Gender-based violence is defined as ‘any harmful act that is perpetrated against a person’s will، and that is based on socially-ascribed (i.e. gender) differences between males and females. Gender based violence manifests in form of Sexual violence (rape، sexual assault، sexual harassment), Physical violence (hitting، slapping، beating), Emotional violence (psychological abuse), Economic violence (denial of resources) and Harmful traditional practices (forced marriages، female genital mutilation).
Gender based violence is one of the most severe forms of gender inequality and discrimination in Uganda and remains a critical Public health global health problem and one of the most pervasive human rights violations of modern time. It is an issue that affects women disproportionately, as it is directly connected with the unequal distribution of power between women and men thus, it has a profound effect on families, communities, and societies as a whole. These Gender inequalities limit the ability of women and girls to fully participate in, and benefit from development programmes while formal and informal institutions, such as religion, family, marriage as well as social and cultural practices play a major role in perpetuating gender inequalities in Uganda.
Gender based violence undermines the health, dignity, security and autonomy of its victims, yet it remains shrouded in a culture of silence. Violence often remains hidden, as survivors fear for their safety or are stigmatized. Victims of violence can suffer sexual and reproductive health consequences, including forced and unwanted pregnancies, unsafe abortions and miscarriages, traumatic fistula, sexually transmitted infections (STIs), preterm birth and stillbirth.  It is also associated with mental health outcomes, including posttraumatic stress disorder, anxiety and depression, and an increased risk of ideated or attempted suicide, or suffer other health consequences.
Physical, sexual, or psychological harm by a spouse or partner is a major factor in maternal and reproductive health. Women suffering from intimate partner violence are less likely to adopt contraception and are 46 to 69 percent more likely to have an unintended pregnancy. Abusive partners are 83 percent more likely to coerce a pregnancy, through forced intercourse or birth-control sabotage, and women in abusive relationships are 2.7 times more likely to seek an abortion. Women suffering from abuse are twice as likely to have a miscarriage and their children are 3.9 times more likely to have a low birth weight, while infant diarrheal diseases are 38 to 65 percent more common in children born to mothers suffering from abuse. As CEHURD, we believe that Improving the equity and value of women and girls is a very important means of improving population health.
According to the UDHS for 2011 and 2016, the trends show that sexual violence is higher among the women. While Current husbands were found to be the leading perpetrators of both physical and sexual violence. Major improvements in GBV are attributed to increased awareness campaigns by both state and non-state actors in enforcement of the GBV policy. However, more needs to be done to further fight both sexual and physical violence (DFID, 2016).
Uganda is a state party to nearly all international human rights conventions as well as relevant regional protocols with explicit provisions for gender equality and recognize Gender based violence as a form of discrimination. The 1995 constitution and broader normative and legal and policy frameworks reflect global standards, are strongly supportive of Gender Equality (GE) and, within recent policy documents, address gender-based violence (GBV) explicitly.
Uganda was active in the post 2015 development process; it was one of first countries to integrate the principles and goals of the Sustainable Development Goals (SDGs) into its National Development Plan (NDP) even before the global documents had been finalized. Both gender equality and GBV are featured in Uganda’s second NDP and evident in diverse sectoral plans. The government signed onto, endorsed and ratified principles which are enshrined in the UN convention on elimination of all forms of discrimination of women (CEDAW), The Beijing platform for action, Global Agenda 2030 Sustainable Development Goals (SDGs). The women’s access to SRHR is integrated in Uganda’s vision 2040, and it adopted the National GBV policy and Action plan 2016, and the national male engagement strategy in 2017.
The National Health Sector Plan reflects a rights-based approach and acknowledges international conventions. 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. Similarly, the interconnected work on ending child marriage and teenage pregnancy is framed by the new dialogue on leveraging for development the demographic dividend of a large, youthful population.
