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How to Develop and Support Justice Programs for Public Health

Photo credit: Sven Torfinn for the Open Society Foundations

This resource guide complements the Open Society Foundations’ recent publication Justice Programs for Public Health: A Good Practice Guide. It includes all publicly available sources used in preparing the Guide, as well as further readings and additional practical resources from the field, such as videos, training manuals, forms and templates for case management and documenting human rights abuses, and sample baseline and advocacy reports.

We hope the resources in this online guide will prove helpful to implementers and donors interested in supporting programs that advance the health and human rights of socially excluded groups.

For digital access to the full publication Justice Programs for Public Health: A Good Practice Guide, follow this link to download the Guide on the Open Society Foundations’ Public Health Program website:
Justice Programs for Public Health: A Good Practice Guide

This introductory section includes a range of resources that offer evidence on the public health benefits of justice interventions and that show the basis for such interventions in international law and policy.

Introductory reading materials

This section of the Toolkit includes resources related to the populations that Open Society focuses on in its access to justice work: sex workers, people who use drugs, people living with HIV, people in need of palliative care, Roma, and people with intellectual or psychosocial disabilities. Cutting across these groups is their common treatment by state actors, health care providers, and segments of the broader public as unworthy of recognition and undeserving of human rights protections. The resources below offer information on the most prominent abuses carried out against these groups, the health impacts of these abuses, and how to partner with these groups to advance their health and human rights.

Sex Workers

The criminalization of sex work is linked to a host of human rights abuses that bear negatively on the health of sex workers and the broader public. Sex workers in many countries are routinely subjected to arbitrary detention based on police profiling. While in custody, many sex workers suffer rape, beatings, intrusive body searches, mandatory HIV testing, extortion, and other degrading treatment at the hands of law enforcement agents. Outside custodial settings, laws against keeping a brothel and zoning rules intended to eliminate sex work from a given area force sex workers to work in remote locations, where they are more vulnerable to abuse. Moreover, laws against communicating about paid sexual services restrict sex workers’ ability to warn each other about dangerous clients. In medical settings, many health care providers are unwelcoming to sex workers and obstruct their access to the care they need to stay healthy.

The resources below offer more detailed information on the abuses that sex workers face as a result of the criminalization of sex work. These resources also explain the benefits of legal and paralegal services tailored to sex workers and the importance of designing and delivering such services in partnership with sex worker communities.

People Who Use Drugs

The criminalization of drug use and possession obstructs the harm reduction efforts that have been shown to improve the health of people who use drugs. It also occasions police practices that infringe the health and human rights of this community, including unlawful arrest, physical and psychological abuse, and the extraction of false confessions. In prisons and detention centers, many people who use drugs are cut off from the medical support they were receiving before their arrest—such as antiretroviral or opiate substitution treatment—and are held in wretched conditions, leading to deterioration of their health. Upon their release, people who use drugs are often subjected to drug registration systems that bar them from exercising their child custody rights or obtaining driver’s licenses or employment. Health care systems are often unwelcoming to people who use drugs, in many cases violating their rights to consent and confidentiality and denying them treatment.

The resources below provide evidence on the health effects of the human rights abuses faced by people who use drugs. They also explain the need to complement harm reduction services with adaptable legal support that meets people who use drugs where they are at and involves them in program design and delivery.

People Living with HIV

The stigma and discrimination experienced by people living with HIV limit the effectiveness of global efforts to make HIV treatment and prevention supplies more accessible. Misinformation about HIV and prejudices about particular social behaviors give rise to stigma on local and national levels, in areas of life ranging from the family home to education, employment, and health care. Many countries reinforce this stigma through discriminatory laws that criminalize HIV transmission or that impose travel restrictions on people living with HIV. The rights of people living with HIV to consent and confidentiality are also frequently violated in health care contexts, placing them at risk of violence, neglect, and ostracism on the part of family and community members. All of these measures deter individuals from learning their status voluntarily and accessing the services they need to stay healthy.

