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).[1]

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[2]. 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.[3]

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. ^[4] 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^[5]. 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.[6] 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.^[7] 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).^[8]

STATE PROGRESS

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.[9]

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.

1. 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.
2. 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. 
3. 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 ^[10]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.

Recommendations

• 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

CONCLUSION

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.

 REFERENCES

1. 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
2. Understanding the critical linkages between Gender based violence and sexual reproductive health rights. www.arrow.org.my .
3. 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.
4. Bourdieu, P. (1998). La domination masculine. Paris: Editions du Seuil.
5.  Cornell, R. W. (1995). Masculinities. Cambridge: Polity Press.
6.  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.
7. Spotlight initiative to eliminate violence against women and girls. country programme document.
8. WHO/UNAIDS/UNICEF (2010) ‘Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector the country- Progress Report 2010.
9.  WHO/UNAIDS/UNICEF (2011) ‘Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011.
10. 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

CEHURD.

---

[1] https://www.unfpa.org/sites/default/files/pub-pdf/-Facilitator1s_Guide_English_InDesign_Version.pdf

[2] ASIAN PAIFIC RESOURCE AND RESEARCH CENTER FOR WOMEN .WWW.ARROW.ORG

[3] (World Health Organization، Global and Regional Estimates of Violence against Women، 2013، http://bit.ly/1oTfGVG ).

[4] Ibid

[5] https://www.wilsoncenter.org/event/the-impact-violence-against-women-maternal-health

[6] Ibid

[7] Ibid

[8] https://www.ubos.org/wp-content/uploads/publications/03_2019UBOS_Gender_Issues_Report_2019.pdf

[9]

[10] 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 18^th 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.

References

Anastasi, E., Borchert, M., Campbell, O., Sondorp, E., Kaducu, F., Hill, O., & Okeng, D. (2015).

Losing women along the path to safe motherhood: Why is there such a gap between women’s use of antenatal care and skilled birth attendance? A mixed methods study in northern Uganda. BMC Pregnancy and Childbirth. Retrieved from (Böhret, 2018)

Atuhaire, R., & Kaberuka, W. (2016). Factors contributing to maternal mortality in Uganda. African Journal of Economic Review, 4(2). Retrieved from https://www.ajol.info/index.php/ajer/article/view/136040

Böhret, I. (2018). Maternal Mortality in Uganda. https://doi.org/10.13140/RG.2.2.16930.07361

Cleeve, A., Oguttu, M., Ganatra, B., Atuhairwe, S., Larsson, E. C., Makenzius, M., … Gemzell-Danielsson, K. (2016). Time to act—Comprehensive abortion care in east Africa. The Lancet Global Health, 4(9), e601-e602. doi:10.1016/s2214-109x (16)30136-x Ensuring Every Woman Can Deliver with Dignity. (n.d.).

Retrieved from https://www.souluganda.org/maternalhealth

Girls not Brides. (n.d.). WHAT’S THE CHILD MARRIAGE RATE? HOW BIG OF AN ISSUE IS CHILD MARRIAGE? Retrieved from https://www.girlsnotbrides.org/child-marriage/uganda/

Priorities for Safe Motherhood. (2016). Retrieved from http://www.safemotherhood.org/priorities/index.html

Roback Morse, A. (2014, January 10). Definitions of maternal mortality.

Retrieved from https://www.pop.org/definitions-of-maternal-mortality/

Save the Children Uganda. (2018, November 14). ONE GIRL EVERY MINUTE IS AT RISK OF CHILD MARRIAGE IN UGANDA, WARNS SAVE THE CHILDREN. Retrieved from https://uganda.savethechildren.net/news/one-girl-every-minute-risk-child-marriage-uganda-warns-save-children-1

Sofia Garsbo, I. (2018). Early marriage in Mbale District, Uganda: Examining young women’s perceptions, agency and the influence of The Hunger Project Uganda (Unpublished doctoral dissertation). University of Amsterdam, Amsterdam.

United Nations International Children’s Emergency Fund Uganda. (2019, September 20). More women and children survive today than ever before – UN report. Retrieved from https://www.unicef.org/uganda/press-releases/more-women-and-children-survive-today-ever-un-report

United Nations Population Fund. (2011, March 2). Keys to improving maternal health: education, resources and community partnerships. Retrieved from http://unfpa.org/news/keys-improving-maternal-health-education-resources-and-community-partnerships

World Health Organization. (2019, September 19). Maternal mortality. Retrieved from https://www.who.int/news-room/fact-sheets/detail/maternal-mortality

The author of the article can be reached out through sefinewd@gmail.com / sgezahegn@brandeis.edu.

THERE IS NO WAY ANYTHING IS GOING TO BE DONE FOR THE YOUNG PEOPLE WITHOUT THEM BECAUSE IT WILL BE AGAINST THEM! (THE IMPORTANCE OF MEANINGFUL YOUTH PARTICIPATION)

I agree with World Contraception day ambassador Nana Abeulsoud when she states that today there are more young people than before and therefore youth voices matter because no one is more convincing to define the future through innovation but the largest population. It is common knowledge that Uganda has the second youngest population in the world with about 78% below 30 years and half of that below 15 years. We should also note the alarming growth rate which is 3% per annum, the unemployment rate of the youth which is 38% and the rate at which teenagers are getting pregnant has increased from 24% to 25%. It is on this premise that I focus on Adolescent girls and young women.  Adolescent girls and young women (AGYW), especially in sub-Saharan Africa, are highly vulnerable to HIV. In 2015, up to an estimated 450,000 new infections occurred among AGYW aged 15-24 years globally, translating into approximately 1,229 new infections per day.^[1] In Uganda, where AGYW are estimated at 6,569,000 or 16% of the population, up to 29,640 infections occurred in 2015.^[2] In 2014, HIV prevalence among young people aged 15-24 years was estimated at 3.72% for women and 2.32% for men.^[3] New HIV infections among AGYW are substantially higher than among males of the same age because HIV is more commonly acquired from male sexual partners who are a few or several years older.^[4] Findings from the Uganda AIDS Indicator Survey conducted by Ministry of Health revealed that 3% of adolescent girls 15-19 years live with HIV, and that prevalence doubles (7.1%) by the time they are 24 years.^[5] Estimates for 2015 show that the country registered an estimated 83,000 new HIV infections, 22% of them among AGYW, among whom an average of 50 infections occurred on a daily basis.^[6]

