400 1373 1358 1357 1356 1226 1200

1000 910

800

600

400

124 200

0 2011 2012 2013 2014 2015 2016 2017 Year of programme

SEX AND AGE DISTRIBUTIONS

Women remain the largest group seeking help (overall %: 93); with majority coming from the age group of 13-15 years (overall %: 41) while the largest number of male survivors came from the age group of 5-2 years old (overall %: 44%). 69% of the survivors are children, less than 15 years old.

29 MSF counselor helps the victim come to terms with the rejection and urges her to continue ART and warns her of the consequences of HIV.

30 SGBV Report 2011-2017

Theoretical workshop in management of the sexual violence survivors.

MSF counselor helps the victim come to terms with the rejection and urges her to continue ART and warns her of the consequences of HIV.

31 Graph 2: Proportion of gender/ age group reported from 2011 - 2017 in Mbare clinic

Proportion of gender per age group reported from 2011-2017 in Mbare clinic

17.7%

15.4% 43.4%

41.6% 24.8% 11.8% 11.4% 20% 0.2% 6.7% 6.3% 0.4% 0 - 4 5 -12 13 - 15 16 - 24 25 - 44 > 45 Age Group

Female Male

Table 6: Proportion of different types of sexual assault per age group reported in Mbare clinic from 2011-2017 (out of 8200 survivors)

Aggravated Consensual Age Rape/Sex Sex with Suspected indecent Sexual Sodomy Non-sexual Compelled sex between Missing minor cases assault touching aggression rape minors

0-4 years 44.1% 0% 21.6% 8.2% 10.5% 2% 0.9% 0% 0% 12.7%

5-12 years 56.7% 2.4% 12.4% 7.4% 6.3% 6.2% 0.9% 0.06% 0.4% 7.2%

13-15 years 42.8% 33.7% 10.3% 1.7% 2.1% 0.8% 0.2% 0% 2.4% 6%

16-24 years 82.4% 7.8% 2.5% 3.5% 0.7% 1.3% 0.2% 0% 0.5% 1%

25-44 years 84.4% 0.2% 1% 9.4% 0.6% 3.5% 0.4% 0.2% 0% 0.4%

>=45 years 83.3% 0% 0% 3.3% 10% 0% 0% 0% 0% 3.3%

Total 58.4% 15.9% 9% 4.4% 3.2% 2.4% 0.4% 0.3% 1.2% 5.2%

Absolute 4789 1304 738 361 262 197 33 25 99 426 Total

32 SGBV Report 2011-2017

Table 7: The definitions of different crimes utilized in this study are outlined as below, and the difference in relation to Zimbabwean law is also described: Crimes Definitions Refers to cases of penetrative sexual intercourse of women who did not Rape: consent (excluding cases of minors who reported to have given consent). Sex with a minor refers to consensual sex between a minor below the age Sexual of 16 years with another minor or with an adult. The term statutory rape has intercourse not been used in this document, in order to make a clear distinction between with a minor: forced sex and sex with a consenting minor. Suspected case refers to cases where the survivor denies any assault or Suspected is unable to give any history (in case of very young children or because of cases: physical or mental capacity). Suspected cases also covers cases where minors who are suspected of having a sexual relationship with a “boyfriend” and are brought to the clinic for examination. Where a female has sex with a male against his will (these cases usually Aggravated involve groups of women and weapons or older women with younger boys. indecent Men cannot be raped as per national law though women can be subjected assault: to aggravated indecent assault. But for classification of this study,only men are given this classification. Aggravated indecent assault refers to unlawful and intentional assault that involves penetration of a part of either the victim’s or the perpetrator’s body. Refers to anal sexual intercourse, in the database, it usually but not always Sodomy: refers to a male victim, where as legally non consensual anal sexual intercourse would be considered aggravated indecent assault. Sexual touching (or Where a person experience attempted rape or other sexual advances. attempted rape):

Over time, the types of sexual assault presenting to the clinic remains largely the same, rape SGBV consultation in the Edith Opperman Clinic remains the most commonly reported crime across all age groups (59%) followed by sex with a minor (16%) and suspected cases (9%). Since 2015 there is a slight increase noted in the number of suspected cases reporting in the clinic and the number of sex with a minor slightly decreased.

This could be because parents are sending their children faster to the clinic with the suspicion that their child could be sexually abused especially for the age group of 0 - 4 years old or because they suspect their adolescent child is sexually active whilst the adolescent persists to say that this is not the case.

33 TYPE OF AGGRESSORS AGGRESSORS

Overall, 77.8% are the alleged perpetrators The older the survivor is, the more likely it known to the survivor. Known civilian (33%), is that the perpetrator was unknown as this boyfriend (30%) and family member (15.4%) age group is more mobile and more in are the most reported groups of known contact with strangers than young children perpetrators while the proportion of others who are mostly surrounded by their closest (teacher, pastor, police, client of sex worker) family circle. In the age group is rather small. less than 13 years, a family member has often been reported as aggressor.