The resources below explain how legal services tailored to the needs of people living with HIV can be just as important as medical care, by helping protect their health and human rights in tandem. Certain resources also show the potential for partnering with networks of people living with HIV in developing these legal services.

People in Need of Palliative Care

Palliative care offers a holistic and inexpensive approach to pain and symptom management for patients with life-limiting illness. It goes much further than physical care, offering social, psychological, and spiritual support to patients and their families from the moment of diagnosis onward through treatment and bereavement. Access to palliative care is stunted in many countries, however, due to regulatory barriers preventing palliative care medications from reaching patients, as well as governments’ failure to integrate palliative care into health plans and policies.

The resources below explain the need for palliative care to include measures that help patients with life-limiting illness deal with legal issues, ranging from child care arrangements and property disposition to debt management and access to social benefits. Legal support integrated into palliative care delivery—from hospices to patients’ homes—enables truly holistic care and offers access to justice to both patients and their families.

Roma

Roma communities across Europe face marginalization and suffer discrimination in many aspects of daily life. Despite increasing numbers of educated Roma, poverty and illiteracy remain widespread in Roma communities, limiting their prospects of formal employment and access to basic services. Many Roma live in informal settlements marked by below-average life expectancy and high infant mortality rates. They often lack the identity documents needed to access health care and other critical services. When they do access health care services, Roma are often denied care or provided with substandard care, often alongside degrading treatment, violations of their basic health rights, and extortion. A range of human rights instruments—coupled with EU monitoring efforts and the Decade of Roma inclusion—have shed light on the abuses faced by Roma, but implementation of proper policies and standards remains wanting.

The resources below describe the barriers Roma face to full enjoyment of their health and human rights. They also show the benefits of partnering with Roma-led organizations to address these barriers and to counter the stigma and discrimination facing Roma communities.

People with Intellectual and Psychosocial Disabilities

Across the world, people with intellectual and psychosocial disabilities experience serious human rights abuses and stigma. In Central and Eastern Europe, individuals with both kinds of disabilities are held in remote long-stay institutions where they are provided with inadequate food, heating, and clothing and are subjected to abusive treatment including electroconvulsive therapy, detainment in cage beds, physical and pharmaceutical restraints, and forced sterilization. Violations against people with intellectual and psychosocial disabilities also arise through court-appointed guardianships, where a guardian is assigned wide-ranging powers over a ward whose rights are greatly restricted as a result. In sub-Saharan Africa, people with intellectual and psychosocial disabilities lack basic services and are exposed to sexual and physical abuse on the part of family and community members, including police.

It is important to support community-based programs where people with intellectual and psychosocial disabilities can live as citizens with equal rights and adequate access to health care. This requires providing legal services to facilitate access to essential services and redress for abuse. It works well to integrate this support into an NGO or community-based program already working with people with intellectual and psychosocial disabilities.

The resources below detail the abuses to which people with intellectual and psychosocial disabilities are subjected and point to promising means of protecting their health and human rights.

This section of the Toolkit includes resources related to the five main approaches to legal services that Open Society uses to support socially excluded populations: community-based paralegals, lawyering for the marginalized, integrating legal services into health care, virtual legal aid, and human rights engagement with customary justice structures. As the Good Practice Guide explains, these approaches can both stand alone and complement each other, and deciding which ones will work for a specific population in a specific setting requires an understanding of that population’s needs and concerns in that context. It is thus critical to consult with a wide range of members of the population in question. Access to justice programs work best when their beneficiaries are involved in their planning, delivery, and evaluation.

The end of this section includes some resources related to a sixth approach that Open Society has been experimenting with—namely, the coupling of social accountability tools with legal empowerment strategies. This approach holds particular promise for integration into community-based paralegal programs.

Community-based Paralegals

One way to foster access to justice among socially excluded groups is to train and deploy paralegals drawn from these communities. These paralegals have the trust of their peers, which helps them serve as a bridge between their community and the lawyers involved with an access to justice program. Community-based paralegals are well placed to provide members of socially excluded groups with legal education, document and challenge violations as they occur, mediate administrative and private disputes, help draft important documents, help their peers navigate government agencies, and contribute to a strong community movement. For populations with severe illness, it can work well to train frontline health care providers—who know their needs well—as paralegals.