The government of Uganda has developed the National SRHR/HIV/GBV Integration and Linkages Strategy to guide integrated programming and resource mobilization. The strategy highlights opportunities and entry points for SRH/HIV/GBV integration. An Assessment and studies on integration including the National SRHR/HIV/GBV Linkages and Integration Rapid Assessment; a facility assessment on SRHR/HIV /GBV integration and an assessment on SRHR/HIV/GBV integration in Global Fund programming. Results of these assessments are being used to inform resource mobilization efforts, revision of the national SRHR/HIV/GBV Integration and Linkages Strategy and development of standard tools and job aides to support service delivery.
GAPS IN INTERLINKING GBV AND SRHR
However, despite the strong normative framework on Gender inequality, including regulations, guidelines, protocols and even district level laws and ordinances, actual implementation of the policies has been challenging. The SDGs can only be achieved if Uganda as a state understands and accepts their ultimate responsibilities to fulfil obligations to international treaties and agreements and must performs them in good faith, state obligations entails compliance by government units across different sectors. Eliminating gender based violence requires the obligation of states on the principles to Respect rights of women, Protect rights of women, Promote rights of women, Fulfil rights of women and Obligation of means and results.
There is a challenge in implementation of existing laws and policies, several laws remain pending while others require amendment and other development of comprehensive implementing policies and regulations. To more effectively protect the rights of women and girls, address discriminatory implementation of laws and ensure effective SGBV /SRHR integration.
- Marital rape is not criminalized under the laws of Uganda due to delays in passing the marriage bill 2017 which bill was initially the marriage and divorce bill 2009.
- The laws of evidence and penal code provide that for any allegation of sexual assault there must be corroboration by the third party making it very hard for women to prove husbands assault of his wife in the private space like bed rooms.
- The HIV prevention and control act requires all victims of sexual violence, pregnant women and the partner of a pregnant woman to undergo routine HIV testing, which is a barrier to many women accessing SGBV and SRHR services and can expose women to increased violence particularly intimate violence.
Allocation of resources to implement laws policies and regulations, institutional and staff capacity and accountability mechanisms remain weak. The development of the social development sector plan (SDSP) provided a framework or all ministries, departments and agencies including health, justice, police among others to priorities integration of gender equality issues in their annual plans and budget reinforced by gender and equality certificate. However ministries departments and agencies and the decentralized structure do not adequately priorities financial resources for GBV SRHR integration and there is a gap in the budget allocations for gender equality.
The national SRHR guidelines and service standards were revised but were recalled at ministerial level. While the national sexuality Education framework does not cater for girls outside of formal education and resources for its implementation have not yet been secured.
There is a Gap in the legal literacy capacity of ministries, departments and agencies and the sub national governments to engage in participatory –planning and gender – responsive budgeting and to implement GBV legislation and services. The lack of multi –sectorial mechanisms, with linkages to civil society, to oversee financing and accountability for GBV /SRHR programming hinders implementation.
There is a weak implementation of the right based approaches and insufficiencies in programming and implementation of gender responsive interventions for access to justice. Health and police personnel at sub national level are still not aware of the changes to the PF3 form, and lack training in filling of the form yet in many service points, the police forms 3A and 24 are not available
State actors working around GBV prevention and response remains under funded, with further work needed to build capacities of institutions to deliver GBV response and prevention programmes and integrate SRHR services. This lack of capacity continues to hamper efforts to implement legislation and policy. Funding is often allocated at the national level and does not trickle down to sub national levels. This has been evidenced by police officers being constrained with fuel to facilitate arrest or investigate GBV cases. Health workers running out of emergency contraceptives and cotton swabs to facilitate examination of SGBV survivors yet still the long distance from communities to courts of law is often prohibitive to the optimal access to these services.
While coordination and referral mechanisms exist, they are often in operative and unfunded at sub national level and ineffective in ensuring continuum of support for survivors of Gender based violence. The district chain- linked committees (DCC) coordinate action within the JLOS sector, including cases of Gender based violence, but are often in active at the district level due to insufficient funding.
