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HEALTH IN ACTION
A Holistic, Person-Centred Care Model for
Victims of Sexual Violence in Democratic
Republic of Congo: The Panzi Hospital One-
Stop Centre Model of Care
Denis Mukwege
1,2
, Marie Berg
3,4
*
1Panzi General Referral Hospital, Bukavu, Democratic Republic of Congo, 2Panzi Foundation, Bukavu,
Democratic Republic of Congo, 3Institute of Health and Care Sciences, Sahlgrenska Academy, University
of Gothenburg, Gothenburg, Sweden, 4Centre for Person-Centred Care (GPCC), University of Gothenburg,
Gothenburg, Sweden
*marie.berg@fhs.gu.se
Summary Points
• One-Stop Centre (OSC) is an innovative, holistic, person-centredcare model developed
in recent years for survivors of violence against women and girls.
• OSC at Panzi Hospital in eastern Democratic Republic of Congo has been developed
after years of treating girls and women who have been raped in combination with
extreme bodily harm.
• OSC comprises four pillars, covering medical, psychosocial, legal, and socioeconomic
care needs, which are fulfilled in partnership. Based on genuine listening to a harmed
girl’s or woman’s personal narrative, personalised care is planned, implemented, and
documented with the aim of achieving health and reintegration in society.
• OSC gives more than holistic individual care; it provides a platform for achieving a
healthy life at the micro- (the person) and meso- (local society) levels and, if conscien-
tiously and systematically implemented in all health care structures, facilitates achieve-
ment of the right to health for all on the macro (national) level.
The Challenge
The provision of sexual and reproductive rightsand health is an important component in
ensuring the highest attainable standard of health [1,2]. However, this is a challenge in the
Democratic Republic of Congo (DRC), especially in the eastern part, where rape of women and
girls, with extreme sexual violence, has been a leading cause of individual and societal suffering
in the last decades. Rape in combination with extreme bodily harm has been used as a war tac-
tic by armed groups and has escalated as a newpathologic societal behaviour among civilians.
The sexual and bodily violence related to rapes is not only about destruction of women’s physi-
cal and mental functions; it is about the right to health and socioeconomic life of a society
[3,4].
PLOS Medicine | DOI:10.1371/journal.pmed.1002156 October 11, 2016 1 / 9
a11111
OPEN ACCESS
Citation: Mukwege D, Berg M (2016) A Holistic,
Person-Centred Care Model for Victims of Sexual
Violence in Democratic Republic of Congo: The
Panzi Hospital One-Stop Centre Model of Care.
PLoS Med 13(10): e1002156. doi:10.1371/journal.
pmed.1002156
Published: October 11, 2016
Copyright: ©2016 Mukwege, Berg. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Funding: This work has been funded with support
from University of Gothenburg. The Survival of
Sexual Violence project, the basis for the
development of the One-Stop Centre care model,
has been mainly funded by European
Commission’s Humanitarian Aid and Civil
Protection department (ECHO), PMU Interlife
Sweden, the Swedish International Development
Cooperation Agency (Sida), and, recently, by
la¨karmissionen and musikhja¨lpen in Sweden. The
funders had no role in study design, data collection
and analysis, decision to publish, or preparation of
the manuscript.
Competing Interests: I have read the journal’s
policy and the authors of this manuscript have the
following competing interests: DM is director of
Panzi Hospital and Panzi Foundation.
The Panzi General Referral Hospital in the Ibanda Health Zone in Bukavu, South Kivu, east-
ern DRC, has, from its start in 1999 throughto 2015, treated 48,482 women followingextreme
sexual violence. Since 2004, this care is organised under the Survival of Sexual Violence (SSV)
project. In addition, 37,382 women received treatment for gynaecological problems after com-
plicated childbirth or poor medical treatment, of which many were the results of rape [5]. This
experience has developed the medical skills of staff, enabling them to treat severe conditions,
such as vesicovaginal fistulas, that they would rarely have seen elsewhere. It has also identified
that medical care alone is not enough to heal, comfort, and restore the needs of suffering girls
and women [3]. For holistic recovery and achieving a healthy life, a wider holistic care model is
needed. In this article, we describe how a “One-Stop Centre (OSC) Care” model has developed
to provide holistic care and complementary services in Bukavu and surrounding health care
facilities and communities. Our backgrounds are as follows: DM is director of the Panzi Hospi-
tal, a gynaecologist, and an obstetrician who has, for 15 years, treated numerous patients with
sequelae after extreme sexual violence and complicated childbirth or complications after child-
births managed at low-quality maternity care settings; and MB is a professor in Health Care
Sciences specialising in reproductive and perinatal health and a registered nurse midwife with a
long experience of working in DRC, but not specifically with the survivors of sexual violence.
