**3.3.4 Poorly integrated care for HIV/AIDS and GBV**

In this locale, there is a marked inability to integrate social-psychological, medical and legal processes for HIV/AIDS and GBV care. The rural communities are used to their traditional laws and have poor knowledge of the formal systems for addressing GBV:

*The people from the 'bundus' (olden days) … most of them don't even know that they must report. The ones that are not informed don't know what to do, especially those from rural areas.* 

Police have little experience or sensitivity-training when it comes to dealing with interpersonal issues that are considered to be private matters:

*Police officers will show up at a school and say "I have come here to see the rape child" in a big loud voice so that everyone will know, so that is very poor sensitivity. It's just another crime which I think needs to be investigated.* 

The medico-legal system in rural South Africa faces enormous capacity and coordination challenges, both in terms of fulfilling women's rights to adequate post-sexual assault care, and bringing perpetrators of rape to justice:

*There is definitely a problem with logistics though and follow up of these rape cases…. With the junior doctor, the counseling is good, but who will take the specimens? It's the junior doctor, who by the way doesn't know how to do it properly. And then two years later the magistrate throws it out because the examining doctor is now in Canada, and that's it.* 

Overall, the rural context of HIV/AIDS and GBV amplifies the impact of availability, affordability and acceptability barriers to health system access:

*Post-prophylactics in this society is a tragedy because women are raped routinely in this country and they rape very violently and they rape the people who are at the highest possible risk for HIV and there isn't a way that a woman can rush somewhere to get access to PEP. It doesn't exist. If you had money, and you had understanding, you could rush to a pharmacist. You could get a script there, pay for it and pay for prophylactics and start your treatment. But if you didn't have knowledge and you didn't have money, there absolutely isn't a way for you to get PEP.* 

Many respondents suggest that a local rape crisis centre is the solution.

#### **4. Discussion**

Adequate access to health services can be conceptualized as the fit between population health needs and health system resources. Health needs are multi-dimensional and multicausal, and encompass environmental, physical, psychological, economic and political agents. Consequently, to meet these needs, the development of health system resources must go beyond improving financial and human capacities, and also address suitable sociocultural-political conditions, operational plans and understandings of professional health care from community perspectives. These elements are particularly important for preventive health care in situations of GBV and HIV/AIDS.

*sometimes people behave in a risky way because they have to deal with the first and second need and the third need. ("HIV will kill me six years from now, but hunger will kill me in a short while from* 

Ironically, in the context of a conservative rural health care environment, gender violence may be viewed as a legitimating pre-condition for a woman to get prompt sexual health care. Exposure to HIV as a result of violence is more accepted in a clinical setting than is exposure due to consensual unsafe sex, which is often considered by health care staff to be

In this locale, there is a marked inability to integrate social-psychological, medical and legal processes for HIV/AIDS and GBV care. The rural communities are used to their traditional

*The people from the 'bundus' (olden days) … most of them don't even know that they must report.* 

Police have little experience or sensitivity-training when it comes to dealing with inter-

*Police officers will show up at a school and say "I have come here to see the rape child" in a big loud voice so that everyone will know, so that is very poor sensitivity. It's just another crime which I think* 

The medico-legal system in rural South Africa faces enormous capacity and coordination challenges, both in terms of fulfilling women's rights to adequate post-sexual assault care,

*There is definitely a problem with logistics though and follow up of these rape cases…. With the junior doctor, the counseling is good, but who will take the specimens? It's the junior doctor, who by the way doesn't know how to do it properly. And then two years later the magistrate throws it out* 

Overall, the rural context of HIV/AIDS and GBV amplifies the impact of availability,

*Post-prophylactics in this society is a tragedy because women are raped routinely in this country and they rape very violently and they rape the people who are at the highest possible risk for HIV and there isn't a way that a woman can rush somewhere to get access to PEP. It doesn't exist. If you had money, and you had understanding, you could rush to a pharmacist. You could get a script there, pay for it and pay for prophylactics and start your treatment. But if you didn't have knowledge and you* 

Adequate access to health services can be conceptualized as the fit between population health needs and health system resources. Health needs are multi-dimensional and multicausal, and encompass environmental, physical, psychological, economic and political agents. Consequently, to meet these needs, the development of health system resources must go beyond improving financial and human capacities, and also address suitable sociocultural-political conditions, operational plans and understandings of professional health care from community perspectives. These elements are particularly important for preventive

laws and have poor knowledge of the formal systems for addressing GBV:

*The ones that are not informed don't know what to do, especially those from rural areas.* 

*now.")* 

preventable.