Stock out of SRHR commodities and Lack of access to SRHR services and essential medical services for survivors of Gender based violence. Most up country health facilities across the country lack necessary medical supplies and capacity to treat survivors of violence, particularly sexual violence. This includes shortage of rape kits, PEP, emergency contraception and pregnancy kits, and medication for treatment for STI. Yet girls and Women and girls usually lack access to information and experiences on the barriers and stigmas which exclude the from receiving essential services which leaves them and adolescent girls vulnerable to unwanted pregnancies, unsafe abortions and exposure to other sexually transmitted infections.
Structural weaknesses within the health sector and lack of human resources make it difficult for it to fulfil the requirement under the law. Few licensed medical practitioners are willing to appear in court as expert witnesses yet still they are a rarity in rural and urban Uganda and they have so far generally been unprepared and unforthcoming to fulfil their new additional duties as expert witnesses before the Courts. There is a lot of bureaucracy in terms of facilitating the health workers to court to testify and the burden is shifted to the poor survivors who cannot afford such charges leading to frustration of cases.
The country has few operational GBV shelter homes for rehabilitating victims of gender-based violence (GBV).and worse still those available are facing financial constraints and closing temporary. In the shelters, survivors get legal aid, psychosocial services, temporary accommodation and referral to GBV survivors’ services. Government through the MGLSD should recommend for should CFPU reception centers to upgrade to shelters and allocate budget for the same to have them furnish and offers services to GBV survivors.
- Ensure the implementation of the various legislation and policies on GBV and SRH at the national and sub national levels. This requires joint actions between non-state actors addressing the links between gender-based violence and SRH working together with state institutions to advocate for the implementation of the same all levels.
- Social, economic and legal gender inequalities in Uganda need to be addressed in line with the Bill of Rights as provided for the constitution of the republic of Uganda. Doing so would reduce the disproportionately high levels of GBV affecting the reproductive health of women in Uganda.
- Government response should be more strategic and holistic in order to safeguard the lives of Ugandans with effective early warning systems. The mitigation strategies should include the health sector and provision of psychosocial support to the survivors. Mechanisms to rehabilitate the perpetrators of violence should be defined, tested and evaluated for feasibility and sustainability. The government should take the lead in implementing these measures.
- Safe houses for GBV survivors to recover or as transitional stops have been reported to respond to the immediate needs of survivors. One-Stop-Centers such as those found in Rwanda, Malawi and South Africa which include a police station, hospital and a safe house for survivors all under one roof should be emulated.
- Incorporate a health sector response within the inter – sectorial response to gender-based violence. A health sector response that is comprehensive and based on women`s rights is an essential and strategic delivery point to respond to gender based violence. This will enable early screening and detection of gender based violence and quicker intervention.
- Provide treatment and care for victim- survivors who are at the crisis point and reduce maternal deaths and the burden of disease caused by gender based violence. Health sector responses to gender based violence can be systematic within health facilities. Every health service provider should under g a regular and consistent gender sensitization to appreciate issues of gender based violence
- The government should ensure universal access to family planning information and services and invest in a country wide sensitization program on reproductive information.
- The state should remove all legislative barriers that prohibit young people especially unmarried young women from accessing sexual and reproductive health services and family planning.
