I recently attended a community paralegal training on promoting accountability in health care delivery in Makeni, Sierra Leone. During the training, a community paralegal named Elizabeth Massalay talked about bringing her niece to a clinic in Moyamba district to receive immunizations that the government provides free of charge thanks to the Free Health Care Initiative (FHCI), which offers free health services to pregnant and breastfeeding women and children under five. Mothers queued for free immunizations, painting a hopeful picture for a country that ranks 180 out of 187 in the 2011 Human Development Index and where almost one in three children die before reaching the age of five.
However, against this promising backdrop, Elizabeth saw that the nurse was demanding six cups of rice from each mother before providing the immunization. Elizabeth was witnessing how breakdowns within state institutions—including absent nurses, improper user fees, and “leakage” of up to 30% of FHCI drugs (according to government and UNICEF statistics)—undermine health care delivery. Responding to such breakdowns requires an understanding of health policy and regulations—what the state must provide and to whom—and knowing where and how to apply pressure when the state fails to do so.
In Sierra Leone, community paralegals (lay persons trained in the law) are on the front line of navigating administrative accountability channels. Although Sierra Leone has only about 200 practicing lawyers, paralegals provide basic justice services in approximately 36% of the country’s chiefdoms. Paralegals can contribute something unique and important to health service delivery, beyond what health workers alone can offer. This is because effective health care delivery requires not only adequate staff and health inputs—it also requires accountability.
Elizabeth intervened, telling the nurse that any charge was improper under the FHCI, and remained at the clinic the rest of the day to monitor the nurse. In the long run, a paralegal like Elizabeth might engage the village health committee, a local accountability structure tasked with ensuring effective clinic operations, and make unannounced visits to the health clinic to monitor FHCI services.
Yet Elizabeth’s story also illuminates the challenges in achieving “legal empowerment” in service delivery. To greatly impact services, community paralegals must tackle injustices with origins far more complex than the actions of an individual nurse. What if the nurse has inadequate training? What if, despite the FHCI’s promises, the nurse lacks drugs? Such community-level problems are challenging to diagnose, monitor, and solve, and they often pit paralegals against powerful interests in the community and beyond. Ultimately, paralegals should aspire to become less essential in solving these problems by engaging citizens in the avenues for redress and emboldening citizens to engage institutions themselves. Such empowerment is essential to the broader and exigent missions of ensuring quality, sustainable health care delivery under the FHCI and creating a robust civil society to hold government accountable.
The World Bank’s Justice for the Poor program, with support from the Nordic Trust Fund, is working with Namati to track paralegals’ work. The program will assess whether paralegals improve service outcomes and serve as a useful complement to more traditional accountability tools such as scorecards, community compacts, and non-financial awards that the government of Sierra Leone is also evaluating with the World Bank’s support.