Table 5 Constraints on legal empowerment programs

Inconsistency in paralegal capacity

• Paralegals not always supported after training

• Paralegals come from marginalised communities, and as such, may require significant training and support to learn about rights, entitlements, and the details of health policy

• Paralegals may be overwhelmed with case-loads and lack the time and support to think about and address the upstream causes of the cases

• Frequent turnover, especially among volunteer cadres, loss of institutional memory; may be more common among women, who may be focus of the programme

([9, 34, 40, 48, 49, 50, 51, 52]; interviews)

Lack of formalised role for paralegals

• In some countries, paralegals and LE organisations are seeking formal recognition for paralegals in national law, as well as accreditation processes

• When roles are not recognised or ‘registered’ no customised training for them

([50, 52]; interviews)

Even with support, formal judicial or other processes can be inaccessible or infeasibly long

• Even when paralegals understand processes, they can be long; marginalised individuals may lack the time or may lose legal personhood over the course of case resolution or belief that the process will bear fruit

([24, 42]; interviews)

Customary law processes can reinforce social inequities

• In cases where those claiming rights are marginalised, the customary system may reproduce such inequities, especially when they are mediating between two parties, e.g. a poor woman who has experienced discriminatory treatment by a health provider

([49]; interviews)

Poor state capacity to respond

• Even where public officials are motivated, they may lack the resources, incentives, and/or expertise required to respond to complaints

• Making demands on an ill-equipped bureaucracy can result in failure or even retaliation

([9, 24, 53]; interviews)

Unclear entitlements

• When rights and entitlements are not well enumerated (e.g. what drugs should be available at primary health care level?) then use of legal empowerment is impractical

([34, 44]; interviews)

Social hierarchies

• Pervasive discrimination and other norms can undercut individual and institutional responsiveness to complaints from groups/communities (e.g. drug users, ethnic minorities)

• Paralegals from minoritised communities can face risks and stigma when approaching individuals with more power as well as state institutions

([35, 40, 45, 47]; interviews)

Donor priorities not aligned with community need

• Many programmes are donor driven and are siloed from broader state processes

• Programme accountability is typically upwards to donors rather than to communities

• Short term programmes aiming for long term change face challenges

• Funder reluctance to support NGOs to take up politically sensitive issues

([49, 50, 54]; interviews)