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.

We are pleased to announce that the problem for the 7th Annual CEHURD moot court competition 2020 is out! Good luck to the participants.

Rose (not real name), a 15-year -old girl of school going age, is now eight
months pregnant and about to deliver after being allegedly defiled by a
paternal uncle. Being an orphan with no immediate family to turn to, she
struggles daily to find decent shelter and meet her basic needs. While she
stays in the care of a well-wisher, her case was only reported to the Police
when she was five months pregnant. The delay in reporting her case was
caused by the alleged offender who has threatened the life of Rose and
anyone that attempts to provide shelter and seek justice for her.

Rose is a classic example of many girls whose stories have been
normalised in our societies. They barely see the light in the corridors of
courts of justice due to other contributing factors that have resulted into
immense physical and mental traumatic suffering.
Many children and young people are yet to receive justice for the abuses
inflicted upon them due to the failure of the different stakeholders playing
their respective roles in the chain of justice.

A gap in access to information
In 2019, 13,613 defilement cases were reported according to the Police
Annual Crime Report. Center for Health, Human Rights and Development
(CEHURD) has so far recorded 21 cases through their Community Health
Advocates and their toll-free line (0800313131). Many of these have not
received sufficient redress from the Police and the Courts of Law. The few
that have been settled out of court, are usually done so in ways that do not
favour the justice needs of the children affected. As such, access to justice
for children in Uganda remains a dream.

Access to sexual and reproductive health and rights (SRHR) information
continues to be among the most controversial and contentious topics in
Uganda’s legal and policy environment. This is because of the competing
approaches in policy debates and legal approaches that range from religious and cultural perspectives that inform our different backgrounds. A combination of factors such as limited access to a wide range of sexuality
information and education for both in and out of school young people, rape,
defilement and poverty continue to account for the numerous teenage pregnancies and child marriages in Uganda.

The lack of information among adolescent girls and young women such as
Rose shows that many of them are not empowered about their SRHR. It
further demonstrates the violence adolescent girls and young women go
through as a result of sexual violence coupled with the lack of SGBV shelters
from where they can receive psychosocial support.

Three out of 10 teenage girls become pregnant before they reach 20 years
of age and over 300,000 babies born in Uganda are born by adolescents
aged 15-19 years. Teenagers in rural areas are more likely to start child
bearing earlier than those in urban areas; 27 per cent and 19 per respectively. It is important to note that one of the major drivers of teenage
pregnancy is an early sex debut among young people. According to the
Uganda Demographic and Health Survey of 2016, 10 per cent of women
and 17 per cent of men have already had their first sexual encounter by the
age of 15.

Pursuing a child-friendly justice system
The current retrogressive regulations and policies coupled with lack of
sexuality education and other reproductive health and rights information and services have exacerbated the already bad state of young people’s health and well being.

As the world commemorates the Day of the African Child today in memory
of the thousands of black school children who took to the streets on June
16, 1976. They did this to protest the inferior quality of education and to
demand their right to be taught in their language. This is therefore a good
opportunity to not only create awareness about the needs of young people
but also to assess the state of their rights in Africa. It is also a good time to
amplify the need for a continued improvement in their education. The day
draws attention to the lives of African children and encourages people’s spirit of abundance to share something special with a child in Africa.

The Constitution of the Republic of Uganda defines a child as any one
below the age of 18 years. This year’s theme, “Access to a child- friendly
Justice system in Africa”, reminds us of the restrictions that our current
policies have. It is also an opportunity for duty bearers to help the Ugandan
child enjoy their right to access to friendly justice, sexuality education and
other health information and services. This access would counter the
problems of unplanned pregnancies, pregnancy related complications and
unsafe abortions that account for a sizable contribution to the maternal
mortalities in adolescent girls and young women. The outbreak of the
COVID-19 global pandemic and its rapid spread throughout the world,
Uganda inclusive, came with increased risk for the population, especially
young people.
The pandemic has equally put many health care systems to the test on the
competence of responding and containing the virus while observing human
rights, particularly the rights of young people.
In Uganda, the state’s response to minimise the spread, has been slow to
address sexual and reproductive health, maternal health, access to justice
and other needs of young people. This is further reflected by the supplementary budget allocations being requested by the institutions of
government to respond to the pandemic. Many of these barely have any
consideration for health and human rights.
Just a few weeks into the outbreak, access to services was already
problematic as a number of rights violations were cited. Numerous media
reports about teenage pregnancies, violence against children, defilement,
and rape, among others were and continue to be reported. All this has been
exacerbated by the lock down as imposed by the President of Uganda which
also caused temporary halting of court proceedings. This has further slowed down the speed at which young people can access justice during this time.
Meanwhile, they continue to experience human rights violations.
This comes at a time when the country continues to grapple with poor SRHR
indicators. This means that young people in and out of school continue to
bear the burden of these negative SRHR indicators. This burden includes
teenage pregnancies, problems accessing essential health commodities like
menstrual health products such as sanitary pads, HIV/AIDS and other STIs
medication, among others. Some of the factors that have contributed to this
state of affairs include the lack of information for young people to enable
them make informed health choices, lack of access to services and all these
are exacerbated by the weak policy and legal environment.