In the age group 13 -15 years old, The type not known perpetrator is used 53% of the alleged perpetrator when the survivors are persisting is the boyfriend. This high proportion that they were not sexually abused could be associated with the high number especially for young children brought to of forced first sexual intercourse, the high the clinic by their parents with the number of consensual sex when the survivors suspicion of being sexual assaulted or are brought to the clinic by their parents or for adolescents who consented to sex when the survivors are coming to report when but claim they are not sexually active yet. the relationship broke down.

According to the Zimbabwean law, the term rape is only used for women. For non-consensual sexual intercourse of men, the term aggravated indecent assault is governed.

Suspected cases are mainly reported in the More than 33% of the 13 -15 years old are young age groups of children 0-4 years (22%) reported as having sex with a minor where while rape is more common in the age group the sex is consensual and the girl doesn’t see 13-15 years old (42%) as compared with older herself as having been raped and often sees age groups where rape counts for more than the man involved as her boyfriend but her 80% of all the reported events. parents don’t condone the relationship and wants the male involved prosecuted.

Suspected victims of sexual and gender based violence can be even as young between 0 - 4 years old. Above image source: MSF Haiti

34 SGBV Report 2011-2017

Table 8:Types of aggressor per age group reported in Mbare clinic from 2011 - 2017 (8,200 survivors)

Type of 0 - 4 years 5 - 12 13 - 15 16 - 24 25 - 44 > 45 years Missing Total aggressor years years years years Known perpetrator 77.1% 79.5% 83.7% 74.6% 52.5% 43.3% 50% 77.9%

Known civilian 66.2% 14.7% 22.1% 32.5% 33.07% 36.7% 50% 33.3%

Family member 58.5% 19.4% 8.8% 12.1% 7.3% 6.7% 0% 14.6%

Boyfriend 60.9% 17.4% 52.8% 32.0% 12.1% 0% 0% 30%

Unknown 58.8% 15.9% 7.9% 21.5% 41% 46.7% 0% 14.2% civilian

Not known 54.8% 15.2% 5.9% 0.7% 0.2% 0% 50% 4.8%

Client 0% sex worker 0% 0% 0% 0% 0.2% 0% 0.01%

Military 0% 0% 0.03% 0.05% 0% 0% 0% 0.03%

Not known 3.0% 2% 1.44% 0.5% 1.2% 0% 0% 1.4%

Pastor 0% 0.06% 0.5% 1.8% 4.2% 6.7% 0% 1%

Policeman 0% 0% 0.1% 0.3% 0.8% 0% 0% 0.2%

Teacher 0% 0.3% 0.3% 0.3% 0% 0% 0% 0.2%

Time of presentation

During the course of the project there has been a steady increase in the proportion of survivors reporting within 72 hours: from 36% in 2011 to 44% in 2017.

This is assumed to be related to increased public awareness as result of health promotion activities by MSF and other service providers on SGBV, the increase in the profile of the Mbare clinic and the strong link between the officers of the Victim Friendly Unit and service providers. Trained community health workers ready to fight sexual violence in the community.

35 Graph 3: Percentage of reporting time within 72 hours and 120 hours from 2011 - 2017, Mbare clinic

Reporting time among survivors from 2011 - 2017

50.2% 50.1% 47.9% 44.4% 42.3% 41.2% 41.2% 42.3% 38.7% 39% 34.7% 38% 33.9% 33.6%

2011 2012 2013 2014 2015 2016 2017

< 72 Within 120 hours

Table 9: Percentage and age group of survivors reporting within 72 hours in Mbare clinic from 2011 - 2017 Age group Number Percentage reporting within 72 hours

0 - 4 years 279 50.6%

5 - 12 years 591 34.7%

13 - 15 years 1082 34.7%

16 - 24 years 797 42%

25 - 44 years 304 58.4%

> 44 years 19 63.3% = Those more than 25 years of age were more likely to report within 72 hours

Age of survivor: Presentation within 72 hours more knowledge on the possible risks related improved with age after 15 years and was to (unwanted) sexual intercourse. The delay also better for the 0 - 4 years age group (51%) in the reporting within 72 hours for the age because adults or caregivers are deciding group 5 -12 years can be attributed to the fact themselves to report and are assumed to have that children are unable to disclose (age, out

36 SGBV Report 2011-2017

of fear or no knowledge) and for the 13 - 15 caregivers often notice during the daily rituals years old especially in case of consensual sex such as changing, bathing or given food signs they don’t see themselves as being raped as that could indicate sexual violence and come they are in love with their boyfriend. Although to the clinic to confirm their suspicion. children under the age of 5 cannot disclose,

