Activists to Pursue Maternal Health Case Against Government

By Andrew Green

Kampala — A petition backed by over 50 NGOs and charging Uganda’s government with failing to prevent the deaths of expectant mothers was thrown out by the constitutional court on 5 June, but the petition’s supporters plan to appeal.

The constitutional court argued that upholding the petition, which urges the government to boost health services, would have forced judges to wade into a political issue that was outside their jurisdiction.

However, the petitioners said the court relied on outdated international law in making its decision and overlooked its constitutional obligation to protect Uganda’s mothers.

Principal State Attorney Patricia Mutesi, who argued the case for the government, said the petition “was asking the court to do the work of the parliament in reviewing the efficiency of the health sector”.

The petition, which centred around the deaths of two mothers (Sylvia Nalubowa in central Uganda and Jennifer Anguko in the north), got nationwide media coverage when it was filed in March 2011. It said the women’s deaths could have been prevented if the health centres where they died had had “basic indispensable health maternal commodities” and if health workers at the facilities had not neglected the two women.

In throwing out the case, the justices suggested the petitioners seek an order from the high court compelling a public officer, such as a government health worker, to carry out his or her duties, or to request compensation for individual deaths from the government.

On 14 June the petitioners filed a notice informing the Supreme Court and the Attorney General’s office of their plan to appeal against the constitutional court decision; they have 50 days to finalize and file the appeal.

Rights denied?

Moses Mulumba is the executive director of the Centre for Health, Human Rights & Development (CEHURD) – the group that originally pushed the petition forward. He said the court’s decision not to wade into a “political question” was based on antiquated law and failed to address the fact that women were being denied rights guaranteed under Uganda’s constitution.

“I think it was very wrong for the judiciary to rely on very old United States jurisprudence to inform their decisions on clear violations of human rights,” he said. The courts should focus on upholding the constitution, he said, instead of “hiding under old political doctrines.”

In a country where statistics show that 16 women die every day from childbirth complications, the activists generally charged the government with perpetuating a maternal death rate that is “unacceptably high”. Ultimately, they are looking for the government to invest more in the country’s health system, to improve care and make sure critical resources are always available.

Valente Inziku, Anguko’s husband and one of the petitioners, said he watched his wife bleed to death as he tried to get nurses at the hospital to attend to her. “When she started bleeding seriously, the only the thing [the staff] did was they came and they told me… to clean the blood,” he said.

“People are disappointed, but we are not stopping there,” said Sylveria Alwoch, of the Uganda National Health Consumers Organization, one of the groups that supported the petition. “We are encouraging people to always report those cases. They shouldn’t be demotivated… They should still have that courage, that vigilance to speak out and bring out those issues.”

Win or lose, CEHURD’s Mulumba said;

the petition had raised awareness of the country’s ongoing maternal deaths and helped rally people around the cause.


Is Criminalization of HIV Transmission Effective? Swedish Case Reveals Why the Answer Is No

By Marianne Mollmann

Earlier this month, a 31-year-old woman in Sweden was sentenced to one and a half years in prison for having unprotected sex without disclosing to her partner beforehand that she is living with HIV.

Even a perfunctory news search reveals that this is not the first time the Swedish justice system has applied criminal sanctions to potential HIV-transmission. In January, a 20-year-old man was sentenced to eight months in prison for having unprotected sex without disclosing his status. In December 2006, a 34-year-old woman got two months, and in January 2003, a 32-year-old woman one year. All of these sentences also required the person living with HIV to pay monetary damages to their former sex-partners.

For anyone who cares about human rights from a health and discrimination angle, these cases raise multiple red flags.

For starters, consensual sex between consenting adults should, in principle, never be subject to government control or regulation. Moreover, the criminalization of HIV transmission has multiple negative outcomes. It leads to distrust in the health and justice systems; it can discourage people from seeking to know their HIV status; it adds to the stigmatization of those living with HIV; and it is ineffective in bringing down HIV transmission.

