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Across Europe, Roma suffer extreme marginalisation, negatively impacting their health. Many cannot access healthcare at all. For others, the health system is a hostile place. At the same time, good legal frameworks are in place to protect health rights, and there is increasing recognition of systemic violations experienced by Roma. Essential to building on this momentum and closing the gap between standards and implementation is Roma ability to conduct legal advocacy. Since 2010, the Open Society Foundations has supported Roma engagement in Macedonia, Romania and Serbia in the following advocacy strategies: i) legal empowerment, ii) documentation and advocacy, iii) media advocacy, and iv) strategic litigation. This article presents a framework developed to evaluate the effectiveness of these efforts and a baseline against which outcomes can be measured in a few years. The evaluation framework provides a qualitative assessment of Roma capacity, accountability for violations, changes in law and practice, and impact on communities. Findings reveal that that presently Roma lack knowledge of their rights and rarely challenge violations. Accountability in healthcare is practically non-existent. However, where legal advocacy has been used, violations decrease, and power dynamics shift. As healthcare becomes more responsive to communities, it also better serves non-Roma citizens.