The resources below explain the benefits of this approach and offer guidance on establishing and managing community-based paralegal programs, with special attention devoted to paralegal training and supervision.

Lawyering for the Marginalized

“Lawyering for the marginalized” refers to a particular approach to connecting lawyers with socially excluded populations. These lawyers go beyond their formal legal training and make efforts to gain their clients’ trust, moving outside offices and courtrooms in order to work in specific locations where members of socially excluded groups may be readily found, including street-based locations, harm reduction sites, and detention centers. Often, these lawyers integrate their legal support into a broader set of services required to meet client needs. A lawyer on an outreach mission might equip herself with harm reduction supplies or food for clients to use or consume before airing their legal problems. In other settings, a lawyer’s services may become integrated into the health care services provided at a medical clinic, hospice, or harm reduction center.

Some of the resources below exemplify how lawyering for the margins works in action, while others set out a broader range of approaches to legal service delivery oriented toward socially excluded groups.

Integrating Legal Services into Community Health Care Settings

Integrating legal services into health care service points is an approach that works well for patients who are already accessing health care services but are unlikely to make their way to separate locations for legal support. This integration enables health care providers to offer more holistic care, by allowing them to connect their patients to legal assistance that helps address the underlying determinants of their health. Legal services can be introduced into settings as varied as HIV clinics, hospices and other palliative care settings, community-based programs for people with intellectual and psychosocial disabilities, and harm reduction centers for people who use drugs.

Some of the resources below focus squarely on the benefits of integrated legal and health care services and how best to perform this integration in practice. Others touch on this approach as but one way to foster access to justice among socially excluded populations.

Virtual Legal Aid

Providing legal information and advice over the Internet—or virtual legal aid—is a model of legal service delivery well suited to settings where affordable and appropriate lawyers are scarce. Websites can hold anonymous online consultations and e-seminars where members of socially excluded groups and their loved ones can obtain a lawyer’s advice in real time. Users may also consult answers to frequently asked questions (FAQs) posted on the website. Virtual legal aid can also be used to offer legal information to state officials, health care providers, and NGOs working on issues relevant to socially excluded groups.

The resources below offer descriptions and examples of virtual legal aid in practice, whether its intended beneficiaries are socially excluded groups themselves or professionals working with them.

Human Rights Engagement with Customary Justice Structures

In certain countries, a key access to justice strategy involves engaging with councils of elders, village chiefs, and other decision-makers whose roles are well recognized and regarded in the community. Working with customary justice structures can be a great way to offer dispute resolution services that are timely, inexpensive, and culturally relevant. Their proceedings are typically structured as mediations or arbitrations rather than as adversarial proceedings adjudicated by a judge. As a result, they are often more conducive to finding common ground than those of formal courts. Customary justice structures are particularly well suited to resolving community-level claims involving property rights, whose effective enforcement depends on community cooperation.

It is critical to ensure that customary justice structures do not apply discriminatory norms against women or socially excluded populations. Often, this requires discussions with their leaders about health and human rights issues to ensure they become sensitive to these groups’ concerns. Training efforts led with community decision-makers should also ensure they are well versed in the formal legal framework, as the resolution of many disputes depends on a coupling of customary and formal tools.

The resources below explain the importance of engaging with customary justice structures in settings where they are present. Also included is a step-by-step guide to developing a community-level dispute resolution program in partnership with local decision-makers.

Social Accountability and Legal Empowerment

Social accountability techniques use citizen participation to demand accountability from public officials and service providers. In a health context, they include the use of community scorecards, citizen report cards, social audits, and applied budget work to enable citizens to advocate for improvements in public health care services. Legal empowerment refers to the transfer of power from the usual gatekeepers of the law—lawyers, judges, police, and state officials—to ordinary people who make the law meaningful on a local level and enhance the agency of disadvantaged populations. The training and deployment of community-based paralegals is a strong example of legal empowerment in action.