- The state should come up with concrete plans for training health service providers and implementing the Standards and Guidelines for the Reduction of Maternal Morbidity and Mortality from Unsafe Abortion in Uganda
Prevention campaigns on GBV/SRHR conducted in Uganda often do not adequately consider the reality of the daily lives of Ugandan women and the difficulties they face in gaining control over their own sexual lives. The rampant spread of HIV/AIDS and the high prevalence of GBV can only be stemmed if the subordinate position of women is acknowledged and addressed. The study results indicate that adolescents and women, among other sub-groups are more vulnerable to GBV. Inefficiencies within the supply chain system which limit effective delivery of both GBV and SRH commodities, with frequent stock outs of commodities experienced across health facilities, Inadequate training of health workers and Community Health Extension workers in integrated SRHR/ GBV services delivery, Socio-cultural barriers including harmful cultural practices and value systems which over look violence against women and girls, limited coordination and effort by health workers to offer services beyond what clients seek for at health facilities and inadequate referrals, Inadequate Human resource to support GBV/SRHR integration should be addressed to effectively integrate GBV and SRHR
The relation between Sexual reproductive health and GBV is mainly through intimate relations that are influenced by socio-cultural factors including gender power imbalances. It is evident that social factors such as the unfavorable economic position of women, and the inability to insist on condom use make Ugandan women unable to negotiate the timing of sex and the conditions under which it occurs. Thus, they are rendered powerless to protect themselves against HIV infection and other sexually transmitted infection, unwanted pregnancies.
- The national male involvement strategy for the prevention and response to gender based violence in Uganda. https://uganda.unfpa.org/sites/default/files/pub-pdf/15_03_18_%20MALE%20INVOLVEMENT%20STRATEGY%2024%20JULY%202017.pdf
- Understanding the critical linkages between Gender based violence and sexual reproductive health rights. www.arrow.org.my .
- The World Bank. Pp 219-244. 3. Amuyunzu-Nyamongo, M. & Kiragu, K. (2005) Gender roles and sexual behavior in Africa. AIDS in Africa: Scenarios for the Future, UNAIDS.
- Bourdieu, P. (1998). La domination masculine. Paris: Editions du Seuil.
- Cornell, R. W. (1995). Masculinities. Cambridge: Polity Press.
- Cornwall, A. & Lindisfarne, N. (1994). Dislocating masculinity: gender, power and anthropology. In A. Cornwall, & Lindisfarne (Eds.), Dislocating masculinity. Comparative ethnographies (pp. 11-47). London and New York: Routledge.
- Spotlight initiative to eliminate violence against women and girls. country programme document.
- WHO/UNAIDS/UNICEF (2010) ‘Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector the country- Progress Report 2010.
- WHO/UNAIDS/UNICEF (2011) ‘Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011.
- The state of sexual reproductive health and rights in Uganda emerging issues JS8_UPR26_UGA_E_Main.pdf.
Compiled by Nakalembe Judith Suzan
Community Empowerment Programme
 ASIAN PAIFIC RESOURCE AND RESEARCH CENTER FOR WOMEN .WWW.ARROW.ORG
 (World Health Organization، Global and Regional Estimates of Violence against Women، 2013، http://bit.ly/1oTfGVG ).
 The government decentralized policy and local government act (1997) transfers responsibility and authority for delivery of many public services to the district local government including health.
By Judith Nakalembe – Programme officer and Lawyer at Center for Health, Human Rights and Development (CEHURD).
CEHURD aims at reducing the effects of unsafe abortion among Adolescent Girls and Young Women (AGYW) using the Harm Reduction Model (HRM) in the district of Buikwe. The HRM is an evidence-based health and human rights framework that prioritizes strategies to reduce harm and prioritizes health in situations where policies and practices prohibit, stigmatize and drive common human activities underground.
It is against this background that CEHURD seeks for a consultant to develop policy briefs on the current legal provision of abortion.
See details attached
Improving Maternal Health and Promoting Safe Motherhood with Three-Pronged Approaches: Education, Human Rights and Access to Reproductive Health Services in Uganda
Sefinew Demlie Gezahegn
(BSW, MA, MS)
Open Society Institute’s Civil Society Professionals Program Fellow (2019/20) at CEHURD
The purpose of this paper is to understand the extent of maternal health problems in Uganda. The paper will explain the major causes of maternal death, complications of maternal health, access to reproductive health services, and interventions to improve maternal health and promote safe motherhood.
Maternal health is the overall health of a mother during gestation, pregnancy, childbirth, and for a period afterwards. Maternal death is “the death of a woman while pregnant, or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy or its management (from direct or indirect obstetric death), but not from accidental or incidental causes” (Roback Morse, 2014, par. 6).
