The Right to Health in Uganda: Implications and Practical ...

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5The Right to Health in Uganda: Implications and Practical Steps to Achieving Universal Health Coverage

Robinah Kaitiritmba, Moses Kirigwajjo, Aloysius Ssennyonjo, Suzanne N Kiwanuka

Key Messages

• Universalhealthcoveragehasbeenpromotedaspracticalexpressionoftherighttohealth.

• Progress has been achieved with regard to the legal mandates ofthe right to health (RTH) inUganda in terms of establishing: a)a minimum core obligation; b) progressive realisation; c) cost-effectiveness; d) shared responsibility; e) participatory decision-making;andf )prioritisingvulnerableormarginalisedgroups.

• The Government of Uganda should make the right to health aclaimablerightandlegallyenforceablefortherealisationofUHC.Thecapacityofgovernmentandsupportfrominternationalpartnersshouldbetakenintoaccounttoensurethatexpectationsarerealistic.

• Therighttohealthshouldnotbeinterpretedmerelyastherighttohealthcarebecauseitmostcertainlyextendsbeyondhealthserviceprovision.

• Furthermore,althoughtherighttohealthisuniversal,itshouldbecontextualisedtoachievabletargetsineachsettingwithmeasurablegoalstoberealisedwithintheavailableresourcesandtime.

Citation: F. Ssengooba, SN Kiwanuka, E. Rutebemberwa, E. Ekirapa-Kiracho (2017), Universal Health Coverage in Uganda: Looking Back and Forward to Speed up the Progress. Makerere University, Kampala Uganda.

97Chapter 5: The Right to Health

• Rightsarenotabsoluteandtherighttohealthdoesnotmeantherighttobeinghealthy;thereforecitizensmusttakeresponsibilitytolivehealthierandmoreproductivelives.

• Mechanisms for citizen voice, participation, engagement andaccountability should be strengthened to ensure equity andeffectivenessforachievingUHC.

• UHCeffortsplans,interventionsandreformsthatdonotprioritisethepoorunderminetherealisationoftherighttohealth.

Introduction

According to the World Health Organisation (WHO), universal healthcoverage(UHC)istheumbrellaconceptfororganisingeffortstowardsthehealth goal of the SustainableDevelopmentGoals (SGDs). According toWHO), “UHC is,bydefinition, apractical expressionof the concern forhealth equity and the right to health” (2).UHCadvances the aspirationsintheWHOconstitutionthatallpeopleshouldattainthehighestpossiblestandards of health as a fundamental human right (3). The concept alsoadvances the linkages between the right to health and the objective ofhealthmadeexplicitbytheAlma-AtaDeclarationof1978,whichcouldbeconsideredtheinitialpracticalstepsforUHCglobally(4).ThePrimaryHealthCare(PHC)conceptimpliedthefirstcitizens’contactwiththehealthcaresystemsandfocusesontheprinciplesofequity,accessibilityandqualityofcaretopromotepeople’shealthandwell-being.Theprincipleofequitypositsthateveryoneshouldbereachedwithservices,whichareclearlydefinedintherighttohealthwhereservicesareavailableandaccessedbyothers.

In designing strategies to advance UHC, decision-makers shouldrecognisethatthistaskisnotjustatechnicalexercise,butshouldbepremisedonhumanrightsandequityprinciples(5).Reformeffortsmustconsidertheexpectations andobligations specified in the InternationalConventiononHumanRightstowhichmostcountriesaresignatories(6).TheInternationalCovenant onEconomic, Social andCulturalRights (ICESCR) (7) states:“Everyonehastherighttoastandardoflivingadequateforthehealthandwell-beingofhimselfandofhisfamily,includingfood,clothing,housingandmedicalcareandnecessarysocialservices,andtherighttosecurityintheeventofunemployment,sickness,disability,widowhood,oldageorotherlackoflivelihoodincircumstancesbeyondhiscontrol.”TheUnitedNations,while

