Abstract
BackgroundLegal empowerment and social accountability are two strategies that are increasingly used to address gaps in healthcare in low- and middle-income countries, including failure to provide services that should be available and poor clinical and interpersonal quality of care. This paper is an explanatory case study of a legal empowerment effort that employs community paralegals and trains Village Health Committees (VHCs) in Mozambique. The research objective was to explore how community paralegals solved cases, the impact paralegals had on health services, and how their work affected the relationship between the community and the health sector at the local level.MethodsThe case study had two components: (1) a retrospective review of 24 cases of patient/community grievances about the health system, and (2) qualitative investigation of the program and program context. The case reviews were accomplished by conducting structured in-depth interviews (IDIs) with those directly involved in the case. The qualitative investigation entailed semi-structured Key Informant Interviews (KIIs) with district, provincial, and national health managers and Namati staff. In addition, focus group discussions (FGDs) were held with Health Advocates and VHC members.ResultsCase resolution conferred a sense of empowerment to clients, brought immediate, concrete improvements in health service quality at the health facilities concerned, and seemingly instigated a virtuous circle of rights-claiming. The program also engendered incipient improvements in relations between clients and the health system. We identified three key mechanisms underlying case resolution, including: bolstered administrative capacity within the health sector, reduced transaction and political costs for health providers, and provider fear of administrative sanction.ConclusionsThis study contributes to the limited literature regarding the mechanisms of legal empowerment case resolution in health systems and the impact of hybrid legal empowerment and social accountability approaches. Future research might assess the sustainability of case resolution; how governance at central, provincial, and district level is affected by similar programs; and to what extent the mix of different cases addressed by legal empowerment influences the success of the program.
Highlights
Legal empowerment and social accountability are two strategies that are increasingly used to address gaps in healthcare in low- and middle-income countries, including failure to provide services that should be available and poor clinical and interpersonal quality of care
The case reviews were accomplished by conducting structured in-depth interviews (IDIs) with those directly involved in the case: the Health Advocate who managed the case (9 total interviews); the client(s) (22 total interviews); and a representative of the health facility (13 total interviews)
We begin with a summary of the 24 cases that we included in our retrospective review, the practical steps Health Advocates took to solve the cases, the proximal impacts of case resolution, and the impacts the program had on “state-society relations.”
Summary
This paper is an explanatory case study of a legal empowerment effort that employs community paralegals and trains Village Health Committees (VHCs) in Mozambique. This paper presents an explanatory case study of a legal empowerment program that incorporates strategies of social accountability. Legal empowerment consists of bottom up efforts to help marginalized people to learn about law and policy, and to use this knowledge to obtain concrete improvements in a relatively short period [2]. Training and deployment of community paralegals or ‘barefoot lawyers’ are one of the most common legal empowerment tactics. Paralegals come from the very communities they serve They function essentially as problem-solvers; they try to bring the remedies enshrined in law and policy closer to communities by working with clients to shepherd complaints through the formal or informal administrative or legal system [3,4,5]
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