The One-Stop Centre Care Model
OSC models of care have, in recent years, been developed globally inseveral settings for survi-
vors of violence against women and girls, especially as a method for scaling up quality ser vices
during post-conflict reconstruction and recovery in low-income countries [6]. Methodologies
are being refinedto extend and improve services for survivorsas well as to build the capacity of
local organisations to take on the issue [7].
Successively, to the extent possible given available resources, the OSC care philosophy is
being established at the Panzi Hospital and in ser vicesrun by the connected Panzi Foundation.
The OSC care model is developed to be a holistic, person-centred system of care aimed at cov-
ering a woman’s essential needs for recovery and (re)gaining of a healthy life, in particular
those women harmedby extreme sexual violenceor a complicated childbirth.It offers a variety
of competences and activitiesin Bukavu and other health care facilities in a vast geographic
area.
The Panzi OSC care model follows generic standards and consensus for what has been
defined as good health care [8]. It is structured in four pillars: medical, psychosocial, legal, and
socioeconomiccare. Its basic standpoint is that empowerment of women is the foundation for
constructing a plausible and prosperous society. It has much in common with a Person-Cen-
tred Care (PCC) approach, based on what is and what constitutes a human [9] and a person
[10,11]: a kind of lifeworld-led health care [12], with essentialities common with the PCC
model for persons with long-lasting conditions and chronic diseases [13]. It treats women who
seek care as a dignified person (not an object) with value, rights, will, and capabilities, which
necessitates trying to understand the situation as the woman understands it. This is done first
by carers carefully and activelylistening to her narrative and identifying her care needsaccord-
ing to the four pillars, in contrast to the extreme, undignifiedtreatment the harmed women
have experienced previously in life. Second, the care plan in any of the pillars is developed in
partnership with and decided in agreement between the woman and the professional specialist
(psychologists, lawyers, economists, and other professionals needed for holistic care). This is
shown in activities such as informing, explaining, and providing support in decision-making,
such as whether to have gynaecological surgery or to process juridical actionagainst perpetra-
tors of sexual violence. Third,the partnership is safeguardedthrough documentationof all care
PLOS Medicine | DOI:10.1371/journal.pmed.1002156 October 11, 2016 2 / 9
Abbreviations: DRC, Democratic Republic of
Congo; OSC, One-Stop Centre; PCC, Person-
Centred Care; SSV, Survival of Sexual Violence.
Provenance: Not commissioned; externally peer-
reviewed.
in structured care plan templates. Several protocols for the different pillars of care are devel-
oped and used to ensure that all needs are explored and performed as necessary and/or wanted.
The person-centred OSC model of care requires a multi-professional team comprising
resources such as doctors, nurses, midwives, laboratory technicians, radiology technicians,
pharmacy assistants, lawyers, paralegals, administrative resources, and people facilitating wom-
en’s reintegration in society. As applied at Panzi Hospital, with its high capabilities in human
resources, equipment, and infrastructures, it cannot be exactly replicated in resource-limited
areas. A reduced and adapted OSC model, which brings it closer to communities, has been
designed and is functioning in some rural areas (such as in Mulamba and Bulenga).
The care model described in this paper focuseson the majority of patients, who are adult
women. As in other settings, sexual violence towards males is also a reality in DRC; 1.5% of the
patients within the Panzi OSC are men. In addition, specific care is given for minors by staff
trained in treating children such as paediatricians, paediatric surgeons, child psychiatrists, and
psychologists. Specially adapted child examination rooms with appropriate equipment have
been developed. In specific cases, such as minors who experience rape by family members and,
after receiving care, are exposed again to the same individualsand the same incidents, the SSV
child is separated from this family member and is hosted together with her mother or family
carer in a transit centre while legal proceedings are initiated. The OSC also organises sessions
of family mediation and reunification. On a community level, its paralegals organise awareness
sessions and education on human rights and collective protection.
Access to the One-Stop Centre
All patients in need of treatment and support for regaining sexual and reproductive health are
welcome to the Panzi OSC. They arrive through a variety of channels, although the majority
enter through the health care system. Many are referred by international and local partner
associations of the SSV project in territories of the South Kivu province. Others are identified
by the Panzi Foundation’s mobile clinic during its field missions by its specificallytrained
para-juridical assistants or by the police.Some arrive themselvesor with support of relatives.