98 Universal Health Coverage in Uganda- Part II

adoptingaunanimousresolutiononUHC,reaffirmedthesefundamentalsand highlighted several issues such as low levels of coverage, inadequateaccesstomedicinesandimpoverishinghealthexpendituresasconstraintstoattainment of these fundamental rights(8).The sameUNassembly urgedall countries towork towardsUHC considering that “UHC implies thatallpeoplehaveaccess,withoutdiscrimination,tonationallydeterminedsetsoftheneededpromotive,preventive,curativeandrehabilitativebasichealthservicesandessential,safe,affordable,effectiveandqualitymedicines,whileensuringthattheuseoftheseservicesdoesnotexposetheuserstofinancialhardship,withaspecialemphasisonthepoor,vulnerableandmarginalisedsegmentsofthepopulation(8).”

ThischapterexamineswhatUgandahasdonetoensurethattherighttohealthisfulfilledandthelessonsandimplicationthereoffortheuniversalhealthcoverageagenda.Thenextsectiondescribestheframeworkthatguidesthiswork, followedby the assessmentfindings, discussionof implicationsand,finally,therecommendations.

What has Uganda done to fulfil the right to health?

The principles that underpin the expression of right to health in UHC efforts.

Sridhar and colleagues (9) derived from theGeneralComment14of theCommitteeonEconomic,Social,andCulturalRights,whichistaskedwithmonitoring compliance with the International Covenant on Economic,Social, and Cultural Rights six key legal principles that should underpinUHCeffortsbasedontherighttohealthperspective.Theseare:a)minimumcore obligation; b) progressive realisation; c) cost-effectiveness; d) sharedresponsibility;e)participatorydecision-making;andf )prioritisingvulnerableormarginalisedgroups.Theseareelaboratedbelow:

a) Minimum core obligation: Irrespectiveof its economic status, everycountryshouldofferaminimumcoresetofprovisionsthatincludethefollowingobligations: i)ensuringaccesstohealthservicesandgoodsinanon-discriminatorymannerparticularlytothemostvulnerable;ii)provisionofessentialdrugsas specifiedbyWHO; iii)distributionofhealthfacilities,goodsandservicesinanequitablemanneriv)adoptingand implementing a sound national health strategy informed byepidemiologicalevidencetoaddressconcernsforthewholepopulation.


Access has four dimensions, namely: non-discrimination, physicalaccessibility, financial accessibility (affordability) and informationaccessibility.

b) Progressive realisation:Countriesshouldavoidretrogressivepolicies.Theyhavetoaspiretobecomebetter thanthepresentandhave legalobligationstomovebeyondthecoresetofprovisionsconsideredastheuniversalfloor.

c) Cost effectivenessofinterventionstomaximisebenefitsfromavailableresources.Countriesareobligedtoavoidexpensive interventionsthatbenefit a few but consider low-cost interventions that benefit themajority.

d) Shared responsibility among states implies that rich countries areobliged to individually or, as part of international assistance andcooperation, provide financial and technical assistance to the poorercounterparts tomaximise the use of available resources as prescribedbyArticle2(1)oftheInternationalCovenantonEconomic,SocialandCulturalRights.

e) Participatory decision making: This is imperative for participatorydecision-making.Themandatorynational health strategies andplansforactionmustbedevelopedandimplementedinaparticipatory,non-discriminatoryandtransparentmanner.Expressedprioritiesshouldbeconsideredinadditiontoepidemiologicalevidence.

f ) Prioritising the marginalised and vulnerable: Explicit attentionshouldbemadetotheneedsofthemarginalisedandvulnerable.Thehealth plans and monitoring systems should address the needs ofvulnerablegroupsinameaningway.Thebenefitpackageshouldincludeneedsofthevulnerableevenifnotcost-effective.

InthesubsequentsectionstheseprinciplesareusedtocritiquetheextenttowhichtherighttohealthhasbeenimplementedinUganda.


