Annually, 16th June is celebrated as the Day of the African Child worldwide. Uganda is party to the Convention on the Rights of the Child, and ratifi ed the African Charter on the Rights and Welfare of the Child on 17th August 1994. This year, the African Committee of Experts on the Rights and Welfare of the Child, established under Articles 32 and 33 of the African Charter on the Rights and Welfare of the Child selected the theme for the commemoration of the Day of the African Child as “30 years after the adoption of the Charter: Accelerate the Implementation of Agenda 2040 for an Africa fi t for Children”.

Article 14 of the African Charter on the Rights and Welfare of the Child recognises that every child has the right to enjoy the best attainable state of physical, mental and spiritual health. This obligates the state to ensure appropriate health care for expectant and nursing mothers and to develop preventive health care and family life education and provision of service. Access to healthcare services is therefore fundamental to the full realisation of the right to health for children. Unfortunately for most children, accessing healthcare services is dependent on obtaining parental or guardian consent.

Adolescents in Uganda face many challenges related to sexual and reproductive health and rights. Adolescents start having sexual intercourse too early, leading to early and unintended pregnancies, early and forced marriages, unsafe abortions, sexually transmitted infections (STIs) and HIV, ill health, dropping out of school, disability and even death. Adolescents therefore need information on STIs, family planning counselling and services, contraceptives, HIV prevention and care services; maternal health services for adolescent mothers, post-abortion care, psychosocial support, and other services in order to smoothly transition to adulthood.

The Uganda Bureau of Statistics released the 2019/2020 National Household Survey Report which indicates that out of a population of over 41 million people, 54 per cent of Uganda’s population is below the age of 18. Of these, 28 per cent are subjected to child labour and 21 per cent live in child-headed homes. Also 15 per cent of adolescent girls between the ages of 15-19 are married by the age of 15, while one out of every four girls is pregnant or has a child. Equally, 66 per cent of all new HIV infections are contracted by adolescent girls yet only 13.1 per cent use a modern method of contraception. These statistics show that the African child in Uganda is not enjoying the best attainable state of physical, mental and spiritual health.

Early sexual debut and teenage pregnancies often mean complicated births and unsafe abortions are often all too common among adolescent girls, requiring emergency obstetric care and post abortion care. But many teenage mothers do not have access to adequate reproductive health care and die while trying to give life. Uganda has one of the world’s highest maternal mortality rates, with 16 mothers dying every day in pregnancy or during and after childbirth. The traditional practice of child marriage and female genital mutilation also persists in many communities, for example in 2013, Uganda ranked 16th out of 25 countries with the highest rate of child marriages.

The consent question

The international and regional legal frameworks do not directly address the question of consent to medical treatment for children, but recognize the rights, responsibilities and duties of parents and guardians to protect their children, and to provide for them, including ensuring access to health care. They majorly require states parties to respect the views of the child in making decisions that aff ect them, and recognise the concept of evolving capacities and that age should be considered alongside maturity, implying that a higher age does not necessarily imply that an individual has matured.

The age of majority, that is the threshold of adulthood, is generally recognised in national and international law to be 18 years. From the reading of the law, the capacity to consent to medical treatment is a preserve of adults. For a minor to receive medical treatment there is a requirement to have the consent of a parent or guardian regardless of whether the child is a mature minor or an emancipated minor and yet adolescents begin to demand for sexual and reproductive health services much earlier. The national policy framework though is a lot more progressive than the law, when it comes to consenting to sexual and reproductive health information and services.

Inconsistencies in the law

It should be noted, however, that individual laws have inconsistencies on capacity to consent for adolescents within themselves, with other laws as well as with policies. To illustrate this, the Constitution, the Children’s Act, the Penal Code and the Convention on the Rights of the Child recognise 18 as the age of majority. However, the Penal Code diff erentiates defi lement into simple defi lement for children aged 16-17 years, from aggravated defi lement for sex with children aged less than 16 years, thus recognising evolving capacities of minors. The Customary Marriage (Registrations) Act recognise that a child aged 16 can marry (and presumably have sexual intercourse), while the Marriage Act sets the minimum age for marriage at 21.