The starting point of the OSC care model is the medical pillar, around which revolves psy-
chosocial services, legal support, and socioeconomic reintegration to ensure holistic care in one
place. This spares the patient from repeating her narrative to every service she needs. Upon
admission, the patient is registered by a coordinating psychosocial worker. This includes listen-
ing to and documentingthe woman’s narrative, identifying primary needs, and assigninga per-
sonal psychosocial worker, a nurse, who remains her contact person, leading and coordinating
the woman’s care plan and treatments throughout her stay. Care is performed both at the hos-
pital as well as in so-called “transit care houses” just outside the hospital, in which patients
coming from far away can stay until they are ready to return to theircommunities. Patients
can, after first treatment started at the Panzi Hospital, get further care in an OSC closer to their
homes.
Medical Care
Medical care starts with a physician consultation, including a medical examination and plan of
further examinations, such as tests for HIV, pregnancy, syphilis, hepatitis B, and other tests for
identifying secondary effects of bodily harm, such as ultrasound and radiography. This effec-
tively determines needed care. Patients are treated on the basis of two different protocols
depending on the amount of time that has passed sincethe sexual violenceincident. For
patients for whom a long time has passed since the sexual violence incident, medical care
becomes more complex and the psychological sequelae becomemore important. Post-exposure
PLOS Medicine | DOI:10.1371/journal.pmed.1002156 October 11, 2016 3 / 9
prophylaxis for HIV and sexually transmitted diseases is provided for women arriving within
72 hours, which is about 10% of the patients, and curative care is given for those arriving more
than 72 hours after the sexual violence incident.
Recommended care is explained tothe patient who, in a shared decision-making process,
signs a consent form and the defined health care plan, allowing the doctors to proceed with
examination. If needed, the woman is referred to a specialist in gynaecology, cardiology, inter-
nal medicine, radiology, or paediatrics.
Psychosocial Care
Psychosocial care starts with meeting a psychologist to identify needs and plan for specific
treatment, which is carriedout individually and in groups. This is in additionto various activi-
ties offered to all women, including drama and music therapy as well as occupational therapy
activities such as basket-making, flower arranging, sewing, and knitting. Such activities pro-
mote processing of experiences and provide relief and feelings of value. Women suffering from
post-traumatic stress disorders, depression, anxiety, and other psychiatric disorders receive
specialist neuropsychiatric treatment. Psychosocial care also, when necessary, includes coun-
selling for a woman’s close relatives. This could be for a husband to overcome anger, bitterness,
and blame related to an incident of sexual violence, couple counselling, such as after domestic
violence, and counselling of next-of-kin to prevent marginalising the harmed woman.
Legal Care
Legal care aims to support women in deciding whether or not to take legal action against their
attacker. This includes actively listening to her narrative to inform and support consciousness
of her human rights, to analyse the situation together, and to support her decisionin how to
proceed. This strengthens the woman’s courage and capacity to act, including expressing her-
self officially and starting a legal process against a perpetrator of sexual or domestic violence. It
also includes assistance with transport to the place where a perpetration/violence has occurred,
arrangement to meet the perpetrator(s), and transport of a perpetrator to tribune in order to
carry out a trial. The decision to start a legal process is always decided upon and signed by the
woman herself.
Socioeconomic Care
For most of the women, traumatic experience marginalises them from family and society and
destroys their economic capability. The socioeconomiccare pillar safeguards a woman’s essen-
tial ability for healthy living, with the view that every woman, regardless of condition severity,
is a resource for herselfand society. The need for additional life skills trainingis identified, and
activities are offered in the transit house (“Dorkas”). These include literacy and mathematics,
household maintenance skills, hygiene, and nutrition. They also gain skills to provide economi-
cally for their household. In “City of Joy,” women with leadership personalities are also offered
women’s activist training.
Socioeconomic actions redevelop the woman’s social network, because sharing similar sto-
ries creates strong sisterhood links. Other activitiesand projects help women, upon return to
their home village, with starting “microfinancing collectives” in groups with a maximum of 30
people led by one of the women with leadership capacity. Each member has to contribute
something: for example, an amount of money or cultivation on a commune field. The collective
members support each other and get a proportion of the gains at year-end according to their
contribution.
PLOS Medicine | DOI:10.1371/journal.pmed.1002156 October 11, 2016 4 / 9
Reintegration in Society
Part of treatment is to plan for and enhance the woman’s return to her community. Follow-up
home visits after leaving the hospital are organised by teams to assess and secure the reintegra-
tion. This includes providing family mediation for those with difficult reintegration, counsel-
ling for couples, psychological support, guidance on medication use, and identification of
additional care needs in any of the four pillars. It also encourages the woman to be part of orga-
nised community collectives, such as microfinancing. In Box 1, a fictionalisedcase narrative
illustrates the OSC care model in practice.