According to the World Health Organization (WHO) (2019), approximately 830 women die daily from preventable causes associated with pregnancy and childbirth. In 2017, the Maternal Mortality Ratio (MMR) in developing countries like Uganda was found to be 462 per 100,000 live births whereas the MMR for high income countries was 11 per 100,000 livebirths (WHO, 2019), a stark 451 difference.
In the East African region, major barriers such as inaccessible Sexual and Reproductive Health (SRH) care services contribute to maternal deaths. To prevent maternal mortality and morbidity, access to comprehensive abortion care and contraceptive services are largely needed. In this East African region, it is estimated that 2.7 million abortions take place annually; however, a majority of these abortions are unsafe and oftentimes a cause for maternal mortality and morbidity (Cleeve et al., 2016).
In 2016, the Ugandan Demographic Health Survey (UDHS) indicated that Uganda has shown slight progress in reducing maternal mortality which was 368 deaths per 100,000 live births compared to 428 maternal deaths per 100,000 live births in 2011(UDHS, 2011; UNICEF Uganda, 2019). In 2016, approximately 15 pregnant Ugandan women were dying every day because of direct causes such as hemorrhage and hypertensive disorder.
Complications (such as high blood pressure, gestational diabetes, anemia, infections, breech position) during pregnancy and following childbirth remain a common cause of maternal mortality. Almost all of these complications develop during pregnancy (Atuhaire & Kaberuka, 2016). In Uganda, hemorrhage (42%), prolonged labor (22%) and unsafe abortion (11%) are the major causes for maternal mortality (Böhret, 2018).
Notably, the above statistics are attributed to subsequent consequences such as violence, lack of education and sexuality education, unplanned and unwanted pregnancy, early marriage, and vulnerability from infections/HIV/AIDS (United Nations Population Fund, 2011). All of which result to lack of assistance and women failing to receive support from their respective communities. In this regard, three major challenges have been identified that inhibit improving maternal health which encompasses; generally weak health systems, inadequate funding for reproductive health, and lack of respect for women’s and girls’ rights at large.
Supporting Opportunities for Ugandans to Learn (SOUL) Foundation (n.d.) indicated that women in rural Uganda are suffering from several barriers to access lifesaving maternal healthcare, mainly associated with delays. These delays include delay in reaching care (lack of transport and road infrastructure), delay in receiving the appropriate and adequate care (lack of skilled birth attendants at delivery), and delay in decision making to seek care. This clearly indicates causes of maternal death are largely preventable with appropriate interventions such as well-equipped facilities, access to trained midwives at facilities, strong referral systems, among others.
Institutions like the Center for Heath Human rights and Development (CEHURD) have over the years worked hand in hand with partners to curb existing barriers to women’s access to maternal health services, safe motherhood and Sexual Reproductive Health and Rights. In 2019 as part of the commemoration of International Safe Motherhood Day, under the theme “Midwives for Mothers” CEHURD held a “National Dialogue on the State of Maternal Health in Uganda” that took place at the Golf Course Hotel in Kampala. This national dialogue was attended by members of Parliament (specifically those from the Parliamentary Committee on Health), officials from the Ministry of Health, Reproductive and Adolescent Health Divisions, Civil Society Organizations, and various coalitions among other stakeholders.
The welcome remarks by Ms. Nakibuuka Noor Musisi, Director of Programs at CEHURD, had an emphasis on Uganda’s alarming Maternal Mortality Ratio(MMR) currently projected at 336/100,000 live births (approximately 6,000 maternal deaths in a year) caused by hemorrhage, hypertensive disorders of pregnancy, malaria, HIV/AIDS among others (Uganda Demographic and Health Survey 2016). Notably, uneducated girls are more at risk of teenage pregnancy (35%) compared to girls with a high school education (17%). According to UNICEF (2015), it is projected that 45% of girls in Uganda get into early marriage even though the legal age for marriage is to be 18 years old (Sofia Garsbo, 2018). In this regard, 40% of girls get married before their 18th birthday where one out of 10 gets married before the age of 15(Girls not Brides, n.d.). Child marriages in Uganda continue to be high and the second worst in the East African community following South Sudan. Contributing factors for child marriage specifically in northern Uganda include lack of education, cultural and social beliefs, and high rate of poverty (Save the Children Uganda, 2018).