Assessment of Uganda’s progress in the realisation of the right to health

a) Commitment to core minimum obligations

Therighttohealthemphasisestheprominenceofthegovernment’sobligationtoprovideacoreminimumpackage,especiallywithregardtoaccesstohealthgoods, facilities and services.TheGovernment ofUganda hasmade bothlegalcommitmentsandestablishedpracticalstepstofulfilthismandate.

i) Commitments expressed in legal and national planning frame-works

In theConstitutionof theRepublicofUgandaof1995, theGovernmentpledgestotakeallpracticalmeasurestoensuretheprovisionofbasicmedicalservicestothepopulation.ItalsoprovidesforacleanandhealthyenvironmentinArticle39(10).

ThecurrentgovernmenteffortstoprogressivelyrealisetherighttohealthinUganda are guided by theNationalHealth Policy II (NHP, 2010/11-2019/20),theHealthSectorDevelopmentPlan(HSDP)andpreviouslytheHealthSectorStrategicandInvestmentPlan(HSSIP,2010/11-2014/15),allofwhichprioritisedtheimplementationoftheUgandaNationalMinimumHealthCarePackage(UNMHCP),whichisinlinewiththeaspirationsofuniversalhealthcoverage(11).TheHSDPadoptsa‘client-centred’approachthat takes into consideration the supply and demand sides of health-caredeliverywhileadheringtotherighttohealthprinciplesofequity,participationandaccountability,amongothers.

TheMinistryofHealth(MoH)alsoadoptedthePatients’Charterasapolicyframework,whichspellsouttherightsandresponsibilitiesofcitizensandentitlements supporting theRights-BasedApproach(RBA) toachievetheprovisionofuniversalaccesstohealthcareinUganda(12).Itisaimedatstrengtheningtherelationshipandengagementbetweenserviceprovidersand users and it providesmechanisms for feedback and redress to enablecitizens’ownershipofthehealthcare.

UgandaisalsosignatorytointernationalconventionsonhumanrightswhichhaveabearingonhealthrightsandtherighttohealthasenshrinedintheWHOconstitution1948.Theseconventions include: theInternationalCovenant on Economic, Social and Cultural Rights (ICESCR), theConvention on the Elimination of All Forms of Discrimination againstWomen(CEDAW),theConventionontheRightsoftheChild(CRC)and


theAfricanCharteronHumanandPeoples’Rights(ACHPR).Internationalcommitments to human rights, including the right to health, provide aguiding framework for legislation, policies and programming at nationalleveltowhichUgandaisontracktomakelegitimatetherighttohealth.

Despite all the above commitments, Uganda still falls short ofguaranteeing an adequate standard of health for its citizens. Uganda’slegislationdoesnotexplicitlyprovidefortherighttohealth.TheConstitution(Art.50)empowersanypersonwhoclaimsthatafundamentalorotherrightorfreedomhasbeeninfringedorthreatenedtoapplytoacompetentcourtforredress(10).However,therearelimitationsontheextenttowhichtheStatecanbeheldliableforfailingtoprotectandfulfiltherighttohealth.Moreover, the Constitution confers the right to health without adequatereferencetotheobligationsoftheStateinfulfillingit.

ii) Commitment to minimum package of servicesTherighttohealthentailsarighttohealthcareservicesthatrespondstothepriorityneedsofpeople,whichmayormaynotbetheprioritiesidentifiedbytheinternationalcommunity,dependingonthecontext.Inaddition,theright tohealth requires that these services beAccessible,Available, locallyAcceptableandofQuality (AAAQ(13).Over theyears, effortshavebeenmadetomakethisarealityinUgandaalbeitwithseveralchallenges.

In Uganda, the UMHCP translates into the core package of healthservices and is clustered under four components: (a) Health promotion,diseasepreventionandcommunityhealthinitiative;(b)Maternalandchildhealth; (c) Control of communicable diseases; and (d) Control of non-communicablediseases(12).However,theUMHCPhasperformedpoorlybecauseofchronicunderfunding, increasedout-of-pocketexpenditure(37percent)anddonordependence(14).Inaddition,accesstohealthservicesinUgandaisstilllimitedbygeographicalfactors,financiallimitationsforthepoorand inadequatehumanresources.Thegapbetween the requiredandavailablefundstofulfilthispackageisverywide;therefore,itaffectsservicedelivery.