The One-Stop Centre Model of Care on Societal Level
Raising awareness and activism is a major factor in thebattle against sexual violenceand to
facilitate the return to life in one’s village. The OSC therefore arranges activities in schools,
markets, churches, and other community settings. These activities teach about human rights
and promote community awareness of sexual and gender-based violence through fruitful dis-
cussions. These discussions encourage taking personal responsibility, standing against rape,
and fighting to eradicate it. These community campaigns also stress the importance of transfer-
ring a victim of sexual violence to a health centre within 72 hours and that women can be
treated for free at the Panzi Hospital (within the SSV project). An example of such awareness
activity in society is shown in Box 2.
The One-Stop Centre Model Has a Right to Health Perspective
The goal of reducing inequities in health requires attention to unfair distribution of power,
money, resources, and everyday life conditions [14]. This includes not only health care itself
but also underlying determinants such as clean water and sanitation, adequate food, safe hous-
ing, access to education, and the possibility of supporting oneself [15]. The essential factor for
health on micro (individual), meso (societal), and macro (national/global) levels is a country’s
governance. This is particularly challenging in DRC. In terms of essential governance [16],
DRC is among the weakest countries in terms of accountability, political stability, absence of
violence/terrorism,government effectiveness, regulatory quality, rule of law, and control of
corruption.
The Panzi OSC model, situated in the eastern part of Congo, is alignedwith the right to
health philosophy. It strengthens the position of women in society not only by treatment after
their traumatic experiences but also through education and training in life skills. Furthermore,
it challenges the prevailing pathological behaviour of sexual violence at the meso level at several
organisational levels of society. These efforts can bring about the policy changes necessary for
improving the right to health.
Lessons Learned and the Road Ahead on Personal, National, and
Global Levels
The OSC, as described here, is a holistic, person-centred care model that treats sexually, bodily,
and mentally harmed women as dignified persons having major needs but also being valuable
resources for their own healing and society. Their narratives are listened to, and, as persons,
they are capable co-creators of their own care plan and healing. We have learned that the per-
sons treated in this care system come out restored not only physically but also in their human
dignity. Thus, the OSC model offersmuch more; it provides a platform for achievinga healthy
life at both the micro (the person) and meso (local society) levels. It is a success that beneficia-
ries are integrated back into their families and communities, such as those grouped in village-
PLOS Medicine | DOI:10.1371/journal.pmed.1002156 October 11, 2016 5 / 9
Box 1. A Fictionalised Case Narrative Illustrating the One-Stop
Centre Care Model in Practice
The individuals and events described below are not real but provide a realistic represen-
tation of the type of patients encountered and services that are provided.
• Furaha, a 17-year-old single woman from a town 220 km south of Panzi Hospital, is
referred by a nongovernmental organisation. In the hospital reception triage, she is
identified as needingtreatment as SSV. The SSV social assistant coordinator registers
her attendance, completes a short demographic document,and chooses a social assis-
tant to be responsible for coordinating the care of Furaha. In a first meeting, the social
assistant listens to Fuhara´s narrative, documents it, and, in agreement with Furaha,
makes a written careplan covering her needs,including examinationby a gynaecolo-
gist and a psychologist.
•The narrative: Seventeen months earlier, Furaha was sleeping at her family home when
two plain-clothes armed military men suddenly entered the house. They spoke the
local language and another language often used by militaries; she presumed they were
members of a local rebellion movement. They took Furaha forcibly, undressed her, and
sexually raped her several times before leaving. Her mother, father, and older siblings
woke up during the incident but did not dare to act. Two months later, Furaha found
that she was pregnant. She tried to hide it from her family, but it became obvious. Fur-
aha was lucky to study at secondary school because she was intelligent, and, although
being female, her parents paid for her studies. However, when pregnancy was obvious,
she was denied continuation by the school director. After a normal pregnancy, child-
birth started spontaneously at term and she arrived at a small hospital. After a pro-
longed labour and signs of severe foetal asphyxia, an emergency caesarean section was
made, and a large baby boy was born;however, he was already dead. Furaha had com-
plications after, including severe pain in the pelvic region and urine passing continu-
ously through her vagina.The harm led her to avoid social contacts, and continuing
studies at secondary schoolwas impossible. This is the situation when Furaha arrived
at the Panzi Hospital eight months after childbirth.
•Medical examination: The gynaecologistfinds a vesicovaginal fistula of 3 cm; the cervix
is not visible, and the uterus is not palpable. Laboratorytests show signs of urinary
infection. The gynaecologist informs and explains that the fistula can be repaired by
operation.