On its part, the Evidence Act stipulates that anyone above tender years – that is 14 and above – can testify in court. The Children’s (Amendment) Act prescribes that a child can be gainfully employed at 16; can consent to adoption at 14; and have criminal liability at 12. The HIV Prevention and Control Act prescribes 12 years as the minimum age for consent to HIV testing and counselling. The National Guidelines for Research Involving Humans as Research Participants set the minimum age for assent at eight to participate in research, emphasising that such assent or dissent, while it has to be accompanied by consent from a parent or guardian, takes precedence.

The National Policy Guidelines and Service Standards for Sexual and Reproductive Health and Rights – SRHR (2006) emphatically states that no parental consent is needed for a client to access family planning. This is a total deviation from the provisions of the law that sets different ages for different responsibilities. In addition, the policy guidelines and service standards recommend combined oral pills for adolescents who are sexually active and clarifies that oral pills have no age limitation. On its part, the adolescent health policy targets to increase contraceptive uptake among adolescents who are sexually active.

The practice in the judiciary of assessing the capacity of young witnesses for capacity to witness (voire-dire) is a practical illustration that children have the capacity to give views and make sensible decisions. This fact has also been confirmed by SRHR service providers that participated in this study. The findings suggest that age appropriateness is not widely understood or applied in the provision of sexual and reproductive health services information and services to adolescents. The more practical guide has been demonstrated to be service need, defined as sexual activity.

It is also important to note that the law, policy and practice have legitimised the self-determination of mature and emancipated minors in consenting to medical treatment, and by extension, including for fellow minors, at least in the case where minors are parents. As already noted the law allows minors to get married provided they obtain parental consent which brings about a requirement for spousal involvement or consent before a woman can acquire reproductive services.

The ambiguity and restrictions surrounding the requirement of consent have acted as an obstacle to access to health care services for minors, especially for sexual and reproductive health services because most minors start having sex without telling their parents or guardians and by default seek sexual and reproductive health services without consulting their parents or guardians because they consider it to be shameful. Mandating them to provide parental or guardian consent will keep them away from seeking much needed health services.

On this Day of the African Child we therefore call upon necessary stakeholders to harmonise the laws and policies on informed consent for healthcare services to adolescents to improve access while providing guidance on administration of informed consent to young people of diff erent ages and for diff erent healthcare services. There is also a need to develop criteria to guide service providers in assessing capacity to consent, considering all relevant parameters beyond the age of the client. Should this be done Uganda will be well on the way to realising Article 14 of the African Charter on the Rights and Welfare of the Child.

A version of this article was first published in the New Vision on Wednesday 16th June 2021 page 22.

“When COVID-19 came in, as the older child at home I had to go with my mother to wash clothes and fetch water for people to earn money since school had stopped and there was not enough food and essential commodities at home. At this time I don’t think I can go back to school because I have to look for money to cater for my siblings’ education,” Seventeen-year-old Jane narrates. 

By Edith Sifuna

At the beginning of 2020, World Health Organization (WHO) confirmed COVID-19 a public health emergency of international concern and has since caused widespread fears and strains on different systems worldwide. Different guidelines and directives have been put up by different countries, Uganda inclusive, to curb down its spread and as such have affected many systems, children’s rights and welfare being the most affected.

The pandemic has had a profound impact on Children’s rights, majorly their right to an adequate standard of living, right to protection from child labor and right to education among others. This health crisis has aggravated many of the main social and economic catalysts of children’s rights abuse such as limited access to education, early pregnancies, child marriages and poverty. 

This means, as we celebrate this year’s Day of the African Child under the theme, “30 years after the adoption of the Charter accelerate the implementation of Agenda 2040 for an Africa fit for Children”, as economies are shutting down and stay-at-home orders are becoming the new normal, the Government of Uganda needs to come up with strategies to address the unspoken damages caused by the COVID-19 pandemic to children’s rights.  

The pandemic has disrupted access to reproductive health services and information hence exposing many girls to unwanted pregnancies during the lockdown. Most young people have had sexual encounters either consensual or non-consensual, and due to their inability to access reproductive health services, they have ended up pregnant exposing them to dangers of early marriages and other birth complications such as fistula, unsafe abortions and or death.

It is expected that 13 million more child marriages could take place by 2030 which would have otherwise been managed. Child marriages are not only a violation of girls’ human rights and their rights as children, but are also characterized by sexual gender-based violence from their partners. The pandemic has disrupted all efforts intended to end child marriages and this calls for Government’s intervention to implement and strengthen effective child-friendly national legislative, policy and institutional frameworks addressing such challenges as per Agenda 2040. 