Fusing social accountability techniques with legal empowerment strategies promises to strengthen the effectiveness of each. Social accountability techniques can serve as an important source for legal cases, surfacing community-level injustices that individual clients may not raise and calling for attention to state failure in enforcing social and economic rights. Social accountability practitioners’ use of aggregate data can also be a catalyst for community engagement. Legal empowerment strategies can address individual grievances as well as challenge policies and set new precedents and standards against which future social accountability measures can be undertaken. Legal empowerment’s connection with lawyers also adds ‘teeth’ to the advocacy efforts of social accountability practitioners.

The resources below offer further explanation of social accountability tools, as well as examples of their application alongside legal empowerment strategies.

This section of the Toolkit includes resources pertaining to a variety of preliminary considerations that implementers and donors may wish to consider before supporting or scaling up an access to justice program.

Assessing the Need

Needs assessments can help implementers and donors determine which justice services are best suited to a particular setting. They can also serve as a baseline against which to measure a program’s progress over time. To be effective, the needs assessment process should involve members of socially excluded groups. Community members can be asked about the abuses they commonly experience and whether or how they tend to access legal services. Interview participants can also serve as key players in designing and delivering the access to justice program under consideration. It is also helpful for a needs assessment to reflect consultations with those who regularly interact with socially excluded groups, including NGOs already working with the community, health care providers, and law enforcement agents. These actors may serve well later as partners or referral points.

The resources below span a wide range of sample needs assessments.

Educational Activities

Educational activities are critical to raising rights consciousness and providing important legal and practical information among both socially excluded groups and those whose everyday decisions affect them. In many cases, rights training is a prerequisite for an access to justice project. Training workshops led with socially excluded groups can provide them with practical guidance on claiming their rights. Trainees can then share this knowledge with their peers, whether as paralegals or more informally, and help generate demand for legal services at the same time. When training community-based paralegals, workshops should include a skills-building component in addition to covering the substantive law.

Workshops held with health care and legal service providers are critical to ensure high-quality services are provided to patients and clients from socially excluded groups, and that these professionals are equipped with necessary skills. Workshops led with duty bearers such as law enforcement authorities, government officials, and community decision-makers can help prevent violations before they occur as well as facilitate redress for abuses.

All training workshops should be interactive, drawing first on participants’ experiences before making connections to the legal framework. Training should also be ongoing particularly for community-based paralegals, in order to ensure high-quality services. For law enforcement officials, judges, and legal and medical professionals, the sustainability of human rights training can increase by integrating it into their educational curriculum.

Some of the resources below address the importance of human rights and legal education and offer guidance on how best to deliver it in a variety of contexts. Others serve as examples of training manuals developed and used in the field.

Capacity Building

Programs implementing access to justice projects may have capacity-building needs. Their staff may need technical assistance on developing specific project-related skills, or the program as a whole may need help in developing its core functions more generally, such as its governance, strategic planning, administrative procedures, or fundraising.

Capacity-building support can be provided through grants, mentorship, and training workshops. However, it is also valuable to create space for peer exchanges between similar organizations with different strengths and experience. Whichever approach is taken, capacity-building support must be based on trust and in line with an organization’s mission and desires. Ongoing communication is thus critical. Capacity building must also be well coordinated in order to avoid overwhelming an organization. A guided self-assessment can help an organization identify its needs and develop a plan to address them.

The resources below offer guidance on delivering capacity-building support in a health and human rights context.

This section of the Toolkit includes resources related to the main justice services that access to justice programs typically provide to their beneficiaries. While legal representation and assistance with documentation are also critical to a program’s justice services, this section of the Toolkit focuses on resources relevant to alternative dispute resolution (ADR) methods and referrals and partnerships.

Alternative Dispute Resolution Methods

Alternative dispute resolution (ADR) methods, including mediation, arbitration, and counseling, are a key component of access to justice programs. They enable program staff to help resolve their clients’ disputes quickly, inexpensively, and without resort to the formal court system. In offering ADR services, it is important that programs ensure their clients and the opposing parties give their informed consent to the process in question. Staff should also consider how agreements will be enforced (e.g., presence of signing witnesses, devising a plan for follow-up, careful drafting of mediation agreements).