*needs to be investigated.* 

**4. Discussion** 

**3.3.4 Poorly integrated care for HIV/AIDS and GBV** 

personal issues that are considered to be private matters:

*because the examining doctor is now in Canada, and that's it.* 

affordability and acceptability barriers to health system access:

*didn't have money, there absolutely isn't a way for you to get PEP.* 

health care in situations of GBV and HIV/AIDS.

Many respondents suggest that a local rape crisis centre is the solution.

and bringing perpetrators of rape to justice:

While the access framework used in this paper is useful for categorization of different dimensions of access, there is also a need for exposure of underlying mechanisms that contribute to these barriers. Three major mechanisms affecting access to HIV/AIDS and GBV services in the KwaZulu-Natal rural health care system may be posed from this study. First, due to many years of isolation during the apartheid era, the health professions maintained many traditional features. They were less influenced by broader paradigmatic and practice shifts occurring in health systems in other parts of the world. There continues to be considerable role differentiation and a clear medical hierarchy in South Africa. At best, the health professions are just emerging from a model of health that minimizes a social or community perspective on causes or solutions for health problems. Such medical elitism leads to hierarchies of treatment modalities, for example, an overdependence on postinfection testing and pharmaceutical treatments over the prevention and promotion of healthy social environments. Second and third tier health workers (nurses and VCT counselors) expect full health services (e.g., PEP) for themselves, yet there is not an effective system in place to similarly protect or treat community members. Individual social work professionals are viewed as primarily responsible for managing the consequences of gender based violence, but are restricted to working in clinical settings and are rarely exposed to community conditions that underlie such violence. Overall, traditional power differentials continue to separate health professionals from each other and from the communities they serve. Those who work in areas that carry elements of cultural stigma or shame (GBV or HIV), and more generally, in counseling, prevention or palliative roles (as opposed to curative), experience lower status and professional devaluation. These power dynamics, combined with overwork and lack of resources, is leading to ever-increasing burn-out among those providing GBV and HIV/AIDS related care. This situation is not unique to South Africa and has been recognized by the World Health Organization in its Integrated Management of Adult and Adolescent Illness model that promotes task shifting from doctors to nurses and from nurses to community health workers [World Health Organization, 2004].

Second, there is considerable stereotyping of rural and poorly educated populations. Gender based violence victims may be viewed by health staff as being in primitive social relationships that condone male violence as normative. The female victim is often seen as sharing responsibility since she has stayed in an abusive relationship. Alternately, women are viewed as being victims of an accepted rural tradition of rape. There is little understanding of a middle dynamic that is neither collusive nor coercive, but relational. Generally misunderstood is the victim's deeply ingrained role in 'absorbing' her male partner's anger, frustrations, and violent reactions to persistent social and economic deprivation.

Third, rural South African society presents differing perspectives on appropriate hierarchies for action related to HIV/AIDS and gender based violence. The health care worker considers the proper order of priority to be actions within their scope of practice and experience, that is, HIV/AIDS testing, treatment and prevention education. Poverty alleviation and addressing the social causes of violence are given much lower priority by health workers as these are more distal in the causal chain. Community members, however, consider hunger relief and safety from violence as their most immediate priorities, without which, longer term poverty relief and HIV/AIDS treatment implementation become meaningless. From both perspectives, within a limited resource environment, only the

An Institutional Analysis of Access to

communities given existing service gaps.

urban areas.

GBV/HIV Services in Rural KwaZulu-Natal, South Africa 101

Concrete examples of such transformation are already being achieved in urban South Africa with regard to HIV/AIDS services. These include the establishment of anonymous, rapid VCT sites that are crucial for HIV/AIDS prevention and treatment programs [Joint Monitoring Committee on the Improvement of the Quality of Life and Status of Women, 2001a]. Also, Senderowitz [1999] identified several physical and operational characteristics that transform health facilities to being "youth-friendly". These include the creation of a separate space and special times for adolescent clients; hours that are convenient for schoolgoing youth; the establishment of clinics in locations convenient for youth; adequate space and sufficient privacy in clinics; and comfortable, youth-oriented surroundings (posters, audio-visual material on youth issues, avoid overly "sanitized" décor). Finally, the Community Agency for Social Enquiry [Community Agency for Social Enquiry, 2001] determined through its survey of urban HIV/AIDS service organizations that government could establish or fund HIV/AIDS information/resource drop-in centres to take the burden off clinics, develop programs focusing on AIDS discrimination and stigma, and develop clear policy guidelines that standardize training for health care workers. Similar

recommendations could be adapted for the South African rural environment.