To enhance physical accessibility, progressively the population livingwitharadiusof5kmfromahealthfacilityincreasedbutlaterstagnatedatabout72percent(11).Therearedisparitiesingeographicalterms,withmosthospitals,pharmaciesanddiagnosticcentresfoundinurbansettings,mostlyKampala city (15).On a positive note, the governmenthas leveraged theprivatenot-for-profit(PNFPs)sub-sectorinsomehard-to-reachsettingsto


expandphysicalaccess(16).Theaccessibilityagendaisfurtherconstrainedbyshortagesindrugsupplies,technologiesanddiagnostics(Chapter13)andhumanresourcesforhealth(Chapter12).

Evidenceshowsthatcitizens’contributiontohealthcarecanunderminethe realisation of the right to health. InUganda health services at publicfacilitiesweremade free following theabolitionofuser fees in2001(17).This policy led to an increase in service utilisation although the benefitswere not sustained over time (18). As noted in the chapter on resourcesmobilisation,governmentspendingonhealthhas laggedbehindtheothersourcesofhealthfinancingnamelydonoraidandhouseholdout-of-pocketexpenditures.Similarly,Ugandahasapluralistichealth systemcomprisingboth the public and the private sectors. AsUgandans shop for care fromnon-publicfacilities,theyareexposedtoout-of-pocketexpenditureswhichmay sometimesbe catastrophic to thehouseholdsor thehealth facility incasetheclientscannotpay(19).Thegovernmenthasalsoprovidedresourcecontributionsintheformofprimaryhealthcaregrants,drugcreditlines,staffsecondmentstothePNFPstohelpoffsetthecostsofprovisionofservicesin this sector, contribute to reductionofuser fees and,ultimately, lead tofinancial accessibility.However, due to stagnation in government supportandtherisingcostofserviceprovision,thevalueofgovernmentsupporthasreduced,thusunderminingthereductioninuserfees.Furthermore,exposureto catastrophic health expenditures disproportionately affects the poorersegmentsofthepopulation(20).

iii) Addressing determinants of healthAccording to the Committee on Economic, Social and Cultural Rights:“Therighttohealthiscloselyrelatedtoanddependentupontherealisationof other human rights, as contained in the International Bill of Rights,includingtherightstofood,housing,work,education,humandignity,life,non-discrimination,equality,theprohibitionagainsttorture,privacy,accessto information,andthefreedomsofassociation,assemblyandmovement.These and other rights and freedoms address integral components of therighttohealth”(7).AccordingtoFriedandAssociates,effortstorealiserightsnecessarilyextendbeyondservicesandcommoditiesanddrawsattentiontoother socialdeterminantsofhealth, includingeducation, trade,water andsanitation, vector abatement and tobacco control, notwithstanding non-discriminationwithinthehealthsystem(21).Aframeworkformonitoringhealthsystemoutcomesthatwillidentifygapsduetodiscriminationshould


be designed basing on coverage and other factors outside the health caresystem(22).

ThesecondobjectiveoftheUgandaHealthSectorDevelopmentPlanarticulatescommitment toaddress social, economicdeterminantofhealth(11). It advocatesmulti-sectoral collaborationandoperationof thehealthservicesinallpolicystrategies.Thisisanimportantsteptowardsgovernment-wide efforts to achieveUHCobjectives.The realisation of the direct andindirectlinkagesbetweenhealthandotherSGDs(23)providesaspringboardtoinstitutionalisegovernment-wideeffortsforhealthimprovementstowardsachievingnationaldevelopment.Therefore,progressiverealisationshouldgobeyondthehealthcaresystemandaddresstheunderlyingdeterminantsofhealthandshapetheagendaforUHCwhichaimsatprovidingaccesstoquality, safeandaffordableessentialhealthcarewithoutsufferingfinancialhardshipwhenpayingforservices(2).