Gender: Although the data shows that there is a not come. This variation could be explained significant variation in reporting time according through the fact that consensual sex with a to gender, men are more likely to report within minor is only reported for girls and not for boys 72 hours (55%) compared to women (42%), resulting in a drop down of the reporting time this cannot lead to the conclusion that if a for the females as this group is known to report man is sexually assaulted he will come faster late. to the clinic than a women as they almost do

Table 10: Overall percentage reporting within 72 hours according to referral system in Mbare clinic from 2011-2017

Types of referral Number Percentage reporting within 72 hours

Relative/Friend 13 25.5%

Community member 2 25%

Childline 24 17.5%

Awareness Campaign 35 58.1%

Police 2935 40.3%

Health Insurance 42 40.8%

NGO 5 35.7%

Self 1 14.3%

TotalOther 116 47.68%23.9%

People coming from an awareness campaign, police or referred by health insurance were more likely to report within 72 hours

Type of referral system and knowledge on Mbare clinic: Survivors who came directly to the clinic before going to the police reported within 72 hours through information from friends or relative (86%), community member (67%), Childline (64%) or awareness campaign (62%).

37 Reasons recorded for delay after 72 hours in SGBV data base

Emergency contraceptive pill given to a sexual violence survivor. MITIGATIONS OF MEDICAL OF MEDICAL MITIGATIONS VIOLENCE CONSEQUENCES OF SEXUAL

MITIGATIONS OF MEDICAL CONSEQUENCES OF SEXUAL VIOLENCE

Against the background of a high HIV 1. Post Exposure Prophylaxis (PEP) against prevalence rate (14% in Zimbabwe) and HIV infection the high proportion of female survivors of child-bearing age, the time of presentation Post Exposure Prophylaxis or PEP treatment is essential to prevent new HIV infections of anti-retroviral (ART) medication for 28 days and reduce unwanted pregnancies and is provided to all survivors with an HIV negative complications related to unsafe abortions or status presenting within 72 hours in the clinic as deliveries. Arrival within 72 hours is crucial to prevention against HIV infection. Overall 73% receive the complete comprehensive package (2293 out of 3141) of the survivors reporting of preventive care and treatment including within 72 hours started PEP, 20% didn’t need post exposure prophylaxis against HIV PEP because of the known HIV positive status infections and unwanted pregnancy. Up to 120 and 7% didn’t start PEP because they refused hours it is still possible to receive emergency medication for the following reasons: contraception. However it is never too late for a • they believed that they could not contract survivor of sexual violence to report to mitigate HIV since the abuse that happened did other consequences of sexual violence as not expose them to the risk of contracting STI’s, Hepatitis B and Tetanus infections, HIV psychological consequences and physical • they declined to be sexually abused injuries. • they needed to have more time to decide • they didn’t want to take PEP as people

38 SGBV Report 2011-2017

would assume they are HIV positive or want to terminate the pregnancy (TOP). • out of religious beliefs An average of 1-2 request letters for TOP per • all the survivors present in the clinic are month are send to court to be granted but offered an HIV test to define their HIV there are no data available on how many TOP status at the first visit, although it is not were carried out since the start of the project compulsory before starting PEP, and after as many of the survivors do not come back for three months to close the window period follow-up or are not reachable by phone to find (3 months period before HIV antivirus out the process of their request. can be detected in the blood.). As many survivors are not coming back for their 4.STI prophylaxis and treatment:The three months follow - up visits or are going survivors of sexual violence may contract to another health structure to be tested, STIs as a direct result of the assault. 85% of there is no accurate data available on all survivors were recorded as being given how many survivors are seroconverted STI prophylaxis and 7% recorded having and tested HIV positive after three months symptoms of an STI. STI prophylaxis is not despite they completed PEP treatment. given systematically; it depends on the type of the event. 2. Emergency contraceptive pills against unwanted pregnancy (ECP) 5. Tetanus vaccine: Only 10% of the survivors Emergency Contraception Pill (ECP) is offered were administered a tetanus vaccine as the to all female clients of child-bearing age who number of cases coming to the clinic with dirty present to the clinic within 120 hrs after sexual wounds, breaks in the skin or mucous is rather abuse, if they could be at risk of pregnancy. low.

6. Hepatitis B vaccine: 23% of the survivors Increased public awareness on who arrived within 2 weeks in the clinic received SGBV contributed to an increase in a Hep. B vaccines as many of the survivors are proportion of the survivors coming already vaccinated according to the national to the clinic within 72 hours but due vaccination schedule. to the fact that the perpetrator is known in the majority of the cases 7. Termination of Pregnancy Termination of and the existing cultural practices Pregnancy (TOP) is only legal in Zimbabwe and beliefs; the survivors are facing when the pregnancy is the result of rape, incest, many challenges out of fear of the or if there is a serious threat to the mother’s consequences of reporting abuse. life and if the child is likely to be born with a serious handicap. TOP is not granted when the pregnancy is the result of consensual sex Overall, a total of 79% of child-bearing female or marital rape. survivors received ECP. The other 21% refused because the abuse that happened didn’t expose them to the risk of getting pregnant (sexual touching, suspect), or because they had any method of family planning or they didn’t want to take any medication.

