Unresolved Maternal deaths

The Constitutional Court of Uganda on 30th September, 2019 formally heard Constitution Petition No. 16 of 2011. This case was filed in 2011 by the Center for Health Human Rights & Development & others against the Attorney General, challenging the unavailability of basic maternal commodities, the unethical conduct of health workers in public health facilities and failure of government to provide emergency obstetric care services among others.

On 2nd October, 2018, the President of the Republic of Uganda, His Excellency, Yoweri Kaguta Museveni officially commissioned the Mulago Specialised Women’s and Neonatal Hospital which was constructed to offer specialised services to women and children. On 18th September, 2018, Dr. Ruth Acheng, the Minister for Health made a ministerial statement on the operationalization of Mulago Specialised Women’s and Neonatal Hospital wherein she stated that there will be user fees charged for the services offered at the Hospital. The pay policy put in place categorised services offered at the hospital as Standard, VIP and VVIP services.  Furthermore, a waiver committee to determine who qualifies to access free services at the facility was to be put in place. This is an act of retrogression in the progressive realisation of the right to health and access to medical services. This prompted the Center for Health, Human Rights & Development to file Miscellaneous Cause No. 235 of 2019 against the Attorney General challenging inter alia the act of turning a public service into a private hospital at the Mulago Specialised Women’s and Neonatal Hospital.

It is over eight years since Constitutional petition No. 16 of 2011 was filed but there has been no redress from Court. Maternal deaths continue to happen in both public and private health facilities; some of these deaths are reported, others are concealed especially those happening in private health facilities.

In private health facilities, the vice is on rise leading to high maternal deaths; there are several instances of maternal deaths due to negligence and we highlight a few in this article. On 28th September, 2018, a mother admitted at St. Charles Lwanga Hospital in Buikwe District died along with her baby because of the hospital administration’s failure to refer her to another hospital for better management. The medical personnel supposed to attend to her were not on duty and the cashier tasked to provide the medical bill for payment before the discharge and referral of the mother was absent.

On 13th March, 2019, a mother lost her child at Alshafa Modern Hospital in Jinja District because the doctor supposed to attend to her reached the hospital late and the insistent requests by her to be referred to another facility were rejected. On 12th July, 2019, another maternal death occurred following the actions of a doctor at Butiru Chrisco Hospital in Manafwa District who failed to refer an expectant mother for better management because that referral would cause his hospital to lose funds which were being paid by USAID under the Uganda Voucher Plus Activity. On 20th October, 2018, a mother admitted to Kibuli Hospital underwent a cesarean section and spent over four hours in the theater; she was wheeled out of theater and placed in the ward while still unconscious. She was unattended to for more than 6 hours despite the fact that she was bleeding and eventually died.

These continuous maternal deaths raise the big question on who bears responsibility for all these deaths. Under Objective XX of the National Objectives and Directive Principles of State Policy of the Constitution of Uganda provides that the state shall take all practical measures to ensure the provision of basic medical services to the population.

The right to life is guaranteed under Article 22(1) of the Constitution of the Republic of Uganda. Clause 4 of the Uganda Medical and Dental Practitioners Council Code of professional ethics states that a practitioner shall not violate the human rights of a patient, the patient’s family or his or her caregiver. Furthermore, a practitioner is not to carry out any specific actions that constitute a violation of bill of rights enshrined in the Constitution of Uganda and international human rights law. Are health workers really aware about the provisions in the bill of rights or other international human rights laws in respect to health?

In Uganda, the health profession has many bodies that regulate the different medical professions; the Medical and Dental Practitioners Council is a body corporate established by an Act of Parliament – the Medical and Dental Practitioners Act, Cap 272 responsible for licensing, monitoring and regulating the practice of medicine and dentistry in Uganda. The Nurses and Midwives Council established by the Nurses and Midwives Act, Cap 274 mandated to train, register, enroll and discipline nurses and midwives of all categories in Uganda. The Allied Health Professionals Council is established under the Allied Health Professionals Act, Cap 268 mandated to regulate, supervise and control allied health professionals (Clinical officers). When a violation of human rights in respect to health particularly through medical negligence arises, complaints ought to be lodged with the appropriate bodies.