In fact, UNAIDS (the Joint UN Programme on HIV/AIDS) recommends that governments limit criminal sanctions for HIV transmission to cases where all of three conditions are met: the person charged 1) knows he or she is living with HIV; 2) acts with the intention of transmitting the virus; and 3) actually transmits it. UNAIDS also recommends that cases of such intentional HIV-transmission should be tried under generic criminal provisions for bodily harm or assault, and not under HIV-specific provisions.

Public health and human rights activists are clear on this. That is why the Swedish Embassy in France was defiled with paint-filled condoms in protest against the 2003 ruling. And that is also why my own reaction to the ruling was to declare it “bad” over twitter, a statement that was re-tweeted several times.

A closer read of the cases highlighted in the Swedish media, however, leads me to reconsider, at least in part.

If the media-accounts are accurate, the Swedish government has, in fact, partially followed UNAIDS recommendations. The convicted individuals all knew their HIV status and the cases were brought under general criminal law provisions on grave assault, physical abuse and attempt to cause physical harm. So far so good.

The two remaining questions — intent and actual transmission — are more difficult to gauge.

Consider this.

In most of the cases, the convicted person either has multiple convictions over several years for the same thing, or the conviction is based on multiple unprotected sexual interactions with different partners without disclosure. It is perhaps valid for prosecutors to ask if, absent proof of intent which is hard to produce, the fact that an individual living with HIV repeatedly and knowingly exposes someone else to a deadly virus shouldn’t count for something.

Further, actual HIV transmission may not be the only harm caused. The 20-year-old convicted man was charged with having unprotected sex with eight women, none of whom ultimately ended up HIV-positive, though they all claimed to have suffered severe emotional trauma as a result of the experience. In cases of domestic violence we often ask prosecutors to consider emotional distress as real harm, so why require actual transmission in order to prove harm in this case?

Then again, consider this.

The 20-year-old man was born HIV-positive and is being charged as an adult also for those unprotected sexual encounters that occurred when he was a teenager. He was initially placed in solitary confinement, seemingly because of his HIV status.

Also, one of the convicted women alleged she had been raped. The male partner produced evidence to the contrary and she later withdrew the allegation. Nevertheless, coercion and fear are highly relevant when it comes to decisions about how and when to disclose HIV status. Research indicates that many women, in fact, are reluctant to disclose their HIV status because they quite legitimately fear abuse.

And with regard to actual harm caused, it is at least possible that the ramped-up attention to the cases have contributed in some part to the severity of the emotional distress of the sex partners.

It is, of course, reckless to knowingly expose anyone to real danger, also through potential HIV-transmission, even if the danger ultimately does not materialize. This is a notion the UNAIDS recommendations to a large extent fail to acknowledge.

But the highly publicized use of the criminal law in Sweden to punish those living with HIV for being timid about their health status does not make it easier for anyone to disclose. So perhaps the real question with regard to any government’s approach to HIV transmission should not be whether it follows UNAIDS recommendations, but rather if it is effective.

An educated guess says not so much.

This article was first published on RHRealityCheck.


The sick hospital system in Uganda

The death of Cecilia Nambozo in the labour ward of Mbale Hospital,
last month, mirrors the massive problem health centres are facing all
over the country. She is just one in 16 who die everyday during

The government last Wednesday outlined a six-point ‘fire-brigade’
response to salvage the country’s ailing health care system after the
death, during labour, of a primary school teacher in Mbale District
sparked public fury countrywide.

On September 6, when Cecilia Nambozo died, 15 other expectant women also passed on, their deaths unreported, since the Health ministry says 16 would-be Ugandan mothers lose their lives in labour daily. Thus the 5,840 annual maternal deaths backpedals the country’s drive to achieve Millennium Development Goal Five of reducing maternal
mortality by three-quarters by 2015.

