By Gloria Laker – A programme officer at Center for Health, Human Rights and Development (CEHURD)

The COVID-19 pandemic has highlighted grave weaknesses in many countries’ protections for children, including inadequate health care and social protection systems, and the lack of emergency plans for large-scale school shutdowns. The choices which the Ugandan government makes now are crucial, not only to mitigate the worst harm of the pandemic, but also to benefit children over the long term.

Children are not the face of the COVID 19 pandemic since the majority of the affected and infected are the elderly but they risk being among its biggest victims. While they have thankfully been largely spared from the direct health effects of COVID-19 – at least to date – the crisis is having a profound effect on their wellbeing. The United Nations Children’s Emergency Fund (UNICEF) reports that all children, of all ages, and in all countries, are being affected, in particular by the socio-economic impacts and, in some cases, by mitigation measures that may inadvertently do more harm than good. This is a universal crisis and for some children, the impact will be lifelong.

For most children, home represents a source of security and safety but for a few children the opposite is tragically the case. Violence by caregivers is the most common form of violence experienced by children. Children are also often witnessing to domestic violence in a home, the rates of which are thought to have increased in many countries, as detailed in the policy brief of the UN on the impact of COVID-19 on women. ^[1]Such acts of violence are more likely to occur while families are confined at home and experiencing intense stress and anxiety. UNICEF reports that over 60 percent of all children worldwide live in countries where a full or partial lockdown is in place.

Spaces that can be accessed by children to report abuses have been closed. Lockdowns tragically also present an opportunity for child abusers to harm children. Being innocent and vulnerable, children rarely are in a position to report such heinous acts. social work and related legal and protective services for children are being suspended or scaled back at this time of increased need, children no longer have the same access to teachers to report incidents at home, -. Children’s reliance on online platforms for distance learning as stipulated by various schools and the government has also increased their risk of exposure to inappropriate content and online perpetrators that can have the opportunity to negatively groom children. Growing access to digitalization may magnify children’s vulnerability to harm. Children may become susceptible to all kinds of sexual content in the media.

In Uganda, just like in most countries, 95% of sexual abuse happens to a child by a person the child knows or has a familial relationship to. Due to the lock down, children are put in the confined space where the abusers have easy access to them far away from the prying eyes of the teachers and other support staff in schools. There is also likely going to be an increase of teenage pregnancies since children are at home and most are found idling at trading centers with no work to do to keep their minds busy.. Furthermore, the economic impact of COVID-19 in some communities may contribute to school dropouts since many parents will not afford to return their children to school after the lock-down, this may lead to increase in child marriages and also teenage pregnancy and child abuse.

Some of the devastating effects of COVID 19  may affect particularly vulnerable children who may become  susceptible to trafficking  and other exploitation, including sexual exploitation, forced begging, selling goods on the streets, and other child labor. Older children may drop out of school to try to support younger siblings.

Maud de Boer-Buquicchio, Special Rapporteur on the sale and sexual exploitation of children, and Najat Maalla M’jid, Special Representative on violence against children, issued the appeal, emphasising that parents, caregivers, service providers and law enforcement officials all need extra support to minimize the heightened risks to youngsters. This calls for recommendations like the following;

Governments should ensure that adequately staffed and equipped child protection services and law enforcement are available and accessible to all children.  This includes toll-free 24-hours hotlines, free texting services, remote psychological and social services and mobile shelters for minors.  

We should all make significant efforts to support frontline operators in the child protection services, neighborhood and community watchdogs and law enforcement”, the experts said, and equally, empower children to respond to the crisis through peer-to-peer initiatives. Governments should recognize SRHR services as essential in times of crisis, and remove barriers to access. This can be done through, for example, allowing remote access to contraception and abortion services via telemedicine and by allowing pharmacies to provide services. 

Supply chains should prioritise SRH products. This should include contraception and menstrual health items, which are central to girls’ health and autonomy, and a key strategy in addressing child marriage.  Adolescent girls should have access to relevant information about how to prevent and respond to the pandemic in ways they can understand, including in relation to regular hand washing and positive hygiene behaviours, including menstrual hygiene. Community sensitisation should continue as part of distance learning to ensure that parents, leaders and other community members are aware of the importance of education especially for the girl child.  Adolescent girls (and boys) should continue to have access to comprehensive sexual education (CSE), SRHR information and referrals to services as part of distance learning while schools are closed. 

Education and other support workers should receive training to ensure that they have the knowledge and skills needed to recognise and prevent violence against children, and the risk of child marriage, through safe referral practices and protection services.

 When schools reopen, pregnant girls, married girls and young mothers should be fully supported to return to education. This might involve flexible learning, catch-up courses and accelerated learning opportunities. It may also involve checking school enrolment lists by heads of schools to identify and follow up with those girls who have not returned to school.

A version of this article was originally published in the Daily Monitor.

The Center for Health, Human Rights and Development (CEHURD) currently has a career opportunity for a Finance Expert. The ideal candidate should have commitment to work with a dynamic organization working on issues of Health and Human Rights.