Participants at the National Dialogue identified common challenges they are facing in providing maternal health services in Uganda, which include lack of dignity and respect at facilities, limited human resource, unaffordable costs, and lack of medicine. Furthermore, emphasis was on delays as a fundamental cause for maternal mortality due to lack of blood, lack of transportation, inadequate staff in facilities and delay in decision making. As an intervention, National Dialogue participants came up with solutions such as blood donations (community blood harvesting), institutionalizing Maternal and Perinatal Death Surveillance and Response (MPDSR), increasing quality of care initiatives, high stakeholders’ engagement and referral systems to address maternal mortality in Uganda.
Another essential part of the dialogue was evaluating the implementation of the 2011 Parliamentary Resolution on Maternal Health. The resolution incorporated issues such as maternal death audits; Abuja Declaration of 15% of Gross Domestic Product (GDP) budgeting for health sector; midwifery training curriculum; addressing the shortage of medical professionals; community empowerment to fight against maternal mortality; and parliament annual reports on the status of maternal mortality. In order to realize these essential themes, members of parliament, representatives from the Ministry of Health, Civil Society Organizations, and other coalitions agreed to continue working hand in hand on improving maternal health by providing alternative policy options and working with communities closely.
All in all, the state of maternal health is a pressing global concern specifically in Uganda due to low funding for health care services, insufficient infrastructure (roads, electricity), lack of enough skilled health workers, inadequate supplies in facilities, lack of education and sexuality education, cultural practices and beliefs. As a result of such disparities, maternal mortality remained high.
Safe motherhood can be realized through providing human rights guarantees, such as the right to access to full information and quality services to make informed decisions without barriers (be it legal, political or health related) and free from any violence or intimidation activities. Essentially, the prevention of maternal death and illness is a basic human right, and most importantly, it is a social justice issue. Every woman is entitled to the right to life, safe maternal health care, non-discrimination, and equality. In order to improve maternal health and reduce maternal mortality, the following approaches are recommended.
Approach One: educating women and girls offers the opportunity to delay marriage and the first birth until adolescents are physically, psychologically, and economically well prepared to be healthy mothers. Given these points, health information and contraceptive services should be available for teenagers and adolescents to help them make informed decisions for a delayed marriage and first birth. Empowering women and girls through education further benefits them to claim their rights (including their sexual reproductive health rights); escape from the poverty trap; and essentially to protect themselves from traditional and cultural practices.
Approach Two: access to facilities with adequate supplies, skilled health workers (gynecologists, midwives, nurses, obstetricians, and medical officers) and infrastructural developments (roads) must be available for coordinated standby maternal health services. Solving access issues lessens maternal deaths caused by preventable delays. Furthermore, skilled health professionals should attend all childbirths specifically to avoid hemorrhage (severe bleeding) and infections after birth.
Approach Three: partnerships and stakeholders’ active engagement is an invaluable resource in creating safe motherhood in communities. In order to reduce the maternal mortality ratio to less than 70 per 100,000 live births to achieve the Sustainable Development Goals (SDGs) by 2030, the collaboration of major stakeholders is largely needed. They together may host maternal health and safe motherhood awareness raising programs such as TV shows (dramas), radio talk shows, campaigns on social media and brochure distributions throughout Uganda. They also can push the government to formulate and implement policies to reach out the most vulnerable and indigenous communities in the realization process of safe motherhood and improved maternal health.
In conclusion, integrating of these 3 approaches will go a long way in the realization of safe motherhood in Uganda.
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