How then do these bodies that regulate the health profession and other stakeholders contribute to the reduction in maternal deaths in Uganda? The Uganda Law Society has partnered with the Uganda Medical Association in a number of activities for example on 30th August, 2019, the Uganda Law Society organized the first ever  Health Awareness Day for lawyers and invited the President of the Uganda Medical Association who came along with a team of doctors to speak to the lawyers that had gathered. This partnership is a strong partnership and an avenue for lawyers, medical professionals and other stakeholders to learn and embrace a human rights-based approach to tackling issues that arise in respect to the right to health.

The Ministry of Health is a key stakeholder in respect to health-related matters since it bridges the gap between the people and the medical profession since it supervises both government and private health facilities within the country.  Many public health facilities in the country have no medicines, basic services, no trained health workers to attend to people seeking health services including women seeking maternity services. In the absence of immediate intervention by medical professionals, the rates of maternal mortality continue to increase and issues surrounding maternal mortality are not addressed or resolved.

In light of the above, there is a wide gap that needs to be filled by different stake holders to fight this vice and reduce maternal mortality in Uganda so as to achieve social justice in health.

Namaganda Jane Kibira and Ajalo Ruth

Center for Health Human Rights and Development. (CEHURD)

Understanding Health and the Law

Health and the law is an emerging area of legal practice beset with a visible lack of national jurisprudence. The relationship between the law and health starts from the definition of the two terms; The World Health Organization (WHO) defines ‘health’ as a ‘state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity’ and the law is defined as ‘the system of rules which a particular country or community recognizes as regulating the actions of its members and which it may enforce by the imposition of penalties’. The marriage of the two gives us Health and the law which refers to those enforceable laws established by government and applied to people for the purpose of building a healthy society.

In Uganda, health and the law did not exist as an independent area of practice until recently. It was largely embedded within the law of tort under medical negligence, constitutional law under quarantines for reasons of public health and safety and in criminal law under imposing sanctions on health workers for committing negligent acts. Health and the law has slowly garnered force in India and South Africa as seen in the 1998 case of Soobramoney v the Minister of Health (KwaZulu Natal), the Constitutional Court said that the government was justified in restricting access to kidney dialysis, because of the high cost of this type of care, and the need for the government to have reasonable plans for spending its health care resources.

In the 2002 case of Minister of Health v Treatment Action Campaign, the Court stated that the government was wrong to restrict access to the antiretroviral medicine, nevirapine, that is effective in reducing the risk of mother-to-child HIV transmission and ordered the government to make the medicine available to pregnant women living with HIV.

The principal legislation informing health and the law in Uganda is found in the Constitution of the Republic of Uganda, 1995 which creates an obligation on the State to ensure that all Ugandans enjoy opportunities and access to health services and ensure provision of medical services to the population. It can also be found in acts of Parliament which include the Public Health Act Cap 281, Insurance Act 6 of 2017, the Medical and Dental Practitioners Act Cap 272, the Nurses and Midwives Act Cap 274, the Allied Health Professionals Act Cap 268, Mental Treatment Act Cap 279, Venereal Diseases Act Cap 284, National Medical Stores Act Cap 207 and National Drug Policy and Authority Act Cap 206.

Health and the law has also seen a slow but sure growth in the courts of law where the Courts have set precedent in several cases such as the cases of Joyce Nakacwa vs. Attorney General Constitutional Petition No. 2 of 2001 which was unfortunately not heard on its merits, there is also Sarah Watsemba Goseltine and Baby David Goseltine vs. Attorney General High Court Civil Suit No. 675 of 2006 which discusses medical negligence. Medical negligence contributes to death, damage, injury of patients.

Although the legal framework provides for redress against medical negligence in form of civil and criminal law, these laws are inadequate because it is hard for a victim to prove medical negligence against a medical professional let alone extract payment of damages from the government.

The case of CEHURD vs AG Constitutional Petition No. 16 of 2011 challenges inter alia the non-provision of basic indispensable maternal health commodities in government health facilities but the Petition was struck out for raising political questions but this decision was overturned by the Supreme Court in Constitutional Appeal No.1 of 2013 and the petition was forwarded back to the Constitutional Court to be heard on its merits. On 30th September, 2019, the Constitutional Court heard arguments for and against this matter which was adjourned for a ruling which will be delivered on notice. There is also a growing connection between medical negligence and the right to health as seen in the cases of CEHURD & 3 ORS vs Nakaseke District Local Administration Civil Suit No. 111 of 2011 and CEHURD & 2 ORS vs Attorney General Civil Suit No. 212 of 2013 which discuss the right to health and medical negligence.