Programs should be wary of using ADR in cases involving clear imbalances in information or power between disputing parties, such as where one party is a child or a state official. ADR techniques are also poorly suited to criminal cases, which call for the strong procedural safeguards the formal court system can provide.

The resources below set out further guidance on using ADR to optimize a program’s justice services.

Referrals and Partnerships

Referrals and partnerships are critical for meeting clients’ wide-ranging needs. Programs should refer clients to psychosocial, financial, and health-related support as they deem it necessary. They should also refer clients to other legal services where they lack the expertise, funds, time, or other resources needed to address their problem.

Programs should develop referral guidelines for a program’s frontline staff to use in identifying problems and referring clients to other services. Clients should also receive referral forms they can take with them to the receiving organization, which will be encouraged to report back on the actions it takes as a result. It is good practice for access to justice programs to follow up with referred clients to see whether they acted on the referral and whether it helped resolve their problem. If necessary, training can be offered to key staff at a receiving organization to ensure they are equipped to work with socially excluded groups. Over time, organizations that refer clients to one another often may wish to formalize their relationship using Memoranda of Understanding that clarify each partner’s respective mandates and shared expectations.

A further step is to develop or support formal partnerships between programs having different expertise and different connections to a given population. Partner organizations can exchange knowledge and other resources and coordinate their monitoring and advocacy initiatives. These partnerships need not arise only between similar NGOs; rather, they can also extend to appropriate government agencies in certain contexts.

The resources below set out further guidance on developing referral systems and partnerships.

This section of the Toolkit includes resources on monitoring, or the collection and use of program-level information to strengthen service delivery and evaluate program effectiveness. Case management procedures, program evaluations, and the documentation of human rights abuses in the field all help access to justice programs develop the evidence base needed to carry out or support related advocacy activities. They are also critical tools for persuading donors of the need for support and the impact of services provided.

Case Management

Case management procedures help a program strengthen its internal operations and overall effectiveness. Client intake and case forms are important for helping program staff organize their client selection and track their effectiveness over time. Feedback forms can also be developed to allow clients to rate the quality of services they have received. For all these forms, data should be disaggregated according to age, gender, and other relevant distinctions to help staff determine the extent to which they are reaching their intended beneficiaries. In addition, it is important that case management data be fed back to a program’s frontline staff and inform a program’s ongoing design.

Program staff usually require training to ensure they know what data to collect and how to process it in a way that protects clients’ confidentiality. However, case management need not involve a sophisticated client database; it can easily be facilitated using a simple template form that can be adapted according to program needs.

Some of the resources below offer examples of template forms that access to justice programs can use to develop their case management processes. Others address the value of case management and how to perform it effectively.

Evaluations

Evaluations of program effectiveness help staff members understand and improve the impact of their services on the health and human rights outcomes of their beneficiaries. They also provide support for funding requests. The health and human rights indicators defined at the inception of an access to justice program will help evaluators determine the program’s progress toward its desired outcomes. Performing an evaluation also presents an opportunity for revisiting these indicators and amending them as necessary.

In all cases, evaluations should be carried out with the involvement of the populations a program works with. This helps ensure a program heeds a human rights–based approach and results in more accurate and relevant data.

Not all programs require a comprehensive evaluation of their activities and processes, which can be expensive and time-consuming. Implementers may choose instead to conduct evaluations of individual aspects of program operations, such as its training workshops or referrals processes.

Some of the resources below serve as examples of program evaluations, which implementers and donors may find helpful to consult before conducting their own. Others delve further into the importance of such evaluations and how best to perform them.

Documenting Human Rights Abuses

The documentation of human rights abuses in the field is also a form of monitoring, and one particularly well suited as a springboard to broader advocacy. Members of socially excluded groups can take the lead in this documentation. In roles as paralegals or outreach workers, they can use questionnaires in the field to capture information about violations they observe or learn about. Program lawyers can supplement this data by tracking whether or how the justice system addresses these abuses.

