In November 2019, Mr Fredrick Kato, a senior clinical officer at Mukisa Medical Clinic received a patient who had carried out an abortion somewhere in Buikwe District. She was in critical condition. Mr Kato provided Post-Abortion Care to her and thereafter referred her to Lugazi Referral Hospital for an abdominal scan. A few days later, the patient returned to Mr. Kato’s facility for further treatment but since she had not gone for the scan as he had recommended, Mr Kato referred her to the referral hospital again.

On April 6, 2020, police officers from Lugazi Central Police Station arrested Mr Kato. The girl’s parents, who were in town when the Police made the arrest, accused Mr Kato of carrying out an abortion on the girl. Mr Kato was therefore arrested on allegations of carrying out an abortion, which is a criminal offence under the Penal Code Act. The Ugandan Constitution does not explicitly prohibit abortion. Article 22(2), which states that “[n]o person has the right to terminate the life of an unborn child except as may be authorised by law”, does not preclude access to termination of pregnancy; it simply requires a legal framework to do so.

Our Community Health Advocates at the grassroots were able to identify this case and reported it to our Litigation team for legal support. On May 11, 2020, the Legal Support Network applied for bail for Mr Kato, basing on the standards and guidelines by the Ministry of Health that permit health workers to provide Post-Abortion Care.

“The law doesn’t favour me, I made an oath as a health worker to save the life of my patient but the legal and policy environment in which we operate is not clear and it puts us in a vague state when it comes to providing services such as Post-Abortion Care,” Mr. Kato shared some of the challenges that health workers face, especially when providing maternal healthcare for women. 

He called upon the government to amend such policies that put health workers in a predicament when choosing whether to save the life of their patients or let them die in fear of being caught on the wrong side of the law.

“I am grateful to the Center for Health, Human Rights and Development for putting up functional structures of Community Health Advocates and the Legal Support Network that protect and defend the rights of health workers and people in the community at large. I also thank them for having me out of jail after one month, especially in this time of the lock down where transport is a problem; they managed to get me out, and back to my family.”

Compiled by Faith Nabunya- Communications, CEHURD.

Moses Mulumba, Executive Director -CEHURD

As the state and non-state actors take steps in dealing with COVID-19, I would wish to remind them of the need to urgently strike a balance between these prevention approaches and rights with collective responsibilities. While the state must take efficient intervention, which includes undertaking the right to health impact assessment of interventions, individuals should be taking responsibilities of complying with guidance from the Ministry of Health including social distancing, hand washing and taking other measures that have been identified as effective in preventing the further spread of the virus.

From a right to health perspective, it is important for the government of Uganda to ensure that prevention and treatment measures in form of supplies and commodities, such as sanitisers of sufficient quality, are available, accessible, and affordable for the most vulnerable communities including: the older persons, those under incarceration, refugees and the very poor. There is also dire need to devise strategies on how poor households, communities and hard-to-reach places without access to clean water, or those who cannot afford and / or access soap, detergents and sanitisers can utilise the prevention measure on hand washing with soap and water. Equitable access to information on COVID-19, must be availed to those that may not access it through the conventional avenues.

Community participation and solidarity are pillars that have historically been critical in controlling and managing similar outbreaks in Uganda. The effective use of the formal and informal community participation structures in our health system will ensure that communities are active and informed participants in the creation of a responsive health system. In the social isolation mechanism, identification of cases and first management of these cases starts from the family unit and the communities and as such; communities must be viewed as active participants who need to be provided with sufficient, updated and timely information including clearly defined referral systems for the management of COVID-19 cases.

In times like these, the Government’s obligation of protecting the public from third parties violating the rights of communities becomes very important. We envisage that cases of private actors seeking to make earnings out of the desperate situation on COVID-19 will be on the rise. The much-needed commodities like sanitisers, soaps, masks etc will be faked and/or counterfeited and in some cases sold on the black market much more expensively to the communities. In places where there is absence of government isolation centres, private sector facilities may be provided as an option but at a cost that is unaffordable and out of reach for many of those that are subject to quarantines. Research attempts, including clinical trials will be common and some of these may threaten the key ethical and human rights principles of research. The government needs to make full use of the policy space Uganda has in intellectual property as an LDC to enable it utilise new innovations. We therefore call upon the state to pay particular attention to the right to health implication of commercialisation of commodities and other key services in the era of COVID-19. 