Health and the law has now expanded with the growing subscription to medical insurance and the increase of private actors in the health sector and some of the issues presented before Court now include; rights of persons with mental disabilities, tobacco control, sexual reproductive health, access to medicines, access to health information, quality of health care in private health facilities, businesses in the health sector among others.

There are also issues of professional misconduct/unethical behavior by health professionals, medical negligence, unhealthy and unsafe working environment in health facilities which jeopardize patient safety. The non-appreciation of the distinction between rights violations, ethics and medical negligence have also been prominent.

AJALO RUTH

ajalo@cehurd.org

Centre for Health, Human Rights and Development (CEHURD)

Mental health and young people

Suicidal behavior has existed throughout human history, but due to several complex factors, it has increased gradually in all parts of the world and, in the past few decades, has reached alarming statistical levels. Close to 800 000 people die due to suicide every year, this is one person every 40 seconds.

It is important to emphasize that it is a topic that has attracted the interest of most fields of study for centuries, which is why it has been explored by philosophy, religion, medicine, sociology, bioethics, law, and psychology, among other fields. It is often believed that it is only adults who exhibit suicidal behaviors, but it should be made known that many children and young people engage in this kind of behavior as a result of violence, sexual abuse, bullying and cyber bullying.

A student in his final year pursuing Medicine at Makerere University this year committed suicide for losing his savings from his first year over 15 million shillings. Well most of you are wondering why a university student in his final year can decide to commit suicide for just 15 million shillings, it is very possible. A lot of focus is put on the adults forgetting that young people too face psychological torture that can mentally perturb them. Assume this student had someone to talk to about this, maybe he would be among those that are to graduate. Let us help society learn about the signs and symptoms, risk factors and warning signs, and ongoing research about suicide and suicide prevention because the effects of suicide go beyond the person who acts to take his or her life: it can have a lasting effect on family, friends, and communities.

Suicide is a global public health problem that deserves the attention of all the actors in the field of mental health, including scientific and professional organizations, organizations for mental health users and their families, and universities. It deserves particular attention from government and national health authorities, since it is their responsibility to craft policies and directives aimed at establishing strategies to prevent suicide and promote the public’s mental health. Not leaving out the role of both print and audiovisual communication media and of social media, their participation can have positive as well as negative effects, depending on how they address this subject.

There are numerous complex factors that contribute to suicide, but what is most important is that all of our actions must be geared toward prevention. Accordingly, it is important that trans-sectoral and interdisciplinary action be taken by all of the actors involved.

Getting people to talk about a subject that tends to be a taboo and about which many hold mistaken and prejudiced ideas will help the community to learn about the risk factors so that they can identify and learn to address them.

Suicide is preventable and can therefore be avoided, which is why all of our efforts and public policies should focus on prevention. However, oftentimes, people who suffer from mental illness lack access to mental health services, sometimes because there are no services in their community and sometimes because they must wait months to be seen.

By: Faith Nabunya

Communication Associate at CEHURD

Press Release: Landmark Hearing on Maternal Deaths Proceeds in Uganda’s Constitutional Court

(KAMPALA) Today a civil society coalition of more than 40 health rights organizations welcomed the start of Constitutional Court’s hearing of Petition 16 of 2011. This health rights case, filed on March 4, 2011 by the Centre for Health, Human Rights and Development (CEHURD), was triggered by the preventable deaths of Jennifer Anguko and Sylvia Nalubowa, two women who died while giving birth. The activists claim that Uganda’s government is failing to fulfill fundamental rights guaranteed under the Constitution, resulting in an epidemic of preventable deaths of women. Constitutional Court dismissed the petition in 2012, on the grounds that the Court lacked standing to hear the case on its merits. CEHURD appealed to the Supreme Court (Constitutional Appeal No. 1 of 2013) and on September 30 2015 the Supreme Court ruled that Constitutional Court’s dismissal was incorrect, and must hear the petition.

More than 16 women die daily in Uganda from preventable causes including hemorrhage, sepsis, unsafe abortion, obstructed labor, and pre-eclampsia. There has been no statistically significant decrease in maternal mortality in Uganda for the last eight years (source: Uganda Demographic and Health Survey 2016 Key Indicators Report, page 58). Uganda’s severely high rates of teenage pregnancy also contribute to preventable maternal deaths—25% of young women 15-19 in Uganda is pregnant or a mother, one of the highest rates in sub-Saharan Africa, a statistic that has remained unchanged since 2006 (source: Uganda Demographic Health Survey, 2016).

