The Irreplaceable Maternal Health Champion -Dr Charles Kiggundu

By Nakibuuka Noor Musisi

Dr. Charles Kiggundu will be remembered for being an extraordinary health service provider, a down to earth person who worked with passion to advance women’s rights. It has been five difficult months of advocating for sexual and reproductive health and rights without this great champion. To anybody that has engaged in advocacy for women’s rights, I am certain you did not miss his presence and input.

– Ms noor nakibuuka musisi

Dr. Kiggundu was and still remains an irreplaceable maternal health champion that the Sexual and reproductive fraternity has ever had. For over 30 years of his professional career, Dr Kiggundu worked to advance sexual and reproductive rights in Uganda. With him, the gap between advocacy and service provision was bridged. He brought on board the insight of the lived realities of service providers with the legal fraternity. 

 “How do we get an ambulance to collect a gravida 10 9 previous scar at 28 weeks with preterm labour from Ndejje Bombo?” Kiggundu Charles’ last message sent on 25th December 2020.

While the world went to sleep on Christmas day, at about 8:48pm on 25th December Dr Kiggundu was thinking about a mother in labour. 

I first met Dr Kiggundu at a meeting organized by the Center for Health, Human Rights and Development (CEHURD) to analyse the laws on sexual and reproductive health and rights in 2012. CEHURD had initiated a campaign on maternal health in Uganda and had sued the government of Uganda for its failure to protect women and their lives despite the natural maternal functional role they played in society. This later came to be known as the famous land mark maternal Health case, Constitutional petition No. 16 of 2011. 

Being a health service provider, Kiggundu together with a team of lawyers played a critical role in addressing questions around maternal health legislation. He made things look easy as he spoke from a humanistic and an informed point of view, citing lived realities of what women go through while accessing reproductive health services. He was the only health service provider who was part of the CEHURD’s Legal support network (LSN), a network of lawyers that provide legal advice and representation to health service providers caught up in the criminal justice system while providing essential sexual and reproductive health services. The advocates under the Network have continued to support efforts towards strategic litigation, legal and policy reform and empowerment of health workers qualified to SRH services in accordance with the laws and policies in Uganda). He later came to refer to himself as a “learned friend” and to others he called himself a “midwife”

What a way to commemorate the international day of the Midwife without Kiggundu! What a life to reckon!  

Tuesday, December 29th 2020 is the day God tested our patience and courage and took away our own Charles Kiggundu. The news of his demise threw us off balance!

“Noor, I have information that is not yet confirmed. I have read on Dr Sabrina Kitaka’s social media page that Dr Kiggundu has passed on. Can I share the screen shot? Do you think we should tell people?” One of the workmates reckoned.

I froze for a moment and failed to respond. I realised that for the past ten (10) years of my engagement with Dr Kiggundu, he had never missed my phone call. I was quick to tell a friend to wait to share the news so that I call him. As the phone rang with no response, I could not feel my legs anymore. My eyes got filled with tears. I knew the information could be true. Before I could hang up, a colleague from the Association of Obstetricians and Gynaecologists in Uganda, Dr Kiggundu former workplace rang me. 

“Noor, I am sorry but your friend Kiggundu has gone to be with the Lord. It is unbelievable that we have lost Kiggundu to COVID-19. It is sad that we could not save the life of a brave man.” He noted. 

The demise of Dr Kiggundu leaves a lot to think about. Early last week, CEHURD filed a case challenging the Attorney General for failing to act on orders of Court given in Constitutional petition No. 16. As we reached out to people to attend to a press conference, I realised we missed an important person, one who would tell a story from his own humanistic experience of delivering women. That person who had mastered the art and intersectionality between the law and health. 

We continue to miss a kind, approachable and welcoming person. He mentored many of us into advocacy and spoke about women’s rights with passion and he always had a story to tell prior to a training. Dr Kiggundu occupied policy development places and his advocacy influenced cases before courts of law.  

He will be remembered for being an extraordinary health service provider, a down to earth person who worked with passion to advance women’s rights. It has been five difficult months of advocating for sexual and reproductive health and rights without this great champion. To anybody that has engaged in advocacy for women’s rights, I am certain you did not miss his presence and input. 

Dr Charles Kiggundu was born in 1965 at Kasana, Luweero District to the late Wilson Kabaale and Nsangi Esther Ruth. He was married to Mrs Ndagire Harriet Kiggundu, left behind 9 children and was laid to rest on 31st December 2020. 