The Finance Expert will be responsible for providing high quality accounting and financial services to CEHURD and providing professional guidance and leadership to the finance team.  S/he will be responsible for formulation and implementation of accounting policies relating to financial planning, grants management, sub granting and management accounting. S/He will be responsible for reviewing all financial transactions and reports to ensure accuracy; and that CEHURD’s accounting practices meet the appropriate accounting standards and expectations of different donors.  

Please note that the deadline for application is 2nd October 2020.

by Daniella Khanani

In 2018, a six-year-old girl’s limb was amputated as a result of a medical error. The medical personnel injected the wrong drug in the child’s arm, causing complications. The amputation had to happen in order to avoid further complications that would have led to the girl’s death.

When patients seek health care, they are exposed to potential risks, errors and harm as the little girl’s experience illustrates. For more than a decade, the status of patient safety globally was discussed without clear steps forward. This went on until May 2019, when the World Health Assembly agreed to mark off every 17th September as World Patient Safety Day. The major objective of marking the day is to create awareness about patient safety and urge, especially for the member states to show their commitment in making health care safer.

Patient safety, according to the World Health Organisation, refers to a healthcare discipline that emerged with the evolving complexity in healthcare systems and the resulting harm in facilities. . This basically aims at reducing and preventing the risks, errors and harm that occurs to patients during the provision of health care.

This year, the focus of World Patient Safety Day is on health workers. This is timely because the slogan states, “safe health workers, safe patients”. The COVID-19 pandemic has brought this truth to life since people are wary of visiting medical facilities if they even suspect that some of its personnel have tested positive. Yet there is no running away from medical workers if people are to enjoy the right to health.

One of the elements of the right to health is the quality of care. This envisions the provision of scientifically and medically appropriate health services, including availability of skilled medical personnel, scientifically approved medical equipment and unexpired drugs, to mention but a few.

Statistically, over 2.6 Million deaths occur annually due to unsafe care of patients in hospitals yet over 80 per cent of the harm created in different health facilities can be avoided. The most common reasons for the occurrence of harm to patients include: Medical errors caused by wrong prescriptions of medicines by unskilled or negligent medical personnel; lack of standard procedures for storage of medications that look alike; poor communication between the different health providers; lack of involvement of patients in their own care; and unsafe surgical and transfusion procedures, among others.

In Uganda, the recurring causes of an unsafe environment for patients include the existence of numerous unskilled personnel in the health facilities and low patient involvement in their own safety. The Uganda Alliance of Patients Organisation (UAPO) is one of the entities that deals with the protection of patients’ rights in the country. The Alliance organised a workshop in 2019 and one of the attendees had this to say:

“I had a health condition and though I was in much pain, I did not want to be treated by a general doctor, I wanted a female specialist, the doctor on duty told me that if I wanted to get better, I should allow being treated by any doctor, I insisted that I wanted a specialist, they asked me whether I wanted to get better or see a specialist, they got bored with me and said I had “lugezigezi”, to mean being difficult.

This indicates the likelihood that Uganda health workers at the facilities don’t give the required time and attention to heed to the patients requests. .

With the celebration of World Patient Safety Day, it’s important for the various health workers and the persons in charge of health facilities in the UN Member States, to ensure that credence is given to health workers as this trickles down to the patients.  Supported health workers will be in a better position to support their patients.  Additionally, this would prevent patients from resorting to self-medication as well as unapproved herbal medicines that have dire effects.

Supporting health workers

The Ugandan government needs to ensure that more skilled doctors are deployed in the health facilities because the patient- doctor ratio in Uganda is 1: 25725 whereas the patient Nurse ratio is 1:11000. The inadequately staffed health facilities is one of the reasons for the increased danger to patient safety/This leads to the overworking of medical officers at these stations, making them prone to being rude and contemptuous towards patients, especially when the patients have no money to pay for their services.

There have been numerous complaints by patients of medical officer’s negligent and uncouth behaviour towards them. This is majorly as a result of discontentment and the fact that the government underpays them, in addition to the staffing issues highlighted earlier. The government therefore has to cater for the health workers’ welfare, especially with regard to their pay, which will improve their attitudes. This is an obligation that can only be carried out by the government.

The health sector in general requires more funding than it currently receives. The Constitutional Court in its recent judgment in CEHURD & Others V Attorney General Constitutional Petition No. 16/ 2011, given in August 2020, noted that there was need for the government to increase funds allocated to the health sector. This is in order to reduce the corruption of the various health workers at these institutions and to ensure that all patients are able to access basic healthcare services at each health centre in the country, free of charge.

Once this judgement is implemented, then the status of patient’s safety countrywide, especially the pregnant mothers, will greatly improve. In turn, this will reduce the number of mothers that die due to inaccessibility of quality care.

Patients should be able to afford health services

The commercialisation of health services by the service providers needs to be checked. A few weeks ago, the Ministry of Health announced that Mulago hospital will be charging $65 (approximately Shs240,000) for voluntary COVID-19 tests. With the looming economic breakdown that has been caused by the pandemic and the laying off of most labourers from their workplaces, this fee is unreasonably high and makes the health facility inaccessible to persons who earn less than a dollar a day. This puts the life of persons who would genuinely like to know their status but cannot afford the test, at risk.. Such commercialisation of health services, especially in developing countries like Uganda therefore needs to end in order to ensure that health services are accessible to all.