The primary defense argued by Government over the last 8 years the case has been in Court is that Uganda is too poor to fight maternal mortality effectively. Recent evidence contradicts that claim: the FY2019/20Appropriations Bill contains a 20.9% expansion in the overall budget compared with FY2018/19. The increase is largely for Security (increasing from 6.3% to 9.3% of the budget) and Works and Transport (increasing from 14.6% to 16.2%). The Health budget share shrinks from 7.1% to 6.4%. By contrast, “Classified Expenditure and Assets” increased dramatically from UShs 934 billion in FY2018/19 to UShs 2.582 trillion in FY2019/20—the same size as the entire health budget.

Compounding the crisis caused by government under funding, are a series of recent policy shifts. In 2018 Government shut down free maternal health care services provided by Mulago National Referral Hospital, and instead opened a USD25 million super specialized private women’s clinic with no public wing. The private hospital charges exorbitant user fees most pregnant women cannot afford. Although government a decade ago pledged to provide emergency maternal health care services at local level by equipping Health Center IVs with the surgical theatres, health workers and commodities needed to save pregnant women’s lives, that promise has been broken, forcing pregnant women to rely on the national referral hospital.

The corrective actions being sought through this Constitutional Court Petition would help remedy these gross inequities, according to the advocates. “Deaths from maternal mortality could be largely eliminated in Uganda,” said Noor Musisi of CEHURD. “What we are missing is political will.”

Contact: Noor Nakibuuka Musisi, CEHURD 0782 496 681 or Asia Russell, Health GAP 0776 574 729

What a shame! Stealing from the sick?

What a shame! Stealing from the sick? – Nakibuuka Noor Musisi

On the evening of June 17th 2019, I fell short of words. For the first time I watched television past 11:00pm. It was a shocker watching what I refer to as “a well-planned game” happening in my country, moreover in the health sector. I thought to myself, who is behind this, why steal from the sick? All these questions and thoughts ran in my mind. I waited to get responses from the video in vain. What a shame!

Efforts to put an end to this vice have been watered down by the government’s non responsive attitude towards clear evidence like the famous NBS /BBC video titled “stealing from the sick” https://www.youtube.com/watch?v=d41_BaVygQI.  It is unfortunate that Uganda has shamelessly remained silent over this the ordeal, an indicator, in my opinion that the State has failed to account back to its citizens.

I have worked in the civil society health – human rights sector for close to 10 years. Throughout these years, I have interacted with various civil society organizations, government entities, private actors and development partners among others. These have had various approaches towards ensuring that the end beneficiary whom I will refer to as a rights holder does access better health care services wherever they are. The approaches used have been budget advocacy, trainings, human rights-based approach empowerment of communities to seek services, holding district health assemblies, talk shows, community dialogues, community score cards to mention but a few. While these approaches seem diverse, they all point to ensuring that service provision gets better, that you and I enjoy health care in this country.

On several occasions, and for this particular ordeal, social media has been used by people to express their dissatisfaction.  It is such a powerful tool that information does not only reach a wider part of society (nationally and globally) but the target people. I am very certain that the leadership in this country did view, read and analyse the video as well as reactions from people. My expectation was that the state would act. Unfortunately, to date, we have not received a formal communication from the government on what happened and why. What this means to me is that the state has breached the contract it has with its citizen- the social contract. What a shame!

Like any other citizen, and as a health service user as well as a rights holder, my so many questions have never been answered. I am hesitant to conclude that sections/ agents within the government are involved in stealing our medicine- we the sick. What a shame! Again, one would be hesitant to question why the investigative team was rather stopped (the video is not complete), put under police custody and no case has ever been opened against them.

These happenings have a very huge impact to the health sector now and in the years to come. I am certain that Uganda has all the expertise, resources and tools to put these vices to an end. It is very unfortunate that as a country we are silent yet health facilities have continued to deteriorate at the expense of these few people. Shame my beloved country, shame my government, shame, shame shame!!!. There is still room for improvement, something can always be done and this call goes out to the State to act.

The writer is a human rights advocate and a lawyer at the center for Health, Human Rights and Development (CEHURD).