3. A pregnancy test was taken by 97% of female survivors. 14% of the pregnancy tests were positive. All pregnant survivors are asked Medication received at the clinic for Post if they want to proceed with the pregnancy Exposure Prophylaxis. (keeping the baby or given up for adoption)

39 SCALING UP LEGAL AND SOCIAL SUPPORT

The Termination of Pregnancy Act stipulates that termination can or may take place up to 28 weeks. Health workers prefer to perform TOPs at or before 13 weeks gestation as medically much safer. Application form for TOP is filled in by doctors outlining the circumstances of sexual abuse including timing and information about how advanced the pregnancy is. The Investigating Officer makes the request for a Court Order for the TOP and will accompany the victim to the court to arrange for an application for the court order. Once a court order has been granted, the pregnancy should be terminated by a medical doctor as early as possible.

Through social work, the team gained insight identified to be in need of support guided by the and a lot of experience into the complex social criteria checklist by the nurse counselors and context in Zimbabwe, the needs for social been referred to the social worker for further support, liaising with Department of Social support. Among them, more than 20% have Services and other partners to better support been referred to the shelters of safety through and manage the survivor’s social needs and DSS for minor survivors and Musasa project how assistance to survivors of sexual violence for adult female survivors and more than is played out in practice in Zimbabwe. 85% to other external service providers in the government system and civil society for further Approximately 30% of the survivors are psychological, social or legal assistance.

Sexual abuse survivors need support and guidance of nurse counselors, social workers, government and the civil society.

40 SGBV Report 2011-2017

Table 11: List of main service providers for psychological, social and legal support for survivors of sexual violence within Harare (not exclusive)

NAME SERVICE PROVIDED

Place of safety, safety assessment home places, management of minors in Department of Social Services conflict of law, educational assistance, birth certificate, child marriage, adoption, rehabilitation, custody, public assistance etc

Places of safety, pregnancy support, income Musasa project shelter generating project psycho-social support for women in general

Pregnancy crisis Pregnancy support

Zimbabwe Women Lawyers Association Legal assistance for adult survivors (ZWLA)

Justice for Children Trust Legal assistance for minor survivors

Legal resources centre Legal assistance for all survivors

CATCH Psycho-legal support for survivors and minor perpetrators

Public prosecutor magistrate court Case follow up

Victim friendly unitC ase follow up and statement recording

Childline Counseling

Harare hospital Psychological support

Leonard Cheshire Disability and logistic support for survivors living with disability

Chiedza care centre Education support

Runyararo Foundation, Hupenyu Hutsva, Places of safety Mashambanzo children’s homes and foster parents

41 KNOWLEDGE, ATTITUDES, KNOWLEDGE ON SGBV PRACTICES PERCEPTION STUDY (2015) Knowledge about medical services available for SGBV has improved since KNOWLEDGE ON SGBV A follow up knowledge, attitudes, practices 2010. 87% of people interviewed in 2015 ,perception study (KAP study) was carried out reported having received messages of rape in August 2015 in close collaboration with the compared to 71% in 2010. In particular, the University of Zimbabwe, Centre for Applied Social proportion that had heard information on sciences (UZ-CASS) to assess if there were seeking help within 72 hours, preventing changes in the knowledge, attitudes and health STI, HIV and pregnancy and that seeking behavior on SGBV of the population counseling is available had shown marked of Mbare compared with before the start of the improvement, however still less than 50% project in 2011 (Baseline Study report 2011). of the respondents reported to have heard of all these messages.

There was a little improvement in the The increase in the number of survivors proportion that knew that they could seek shows a change in health-seeking behaviour medical help without the legal help. The linked to the increased awareness of the proportion of people that had heard of any need for and availability of medical care after social or legal messages was very low. 63% rape but there is still a lack of information on of the respondents knew the SGBV clinic at the legal and social support services. Edith Opperman. This determined people’s ability to access information and services.