b) Progressive realisation and national capacity

Theright tohealth is the enjoymentof thehighest attainable standardofhealthasoneofthefundamentalrightsofeveryhumanbeingwithoutbeingdiscriminatedagainst.ItisanobligationbythestatetoprogressivelyrealisetherighttohealthasrecommendedbytheInternationalCovenantonEconomicSocial and Cultural Rights (ICESCR) and the Sustainable DevelopmentGoals(24).Thereis,however,acaveatonthisidealasitsrealisationshoulddependonthecapacityofthenationtodeliver(7,9,25).Thisbringstotheforetheconceptofprogressiverealisationoftherighttohealthwithinthecontextsofdifferentcountriesandtheissuesofnon-discriminationinhealthcaredelivery.Thereisacalltoavoidretrogressivepoliciesandcommitmenttogobeyondtheminimumcore.

InUganda,thecommitmenttotheprogressiverealisationoftheRHTisexplicitintheconstitutionandpolicyandplanningdocuments.However,more still needs to be done. For example, according to the InternationalLabour Organisation, Uganda is yet to ratify 59 international legalinstruments,11ofwhichcouldimproveherreadinesstofast-trackrealisationoftheRTHandUHC.Thedecliningtrendintheproportionofgovernmentbudgetaryallocationstothehealthsectorhasbeencitedasanindicatorofretrogressivepolicy(seethechapteronresourcemobilisation).Thisapproachdemonstratesthenarrowfocusonhealthasbeingthesoleresponsibilityoftheheathsectorandunderminesthemulti-sectoraleffortsandinvestmentsindeterminantsofhealth.


UHCentailsprogressiveexpansioninthepopulationbeingcovered,theservicepackagesbeingprovidedandtheproportionofhealthcarecostscoveredbyprepaymentmechanisms(26).Inviewofthis,arenewedcommitmentandacceleratedprogresstowardsUHCshouldupholdtheprinciplethateveryonereceivesneededhealth serviceswithoutfinancial hardship in a progressivemanner, hence nuancing expectations. This principle is also expected toguidesectorreforms,suchastheestablishmentofnationalhealthinsurance,toensuretheavailabilityofaroadmaptoprogressivelyexpandpopulationcoverageandservicepackages.

c) Cost-effectiveness of health care services in Uganda

InUganda,75percentof thediseaseburden ispreventableandyet thereis high expenditure on the medicines, which turns the focus to cure asopposedtoprevention(14).Itisnotacceptablethatsomemembersofsocietyshould facedeath,disability, ill-healthor impoverishment for reasons thatcouldbeaddressedatlimitedcost.Thisisanareawhereevidenceshouldbegeneratedtoguidethedesignofacost-effectivebenefitpackage.Thechapteron purchasing (10) elaborates the challenges of the rising cost of serviceprovision,suchastechnologies,withoutnecessarilybenefitingthemajorityofUgandans.ThechapteralsohighlightsthedriversofinefficienciesintheUgandasectorsuchascorruption,absenteeismandpoorsupplysystemsthatrequireattentiontowardsUHC.

d) Shared responsibility

The principle of shared responsibility obliges high-income countries tosupportlow-incomenations.Asdemonstratedinseveralchaptersinthisbook(forexample,thoseonresourcemobilisation,globalisationandgovernance),UgandahasreceivedmuchsupportintheformofDevelopmentAssistanceforHealth(DAH).Thefinancialandtechnicalassistancehascome,though,with constraints of earmarking, unpredictability, off-budget programmingandmal-alignmentwithnationalpriorities(27).Thisimpliesthatashigh-income countries individually or, as part of international assistance andcooperation, provide financial and technical assistance to Uganda, effortsmustbemadetomaximisetheallocationoflocalresources.Theprincipleofsharedresponsibilityalsoimpliestheneedforacountrytoavoidactionsthatmayharmothercountriesortheattainmentoftherighttohealthinothercountries.Thisiscouldbetranslatedatnationallevelsuchthatsub-nationalunitslikedistrictsproactivelyavoidactionsthatwouldunderminetherightsofotherUgandansinothergeographies.