We call upon the Government of Uganda to pay extra attention to vulnerabilities in the communities and those faced with the burden of being healthcare providers and carers in the times of COVID-19. While the majority of the reported cases in different regions are men, women are the care-givers which, not only puts them at a higher risk of contracting the virus, but also neglecting their other health and human rights. With social distancing and self-isolation, no alternative options are being proposed and implemented to ensure that girls and women continue to access sexual and reproductive health services. Those in prisons and police custody have particular vulnerabilities and interventions packages should be defined to reduce their risks.

We need to evaluate the extent to which information is reaching those in hard-to-reach areas such as islands, remote and inaccessible areas, pastoral communities, and settlements for refugees and internally displaced persons.

Lastly, as General Comment 14 on the Right to the Highest Attainable Standard of Health provides, violations of the right to health occur when the state, among other things deliberately withholds or misrepresents information vital to health protection or treatment. This can also happen when the state suspends a legislation or when it adopts laws or policies that interfere with the enjoyment of any of the components of the right to health. Given that Uganda’s legislation on public health is over 85 years old, we must make an urgent effort to review the key provisions under the Public Health Act that are central for Uganda to have effective responses for global pandemics like COVID-19. Regulatory approval for new medicines and speedy attention to developing new formulations for the prevention and treatment of COVID-19 are important considerations too.

Let us all take care of ourselves, those around us and stay healthy.

The writer is the Executive Director of Center for Health, Human Rights and Development (CEHURD)

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

Christopher Baguma | Community participation and COVID-19

Community health was an idea mooted by world leaders in 1978 that created the Declaration of Alma-Ata, which reaffirmed access to health as a fundamental human right and identified primary health care as the key to attaining the goal of health for all. During the 30^th anniversary of Alma-Ata in 2008, leaders discussed the role of primary health care in achieving the United Nations’ Millennium Development Goals. This led to rejuvenated calls for use of community health workers (CHWs) as a form of community participation. 

Since the Alma-Ata declaration, successive Ugandan governments have acknowledged the relationship between health and poverty and in the 1990s, with the help of development partners, community health interventions were implemented. In 1999, Uganda’s health policy included community empowerment and mobilisation for health as key elements of the national minimum health care package and subsequently made a commitment to the Abuja Declaration of 2001 This also demonstrated the benefits of community-based interventions and opened the way for a strategy based on Village Health Teams (VHTs). The National Village Health Team (VHT) strategy and guidelines in Uganda were developed in 2000 and by 2003 country-wide roll outs of the VHT strategy had commenced. VHTs are lay people, working in a voluntary capacity, acting as a link between the formal health sector and their communities. They are given basic training on major health issues, including childhood diarrhea, malaria and pneumonia, and play a role in disease surveillance through activities such as data collection and reporting. 

In the wake of COVID-19, the Government of Uganda under the leadership of President Yoweri Museveni issued guidelines initially including the closure of  all schools and places of worship for 30 days and the suspension of travel both in and out of the country with the hope that such measures will slow the spread of the disease. However, as the number of infections increased and the president announced more guidelines ranging from quarantine, restricted internal movements and a curfew. These preventive measures are certainly a good start, but they may not be enough, especially given the systemic and deep-rooted challenges facing Uganda’s public health system.

However, there is no clear mechanism from the Ministry of Health that links communities with existing health care services which is done by the Community Health Workers and Village Health teams using community-based approaches. Accessing health facilities is challenging and expensive for those living in remote and rural areas. Most of the information regarding the COVID-19 pandemic is in English, which means rural communities might not have access to or might find it difficult to understand publicly available information. This raises challenges in accessing timely and relevant information as well as  health services. Prolonged periods of quarantine and movement restrictions are causing emotional unrest and anxiety, gender-based violence including sexual exploitation, interrupted access to sexual and reproductive health services, including access to family planning within the communities.  

To address all these issues, the communities must meaningfully participate in health programmes at the local level. The government should therefore engage community health workers and village health teams to increase coverage and cost-effectiveness of health services delivery in the COVID-19 period. To the CSOs, use the existing community structures like peers, champions and paralegals, among others in rural and urban areas to engage these structures to build strong grassroots coalitions that could reach out to the marginalized communities in the response to COVID-19.

Center for Health, Human Rights and Development (CEHURD) in the fight to reduce the spread of COVID-19 has engaged its community structures; known as Community Health Advocates (CHAs) by designing communication materials highlighting COVID-19 prevention strategies and a toll free line 0800313131 to report any health issue arising within the community that need our intervention. The CHAs work with communities to navigate the healthcare system at the local level by providing information on health, community resources and their rights to health. They work with the communities in identifying and reporting health issues and concerns to the duty bearers. These CHAs have a strong understanding of the healthcare system and resources available within the community as they provide health education to the community related to disease prevention, screenings, and health practices. They do promote community action and garner support to motivate them to seek specific healthy policies by engaging local authorities, healthcare providers and other organisations to develop a more coordinated approach in accessing health services. The coordinated approach is realised due to the existing structure which starts from the community, parish, sub-county and district level with the leadership of the district coordinator and strategic support and coordination from CEHURD secretariat. 

