Drug users will avoid a needle exchange programme if they spot a police car cruising nearby, and sex workers will readily toss their condoms in the trash if they risk getting arrested for soliciting. Around the world, the most marginalized groups in society – from Roma to HIV-positive people to sex workers to drug users – are reluctant to access basic health services because they fear arrest, intimidation and harassment.
While donors and governments spend vast amounts to put these critical services in place and maintain them, unless the most at-risk people are able to access them, the money is wasted and, perhaps more importantly, the health-related Millennium Development Goals will never be met.
In a recent report, Bringing Justice to Health, the Open Society Foundations (OSF) documents the impact of creative and low-cost grassroots legal initiatives that can help stop the most discriminated-against groups from falling through the health net. The report outlines 11 pilot programmes in South Africa, Kenya, Uganda, Macedonia and Russia that are bridging the divide between human rights and access to health services.
These interventions, which the OSF has been funding for the past eight years, use a range of approaches to accomplish this goal, from providing paralegal assistants (usually drawn from the community experiencing the discrimination), to integrating legal services into existing health services, and offering online legal aid. “It’s all about recognizing that every human being – whether they use drugs, are sex workers, living with HIV or in need of palliative care – has rights. One of the most important of these is access to health,” says OSF Law and Health Initiative director Ralf Jürgens.
In South Africa, although buying and selling sex is illegal, cases seldom make it to court. Nevertheless, many sex workers get arrested, detained for days, harassed and intimidated. Often their only means of escape is paying bribes to policemen. When the Women’s Legal Centre (WLC) in Cape Town began employing sex workers as paralegal assistants to give legal help to their colleagues, they saw a shift. “When I see a police officer these days, I tell him that I work as a paralegal with WLC, and he backs off right away,” said Garonessa, a sex worker turned paralegal.
What is so powerful about this type of intervention, says Jürgens, is that it not only benefits individuals, it is changing perceptions. When the powerless realize that they do in fact have power, we see “systemic changes”, he says, citing evidence of a change in attitude by police leadership in Cape Town.
Similar interventions are helping sex workers in Busia, Kenya, who are “routinely subjected to rape, assault, and harassment at the hands of their clients, the police and the owners of the bars where they [work]”, even though sex work is not illegal. When a self-help group, Survivors, hired a lawyer to defend them and take legal action against the people abusing them, relations with the authorities improved, the report notes.
Russia has a harsh penal system against drug users, a hangover from the Soviet era, and a quota system that rewards police for the number of drug users they arrest and detain. Many lawyers are also corrupt and open to bribes, often failing to work in their clients’ interests. The Institute for Human Rights in Moscow, which aims for a harm-reduction approach to drug use, launched an interactive legal information website in 2007 to help drug users become “legally literate” and represent themselves. The service now answers more than 160 questions each month and gives legal information to people who would otherwise have no access to it.
LBH Masyarakat in Indonesia, and the Omari Project in Kenya’s coastal towns of Lamu, Malindi and Mombasa, where injection drug use is extremely high, are two grassroots projects that deploy paralegals to help get drug users released from prison, and those who are HIV-positive on medication.
In Kenya and Uganda, paralegals are helping sick people access their legal rights. The Kenya Hospices and Palliative Care Association (KEHPSCA) assists patients with problems that include property, inheritance and wills, protection against domestic violence, and prescribing opioids for pain management. Another Kenyan organization, the Legal Aid Centre of Eldoret (LACE), has set itself up “as a one stop centre for medical treatment and legal advice”.
The Uganda Network on Law, Ethics & HIV/AIDS (UGANET) deploys its paralegals on bicycles, which enables them to cover long distances. Wearing special jackets to identify themselves, they give legal help to people living with HIV, who are often harassed and chased off their properties.
The impoverished Roma community in Macedonia still faces tremendous hurdles in accessing health and legal services, and experiences “disrespect, abuse, and systemic lack of communication” in healthcare settings, says the OSF report, even though universal healthcare insurance was made available to all Macedonian citizens in 2009. Right to Health, a project created by four Roma human rights organizations, now has 12 trained community paralegals to help Roma living in slums obtain better treatment.
Serving those in need
It’s not about “imposing ready-made solutions, but working with the communities to identify ways that they can use the law to work for them”, says Jürgens. The laws are usually in place, it's just they are not serving those who most need them. Lawyers are few in number, their services are prohibitively expensive, and their office hours tend not to coincide with those of their potential clients. Often they are prejudiced against people who use drugs or are HIV-positive. Paralegal programmes bring the law to people where they are.
“Our message is that these programmes work. They facilitate access to justice and the fulfilment of people’s right to health. They are inexpensive, and they allow investments in treatment and health to go much further because they address the underlying reasons why people can’t access these services,” Jürgens says.
The OSF wants to see these community-driven pilot programmes replicated and expanded, with assistance from bilateral and multilateral funders like the Global Fund to Fight Aids, Tuberculosis and Malaria. Donor nations are still reeling from the impact of the global recession, so there is increased pressure to focus on areas “where we can have maximum impact”, says Krista Lauer, director of the OSF Global Health Financing Initiative. Legal intervention, she notes, is one of the most effective ways to make this happen.
But health funders tend to target health programmes and justice funders focus on justice-oriented programmes. “We are tying a hand behind our backs if… marginalized people can’t access [services] because they will suffer criminal actions as a result. We want to bring about integration. The pilot programmes show that this works,” says Lauer. There are “promising signs” from the Global Fund, which has included the promotion of human rights in its five strategic objectives for 2012 – 2014.
Marijke Wijnroks, Chief of Staff at the Global Fund, says it had been committed to advancing human rights since its inception in 2002, but recently strengthened its mandate to do so because of “strong scientific evidence to show that targeting programs to populations that are most affected” is fundamental in defeating these diseases, many of which “disproportionally affect the groups of people who are criminalized and at the margins of society”.
The Global Fund recognizes that if human rights are upheld, other conditions for secure financial investments - like the rule of law and legal transparency - tend to be in place, said Wijnroks. “The safer our investments are, the more people we can reach.”