The economic pressure has caused such a huge economic burden for a country like Uganda, most vulnerable communities/ families have resorted to forcing their girls who are pregnant into marriage due to income constraints, perceiving them as financial burdens rather than children with a future to realize and rights to uphold and protect. 

Furthermore, the closure of schools/learning institutions due to COVID-19 pandemic has greatly interjected the education for many children, especially the girl child. Many of them will not be able to return to school as a result of increasing pressure to work and meet individual or family needs, let alone stigma for pregnant girls/ young mothers attending school, while others have lost contact with the education system, especially those from vulnerable communities with no option of distance/ e-learning.

When President Yoweri Museveni ordered schools closed on March 18, 2020, this further contributed to an increase in child labour. The pandemic resulted into a massive closure and unprecedented loss of jobs and loss of income in many families introducing many children to the workforce characterized by hazardous and exploitative conditions for survival. Although the Government of Uganda came up with a strategy to distribute food items, most families did not receive any COVID-19 relief and those who received it, it did not sustain them for long. According to the International Labour Organization, the number of children in child labour decreased by approximately 94 million between 2000 and 2016, representing a drop of 38 per cent. A rise in child labour was therefore an inevitable consequence of the pandemic as children become primary bread winners for their families after losing a care giver or their care giver losing a source of income. 

We therefore call upon Government and duty bearers to prioritize children’s rights by protecting them against any challenges that have come with the COVID-19 pandemic such as sexual exploitation and abuse including inducement, coercion or encouragement to engage in sexual activities and customary/ cultural practices that are harmful to their wellbeing, health, education and socio-economic development. 

Measures to mitigate the effects of the COVID-19 pandemic should be put in place such as increasing chances for pupils to stay in school and access to health related information on reproductive health and rights. Keeping girls out of child/early marriages will boost the country’s/communities economic growth saving them on resources and pressure on the health sector that would otherwise be used to manage the effects of early pregnancies such as maternal and infant mortality. 

It is therefore important that the Government of Uganda implements Agenda 2040 whose main objective is to restore the dignity of the African child and establish long-term strategies that will contribute towards sustaining and protecting children’s rights in Africa. This is strongly emphasized in aspiration 2, 6, 7 and 9 of the Agenda 2040 where; Governments need to put in place effective child-friendly national legislative, policy and institutional frameworks; ensure that every child fully benefits from quality education; that every child is protected against violence, exploitation, neglect and abuse; and that every child is free from the impact of armed conflicts and other disasters or emergency situations respectively.   

Ms Sifuna is a Programme Officer in the Campaigns, Partnerships and Networks programme at CEHURD.

FOR IMMEDIATE RELEASE:
WEDNESDAY, 16 TH JUNE 2021
Kampala – Uganda

Today, the undersigned civil society organisations have convened the press to express concerns over access to Oxygen therapy in the country. Oxygen is an essential life-saving commodity which must be accessed in a timely way when needed. It is essential for people with Covid-19 as well as those with other health conditions, such as pneumonia,
cancer and cardiovascular diseases, among others.

Research indicates that access to Oxygen in Uganda has been problematic in the past. Most hospitals
have some Oxygen supply. However, these hospitals continue to struggle with various challenges such as
dependable delivery and effective use of Oxygen. In addition, there is a lack of knowledge and skills among
health-care providers on some aspects of Oxygen therapy, such as commodity delivery and pulse oximetry.
These gaps have been further exacerbated and exposed by Covid-19. This context has an impact on the
availability, accessibility, acceptability and overall quality of Oxygen in the country.

Through the enactment of the National Scale up of Medical Oxygen Implementation Plan 2018-2022 1 , the
Government of Uganda committed challenges for the availability, access and quality of Oxygen therapy in
the country. The Plan aims to increase the availability and utilization of oxygen in higher level facilities
along four main objectives namely: providing a national strategic framework to guide scale up of oxygen
supply and utilization; securing, maintenance and replacement of oxygen therapy and diagnostic equipment
through the regional workshops and the National Medical Store; providing a framework for training of staff
in health facilities on rational use of oxygen and basic maintenance of equipment as well as providing an
advocacy instrument to secure funding to support oxygen scale up interventions. The Plan was projected to
cost an estimated investment of USD 4.3m in the initial year of 2018 and annual costs of USD 1.5m per
year thereafter. However, previously, an uneven electricity distribution, malfunctioning oxygen cylinders,
limited access to pulse oximetry, inadequate staffing as well as lack of continued professional training have
been cited as the biggest impediments to access to Oxygen.