An 18 year old woman receives results of her HIV test

42 SGBV Report 2011-2017

Table 12: To show what information had been received on rape

2010 2015

Had received some sort of information on rape 71% 87%

MEDICAL 19% 51% Seek help within 72 hours

22% 46% Prevention of HIV and STI is possible

Prevention of pregnancy is possible 12% 42%

Medical help can be given even if you don’t seek legal help 12% 17%

Counseling can be provided 24% 43%

LEGAL 5% Information received related to special place for victim friendly support 11%

SOCIAL 3% 6% There are organizations that can support you to find the help you need

KNOWLEDGE 70% 80% Knew that there is a time limit in which to seek medical help

Knew that time limit is 72 hours 11% 53%

KNOWLEDGE ON SERVICE PROVIDERS

MSF Edith Opperman Nil 63%

ARC Nil 26%

FST Nil 23%

Other, specify Nil 18%

PERCEPTIONS ON SGBV

There has been an improvement in the 2010 to 92% in 2015. Unfortunately, people’s proportion of people who thought that it was perceptions of the rights of sex workers have a woman’s or a man’s fault to be raped since not improved. A similar proportion of people 2010 ( 39% in 2010 to 20% in 2015) and (23% in suggested it was not possible to rape a sex 2010 to 8% in 2015) respectively. People were worker in both the 2010 (61%) and 2015 (58%) also more likely to think it is possible to rape survey. a man (aggravated indecent assault): 79% in

43 Changes in perceptions and attitudes are difficult and on long term as they are linked to deep rooted attitudes towards women, young girls and rape and linked to a variety of religious, traditional and cultural practices and societal beliefs. PATTERNS OF ASSISTANCE ASSISTANCE OF PATTERNS SEEKING BEHAVIOUR Graph 4: Perceptions of SGBV in 2010 and 2015

Perceptions of SGBV Thought a woman is to blame if she is sexually abused 39%

20%

Thought it is possible to sexually violate a prostitute 61%

58%

Thought it is possible to rape a man

79%

92%

Thought it is a man’s fault if he is sexually abused

23%

8%

2010 2015

PATTERNS OF ASSISTANCE SEEKING BEHAVIOUR

The proportion of people who would seek Despite the intensified HP message medical help or advise a family member to promoting that it is no longer required to go to a health centre first increased in 2015 report first to the police before going to the (70% vs. 82%, 69% vs. 81% respectively) clinic, there has been no change in who although people were still more likely to say the survivors are approaching first as the that they would go to the police first (64%) if police remains the primary entrance port. raped compared to 28% who would go first to a health centre.

44 SGBV Report 2011-2017

A peer educator listens attentively during a meeting.

Table 13: To show assistance seeking behaviour: If someone in your family was raped, what would you do? If you were raped by person within your family would you seek the following help?

Assistance 2010 2015

Medical 70% 82%

Legal 16% 3%

Social 36% 6%

Police 85% 92% If you were raped by someone in your family where would you go first?

Assistance 2010 2015

Health Centre N/A 28%

Relatives N/A 8%

Police N/A 64% If someone in your neighbourhood was raped, what would you do ?

Assistance 2010 2015

Advise to report to the police 94% 93%

Advise to go to the health centre 69% 81%

45 ROLE OF DECENTRALIZATION IN INCREASING ACCESS TO SGBV SERVICES

By the end of the first quarter of 2017, a total health facilities in the community takes time. of 438 survivors received a comprehensive Due to the variation of reporting time per clinic

ACCESS TO SGBV SERVICES TO ACCESS package of SGBV services within one of the from 25% to 89%; a small survey is planned six decentralized polyclinics within Harare. to assess the knowledge of the community on SGBV and support to DHPO’s in mentoring of the CHWs, CCWs and HPOs will be reinforced Data on gender, age, referral system and through training and regular monitoring visits. reporting time Capacity Building: Nurses under mentoring Similar with the data of the Mbare clinic, female are evaluated using a dashboard on quarterly survivors (96%) were the largest group basis. By the end of 2017, 20 of 27 mentees seeking help with the majority coming from the were capable to work independently. A total age group of 13-15 years old (38%) resulting of 84 nurses from CoH have been attached in a low uptake of SGBV services for adult (≥ to Edith Opperman center of excellence 25 yrs : 5%) and male survivors (4%). Also the for a period of 2 weeks to work close to the referral system doesn’t show any difference specialized SGBV nurses and 114 City of with the Mbare clinic. 93% of the survivors Harare nurses have been formally trained. have been referred by the police and only 7% came through other service providers like Referrals for legal and social support: childline dropping centre, childcare centre, MSF supported the decentralized sites in social worker, clinic staff or by themselves. strengthening the linkage with the community workers through training and support (phone, Only 34% of the survivors reported within Graph 4: Number of survivors visits) to ensure a good working referral system 72 hrs. From experience we know that the accessing SGBV services in for survivors. increase in awareness on SGBV and the decentralized sites from 2015 - availability of free services in their nearby 2017 100 Graph 5: Number of survivors accessing SGBV services in 81 decentralized sites from 2015 - 2017 80 71