Nambozo’s case was not particularly unique or the first one to stir
anger. In August 2009, residents attacked Mityana Hospital after
Sylvia Nalubowa of Bussujju village died with her baby during labour
allegedly because staff wanted to take a bribe before they could

Even in the Mbale case, it was reported that medics asked for
Shs300,000, which relatives of the deceased never paid, although the
allegation is yet to be substantiated. Government’s blue-print issued
by Health minister Christine Ondoa says their preliminary
investigations showed Nambozo died due to “negligence” by the health
workers. She said: “Investigations are still going on and that
disciplinary action will be taken on all health workers implicated in
the incident.”

Already, police arrested senior medical staff that were on duty at
Mbale Hospital that fateful day and the Director of Public
Prosecutions is studying the evidence on file against them to
determine if they should be formally charged in court and prosecuted.
Dr Ondoa, herself a consultant paediatrician, in last Wednesday’s
press statement announced measures to crack the whip on all errant
medical staff while promising to make medical supplies available.

Experts say such willy-nilly pronouncements that render health workers
culpable may be music to the citizens’ ears, but masks the systematic
decay, which is at the core of failing service provision at public
health institutions.

Already public health institutions such as Mbale Hospital routinely
report stock-out of essential drugs and supplies alongside shortage of
already poorly-remunerated but overwhelmed staff. It is understood
that some 12 midwives that the Health Service Commission recruited and posted to Mbale Hospital declined to take up the job.

Our investigations show that on the day Nambozo died, 11 hours after
reporting to the health facility, the hospital was apparently being
manned by interns. It had had no sutures (stitch threads) for more
than two months and every expectant mother was required to come along with stitching threads.

The only medical officer on duty, an obstetrician, Mercy Nassali, had
been in the one-bed theatre from morning and exhausted by the evening hours when the condition of Nambozo, who initially appeared likely to give normal birth, worsened. The obstetrician, with the help of one intern doctor, was at the material time attending to a woman with arm prolapse.

Arm prolapse is a condition during which a baby’s hand presents first
to obstruct labour, making it one of the “most serious” delivery
emergencies, according to Dr Rogers Ayiko, a maternal and child health
specialist, working for Doctors with Africa (CUAMM), an Italian health
He said such an emergency can make the unborn baby
suffocate and is usually treated as a first priority to handle. Two
other interns continued handling all patients presenting with labour
complications while one midwife monitored the progress of nine other
women who had reportedly given birth at the hospital.

Dr Daniel Zake, a gynaecologist at Nsambya Hospital, a private
facility, said every maternity bed should be attended to by at least
two midwives. Health workers at public health facilities, however,
told us a midwife at a government facility handles anywhere between
four to 10 expectant women in a day.
This appears to have been the case with the lone midwife on duty at Mbale Health facility on September 6, who was taking care of nine new mothers, resulting in fatigue and diminished quality of care.

Health Minister Ondoa in a separate interview on Friday, said that the
World Health Organisation (WHO) has lately revised its definition of a
health worker to mean a combination of a doctor, nurse and midwife.
Under the health agency’s new guideline, such a cadreship of medical
professionals should handle 1,000 people. “If a country has less than
2.5 health workers per 1, 000 population, that country is in crisis,”
Dr Ondoa said. Uganda is operating significantly below the new WHO

The minister said the country’s present situation is “bad because we
don’t have enough health workers, but it is looking the future is
going to be good”. Why? Dr Ondoa said in the month of September alone, they recruited 150 health professionals and posted them to health facilities most in need and a total 1, 000 new health workers are
likely to be employed by end of next year if ongoing negotiations with
development partners succeed.

It is understood Nambozo’s uterus ruptured with the overweight baby
around 7pm and she wasted away fast because there was no blood stock at both Mbale Hospital and the Regional Blood Bank to transfuse her.
Her relatives had not bought the required sutures either. The National
Medical Stores that manages the budget for drugs and medical supplies
of all public health facilities had allegedly not supplied the
post-surgery stitch threads to the hospital in more than two months.

