Evidence shows that legal empowerment plays a vital role in advancing the right to health. Programs that improve communities’ access to justice are critical in deterring abuses linked to accessing health services.
Legal empowerment organizations in Africa, led by Justice & Empowerment Initiatives (Nigeria), Network Movement for Democracy and Human Rights (Sierra Leone), Namati(Mozambique), and Methodist Church (Sierra Leone), came together to discuss key lessons learned and challenges faced as they work with and support communities to realize their right to health.
Justice & Empowerment Initiatives (JEI) has supported community health educators and advocates from poor and marginalized communities in Lagos and Port Harcourt since 2015.
Long-term improved access to healthcare and health services requires accountability between healthcare providers and the communities themselves.
Over the years, JEI’s access to health work has achieved great milestones by adopting two strategies. First, by building strong partnerships between communities and the nearest primary healthcare centers. By strengthening these relationships, community members are better able to overcome common barriers to accessing health services, including bias and charging of illegal fees. The second strategy is public-facing advocacy campaigns using creative media, including community theater and short audio and video pieces aimed at both educating community members and reporting up and out to the wider public. These strategies reach individuals and audiences in ways that direct advocacy often does not, and this has in turn led to a positive uptake from the community.
According to JEI, community education is also a key part of the solution. To hold health professionals accountable, community members need first to know their rights. In the context of access to health, that means knowing what health services you are entitled to for free under the law, what professional healthcare providers can and can not do. Similarly, in Sierra Leone, the Network Movement of Democracy and Human Rights (NMDHR) helps the communities within which they work, to know, use and shape the law. They make sure that elected leaders are accountable by constructively engaging them, especially on matters of healthcare. For the Methodist Church of Sierra Leone (MCSL), legal education to citizens through community health monitors has helped citizens understand the country’s Free Health Care Policy which in turn helps them hold health workers in their various health centers accountable.
Namati Mozambique uses health advocates to build the power of patients and frontline health workers to increase the awareness and realization of health policies and rights. These health advocates also help facilitate dialogue between healthcare facilities and the communities, in order to make the system more accountable to the communities they serve. Rather than treating patients and community members as victims requiring an expert service (“I will solve this problem for you”) health advocates focus on legal empowerment – the notion that “we will solve this together, and when we’re done you will be in a stronger position to tackle problems like these in the future.” By pursuing solutions to specific grievances, they then draw on this grassroots data and learnings to impact policy and practice nationally.
Another strategy employed by Namati Mozambique is the use of data to advocate for systemic change. They categorize individual and community cases, analyze them, then use this data to help advocate for better response. This data also has helped make improvements at local, provincial, and national levels in terms of infrastructure and service delivery.
Litigation can also be considered as one of the ways to ensure effective healthcare provision and accountability, in some cases. In Mozambique, malaria and HIV drugs are to be administered for free. Discrimination against persons living with HIV is also a crime. Mozambique has a system where victims can go to police stations to report discrimination and extortion, which can then be solved by litigation. However, litigation can only be used to solve such cases and does not extend to addressing issues such as understaffed facilities and the unavailability of drugs. To this end, there is room for civil society organizations to make improvements on policies. Take for example the humanization strategy by the Ministry of Health in Mozambique that says that everyone has the right to receive quality healthcare. When a community member faces challenges in terms of services offered in the healthcare system, civil society organizations in Mozambique then refer to this strategy to advocate for better services from the facility.
On the other hand, NMDHR in Sierra Leone tries as much as possible not to litigate as this may undermine some established working partnerships. Already faced by the problems of being understaffed and working in ill-equipped hospitals, litigation may discourage doctors from working in these very hospitals that serve communities. NMHDR instead focuses on accessing remedies or solutions outside of court.
One of the persistent challenges that JEI’s access to health work has grappled with is the fundamental lack of trust between citizens and government public health practitioners. This distrust is born out of citizens’ everyday experiences of poor treatment. For example, during the COVID-19 pandemic JEI’s community health educators reported several cases of suspected COVID-19 to the Nigerian Center for Disease Control (NCDC) only to be ignored, or pushed elsewhere, despite the NCDC’s mandate to provide services in such cases. As a result, particularly among poorer communities who are frequently excluded from public services, there is a widespread perception that pushing for accountability is not worth the effort it would require.
When NMDHR started their community sensitization work, locals thought that accountability should only be directed to the government. The community has since grown to understand that access to health is a fundamental right and that they should demand good healthcare provision from the healthcare practitioners too. To this end, local communities have since taken over running and management of some health centers by becoming acute decision-makers within these centers.
A big challenge faced by MCSL’s is the delay from the government side while trying to address concerns or fix issues. To try and solve this, they are continuously engaging local authorities and running advocacy campaigns in order to get all stakeholders on the same page.
In Mozambique, despite having sound laws and policies, the implementation of these laws has become daunting. As in Nigeria and Sierra Leone, many Mozambicans don’t know their protections and rights to access good healthcare; and in the chance that they do exercise these rights, there is a slim chance of redress. This has led to a loss of trust in the health system, negatively impacting health service utilization and outcomes.
In the beginning, health workers in Mozambique felt that the health advocates were there to police them. Over the years, they have managed to prove that their mission is aligned with the Ministry of Health; to improve health outcomes in Mozambique. This framing has been critical in building constructive relationships with health workers and health advocates.
When it comes to emergency response, urgency often comes at odds with accountability. When community members are in dire need of healthcare provision, they don’t have the time to ensure that accountability runs its course and that they access the services for free, even in cases where this has been stipulated as a right. To mitigate this, the Sierra Leonean government categorized people who can access free healthcare; no questions asked. They include lactating mothers, children under five, pregnant women, Ebola survivors, and school-going children. It’s important to note that this pronouncement hasn’t been legislated into law. One of the advocacy initiatives by NMDHR has since been to ask the government to formally enact this as a law in order to ensure that urgency does not undermine accountability. Another strategy that NMDHR has used to ensure that accountability isn’t compromised is to try and make sure that whenever drugs are being received by the healthcare facilities, some community members and health care advocates are present to receive them too. This then serves as proof that the healthcare center is well stocked and that community members will not get turned away under the excuse of ‘no drugs available’.
According to MCSL, poverty is not the only reason the community does not visit health centers. The unavailability of trained and qualified personnel is a major contributing factor too. They have since realized that the best way to ensure that these health centers are well-staffed is to have a channel where community grievances can be addressed because it’s only when community members understand that health care provision is a fundamental right, that they will push the government to make it accessible.
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