60 60 2015 54 42 42 2016 40 29 29 27 2017 20 7 12 12 3 0

Budiriro Hatcliffe Glenview Mabvuku Highfields Rutsanana Kuwadzana

Dzivarasekwa 46 SGBV Report 2011-2017

Graph 4: Number of survivors accessing SGBV services in decentralized sites from 2015 - 2017

47 Chapter 4 Challenges

Although a large number of survivors of sexual violence find their way to the SGBV clinic, only one in two survivors are coming within 72 hours and of those accessing care only one in three are coming back for follow-ups. SGBV Report 2011-2017

NO INCREASE IN UPTAKE OF SGBV SERVICES FOR SPECIFIC GROUPS OF SURVIVORS

The majority remains children mainly coming seek help that are difficult to change and to from the age group 13 -15 years old and are overcome in short term. The involvement and female while adults both men and women are input of these groups is necessary to discuss not coming yet. Also the access to care for how they see that access to SGBV services commercial sex workers (CSW) didn’t improve. can be improved.

These survivors are facing many barriers to

Community screenings of the documentary “The Mask” and radio shows are conducted to increase awareness on the life experiences of the survivors followed by discussions in group or on radio to elaborate the strategies on how to overcome existing challenges to make SGBV services more accessible for each survivor of sexual violence.

FIRST ENTRY POINT OF REPORTING SEXUAL VIOLENCE

The majority of survivors remains arriving is an ongoing concern as what happens to at the clinic via the police (>93%), despite the survivors who do not want to report to one of our key messages in our HP activities the police. Not going through the police could is focused on emphasizing that it is no be a first step to seek medical care for adult longer mandatory to go to the police first survivors who are afraid for the consequences before getting medical treatment. This is not of reporting (divorce, being expelled, stigma) a problem as such as there is no significant especially when they were sexual assaulted delay noted on the part of the police but there by their husband or known perpetrators.

Therefore group discussions with people of different age groups and gender are ongoing to define which challenges are hindering survivors of sexual violence to seek medical care directly in the clinic and how to overcome these barriers. However all cases of child survivors (>80%) needs to be reported by the police according to the law, although medical treatment could be sought beforehand.

49 Table 14: Referral pathway to report sexual violence in the Mbare clinic from 2011-2017

Referred 2011 2012 2013 2014 2015 2016 2017 2018 TOTAL by

REFERRAL PATHWAY REFERRAL 89.65% 74.63% 52.50% 43.34% 50% 77.86% 77.86% Police 83% 96.7% 92.7% 93.4% 92.2% 95% 90.1% 95.1% 93%

Childline 0% 0.7% 2.4% 1.98%2.7% 3.74%1.8% 1.8%3.41% 0.99%1.3% 0.11%0% 0.11%1.8%

Awareness 4.8% 0.4% 0.7% 0.4% 2.04% 0.7% 1% 0% 1%

Health 2.3% 1.1% structure 2.4% 0.2% 1.1% 1.6% 1% 1.6% 1.3%

Other 4% 0.9% 14.13%0.2% 0.5%5.39% 3.13%1% 1.31%1% 1.5%0.87% 0% 0.9%

Relative/ 4% 0.8% 1.2% 1.2% 0.3% 1.55%0.2% 0% 0% 0.7% Friend 0.2%

NGO 1.6% 0% 1% 0.15% 0.2% 0.3% 0.2% 0% 0.2%

Community 0% 0% 0.2% 0% 1% 0.2% 1% 0.03% 0.1% member

Teacher 0% 0% 1% 0% 0.2% 2.36%1% 0.41%1% 0% 1%

DSS 0% 1% 0.5% 1.7% 4.2% 6.7% 0% 1% 0.8%

Self- 0.1% 1% referral 0% 0% 0.32% 0.8% 0% 0.3% 2.4%

Missing 0% 0.3% 1.2% 0.15% 3.21%1% 2.36%0% 0.41%0% 0.2% 0.3%

The largest group of survivors is coming from after consensual sex as a minor at a clinic the 13-15 years age group (39%). Although in Harare, Zimbabwe, from 2011 to 2014” most cases were reported for rape, a significant was carried out in 2015 and found that the number was referred to the clinic as minors experiences of those who consent to sex as a who consented to sexual intercourse (36%). minor and those that have experienced forced A study “Care requirements for clients who sex were very different. present after rape and clients who presented

Minors who consented to sex compared minors to ensure they have access to enough to survivors of rape were more likely to be information and protection from HIV, other STIs pregnant and unwanted pregnancy, before they decide The standardised SGBV medical response to engage in sexual intercourse, rather than does not fully meet the needs to protect minors as an emergency at an SGBV clinic because (who have consented to sex) from HIV or a substantial proportion of adolescence are unwanted pregnancies. Clients who present engaging in sex below the age of consent. for having consented to sex as a minor might As response to these identified needs and benefit more from being offered a long term given that adolescents and especially young family planning or being assessed as a sero- girls are disproportionately affected by discordant couple rather than simply PEP and sexual and reproductive health problems, ECP as is relevant for clients who have been adolescent friendly services were added as raped. new component to the project integrated in an More provision of health care is needed for adolescent friendly corner in EO clinic.