At the time of his demise, Dr Kiggundu was heading the Department of Obstetrics and Gynaecology at Makerere University. He served as a treasurer of the Association of Gynaecologists and Obstetricians (AOGU) between 2004 and 2009. He also served as the Vice President (2008-2013) and President of the Association between 2013 – 2015. 

Your life reigns Charles. Rest in peace, you will be deeply missed by the SRHR fraternity, gynaecologist association and Midwifery Association. 

The writer is the Director of programs at the Center for Health, Human Rights and Development.

What the passing of the National Health Insurance law means

The passing of the National Health Insurance Scheme Bill,  2019, by Parliament provides a glimmer of hope in enhancing access to health services. As can be demonstrated by the Rwandan experience, health insurance is instrumental in increasing access to health.

By Peter Eceru

Providing affordable healthcare to the population of low- and middle-income countries is a persistent development issue.

In 2016, the government of Uganda developed a health financing strategy to facilitate the attainment of sustainable development goal three (SDG3) of ensuring Universal Health Coverage.

This can be achieved by making the required resources for delivery of essential health services for Ugandans available, in an efficient and equitable manner. Revenue collection and risk pooling mechanisms such as insurance are one way of doing this.

The dream is that no one should face the risk of impoverishment when accessing healthcare, nor should anyone forgo medical services because of the financial cost of accessing health services.
Currently, the principal mechanism for funding health services in Uganda is through government revenue tax financing.

Out of pocket payments and contributions by health development partners constitute a substantial amount of health financing. Due to the poor quality of health service delivery, many households are compelled to seek services from private medical facilities, which are very expensive.

The cost of access to health services in private places is a huge burden on most families in Uganda, leading to financial hardships for many patients and their caretakers, and often to long-term indebtedness.

It is currently estimated that the total annual health expenditure is 7.5 trillion. Of this, 15 per cent is from government funding, with 42 per cent from donors and 41 per cent from individuals (out of pocket).

These statistics should be worrying because the government has abandoned its responsibility of providing healthcare in this country to donors and families.

The World Health Organisation (WHO) recommends that out of pocket expenditure on health should not exceed 20 per cent of a country’s total health expenditure, otherwise citizens will stand the risk of impoverishment in case a family member falls ill.

In terms of per capita health expenditure on health, Uganda stands at $53, which is less than the standard $84 dollars recommended by the WHO. In comparison with other East African states, this is the lowest.
 
It is evident that public financing available for the health sector remains the single most important constraint to Universal Health Coverage and overall enjoyment of the right to health. Over the last five years, the budget for the health sector has dwindled from 8.9 per cent of the national budget in 2016/2017 to the projected 6.2 per cent in 2021/22 financial year.

In 2019/2020, the needs analysis by the National Medical Stores (NMS) showed that there was a medicines funding gap of 6 per cent in Health Centre IIs, 56 per cent in Health Centre IVs, and 32 per cent in general hospitals. This means that Health Centre IIs are running with only 39 per cent of the drugs they need while Health Centre IVs are operating with only 44 per cent of the drugs they need.
 
The passing of the National Health Insurance Scheme Bill,  2019, by Parliament provides a glimmer of hope in enhancing access to health services. As can be demonstrated by the Rwandan experience, health insurance is instrumental in increasing access to health. By 2015/16, the health insurance cover in Rwanda had a coverage of 86.1 per cent compared to Uganda’s 2 per cent.

The Bill as passed by Parliament may not be perfect, but provides the best opportunity for beginning conversations on increasing funding to the health sector and catering for the poor and vulnerable groups.

By contributing to the health scheme, their dependants will benefit from the insurance and so will the poor  who are incapable of contributing. These shall be entitled to a defined package of healthcare benefits from government contribution  based on Uganda National Minimum Health Care package.

The Health Insurance Scheme will be an addition to the government contribution to the health sector. Government will continue to invest in health promotion and education; disease surveillance and response; immunisation and any other specialised services outside the National Health Insurance Scheme benefits package and health systems investment.

Government will also continue to finance major health sector infrastructural development, specialised medicines, technology and human resources.


Peter Eceru is a Programme Specialist, Health and Human Rights Advocacy at Center for Health, Human Rights and Development (CEHURD)
A version of this article was published in the Daily Monitor Newspaper on Friday 30th 2021.

The Current Rains present a high risk for Malaria

These rains can lead to flooding, which contaminates water sources and increases vegetation around homes, creating a conducive atmosphere for mosquitoes to breed.