There are currently no official up to date reports that point to the extent of oxygen access during the Covid-19 pandemic but media reports in 2020 painted a very worrying picture in terms of the quality of oxygen
patients received and the lack of availability and accessibility for the same. This year the story has not been
any different.

Oxygen is being rationed and health care workers have to make the difficult choice of who can be prioritized for oxygen therapy or not. It is reported that 14% of Covid patients will need oxygen in hospital
and 5% mechanical ventilation in intensive care. On June 9th 2021, the Daily Monitor reported that 10
patients had succumbed to COVID-19 at Soroti Hospital over lack of oxygen. Moreover, there is also the
issue of health workers being arrested over allegations of theft of oxygen cylinders in some hospitals.

As civil society, we are concerned about the many challenges associated with access to Oxygen for
patients with Covid-19 and other conditions in the country, which undoubtedly have an impact on the right
to health. The situation is indeed worrying especially following the second wave of COVI-19. Public
hospitals especially in the capital of Kampala and major cities and towns have run out of Oxygen supply.
Some individuals and families have been able to meet the very high costs of Oxygen therapy in private
hospitals. Other families have resorted to meeting high costs of monitoring Oxygen levels of their patients
and administering Oxygen therapy at home. These options have come with financial exploitation of patients
and families by private suppliers/providers of Oxygen and related tools and equipment, which are focusing
on profit margins. This has driven patients and their families into catastrophic health expenditures.

Some of these families were able to access Oxygen therapy in public hospitals outside Kampala before the
inter-district travel ban, even though this comes with a risk of Covid-19 spread. But the vast majority of
Ugandans cannot afford to pay for access to Oxygen in private health facilities, as well as getting the
Oxygen therapy from home, yet trotting from one public facility to another in search for Oxygen therapy.
This constitutes inequities and social injustices that infringe on the right to health and ultimately draw the
country further away from the realisation of Universal Health Coverage (UHC).

Civil society is further concerned about access to information on Oxygen therapy. Whereas access to
information on health care is crucial for the realization of the right to health, there a lack of systematic and
consistent provision of information specifically about Covid-19 vaccination and now about centres where
Ugandans can access Oxygen therapy.

The Oxygen shortage exists amid health workers being stretched, failure to observe the Ministry of Health
recommended standard operating procedures including within health facilities, scarcity of beds, and lack of
the right information to guide the general public on COVID-19 management, especially on vaccination and
Oxygen access. Lack of information has made the public resort to using local remedies such as use of
herbs without regulation, posing health risks. Civil Society recognizes Government’s current efforts to
expand the local production of Oxygen and recommends that these issues be addressed along with these
efforts.

As Civil Society, we remind Government of its obligations and call for action as hereunder:

1. Improved access to Oxygen therapy by harmonising the coordination framework at the national
   level to scale up Oxygen availability, supply and use.
2. Protect patients and families by regulating costs of Oxygen therapy, related tools and equipment.
3. Consider a supplementary budget for addressing the current Oxygen availability and access crisis
   in the country.
4. Provide systematic and clear communication on the availability and access to Oxygen therapy,
   including the referral pathways.
5. Strengthen community participation on issues of Oxygen access and use, including the adaptation
   of community approaches such as safe Oxygen use at home to decongest health facilities, reduce
   the overwhelming work load on health care workers and prevent health care setting related
   infections.

Undersigned Civil Society Organisations

Action Group for Health Human Rights & HIV/ AIDS – AGHA

African Institute for Investigative Journalism – AIIJ

Action for Rural Women’s Empowerment – ARUWE

Center for Health, Human Rights and Development – CEHURD

Coalition for Health Promotion and Social and Development – HEPS Uganda

Reach A Hand Uganda – RAHU

Uganda National Health Consumers’ Organisation – UNHCO

For more information contact: info@cehurd.org and copy in tumwesigye@cehurd.org or call 0788-
882809.

1 Ministry of Health. National Scale up of Medical Oxygen Implementation Plan 2018 – 2022.
https://www.health.go.ug/cause/national-scale-up-of-medical-oxygen-implementation-plan-2018-2022/