This newspaper understands that when Nambozo’s health deteriorated
sharply, the health workers decided to pick sutures from another
patient and rushed her into the theatre. Already acutely anaemic, she
was pronounced dead at 8.30pm.
Her demise, which Ministry of Health Spokesperson Rukia Mbaziira attributes to false starts by the health workers, exposes the many inadequacies and failures in Uganda’s health systems separately documented in an ad hoc report prepared by the Foundation for Human Rights Initiative (FHRI).

Asked why the government has accused the health workers of negligence when they appeared stretched to the limit amid a dearth of medical supplies, Ms Mbaziira, who admitted “some health system challenges”, said it was incumbent upon decision makers there to summon staff who were off-duty once it determined the workload was overwhelming.

In the meantime, she said, the ministry had decided to absorb all of
this year’s intern doctors on one-year temporal arrangement until the
Health Service Commission formally recruits them at a later date.
FRHI’s 2010 report titled, “The Right to Health Care in Uganda”, shows
the government is in default on its commitments to health; its
allocation of 9.8 per cent of the national budget this fiscal year to
the sector, down from 10.3 per cent in the 2009/10 FY, contrasts with
the 2001 Abuja Declaration that obliges African states to dedicate at
least 15 per cent of their revenues, excluding donor financing, to

Uganda had prior to the declaration accelerated its allocation to
health as a share of the national budget from four percent in 1997 to
nearly 17 per cent in 2000 before dropping the vote to below 12 per
cent in 2003 and 2006.

It was within the period of higher funding to the health sector that
the country shone internationally as a poster child for fighting
HIV/Aids, although much of the money came from donors. That
notwithstanding, the positive results showed in part that increased
investment in health – when officials do not pilfer the resources for
self-enrichment – improves citizens’ welfare and productivity. But
this financial year, the government has engaged a reverse gear and
slashed the Ministry of Health allocation to just 9.8 per cent of the
national budget, injecting more money instead into infrastructure

The Regional Network for Equity in Health in East and Southern Africa
(EQUINET), which monitors the implementation of the Abuja Declaration,
in April 2008 reported vast fluctuations. It noted: “This research
demonstrates that some seven years after the Declaration, many of the
countries are still lagging well behind this target…”
That same year, Nobel Peace Prize Winner Archbishop Desmond Tutu, who is the honorary chair of the ‘Africa Public Health Alliance 15 per
cent Now Campaign’, urged African Heads of State and government not to in any way “revise, drop or further delay implementing the Abuja

Describing the Declaration as the “most important” commitment African
leaders had made towards health financing and development, Archbishop Tutu said: “The continued loss of millions of African lives annually, which can be prevented, is unacceptable and unsustainable. Our leaders know what they have to do. They have already pledged to do it. All they have to do now is actually do it. This is all we ask of them.”

Even when there is marked growth in the number of health facilities,
improving access in parts of Uganda to a four kilometre radius,
according to the 2006 household survey, physical availability of the
infrastructure has not been matched by improved health services
because drugs, diagnostic machines and qualified personnel are
lacking. For example, HRFI researchers found during their study
carried out for six months (January to June 2010), and covering nine
districts, that people in rural areas, frustrated by lack of doctors
and medicines, are increasingly turning to mushrooming yet unregulated
traditional healers for treatment.

Worse still, in most rural areas, as is the case at some urban health
facilities, ambulances are either non-existent, not fueled or in
disrepair to effect transfers during referrals.

The FHRI reported that the government of Uganda is obsessed with
physical presence of health structure but not their functionality. It
also questions the rationale of the National Medical Stores (NMS)
having to manage budgets of all public health institutions when some
lower-tier health centres can hardly quantify their drug requirements
over months, resulting in stock-outs. As such, patients return with
their prescription forms home, staying for sometimes weeks without
medication, and turn up to swamp health centres when they catch wind of delivery of drugs.

The government appears aware of just how the failing health system has exposed it.
In the Wednesday’s press statement, Ondoa announced commencement of maternal and perinatal death audits at health centres to determine their possible causes and recommend implementable control measures.