50 SGBV Report 2011-2017 Minors who consented to sex compared to survivors of rape were less likely:

• To report within 72 hours • To start PEP if eligible • To take emergency contraceptives if eligible • To request a Termination of Pregnancy, if pregnant • To report that they delayed due to fear • To have experienced violence or physical trauma • To display psychological symptoms at presentation • To come for at least one follow up.

A link between the SGBV clinic and the adolescent friendly corner is established :

• To refer adolescents who consented to sex for ASRH education and provision of services as required

• To refer adolescents who were identified as a survivors of sexual violence for comprehensive package of medical care and counseling. According to Zmbabwean law, the age of sexual consent is 16 years

REINFORCEMENT REINFORCEMENT FOR FOLLOW-UP Section 64 and 70 of Criminal Law (Codification and Reform) Act specifies that: • A child under 12 is totally incapable of consenting to sex (rape or aggravated indecent assault, imprisonment for life or any shorter period depending on aggravating factors such as the age of the survivor, the extent of physical and psychological injury inflicted and whether Low uptake of follow up visits the offender was infected with STI’s at the time of rape) Only 30% of the survivors are coming back • Children between 12 and 16 years are for at least one follow up visit (after 1 week rebuttably presumed to be incapable of for those initiated on PEP, 2 weeks, 6 weeks giving consent to sexual intercourse and 3 months) in the Mbare clinic due to a • But if evidence shows that the child was variety of reasons. capable of giving consent and did actually give consent, the perpetrator is guilty of Continued efforts should remain a priority the crime of sexual intercourse or indecent to identify reasons of dropping care and act with young person. potential remedial actions.

Mbare polyclinic Adolecent Corner creates a conducive environment to initiate conversations regarding sexual and reproductive health. SGBV Report 2011-2017

Activities in place to reinforce the follow • Information brochure on importance to up visits rate: come back for follow-up visits given by first visit • Clinic remains open also in the weekend • Reinforcing information during (easier for those that work, study or counseling sessions for survivors need to travel) especially those that are children, • Active follow-up on phone when initiation on PEP, ECP, testing pregnant survivors are not coming on the date of and/or HIV positive, mentally or physically their visit disabled, HIV + in need of referral to • Transport allowance safety house, legal or social services.

Nurse Chigwamba setting aside ART for a SGBV victim to guard against HIV.

Reasons given by survivors for not coming back to the clinic:

• Been relocated to another rural areas Many of the survivors are not reachable by • Living with the perpetrator phone because their phones are normally • No transport money disconnected due to financial problems, • Doesn’t want to think about the deliberate change of number, giving of false issue again and wants to go on numbers or not picking up the phone when with their life seeing clinic number, to prevent follow-up. • Relies on caregiver to bring them to the clinic.

DECENTRALIZATION

Since 2012, the team lobbied for the development Analysis of the data indicated that in clinics of a proper model of SGBV care for sustainable where there are no trained nurses present, integration of services in polyclinics within a relatively high number of survivors have Harare. It took until 2015 that the decentralization been referred to other service providers process for the first sites could be completed and resulting in the drop of data. The fact that provision of SGBV services within polyclinics was many nurses are midwives alternating doing launched. The variation in number of survivors nights and one week off, makes it difficult accessing SGBV services per decentralised site to ensure duty roasters are well allocated. depends on the location of the clinic (prevalence Therefore 5 nurses have been trained per of SV), awareness in the community but mainly decentralised site. From 2017 we have on the availability of trained nurses present in the adapted our goal of “nurses having been clinic. trained per decentralised site” from two to five.

53 DELAYS IN LAUNCH AND ROLL- OUT OF SGBV SERVICES DUE TO HR CHALLENGES

Since 2012 MSF has trained nurses from City Health Clinics and MoHCC structures to increase awareness and knowledge on SGBV and HIV testing followed by on - the - job training at the Mbare clinic. At the end of 2013 at least two nurses per polyclinic had been trained, so that theoretically the nurses could do the work if the structure was in place. However, 2014 has been a set-back year for the decentralization process because of the restructuring of staff in Harare City Health.

The decentralization process has been re-launched in 2015 after receiving the official written grant from Harare City Health, to support them in the roll-out of decentralization of SGBV services within the mainstream of the clinic activities of polyclinics within Harare.