The writer is the Programme Manager -Knowledge Management Program at Center for Health, Human Rights and Development (CEHURD)

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

A warm welcome and lots of good wishes to CEHURD’s Human Resources Manager Ms. Florence Matovu Nakanwagi, an expert with 15 years of experience. Her specialty includes providing strategic direction, developing organisational structures, job analysis, evaluation and grading to ensure internal equity and design of reward policies.
Ms. Nakanwagi has a Masters in Human Resources Management from Edinburgh Business School, Heriot-Watt University, a Bachelor’s in Education from Makerere University, and is experienced in Information Systems Management, Guidance and Counselling, Management, Skills Improvement and Recruitment. She is also a member of the Uganda Human Resource Managers’ Association.

We welcome you and congratulate you on joining our vibrant and dynamic team. May your contribution bring fulfillment and success to you and the entire CEHURD team.

Angella Kyagera 

Program Officer in the Community Empowerment Program at the Center for Health, Human Rights and Development

At the moment, almost all efforts, energies and resources are geared towards COVID-19, the global pandemic. Killer diseases like malaria are almost forgotten. Malaria is a disease transmitted by mosquitoes that kills more than one million people in Africa annually. Whereas it is a preventable and treatable disease, malaria is still the leading cause of death among children under five mostly in the sub-Saharan Africa region yet also a global public health concern that perpetuates a vicious cycle of poverty in the developing world. 

Uganda has the third highest deaths from malaria in Africa and some of the highest recorded malaria transmission rates in the continent, particularly in the areas around Lake Kyoga in central Uganda. The Ministry of Health stated on August 12th 2019 that there had been an increase in the Malaria cases by over 1 million countrywide for the period of June-August 2019. It also stated that there has been a 40% increase in the Malaria cases from 1 million cases in June 2018 to 1.4 million cases in June 2019. The increase in Malaria cases was attributed to seasonality, climate change, reduced net ownership and use due to the aging of nets distributed in the 2017 mass campaign, low malaria prevalence in areas such as Kampala, Population growth and refugee immigration in specific regions. The pearl of Africa also contributes to about 5% of global malaria deaths but strides have been taken to reduce these numbers with a total of 2.2 million nets handed out in 2008 so the proportion of long-lasting insecticidal net (LLIN) coverage has now reached an estimated 84%. Health workers at all levels (including the private sector) were also trained in integrated management of malaria (IMM) in 102 of 112 districts (10,500 HWs), including training in the management of severe malaria. Clinical audits for severe malaria were performed in 34 of 112 districts. The Ministry of Health has also supported districts with increased cases to order and receive emergency services, revised the quantification of ACTs for this financial year, redistributed malaria commodities from facilities and districts with overstocks to those that are facing a stockout of malaria commodities. They are also monitoring malaria cases, admissions and deaths and using data to guide decisions at all levels. This has helped identify and contain many outbreaks and continued the routine distribution of long lasting insecticide treated mosquito nets (LLINs) to pregnant women attending antenatal care and children in immunization clinics. It has also fast tracked the implementation of the 2020 LLIN mass campaigns and introduced new channels of LLIN distribution such as schools in selected districts.

Globally, every year on the 25th  of April, we remember the deaths caused by malaria. It is also an opportunity to   highlight the need for better political interventions in malaria control and prevention. This day marks the milestones in the fight against malaria as well as continuously contributing to the efforts in averting this disease through sensitizing citizens mostly in malaria affected countries on simple actions they can take to prevent and treat this killer disease. As a means of investing in ending malaria, some efforts such as engaging community, national and global leaders to prioritize the fight against this disease have been put in place. 

During last year’s commemoration under the theme “Zero Malaria Starts with Me,’” we called upon relevant stakeholders to highlight the importance of robust health and surveillance systems. These systems can sustain malaria prevention and control interventions for the most vulnerable as the world grapples with COVID-19.  This day also highlights the importance of upholding progress and commitments made in the global fight to end malaria. We call upon all stakeholders to recognise and revitalise the involvement of high-burden countries in Africa, which account for approximately 70% of the global malaria burden as we put an end to this killer disease. 

As we try to address and control the COVID-19 pandemic, let us not forget to equally invest in building and supporting resilient health systems that protect and advance progress against further outbreaks of existing infectious diseases like malaria.