Many observers say the government knows the hamstrings but is just
dithering to fix it – in the process leading public health institution
that offer treatment on the cheap to atrophy as private ones, many
owned by bureaucrats, thrive.

The good news is that Dr Ondoa says this time around her ministry is
determined to provide mama or delivery kits, unlike presently where
NMS charges for their supplies, to hospitals and all village health
teams at no cost; more health centres will be built and blighted ones
renovated and mass sensitisation undertaken to educate Ugandans on
safe delivery methods.

It is hoped these measures will propel Uganda to the league of nations
that have reduced maternal and child mortality but it is uncertain if
the hand of the first female Health minister will indeed heal Uganda’s
ailing health sector.
Source: Daily Monitor

Constitutional Court begins hearing maternal deaths case

The Constitutional Court in Kampala, Uganda, started a case against the Government of Uganda on preventable maternal deaths and the right to health.
The case, Petition Number 16 of 2011, argues that by not providing essential medical commodities and health services to pregnant women, the government is violating the constitutional rights of Ugandans, including the right to health, the right to life, and the rights of women.
The petition highlights the case of two women who died in childbirth; their families were also present at the hearing. Many reports of additional maternal deaths from across Uganda have come to light since the case was filed on 3 March 2011.
The court case was started by a group of activists representing health, HIV/AIDS, human rights, and womenʼs organisations in Uganda. According to the activists, cases of preventable maternal death such as of the two women are commonplace in Uganda.
One of the complainers, Hilda Kironde of Uganda Community Based Association for Child Welfare (UCOBAC) said: “With sufficient funding and leadership, these deaths would stop. We are hopeful that the Constitutional Court will understand the unacceptable plight that expectant mothers face in Uganda.”
The activists call for a 2011/2012 supplementary budget that increases investments in the life-saving emergency care, health workers, commodities and services that could end Ugandaʼs crisis of preventable maternal death.