Although the limited number of nurses available in the clinic sites remains a challenge causing delay in attachment of trained nurses to the Mbare clinic; Harare City Health has been very co-operative to send nurses from the prioritized clinic sites, resulting in decentralization of SGBV services within 10 polyclinics by the end of 2017.

PROVINCIAL ROLL - OUT OF SGBV SERVICES THROUGHOUT ZIMBABWE

After many years of lobbying, the provincial roll-out of SGBV services throughout Zimbabwe since 2017 is a fact.

MoHCC urged the initiative of the Training of Trainers (TOT) workshops on clinical care and management of survivors of sexual violence. Government Provincial health personnel were trained as trainers in collaboration with partners as FST, ARC, UNFPA, UNICEF and MSF to cascade and maintain training to the district hospitals followed by rural health centres, in order to support and sustain full coverage of high q u a l i t y m a n a g e m e n t o f S e x u a l A s s a u l t i n Z i m b a b w e .

MSF will support Harare City Health in the provincial roll -out through given support in training and mentoring of their identified health staff personnel as trainers.

54 SGBV Report 2011-2017

55 VOICE OF SURVIVOR

“Do not betray yourself or others by remaining silent. There comes a time when silence is betrayal” Martin Luther King Jr

56 SGBV Report 2011-2017

VOICE OF THE SURVIVORS OF SEXUAL VIOLENCE

The témoignage of the survivors involvement of well-known and and their family are paramount respected artists seen as role to increase the awareness in the models could have a larger impact community on the devastating on people on the importance to fight aspects of sexual violence. The against injustice and ignorance.

Body mapping is a creative an opportunity to process the therapeutic exercise that involves experience on a non verbal level drawing of pictures, symbols and before expressing it verbally. It words to represent experiences is a therapeutic tool that brings lived through the body. It assists together bodily experience and in distancing the individual from visual artistic expression. their experienceand creates

CONCEPT ARTISTS AGAINST SGBV IN SOLIDARITY WITH THE SURVIVORS

1. The song and video has been created to voice the trauma of the survivors by well known celebrities.

2. The documentary film “The Mask” displaying the life stories of seven survivors before, during and after the sexual abuse. “The mask as a cover to hide….”

3. The mural “Speak out” in Mbare is aiming to educate the community on SGBV and their responsibility to react if violence occurs and to become an ambassador in the fight against SGBV.

4. Book of Hope, and Windows into my Life are based on the testimonies of six survivors.

INCOME GENERATING INITIATIVES

In 2016, eight teen pregnant or young mothers, survivors of sexual abuse participated in a 3 months sewing course conducted by Oasis. The objective was to support skill-building, so that they can continue their life after the trauma that they went through. Four of the girls were selected for one year sewing course after the training.

This initiative can motivate other organizations to support income generating and skill - building activities among the survivors. 57 Conclusion

As a medical organisation, we are concerned about the high levels of sexual violence in Harare and worldwide with a high number of survivors reporting to health care services after being raped. When we also know that the majority of cases go unreported, this speaks volumes about the magnitude of the problem. Sexual violence programs should continue placing patients and their families at the centre of their treatment respecting their human rights and ensure human protection.

The nurse-based care model in Mbare clinic that provides comprehensive medical, legal and psycho-social services 24 hrs, 7 days a week, has proven to increase access to services by the high number of survivors seeking care. Through decentralization of services to City of Harare clinics, the access to post rape services was extended to primary level clinics closer to survivors’ homes.

Medical care after rape is an emergency and consequences of rape in the short and life times are enormous, however access to care within 72 hours remains challenging.

Communities need to engage in raising awareness around sexual violence, denormalize violent behaviours, reduce social stigma and increase knowledge.

The collaboration with other actors providing assistance to survivors of sexual violence in particular the police and VFU to promote prompt medical attention, the VFC, ZWLA and JCT for legal follow up of cases, DSS for cases requiring protection or other social services, Musasa for given safety shelters and pregnancy support are key to obtain these results.

The standardised SGBV medical response does not fully meet the needs to protect minors who have consented to sex from HIV or unwanted pregnancies. More provision of health care is needed for minors to ensure they have access to enough information and protection from HIV, other STIs and unwanted pregnancy, before they decide to engage in sexual intercourse.

While such efforts might not mitigate all barriers to access, they are crucial in improving access to medical care for survivors, who today are largely suffering in silence.

58 SGBV Report 2011-2017

MSF Principles and Values

Core MSF Humanitarian Principles

• Humanity • Impartiality • Independence • Neutrality

Guiding Standards

• Medical ethics • International humanitarian law • Human rights norms and law

Operation Values

• Proximity • Transparency • Accountability • Voluntarism • Associative nature

59 MSF contact details:

9, Bantry Road Alexandra Park, Harare, Zimbabwe. Tel: +263 772 150 679/80 or +263 4 745823 Email: [email protected]

60