– Katia Olaro, Strategic Litigation program, CEHURD

With all the work that has gone into fighting it, malaria still kills tons of people despite the fact that it is preventable. In an article on news.trust.org a 74 year old Rose Acayo of Gulu District narrates how she had been sleeping under a worn out inherited mosquito net which consequently exposed her to malaria infection. Just as she was recovering, her two-year-old grandchild in her care also fell ill which left her with medical bills she could not meet. How can we draw the line for zero malaria infections as this year’s World Malaria Day theme states?

According to the World Health Organisation 2019 report, Uganda was the third highest contributor to global malaria cases, at 13.7 million cases. Globally, we were the eighth highest contributor to malaria deaths at 5,610 deaths. Malaria therefore remains a high cause of death and financial constraints, considering its non-discriminatory nature in terms of age, gender, race, economic or social status. Transmission lines are very thin and so is the severity, failure to stop its spread will continue causing high levels of poverty among the poor as treatment is a financial burden which they cannot afford.

What we can do

As the world puts the spotlight on the fight against malaria, CEHURD joins the rest of the world to ensure acceptable, accessible, affordable and good quality health for all. As a country, Uganda is making efforts to reduce malaria infections and morbidity in a sustainable way through mass media awareness campaigns, and distribution of free mosquito nets, among other interventions.

In a recent press statement, Dr Joyce Kaducu, Minister of State for Health- Primary Health Care revealed that there are currently no malaria outbreaks in the country. She, however, warned that there is a risk of outbreaks due to the ongoing heavy rains in various parts of the country. These rains can lead to flooding, which contaminates water sources and increases vegetation around homes, creating a conducive atmosphere for mosquitoes to breed.  In order to prevent these outbreaks, the Ministry of Health  urges everyone to step up the implementation of preventive measures. This includes sleeping under treated mosquito nets, getting rid of stagnant water, and seeking medical assistance where symptoms present.

Call to action

It is important to improve overall health care. The government should therefore provide quality assured services for malaria prevention and treatment to all the people in Uganda. This will lead to a good standard of health, which contributes to national development. It is also important to ensure that there is sufficient stock of essential supplies and medicines to minimise possible capacity constraints, and reduce the burden on health facilities in providing services to diagnose and treat malaria.

Change also begins with each of us. Let us do our part in preventing malaria, and if diagnosed, seek medical treatment. While preventing COVID-19 is the current issue, let us not forget that “mosquitoes are not in lockdown, they are still free”, as Mr Jimmy Opigo, a programme manager of the National Malaria Control Programme said.

Tuberculosis Remains One Of The Deadliest Infectious Killer Diseases In The World

CEHURD today shines the light on Tuberculosis (TB) as we commemorate the World Tuberculosis day under the theme “The clock is ticking”. This is a call to action towards commitments made by government to end TB especially in the face of the ongoing COVID 19 pandemic which puts these efforts at a risk. The World TB day is commemorated to raise public awareness about the devastating health, social and economic consequences of TB and to call on government to step up efforts to end the global TB epidemic. According to the World Health Organization (WHO), TB remains one of the deadliest infectious killer diseases and each day nearly 4,000 people lose their lives to TB and close to 28,000 people fall ill with this preventable and curable disease. A total of 1,400,000 people in the world died of TB in 2019 alone.

These glaring statistic do not get any better at home as Uganda is one of the 30 WHO designated countries with a high burden of TB and HIV. In 2019 the estimated incidence was 200 per 100,000 people with a mortality rate of 35 people per 100,000.  It is indeed worrying that the cases of TB have even gone up given the little attention to the disease. According to WHO reports, in 2019 Uganda had 65,897 cases of TB notified which is an increase from 57,756 cases notified in 2018.  There have also been reports of high drug resistance which poses a real challenge to the efforts towards controlling the infection. 87% drug resistance was reported in 2019 alone and this calls for more efforts towards research and investment for new medicines. There is however a lurking risk of patents on new medicines which may make these medicines expensive and thereby becoming a barrier to access for many TB patients.

It should be noted that most TB patients in Africa suffer catastrophic treatment costs making access to quality TB treatment impossible despite the disease being curable. In Uganda it is reported that 53% of TB patients suffer catastrophic costs of treatment as indicated in the WHO factsheets on the TB situation in Uganda. Although government has made some efforts toward the control and management of TB through commitments made under the National Tuberculosis and Leprosy Control Program 2016-2020 which aligns with the WHO End TB strategy, more is needed to ensure equitable access to quality treatment for TB patients.

It is disheartening to see that Uganda’s TB financing indicates very little of Government’s political will to end TB as committed under the Control Program and WHO End TB strategy. In 2019 the national budget for TB control and management was USD 37,000, 0000 of which government only contributed 5% while 56% of the financing was by international partners and 39% of the budget was unfunded. The second health sector development plan 2015/2016-2019/2020 is designed to support  government’s commitment to achieving Sustainable Development Goals which among others seeks to “Achieve universal health coverage including financial risk protection, access to quality essential health care services and access to safe , effective quality and affordable essential medicine and vaccination for all by 2030”.