Maternal Deaths Emblematic Of Rot In Uganda’s Healthcare System

Uganda has the uncanny ability of always popping up in the news. The last time my home country captured the imagination of the American public was in early June when the profane, potty-mouthed and hysterical musical “The Book of Mormon” won nine Tony Awards. The happily paradoxical “Book of Mormon” is about two dewy missionaries from Salt Lake City transported to Uganda and their misadventures.
Now the New York Times has come out with this: Maternal Deaths Focus Harsh Light on Uganda.
The article was spot-on. Wielding a slingshot that had its fingers on the pulses of Uganda’s expectant women, the piece threw brickbats at Uganda’s floundering public health system. Foreign aid donors were not spared either as the article questioned the unintended consequences of development aid.
The Birth And Genesis
The embers in the most-recent fiery debate about maternal mortality rates in Uganda were stoked on May 27, 2011 when the Centre for Health Human Rights and Development (CEHURD), a Ugandan NGO, and the families of two mothers who died in government hospitals in 2009 approached the Ugandan Constitutional Court alleging the women’s deaths were caused as a direct result of Uganda’s failing healthcare system. CEHURD, in this landmark petition, alleged that the circumstances that led to the death of these two women were both emblematic and symptomatic of the government’s failure to fulfill its constitutional obligations to provide basic maternal healthcare to expectant mother. They sought to arm-wrestle the government into increasing its budget for maternal healthcare and compensation for the families of the two women.
Accounts of the events that led to the death of the two women are almost the same. Councilor Anguko Jennifer, a civic official in Arua district, sustained a ruptured uterus while waiting for over ten hours to be attended to by a doctor while she was in labor.
She died on the theater table. Sylvia Nalubowa, a mother of seven, was not aware that she was to have twins. The antenatal clinic she attended in her area in central Uganda did not have adequate scanning facilities. When she went into labor, her husband could not raise money to transport her to Mityana Hospital and, according to reports, they had to ‘improvise’ transportation to reach that hospital, 15 kilometers away.
Unable to purchase a Ush 50 000 ($ 25) ‘mama kit’ for use at the hospital’s labor ward, she was left unattended and died. The mama kit package contains a meter piece of cotton cloth, laundry soap, a pair of gloves, a piece of cotton wool, small gauze, cord ligature, and a meter of polythene sheet for the delivery table.
The Sick Life Of Uganda’s Systems
Uganda’s health care system needs CPR. The NY Times story, emphatic in its articulation, painted the picture of a battered, bankrupt and decrepit tragedy.
“At regional hospitals like the one here in Arua, more than half the positions for doctors are vacant, part of a broader shortage that includes midwives and other health workers. A majority of clinics and hospitals reported regularly running out of essential medicines, while only a third of facilities delivering babies are equipped with basics like scissors, cord clamps and disinfectant, according to a 2010 Health Ministry report.”
The government’s response to the joint suit by CEHURD and the families of the two deceased expectant women was telling. Unaccustomed to such Zeus-style thunderbolts on the efficacy of its governance and the healthcare system, government officials dabbled uneasily in obfuscation, saber-rattling and shifting of responsibilities as they guarded their fief.
Uganda has seen rosier times. The Uganda Bureau of Statistics pegged Uganda’s inflation rate at 18.7 percent in July 2011, the highest since February 1993. According to data compiled by Bloomberg, Uganda’s shilling is Africa’s worst performing currency this year after weakening 12 percent against the dollar. Uganda is one of the countries with the highest child mortality rates in the world, according to the State of the World’s Children report.
She holds the 21st last slot out of 189 countries. At least an estimated 45,000 newborn deaths occur in Uganda each year and an equal number are stillborn, making her the country with the fifth highest number of newborn deaths in sub-Saharan Africa.
According to the World Health Organization, Uganda has the world’s highest malaria incidence, with a rate of 478 cases per 1000 population per year. The overall malaria-specific mortality is estimated to be between 70,000 and 100,000 child deaths annually in Uganda, a death toll that far exceeds that of HIV/AIDS. Tuberculosis remains a major public health problem in Uganda, ranking her 18th among the 22 TB high burden countries of the world. About 100,000 new cases of all forms are recorded every year.
A Post-mortem Analysis
Giving handouts to Africa remains one of the biggest ideas of our time — millions march for it, governments are judged by it, celebrities proselytize the need for it. Whenever funds are doled out, press conferences are held and kumbaya moments invoked. What is not ever sufficiently articulated is that development aid has, in some cases, done more harm than good to Africa.
“For every dollar of foreign aid given to the governments of developing nations for health, the governments decreased their own health spending by 43 cents to $1.14, the University of Washington’s Institute for Health Metrics and Evaluation found in a 2010 study. According to the institute’s updated estimates, Uganda put 57 cents less of its own money toward health for each foreign aid dollar it collected.”
In the history of mankind, no country has ever developed by depending on foreign aid. Dambisa Moyo, whose book Dead Aid I plowed through in January 2011, opines that Africa needs to be gradually weaned off development aid and the spigots finally shut off and African governments left to their own devices. Previously a lone dissenting voice, Ms Moyo is garnering a rapidly increasing roster of supporters willing to toll the death knell for foreign aid. More are jumping onto this bandwagon.
What should Uganda do to avert its maternal mortality crisis? Here is a list of suggestions from Ms. Magazine, a blog that prides itself in its ‘fearless feminist’ reporting. Emphasis needs to be placed on adequate remuneration for doctors and other healthcare workers. For a long time, it has been expected that health care workers should toil and serve with their morality’s engines powered by altruism, humanism and nationalism alone. That hasn’t worked. This may be anathema to donors but it needs to be put out there that health care workers with a ‘sufficiently oiled’ vested interest in Uganda are the key to preventing Uganda’s slide into healthcare Armageddon. With that in place, we will probably be seeing the last of the hemorrhage caused by maladies such as absenteeism, presenteeism, healthcare-related corruption and the brain drain. Next would be to institute an overhaul of Uganda’s healthcare system starting with the management of training of healthcare workers being returned to the Ministry of Health from the clearly over-burdened Ministry of Education and Sports.