Whereas the efforts to contain the spread of the coronavirus should be appreciated, the government should not neglect the interventions and delivery of other health services including prevention and treatment of malaria. This therefore means that governments must put in place avenues to make delivery of all health services accessible, acceptable, available and of good quality.  

Experience from previous disease outbreaks has shown the disruptive effects on health service delivery if diseases such as malaria are ignored. For example, the 2014-2016 Ebola outbreak in Guinea, Liberia and Sierra Leone, undermined malaria control efforts and led to a massive increase in malaria-related illness and death in the three countries. COVID-19 pandemic reports from the World Health Organization (WHO) show that in Africa, which carries more than 90% of the global malaria burden, 37 countries had reported cases of the Coronavirus as of 25th March, 2020. To contain the spread of the Coronavirus, most of these African countries declared several measures including continuous lockdowns which are a threat to accessing health services.  

In recent days, there have been reports of the suspension of insecticide-treated nets (ITN) and indoor residual spraying (IRS) campaigns in several African countries due to concerns around exposure to COVID-19.^[1] Suspending such campaigns will leave many vulnerable populations at a greater risk of malaria, particularly young children and pregnant women. WHO strongly encourages countries not to suspend the planningfor – or implementation of – vector control activities, including ITN and IRS campaigns, while ensuring these services are delivered using best practices to protect health workers and communities from COVID-19 infection. Modifications of planned distribution strategies may be needed to minimize exposure to the coronavirus.

Also, delivery of intermittent preventive treatment in pregnancy (IPTp), seasonal malaria chemoprevention (SMC), and intermittent preventive treatment in infants (IPTi) should be maintained provided that the best practices for protecting health workers – and other front-line workers – from COVID-19 are followed. Ensuring access to these and other core malaria prevention tools saves lives and is an important strategy for reducing the strain on health systems in the context of the COVID-19 response.  

There have been reports of disruptions in the supply chains of essential malaria commodities – such as long-lasting insecticidal nets, rapid diagnostic tests and antimalarial medicines – resulting from lockdowns and from a suspension of the importation and exportation of goods in response to COVID-19. 

Coordinated action is required to ensure the availability of key malaria control tools, particularly in countries with a high burden of the disease, and that efforts to limit the spread of COVID-19 do not compromise access to malaria prevention, diagnosis and treatment services.

There are also reports of people taking heavy doses of malaria treatment of Chloroquine like in Nigeria which recorded chloroquine poisoning after Mr. Trump endorsed it for coronavirus^[2] treatment despite the insufficient data to assess the efficacy of either of these medicines in treating patients with COVID-19, or in preventing them from contracting the coronavirus although  there are ongoing clinical trials being conducted in response to COVID-19, including studies looking at the use of chloroquine and its derivative, hydroxychloroquine, for treatment and/or prevention.^[3]

Since 2000, the world has made historic progress against malaria, saving millions of lives however, half the world still lives at risk from this preventable and treatable disease, which costs a child’s life every two minutes. Malaria is increasingly a disease of poverty and inequality, with the most vulnerable at greatest risk of dying from a mosquito bite – particularly pregnant women and children under five in sub-Saharan Africa. In 2018, nearly 900,000 children in 38 African countries were born with a low birth weight due to malaria in pregnancy, and children under five still accounted for two-thirds of all malaria deaths worldwide. Therefore, all governments and states should maintain access to proven, life-saving malaria prevention tools, including insecticide-treated mosquito nets, indoor residual spraying of insecticides and preventive therapies for vulnerable groups as they impose the various restrictions during the COVID19 pandemic.

WHO is monitoring the fast-evolving situation of the COVID-19 epidemic and needs to advise the countries in the malaria-endemic regions on how to establish and effectively execute public health policies. Preventive measures for COVID-19, including case and contact tracing, quarantine and screening, as well as education to encourage good hand hygiene practices, should be in place. Additional and pre-emptive measures must be taken for malaria control in these countries, anticipating the potential challenge that would be faced by the public health system during an outbreak of COVID-19.

Malaria is still a global scourge that is preventable but it’s a disease that is curable. Let’s not forget it during this period as we battle to avert the spread of the COVID 19 pandemic. 

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^[1] https://www.who.int/news-room/q-a-detail/malaria-and-the-covid-19-pandemic

^[2] https://edition.cnn.com/2020/03/23/africa/chloroquine-trump-nigeria-intl/index.html

^[3] https://www.who.int/news-room/q-a-detail/malaria-and-the-covid-19-pandemic