e) Participatory decision-making

GovernanceiscentraltofacilitatingtherighttohealthandUHC.Politicalcommitmentsinfluencehealthfinancingandaccountabilityandalsoenhancecitizencapacitiestoparticipateinachievinghealthforall.Aspectsrelatedtothisareelaboratedbelow:

i) Citizen participation for UHCCitizenparticipation isamajorcomponentofgovernanceandan integralpart of programme design (28). Citizen participation is a process whichprovides private individuals and constituencies with an opportunity toinformandinfluencepublicdecisionsandactionspertainingtotheirhealthandwell-being(29).Theprocessfosterspowerinpeopleforuseintheirownlives,theircommunitiesandtheirsociety,byactingonissuestheydefineasimportant.Itfacilitatesdisadvantagedgroupstogainpowerandexertgreaterinfluenceoverthosewhocontrolaccesstokeyresources(30).ItenhancesthecapacityofpeopletoensurethattheytakecontroloftheirownresourcesandactionsthatimpacttheirlivesinachievingthehighestattainablequalityoflifeasdefinedbyWHO.

InUganda,therehasbeenincreasingrecognitionoftheroleofcitizenengagementinthedevelopmentprocess.TheConstitutionoftheRepublicof Uganda guarantees freedom of association, including the freedom toformand join associationsorunions (Art.29) and the right toparticipatein peaceful activities to influence the policies of the government throughcivicorganisations(Art.38).Participationisoftenusedtomeanmobilisingcommunitiestoutilisehealthservicesandisusuallymeasuredbynumbersinattendance.Asaresult,asmallprivilegedgrouphasusurpedthepowerofthecitizens,whichiscontrarytoArticle38ofthe1995ConstitutionofUganda,whichstatesthatcitizenshavearighttoparticipateingovernmentactivities either as individuals, including technocrats, opinion leaders andpoliticians,collectivelyorthroughrepresentationbylocalleaders(10).Thisimpliesthatcitizensshoulddemandandmonitorthequalityofservicesandvalueadditionandalsoholdserviceprovidersandpolicymakerstoaccount.

Currently there is untapped potential among the citizens foroperationalisingtherighttohealthandachievingUHC.AlthoughpoliciessuchasthePatients’Charterandspaces/foraforparticipationexist,suchastheVHT,HUMCSandlocalcouncils,stillcitizensdonotknowtheirrightsandcapacityhasnotbeenbuiltforthemtoparticipateeffectively.Theavailablespace promotes access rather than understanding and claiming rights and


holdingdutybearersaccountable.Politicshasbeenade-incentivetocitizensandpower.Forexample,thepresidentialpronouncementwhichabolishedtheuserfeesandcreateddocilecitizens–apseudo-welfarestate(falsehope).Citizenshaveincreasinglyabdicatedtheirresponsibilitiestothestate,yettheDecentralisationPolicyStrategicFramework(31)recognisesthecentralroleofNGOsintheimplementationofthedecentralisationpolicy(adoptedin1992)andthusemphasisesthepartnershipprinciple(32):

Mobilisationofpublicopinionandcitizenparticipationincontestedspaces has created controversy within the participatory paradigm.Where there is no consensus, mobilisation can take the form ofcontestation.Contestationinpublicspacesusuallycourtscontroversyor protestation. Constitutions and attendant policy and regulatoryframeworkshavesoughttoincorporatepublicopiniononissuesthataffectpublicaffairs.

Foreffectiveparticipation,citizensmustbeequippedwithtimely,relevantand quality information to empower them to make informed input intoall the processes.Marginalised populations are not institutionally reachedin priority-setting and decision-making, limiting their voices to be heardand thus denying them participation. To sustain the UHC agenda it iscrucialthatcitizenparticipationisembracedbyallstakeholders;thiswouldimprovethecapacityofcitizensandexpandspacesforeffectiveandinclusiveparticipation.Thiswouldreducewastage,promotequalityandensurethatservicesarerelevantandmeettheneedsofthecitizens,whichisinlinewiththerights-basedapproachandaspirationsofUHC.

ii) Citizens’ entitlements and responsibilitiesTherightsarenotabsolute:therighttohealthdoesnotmeantherighttobeinghealthy.Assuch,citizensmustensurethattheylivehealthierandmoreproductivelives.