This is to therefore call upon government on this world TB day to fulfil its commitment towards the END TB strategy by;

  1. Increasing domestic funding towards TB management and control to ensure equitable access to TB quality treatment
  2. Investing in research and development for new and effective medicines to find lasting solutions to drug resistance
  3. To utilize the flexibilities in the Trade Related Aspects of Intellectual Property Rights to ensure that Intellectual Property Rights do not pose barriers to accessing the new and more effective medicines

Teenage pregnancies: Let’s deal with root causes, not outcomes

By Doris Kwesiga

How can we expect girls to aspire to greatness when they are dealing with teenage pregnancies?

Uganda has a predominantly young population, with 53 per cent projected to be under the age of 18 years in 2020 according to the Uganda Bureau of Statistics’ 2020 Statistical Abstract. The country also has a high number of teenage pregnancies, for example among girls aged 15-19 years, 25 per cent have started childbearing, with higher rates in the rural areas according to the Uganda Demographic and Health Survey 2016 report. These rates are worsened by the COVID-19 pandemic lockdown and closure of schools. Different studies and media reports show an increased rate of defilement, pregnancies and early marriages. For instance in 2020, the Daily Monitor newspaper reported that there were 3,430 teenage pregnancies in Kitgum, 1,014 in Kabale, 200 among school girls in Kibuku and 130 underage girls in Lwengo were married, among others. These are the reported cases. Several others remain unreported.

Many of these pregnancies are as a result of defilement. Some are due to engagement in early sexual relationships, sometimes with peers, without accurate information on how to avoid pregnancy, beliefs in ineffective myths, fear of seeking Sexual and Reproductive Health (SRH) services or denial of access when they do. 

The immediate consequences of teenage pregnancies are several but the high mortality rate during birth for teenage mothers, plus frequently conducting unsafe abortions are a serious issue. Other effects, some long term, are the interruption in the girls’ education. Many girls will not return to school, a few may later join vocational education and even fewer will return to the formal education structures they were part of. Other possible effects include contracting HIV, in addition to unemployment and thus lower income. These limit their ability to provide good nutrition and care for their children, thus negative trickle-down effects. 

I would like to commend the Government of Uganda for its recent directive allowing pregnant girls to sit for their final exams that are currently underway, giving them extra time, as well as making provisions for those breastfeeding. This is a positive step in trying to ensure girls are educated and acquire the necessary qualifications. 

However, what next for the girls who then go home to look after their babies? As we continue reflecting on this year’s International Women’s Day theme,“Women in leadership: Achieving an equal future in a COVID-19 world”, we need to reflect on the path to leadership for girls. One of the fundamental boosters to getting into leadership, especially at a national, regional or global level, is education. Although we do have leaders within communities and beyond who may not have gone far with their education and are doing amazing things, to go to higher levels one needs more skills picked up along the education pathway. It also helps with building networks and increasing exposure, among others.

How then can we get girls to aspire to greater things when many of them have had their dreams suddenly brought to a standstill by pregnancy at an early age? While it is good to address the visible issues like ensuring they sit exams, are these not majorly outcomes of policies, approaches and cultures that are detrimental to the lives of teenagers, their babies, families and communities? I believe we need to understand the root causes of the problems and be bold in addressing them. 

One of our focus areas should be on increasing access to SRH information and services among adolescents. For instance, with adequate information about SRH, pregnancy and its negativities among younger women, they would know how to protect themselves and avoid pregnancy in the first place or other diseases like HIV/AIDS, where possible. More so, actually ensuring availability of services to those who make informed decisions to use them, would be helpful. However, this goes hand in hand with passing national policies that are progressive to this end.

Additionally, the issues of Sexual and Gender Based Violence (SGBV) are key and should not be avoided. Part of this could involve engaging boys and men as partners in fighting SGBV, alongside provision of safe reporting avenues for victims, and ensuring access to justice. Indeed, another challenge to adolescents realizing their SRH rights is our cultures and beliefs. However, changing cultures is not an overnight process, but one step at a time could make a difference, starting with sensitising communities that SRH services are not necessarily promoting immorality but also saving lives. 

Ms Kwesiga is a Research Fellow at Center for Health, Human Rights and Development (CEHURD).

A version of this article was published in the Daily Monitor Newspaper on 15th March 2021 page 17.