Urban South Africa is now making advancements in terms of providing comprehensive GBV services, again drawing on an integrated and collaborative approach to care. Many urban areas of South Africa have medico-legal clinics which have evolved into "one-stop clinics". Also called Thutheleza Centres (TTCs), these clinics provide medical treatment, police services, HIV and PEP counseling, PEP and STI prophylaxes and emergency contraceptives, and referrals to NGOs and voluntary organizations for longer-term counseling, all under one roof. TTCs are considered to be "best practices" in post-rape care. However, there is a major service gap in rural areas, where TTCs have yet to be rolled out fully. As respondents for this study indicated, such centres would be invaluable in their

Other major programmatic shifts in the sexual assault arena in recent years include the emergence of Community Forums (some are called "community policing forums" or "medico-legal forums"). In the absence of TTCs, communities have organized regular meetings between governmental and non-governmental service providers (including police stations, health clinics, gender violence and women's NGOs, children's services, Department of Welfare units, and other community organizations). These meetings provide a forum for information-sharing, the development of a comprehensive referral system, identification of problems that still need to be addressed to meet the needs of the community, and the development of strategies (task delegation as well as collaborative activities) to deal with the problems identified. Intersectoral collaboration has become a goal in the area of GBV in informal settlement and township communities, pointing to the beginnings of transformation of traditional hierarchies and structures of service delivery in

Both TTCs and Community Forums are good examples of actions contributing to the "recreation of community". With proper adaptation to the rural context, the replication of similar structures and/or forums in rural areas could improve community capacity to facilitate improved access (in terms of availability, affordability, and acceptability) to GBV and HIV/AIDS services. They would contribute to the breaking down of traditional power hierarchies and the division of labour. They might also encourage health and community

higher priorities are addressed. Consequently, there is a lack of capacity to address population level solutions to causal indicators and determinants of HIV/AIDS and GBV. For example, there is a lack of understanding of concepts such as community viral load and infectiousness, community safety mechanisms and practices, adaptation of community social standards, and the importance of support groups and counseling in a sociallymediated epidemic.

In this study, the relationship between the formal health structures and traditional ones, and between the government legal structures and the customary ones, were porous. This situation compromises access to the full spectrum of care that can be informed by a social understanding of rural communities and their realities, leaving the great possibility that many patients will fall between the cracks. There is a significant absence of collaboration between traditional and modern structures, which creates problems for access into the health care system and access to the police and magistrates. More positively, health care workers themselves identify the need for help in addressing the alleviation of basic risk factors for AIDS such as poverty, unemployment and poor education in rural settings. For them, training about safe water supply and nutrition were sometimes viewed as more important than specific training in HIV/AIDS management.

These findings suggest that an institution building approach to interventions would be useful in addressing HIV/AIDS and GBV issues in rural areas. Jan et al. [2008] suggest that such an institutional perspective would address individual (agency), household (power relations, communication, well-being), community (networks, norms, relationships and responses) and organizational (resources, coordination) levels. These interventions might include formal legislation, specifically for rural and under-serviced areas, concerning resource allocation to health services and the regulation of professionals. These interventions might also include more training regarding social customs and cultural norms that shape rural sexual practices and traditional health care.

Petersen [1999] suggests that a 'reorientation programme' in the new South Africa is necessary to address neglected issues, such as mental health.. Such reorientation initiatives could also be applied to the context of HIV/AIDS and GBV to address the following:


Perhaps of highest priority is the need to conceptualize the institutional role of the community in HIV/AIDS and GBV services. According to the originator of the institutionalist approach [Tool, 1977], as well as others who have used it in the health sector [Jan, 1998], the social value of any intervention should be judged in terms of how well an action contributes to the 're-creation of community', as opposed to simple incremental health gains for individuals. Thus, interventions should also have ongoing value to the community, in this case by affecting the capacity of the rural community to transform itself to a new context.

higher priorities are addressed. Consequently, there is a lack of capacity to address population level solutions to causal indicators and determinants of HIV/AIDS and GBV. For example, there is a lack of understanding of concepts such as community viral load and infectiousness, community safety mechanisms and practices, adaptation of community social standards, and the importance of support groups and counseling in a socially-