•Psychological examination: Furaha meets a psychologist who listens actively to her and
assesses that she is very sad and discouraged and is in need of weekly meetings with the
psychologist to process her experiences further and for mental support.
•Appointments with different professionals: The social assistant has regular follow-ups
with Furaha to verify that her file is updated and that necessary protocols are filled in
and followed. She listens actively and encourages Furaha to express her feelings and
discloses carefully about the needed gynaecological surgery.
• Furaha believes that the fistula is due to sexual violence but is informed that it is due to
a complicated and not optimally managed childbirth. After answering questions and
having enough timeto consider this, Furaha decides to sign an informed consent for
the suggested surgery, which is then planned to occur in 1.5 months. While waiting,
Furaha stays outside the hospital at the One-Stop Centre Transit accommodation and
its house for women with fistulas in the vesicovaginal rectal area. She receives
PLOS Medicine | DOI:10.1371/journal.pmed.1002156 October 11, 2016 6 / 9
savings associations or credit solidarity groups, which are patterns of entrepreneurship and
mutual protection. Such groups are the future of social reconstruction in a post-conflict area.
The OSC concept,as conceived by thePanzi Hospital, was presented and adopted by the
Heads of State and Governmentof the member states of the International Conference on the
Great Lakes Region in Africa at the fourth summit and special session on Sexual and Gender
treatment for urinary infection and has weekly appointments with the psychologist
and also with the social assistant for follow-up of her care and activities from a holistic
perspective. This includes an appointment with the juridical clinic for information and
discussion around the perpetrators of the sexual violence (she decides not to pursue
this) and the definition of Furaha’s socioeconomicneeds. Each day she participates in
different life skill activities, such as learning to knit and sew, seminars about microfi-
nancing, and other activities such as the morning session of singing and worship.
• The surgery succeeds; the fistula is fully repaired and Furaha can urinate normally. In
the post-surgery episode,she continues to meet the psychologists, participate inthe
socioeconomic activities, and successively regain her physical and mental health. In
agreement with her parents, who also have been in contact with the One-Stop Centre
social assistant, Furaha decides to go back to her village and finish the remaining years
at secondary school. Hervision is to studyat university. As her parents cannotafford
to support her economically, she plans to be a member of one of the microfinance
clubs established at her village. By investing in the One-Stop Centre’s “microfinancing
activities,” she plans to save money to buy a sewing machineto make clothes as a way
of financing her university studies.
Box 2. An Example of Awareness Activity in Society
An awareness activity occurredin a village 33 km north of Bukavu because82 girls under
the age of ten were raped duringa short period, and 29 of thesewere cared for by Panzi
Hospital. According to testimony from parents and inhabitants, the perpetrators secretly
entered homes at night, kidnapped the girls, tookthem into the bush to rape them, and
abandoned them to be found later with serious genital lesions. For local community
awareness and mobilisation against these child rapes, representatives of Panzi Hospital,
including the medical director, and V-Men (a movement of men committed to stopping
sexual violence) arranged a large delegation. Activities comprised roundtable discussions
with representatives from the political and administrative authorities, police, the justice
system, and the local army. Radio broadcasts also drew the attention of the governors.
The OSC organisation also trains authorised persons in society in paralegal skills for
acting as informal “lawyers” for individual women and for society, working in close col-
laboration with heath care facility headsand community security systems (police). They
report new assaults to the local security organisation and try to solve problems locally by
organising meetings between offenders and victims.
PLOS Medicine | DOI:10.1371/journal.pmed.1002156 October 11, 2016 7 / 9
Based Violence 2011 [17]. This recognition has encouraged and supported implementation of
the model in some countries of the region, such as Rwanda, Burundi, and Kenya.
Despite the success of the OSC care model, challenges are not lacking, such as acceptance
and integration of mental health into the primary health care system; lack of political will,
which delays the replicationof the OSC model; and the need for ongoing evaluations by staff
on structures and protocols used, followed by revisions.
We believe that if the OSC care approach is conscientiously and systematically implemented
in all health care structures,it is a strong toolto achieve the right to healthfor all, even in a
country that lacks a health care organisation of adequate quality.
Acknowledgments
We thank the participants interviewed at the OSC in headquarters and in the field,and Profes-
sor Cecily Begley for proofreading.
Author Contributions
Conceptualization:MB DM.
Investigation: MB.
Methodology: MB DM.
Resources: DM.
Writing – original draft: MB.
Writing – review& editing: MB DM.
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