The documentation of human rights abuses should not be undertaken as an end in itself. Rather, programs undertaking it should work always with reference to an advocacy plan that includes well-defined and realistic outcomes they hope to achieve in generating this data. This will help in developing efforts that build on this documentation.

The resources below offer guidance on documenting human rights abuses and connecting this documentation to broader advocacy initiatives.

Advocacy

Advocacy efforts are often an important complement to an access to justice program’s individual-level legal services. Achieving long-term impact in health and human rights generally requires efforts to effect systemic change, in addition to addressing the day-to-day legal concerns of socially excluded groups. Often, the delivery of individual-level legal services can shed light on the systemic issues that a program or its partners may wish to pursue in their advocacy efforts

Broadly speaking, advocacy covers any effort to advance the welfare of socially excluded groups by changing laws, policies, practices, or attitudes that have a negative impact on them. This change is accomplished by presenting evidence and arguments for why it is needed, but also by forging a strong emotional connection with one’s target audience. Advocacy also benefits from the development of strong community movements around an issue, something made easier when a program involves community members in its design and delivery. Fostering coalitions with supportive lawyers, civil society organizations, and international partners can also strengthen a program’s advocacy efforts. It is important, however, that each partner’s role be well defined.

Below are some resources that offer broad guidance on advocacy efforts that access to justice programs can either lead or support. More specific resources can be found in the following subsections.

International and Regional Advocacy

International and regional advocacy can be an additional tool for advancing advocacy at the national level. Access to justice programs can undertake this advocacy by making human rights arguments and drawing on treaty obligations in court cases, starting at the domestic level and then appealing to an international or regional human rights body as needed. Programs can also engage in treaty bodies’ periodic state reviews through shadow reports and letters. However, for gains at the international and regional levels to be meaningful, it is important to integrate them into national-level advocacy.

The resources below offer guidance on the international and regional human rights system and how to undertake related advocacy.

Strategic Litigation

Strategic litigation involves the careful selection of cases intended to achieve broad change at the level of law, policy, practice, or social discourse. Programs selecting cases for strategic litigation should consider a variety of factors, including the severity or widespread nature of the problem, the prospects and expected impact of success or loss, the opportunity to collaborate with partners or allies, and the resources required. The following strategies can be helpful in laying the groundwork for strategic litigation: drafting a fact-finding report that establishes patterns of abuse; networking with medical associations that may provide supportive declarations; and soliciting amicus curiae briefs from United Nations Special Rapporteurs.

Strategic litigation is most effective when connected to community mobilization and other advocacy. Socially excluded groups can help document the abuse in question, motivate potential or actual litigants, and band together to create a pressure point around a case. Whether cases are won or lost, strategic litigation can contribute to raising awareness about human rights abuses, fostering coalitions among committed partners, and motivating other branches of government to take action. It is important that the results of strategic litigation be fed back into a program’s monitoring and other advocacy efforts—for instance, by tracking the implementation of favorable or unfavorable rulings in medical and law enforcement practices and in subsequent court cases.

Some of the resources below detail the progress and outcome of strategic litigation cases, while others offer general guidance on pursuing strategic litigation in health and human rights.

Communications and Media

Access to justice programs may also wish to develop a communications and media strategy as part of their advocacy activities. Print and news media, social media, video documentaries, radio talk shows, and live events in the community can help disseminate legal information to socially excluded groups, promote the accountability of state actors, and contribute to sensitizing the broader public. Communications and media techniques can both strengthen a program’s other advocacy efforts and enhance its overall impact.

Political and legislative developments in a country can be great opportunities to highlight the experiences of socially excluded groups. Where mainstream media is reluctant to cover stories concerning these populations in a balanced way, access to justice programs should try to foster relationships with local journalists and alternative media outlets, as well as make greater use of digital media, including social networks and the program’s own website. It can also help to engage journalists in training workshops that improve their understanding of socially excluded groups and their concerns.

Some of the resources below offer guidance on developing a communications and media strategy in a health and human rights context. Others offer examples of programs that have used a variety of media platforms to support their advocacy.

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