Program on Global Health and Human Rights, Institute for Global Health, University of Southern California (Gruskin, Safreed-Harmon); Open Society Foundations (Ezer, Gathumbi, Cohen); International Environmental Law Research Centre, Strathmore University (Kameri-Mbote)
"In Kenya, human rights violations have a marked impact on the health of people living with HIV. Integrating legal literacy and legal services into healthcare appears to be an effective strategy to empower vulnerable groups and address underlying determinants of health."
Legal integration programmes, defined here as programmes incorporating legal aid, training, and representation into existing health services to improve health outcomes and advance human rights, have the potential to promote accountability, reduce stigma and discrimination, and contribute to altering unjust structures and systems. This strategic observation motivated an evaluation carried out to collect evidence about the impact of legal empowerment programmes. The impetus for the research was the observation that it is not yet clear how legal support can best be integrated into health services, within and beyond the field of HIV. Likewise, there is not yet consensus on how best to assess the impact of this work on reducing stigma and discrimination or on improving health outcomes.
This article presents findings from an evaluation of 3 Open Society Foundations (OSF)-funded legal integration programmes, all administered by Kenyan non-governmental organisations (NGOs). Training was a major focus of all 3 programmes. The Christian Health Association of Kenya (CHAK), a provider of HIV-related services in Kenya, implements a legal integration programme through 15 of its 76 health centres and hospitals. The Legal Aid Centre of Eldoret (LACE) is based at a single healthcare facility within the Academic Model of Providing Access to Healthcare (AMPATH) network. AMPATH, a partnership between Kenyan and United States (US) academic medical centres, established LACE to represent people whose access to justice is otherwise limited, particularly people living with HIV. The Coalition on Violence against Women (COVAW), a Kenyan human rights organisation, established its legal integration programme at a post-rape care centre within Kenyatta National Hospital in 2007.
In consultation with the organisations implementing the programmes, the researchers designed a conceptual logic model grounded in human rights principles (emphasising participation, accountability, non-discrimination, empowerment, and linkage to other rights), identified relevant indicators, and then coded structure, process, and outcome indicators for the rights-related principles they reflect. The evaluation included a resource assessment questionnaire, a review of programme records and routine data, and semi-structured interviews and focus group discussions (FGDs) with clients and service providers. Data were collected May-August 2010 and April-June 2011.
Key result: Clients showed a notable increase in practical knowledge and awareness about how to access legal aid and claim their rights, as well as an enhanced ability to communicate with healthcare providers and to improve their access to healthcare and justice. In turn, providers became more adept at identifying human rights violations and other legal difficulties, which enabled them to give clients basic information about their rights, refer them to legal aid, and assist them in accessing needed support.
Other findings (with potential import to the structure and implementation of legal empowerment programmes more generally) are detailed in the areas of:
- Training of clients and providers on legal and human rights issues - For example, CHAK client-training efforts capitalised on the existence of well-established support groups made up of and led by people living with HIV. While some trainings were provided directly to support groups, others used a "training of trainers" model to prepare group leaders to educate their fellow group members about human rights. Many also had links to legal aid: A 2009 training for community members, most of whom were people living with HIV, was integrated with a legal clinic at CHAK's Mombasa site. The training addressed marriage law, succession law, and gender and its impacts on HIV. Immediately following the training, participants had the opportunity to obtain legal information and referrals from on-site lawyers. The training led to at least three cases being carried forward via referrals. CHAK also reported providing human rights training to staff in its HIV, malaria, and tuberculosis divisions, again using a "training of trainers" model.
- Provision of multiple types of legal aid - For example, LACE often tried to help clients resolve cases through informal conflict resolution mechanisms. For example, LACE received a complaint from a woman whose husband had deserted her and seven children after learning that she was living with HIV. The husband's family had taken over land that the husband had allocated to his wife. After receiving letters from LACE, the husband's family agreed that the woman could cultivate the land. LACE was later able to persuade the husband to formally transfer the land to his wife's ownership. LACE's legal aid records document the provision of services to almost 450 clients from the time of the programme's founding in September 2008 through the first half of 2010.
- Referrals - For example, COVAW commonly sent clients to pre-identified pro bono lawyers for cases requiring litigation. Reflecting the range of services needed for individuals to realise their rights, the programme's use of non-legal referrals included referrals to medical services, counselling services, a women’s shelter, a "family preservation initiative", and other sources of psychosocial and economic support.
- Knowledge and awareness of human rights and legal issues - Evaluators used focus group data to compare clients and service providers trained by LACE, COVAW, and CHAK as compared to control groups of untrained clients. "[T]rained clients appeared to have greater awareness of how and where to access legal services to safeguard their rights. Some trained clients spoke emphatically about how learning about human rights had transformed their outlook or their approach to challenges....The trained service providers appeared to be better equipped to provide legal and rights-related information and referrals to clients."
- Service provision and satisfaction with services - "In evaluating client and service provider perspectives on the effects of legal integration on service provision and satisfaction with services, comparisons with control groups (people receiving health-related services but not legal training) suggested that legal integration programme clients developed greater access to legal and non-legal resources and felt more empowered."
- Protection and redress for rights violations - "Referrals to non-legal services constituted an important way in which LACE, COVAW and CHAK advanced a range of health-related human rights....The programmes further sought to systematically improve shared accountability for human rights and shared protection from rights violations. For example, LACE created a network of doctors, nurses, community chiefs and police officers to promote a more effective response to cases of sexual and gender-based violence. LACE's legal officer credited the network with making some chiefs and members of the police more inclined to address rights violations brought to their attention. CHAK established a human rights 'watchdog' group in one community. Participants, including the chief, assistant chief, church elders, health workers and trained clients, underwent training to monitor and report human rights violations."
Obstacles impacting programme effectiveness are outlined. For instance, structural factors such as real and perceived corruption and indifference among community chiefs and government officials were found to impact/impede both formal and informal legal action.
In conclusion, legal empowerment programmes have been shown here to have the potential to promote accountability, reduce stigma and discrimination, and contribute to altering unjust structures and systems. Given their apparent value as a health and human rights intervention, particularly for marginalised populations, further rigorous evaluations are called for to support the scale-up of such programmes.
Journal of the International AIDS Society 2013, 16(Suppl 2):18726 - sourced from "To End AIDS, We Must Fight Injustice", by Ralf Jürgens, December 10 2013. Image credit: CHAK