Recommendations
To undo this harm and correct the above indicators, the government needs
to take bold steps in establishing progressive laws and policies that are
aimed at eliminating the various injustices that continue to affect Uganda’s
children;

1. Fast track the passing of the National Policy on Sexual and
   Reproductive Health and implement the recently approved Age Appropriate Sexuality Education National Framework.
2. Fast track the effective implementation of the National strategy on
   ending child marriage and teenage pregnancies in Uganda of 2015
3. Develop comprehensive multi-sectoral strategies to avert the
   challenges and injustices that continue to ruin lives of children and young people and harmonise legislation on marriage to provide for 18 years as the minimum legal age for marriage.
4. Strengthen the enforcement of laws against defilement, rape and
   other forms of child abuse and establish youth friendly spaces at health units.
5. Facilitate the Courts of Law to hear and determine cases defilement,
   rape and other forms of child abuse to enable children access justice timely.
6. Finalise and pass the Adolescent Health Policy to update issues of
   adolescent health in national and global development trends and context.
7. Government establishes provisional shelters at police stations manned by the Child and Family Protection Unit, to avail SGBV survivors temporary accommodation pending medical examination and investigation of cases to avoid frustrations.
8. That the government ensures that children have access to psycho social support to meet their mental health needs. Train senior women and male teachers on how to provide counselling and deal with the different health needs of young people, including implementation of the Girl Child School Re-entry and Retention Strategy to give any girls who may report to school with pregnancies, an opportunity to continue with their studies.
9. Repeal all those laws and policies that compromise the protection and
   welfare of the children.

In a nutshell, as we celebrate the Day of the African Child, creating a child-
friendly justice system in Africa, and specifically in Uganda, requires a multi sectoral approach and meaningful collaborations. This collaboration should not only be among the different government line ministries and agencies but also with civil society organisations, parents, teachers and the media.

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

By Jacqueline Twemanye

On 24th June 2020, CEHURD received a letter from Mayuge Central Police Station – Sexual Gender Based Violence (SGBV) desk, appreciating CEHURD for the support rendered to them in handling SGBV cases. This to us is confirmation that our efforts are not in vain. CEHURD has for years through it’s Community Empowerment Programme together with the Strategic Litigation Programme been engaging duty bearers and sensitizing people at the grassroots about the fight against SGBV. 
CEHURD has further empowered Community Health Advocates (CHAs) at community and district level to advocate for health and human rights. They have also played a big part in providing information on Sexual and Reproductive Health (SRH) issues and human rights violations especially SGBV cases from the community.

“Cehurd has trained us CHAs on how we can work in communities on different cases mainly those concerning violation of human rights. We have undertaken different trainings with police officers which has created a bond between us and police, and has helped solve different case. I appreciate CEHURD for  empowering us” – Mesach, CHA

According to the Uganda Police Force’s Annual Crime Report, gender-based violence cases that were reported and investigated increased by 4% (from 38,651 to 40,258 cases) between 2015 and 2016. UNHCR 2019 November Monthly Protection Update on Sexual and Gender Based Violence (SGBV) indicates that 4297 SGBV incidents were managed, documented and reported between January and November 2019 in refugee settlements.
CEHURD’s drive to sensitize communities on SGBV culminates from the increasing number of these cases. The National Action Plan on Elimination of Gender Based Violence in Uganda (2016-2020) frames the issue of GBV as an urgent development priority and factor to address in achieving Uganda’s Development Goals for 2020.

“For CEHURD to be recognised and appreciated by the Mayuge Central Police Station for providing legal support to survivors of sexual and gender based violence (SGBV) is a great milestone towards ensuring that SGBV survivors access justice through the Courts of Law.” -Ms Ruth Ajalo, Lawyer at CEHURD.The write is a Communications Officer, CEHURD.

The writer is a Communications Officer at Center for Health, Human Rights and Development.