In this study, the relationship between the formal health structures and traditional ones, and between the government legal structures and the customary ones, were porous. This situation compromises access to the full spectrum of care that can be informed by a social understanding of rural communities and their realities, leaving the great possibility that many patients will fall between the cracks. There is a significant absence of collaboration between traditional and modern structures, which creates problems for access into the health care system and access to the police and magistrates. More positively, health care workers themselves identify the need for help in addressing the alleviation of basic risk factors for AIDS such as poverty, unemployment and poor education in rural settings. For them, training about safe water supply and nutrition were sometimes viewed as more

These findings suggest that an institution building approach to interventions would be useful in addressing HIV/AIDS and GBV issues in rural areas. Jan et al. [2008] suggest that such an institutional perspective would address individual (agency), household (power relations, communication, well-being), community (networks, norms, relationships and responses) and organizational (resources, coordination) levels. These interventions might include formal legislation, specifically for rural and under-serviced areas, concerning resource allocation to health services and the regulation of professionals. These interventions might also include more training regarding social customs and cultural norms

Petersen [1999] suggests that a 'reorientation programme' in the new South Africa is necessary to address neglected issues, such as mental health.. Such reorientation initiatives




Perhaps of highest priority is the need to conceptualize the institutional role of the community in HIV/AIDS and GBV services. According to the originator of the institutionalist approach [Tool, 1977], as well as others who have used it in the health sector [Jan, 1998], the social value of any intervention should be judged in terms of how well an action contributes to the 're-creation of community', as opposed to simple incremental health gains for individuals. Thus, interventions should also have ongoing value to the community, in this case by affecting the capacity of the rural community to transform itself

could also be applied to the context of HIV/AIDS and GBV to address the following:

important than specific training in HIV/AIDS management.

that shape rural sexual practices and traditional health care.


problems at the primary level of care;

mediated epidemic.

system;

members.

to a new context.


Concrete examples of such transformation are already being achieved in urban South Africa with regard to HIV/AIDS services. These include the establishment of anonymous, rapid VCT sites that are crucial for HIV/AIDS prevention and treatment programs [Joint Monitoring Committee on the Improvement of the Quality of Life and Status of Women, 2001a]. Also, Senderowitz [1999] identified several physical and operational characteristics that transform health facilities to being "youth-friendly". These include the creation of a separate space and special times for adolescent clients; hours that are convenient for schoolgoing youth; the establishment of clinics in locations convenient for youth; adequate space and sufficient privacy in clinics; and comfortable, youth-oriented surroundings (posters, audio-visual material on youth issues, avoid overly "sanitized" décor). Finally, the Community Agency for Social Enquiry [Community Agency for Social Enquiry, 2001] determined through its survey of urban HIV/AIDS service organizations that government could establish or fund HIV/AIDS information/resource drop-in centres to take the burden off clinics, develop programs focusing on AIDS discrimination and stigma, and develop clear policy guidelines that standardize training for health care workers. Similar recommendations could be adapted for the South African rural environment.

Urban South Africa is now making advancements in terms of providing comprehensive GBV services, again drawing on an integrated and collaborative approach to care. Many urban areas of South Africa have medico-legal clinics which have evolved into "one-stop clinics". Also called Thutheleza Centres (TTCs), these clinics provide medical treatment, police services, HIV and PEP counseling, PEP and STI prophylaxes and emergency contraceptives, and referrals to NGOs and voluntary organizations for longer-term counseling, all under one roof. TTCs are considered to be "best practices" in post-rape care. However, there is a major service gap in rural areas, where TTCs have yet to be rolled out fully. As respondents for this study indicated, such centres would be invaluable in their communities given existing service gaps.

Other major programmatic shifts in the sexual assault arena in recent years include the emergence of Community Forums (some are called "community policing forums" or "medico-legal forums"). In the absence of TTCs, communities have organized regular meetings between governmental and non-governmental service providers (including police stations, health clinics, gender violence and women's NGOs, children's services, Department of Welfare units, and other community organizations). These meetings provide a forum for information-sharing, the development of a comprehensive referral system, identification of problems that still need to be addressed to meet the needs of the community, and the development of strategies (task delegation as well as collaborative activities) to deal with the problems identified. Intersectoral collaboration has become a goal in the area of GBV in informal settlement and township communities, pointing to the beginnings of transformation of traditional hierarchies and structures of service delivery in urban areas.

Both TTCs and Community Forums are good examples of actions contributing to the "recreation of community". With proper adaptation to the rural context, the replication of similar structures and/or forums in rural areas could improve community capacity to facilitate improved access (in terms of availability, affordability, and acceptability) to GBV and HIV/AIDS services. They would contribute to the breaking down of traditional power hierarchies and the division of labour. They might also encourage health and community

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