While carrying out research on integrating Legal Empowerment and Social Accountability (LESA) for Sexual Reproductive health and HIV services for Young People in Kibwa and Kireku slums, I realized that the biggest challenge these adolescent girls and young women face is lack of information. After being assured of confidentiality, some of them who had had children before 18 and had gotten infected wished they had known of contraception, what to do in case of coerced sexual activity and infection, redress mechanisms and what their rights as individuals are. INFORMATION. That’s what they basically wished they had. Most of them are brilliant with a lot of potential but have been derailed from what they could have been simply because they didn’t have this information.

I have interacted with these young people in our legal aid tents in a number of community outreaches and health and youth camps under different projects and the need cuts across. Some of the cases they report and some of the legal advice they seek is in regards to situations that would have been easily been avoided if they had the information they needed. At one of the most recent community outreaches in Mayuge district, I encountered a 21 year old girl who had had six children in six consecutive years simply because she did not know that she could say no to an early marriage as she was not coerced into it but also because she didn’t know of any family planning methods. This information should also be given to the parents of these young people as I have encountered parents that encourage some of this behavior by giving away their own children to be ‘married’ at a young age which is not right even if they have been defiled.

We therefore have to ensure that all the sexual reproductive health rights information is disseminated to the youth specifically in the hard to reach areas like the rural and slum areas but also involve them in decisions related to and for them. Also, young people need models and not critics like John Wooden said. Criticizing them for the past will not help improve the present and future situation. We should also have confidence in them and give them a chance to work with duty bearers as partners. Meaningful Youth Participation (MYP) means that young people work in all stages of decision-making and can participate on equal terms with adults at a number of levels, or alternatively work independently from adults and make decisions solely with the involvement of youth voices. MYP is a right that all young people have according to the Convention on the Rights of the Child. According to this UN Convention, young people have the fundamental right to participate and access information related to decision-making processes that affect their life and well-being. There is clear evidence that MYP benefits society, has positive effects on their development, strengthens organizational capacity and is key to achieving Sexual and Reproductive Health and Rights (SRHR) program outcomes. The youth should be encouraged to take charge of their lives by addressing their situation and then taking action in order to improve their access to resources and transform their consciousness through their beliefs, values, and attitudes. Policy and decision makers should also appreciate the benefits to the country of sufficiently investing in the young people and the risk/consequences to the country of not investing in their empowerment. Advocacy for SRHR enabling policy and social environment for adolescents and young people and empowerment of adolescents and young people to voice their rights and SRHR challenges that affect them should be intensified.

Since Adolescent girls and young women are the mostly affected as earlier illustrated, the Gender Transformative Approach (GTA) which actively strives to examine, question, and change rigid gender norms and imbalances of power as a means of achieving SRHR objectives, as well as gender equality objectives should also be applied. Male involvement and movements such as the ‘she decides’ movement which I am part of should also be encouraged so that we can have a world where every girl and woman can decide what to do with her body, her life and with her future WITHOUT QUESTION. And just Antonio Guterres (former secretary general of the United Nations) said, we need to place a special focus on young women and girls. So many futures are derailed when young women are pushed out of school, subjected to child marriage or have poor access to education and health care. When we empower Africa’s young women and girls, everyone wins.

The legal Empowerment and Social Accountability (LESA) approach will also go a long way in equipping the young people with the information they need and strengthen the capacity of Adolescent Girls and Young Women (AGYW) and their communities to demand for improved quality of SRH services for AGYW, including protection from sexual and gender-based violence (SGBV).

In a nutshell, youth voices matter because it is through that they can become fully empowered to become leaders in their own right. And for those in the struggle in the fight for the rights of the young people, there are times when you will see results in ten seconds and there are times you won’t see any for ten years. Either way, keep planting those seeds of character, eventually they will bloom.

Kyagera Nairuba Angella

Community Empowerment program (CEHURD)

---

[1] UNAIDS 2016 Estimates. Geneva: UNAIDS; 2016. (http://www.unaids.org/en/resources/documents/2016/HIV_estimates_with_ uncertainty_bounds_1990-2015 )

[2] PEPFAR. Uganda: DREAMS overview. https://www.pepfar.gov/documents/organization/253961.pdf

[3] Uganda AIDS Commission (2015). 2014 Uganda HIV and AIDS Country Progress Report

[4] UNAIDS 2016. HIV prevention among adolescent girls and young women: Putting HIV prevention among adolescent girls and young women on the Fast-Track and engaging men and boys. Guidance

[5] Ministry of Health (2011). Uganda AIDS Indicator Survey. http://health.go.ug/docs/UAIS_2011_REPORT.pdf

[6] Office of the President of Uganda (2017). Presidential fast track initiative on ending AIDS as a public health problem in Uganda; a five-point plan

The Constitutional Court of Uganda on 30^th 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 2^nd 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 18^th 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 28^th 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 13^th 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 12^th 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 20^th 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 30^th 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)