In conclusion, despite the fact that Uganda as a country is making great strides to ensure the protection of patient’s safety countrywide, much more still needs to be done. Safeguarding the rights of health workers, which include putting in place safety measures to protect them and ensuring that patients are able to access health services and facilities at the lowest cost possible. Once these loopholes are tackled, then patient’s safety in the country will be guaranteed.     

By | Moses Mulumba – Executive Director Center for Health Human Rights and Development.

On August 19, 2020, the Constitutional Court of Uganda passed a landmark judgment in which it pronounced that the Government of Uganda’s omission to adequately provide basic maternal health care services and emergency obstetric care in public health facilities violates the right to health, the right to life and the rights of women as guaranteed under the country’s Constitution.

Uganda’s maternal mortality rate is unacceptably high, at 343 per 100,000 live births. This means that Uganda loses 15 women each day from pregnancy and child birth related causes. 

In its judgment, the Court directed the Government of Uganda to prioritize and provide sufficient funds in the national budget for maternal health care. The Court also ordered, through the Health Minister, that all the health care workers who provide maternal health care services in Uganda be fully trained and all health centres be properly equipped within the next 2 financial years (2020/2021 and 2021/2022). 

This judgement followed a nine-year-long process in which the Center for Health, Human Rights and Development (CEHURD) together with Prof. Ben Twinomugisha of Makerere University School of Law and two other petitioners that had lost loved ones in childbirth, in a manner that they described as violating the rights of women in Uganda. 

When the original petition first came up for hearing in 2012, the Attorney General of Uganda, representing the Government, raised a preliminary objection to the petition on the ground that the case raised a political question, and therefore under the purview of the political organs of government and not the judiciary.   The judges upheld this objection and hence threw out the case in June 2012. Dissatisfied with this decision, the petitioners filed a successful appeal to the Ugandan Supreme Court, which is the highest judicial body, under Constitutional Appeal No. 1 of 2013 In this appeal, the petitioners argued that the Constitutional Court made a legal mistake when they applied the political question doctrine. The Supreme Court was persuaded by this argument and directed the Constitutional Court to proceed to hear and determine the petition on its merits. 

The August 19, 2020 decision from the Constitutional Court is critical for a number of reasons. First, it places the right to health and access to basic maternal health commodities within the realm of rights that are now justiciable under Uganda’s Constitution. Chapter four of Uganda’s Constitution is silent on the right to health, but makes relatively strong provisions on the rights of women under article 33. The furthest the right to health could be inferred in Uganda’s Constitution is under the National Objectives and Directive Principles of State Policy, which are always argued as unenforceable. The Court agreed with the petitioners that Objectives XIV and XX, read together with Article 8A of Uganda’s Constitution, oblige the Government to provide health and basic medical services to the people of Uganda. 

Secondly, the case clarifies what the concept of minimum core obligations means from the perspective of the right to health and access to basic maternal health care services in Uganda. The Court cited the provisions of the International Covenant on Economic, Social and Cultural Rights and the African Charter on Peoples and Human Rights and indicated that the Government of Uganda should ensure that it provides adequate equipment and supplies for preventive, diagnostic, and curative services, including training of medical staff and development of treatment guidelines and protocols for the management of maternal complications. The Court emphasized that the Government cannot under any circumstance justify noncompliance with the core obligations which derive from the economic, social, and cultural rights of the individual and group. 

Thirdly, the Court also addressed the question of how progressive realization for maternal health care should be measured in the context of Uganda. While the Court was mindful that progressive realization takes into account a State’s available resources, it noted that the unimplemented policies and strategies in Uganda’s case, as demonstrated by the petitioners, could not be said to be expeditious and effective steps towards the realization of the right to health. The Court held that it was not sufficient for the State to merely argue that there are challenges impeding implementation of policies. The State had to demonstrate the measures or steps taken to realize the provision of maternal health care services to women in Uganda. The mere expression of sentiments in reports made to attract donor funding could not measure up to the required test of reasonable steps. The Court found that the statistical data advanced by the Government did not demonstrate reasonable measures taken when the leading causes of maternal deaths in Uganda – including haemorrhage, high blood pressure, unsafe abortion, and infection — remained the same. 

In conclusion, despite the long and cumbersome process of litigating this case, the judges finally gave the rights to accessing basic maternal health care services and obstetric care in public health facilities in Uganda a place in the Constitution. 

The Court’s order that the Government compile and submit to Parliament, with a copy to the Court, an audit report on the status of maternal health in Uganda at the end of each of the next two financial years (2020/2021 and 2021/2022) is one of the most progressive steps that the Ugandan judiciary has demonstrated in the history of social, economic, and cultural rights in Uganda. 

This Court ruling demonstrates that public litigation continues to be a viable option for protection of social, economic, and cultural rights, as well as ensuring access to justice, despite being a lengthy process. 

A version of this article was published in the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics Blog and the Daily Monitor Newspaper.