The right tohealth is about entitlements, the freedom to choose andtheresponsibilityofcitizens.Entitlementisaprovisionmadeinaccordancewith the legal framework. Countries are also bound by the internationalcommitments, such as universal declarations, for instance the AbujaDeclarationinwhich15percentofthenationalbudgetshouldbemarkedforhealth.Entitlementsmake itobligatory for the state toprovidehealthcareandthuscitizensneedtoknowthestatecommitmentsandclaimthem.


Attainmentof the right tohealth should embrace citizens’ responsibilitiesfortheirownhealthandwell-being(33).Responsibilitiesofcitizensrequirethattheyareempoweredwithinformationtopreventdiseases,promotewell-beingandutiliseavailableservicessuchasfamilyplanning,useofmosquitonetsandimmunisation.Thiscanbeenhancedthroughgeneralcleaningofgrowth centres and zones/villages (Bulungi bwansi), saving initiatives forsolvinglocalhealthproblems.

TheadoptionofthePatientsCharterbyMoHin2009wasadeliberateattempt by the government to provide a framework for its citizens toexercise responsibility and make appropriate choices that promote theirhealth andwell-being.Citizens also have a responsibility tomonitor andpromoteaccountabilityfortheservicesprovidedandupholdtheprinciplesof human dignity, equality and equity at all levels (34). Meaningful andeffectiveparticipationofbeneficiariesinpolicyandprogrammedevelopmentiscentraltoensuringvoiceandaccountability(35).Citizens’responsibilitieswouldrequirethattheyareempoweredwithinformationtopreventdiseases,promotewell-beingandutiliseavailableservicessuchasfamilyplanning,theuseofmosquitonetsandimmunisationagainstwhichtheirresponsibilityismeasuredatbothindividualandcommunitylevels.

iii) Voice and accountabilityFreedomsandchoicesrequirethatcitizensmakeresponsibledecisionsandbeaccountablefortheoutcomesoftheirvoices.Voiceistheabilityofcitizenstoexpresstheirpreferencesandtobeheardbythestate(36).However,citizens’voices are not homogeneous, and sometimes more powerful voices andopinionscancrowdoutthoseofexcludedormarginalgroups(37).

Thecreationofformalmechanismsforvoiceandaccountabilitycanbeeffectiveinopeningupspaceforcitizen-stateaccountabilityandimprovingserviceresponsiveness(38).Forthedifferentcontexts,theclaimfortherighttohealth,thepost-2015healthagendamustspecifyhowcitizenswillparticipateinthedecision-makingprocessessurroundingtheirhealthservicesandtheirphysicalandsocialenvironments(2).Oneofthefundamentalcomponentsof the right to health is citizen empowerment and the establishment ofmechanisms that allow for citizen participation in decision-making ontheir health and service delivery, discern good quality care, and demandaccountabilityfromprovidersofcare(39).Empowermentmeansthatpeopleand communities have both the opportunity and capability to participateeffectively in the social, economic andpolitical spheres. In the context of


decentralisation, empowerment thus refers to increasing the quantity andqualityofopportunitiestoparticipateinlocalgovernanceandlocalservicedelivery;inaddition,itimpliesaspecialemphasisonredressinginequitiesinvoiceandchoice.

iv) Potential of legal means to enforce the right to healthUsinglawsisanimportantmechanismtoenforcegovernmentobligationsandcitizens’responsibilities.Forexample,citizensmayrejectgovernmentprovidedmosquitoes nets and government may not enforce this fully. The legalinstrumentsshouldhelpthegovernmenttocoaxindividualstoavoidactionsthatgeneratenegativeexternalitiestosociety.Legalopportunitiesalsoexistforcitizenstoseekredressincasetheirrighttohealthisnotacteduponbyresponsibledutybearers.Box5.1belowisanillustrationofanempoweredcitizenwhowonthecivilcaseagainstMulagoHospital.

Text Box 5.1: Medical legal approach to advancing health rights

In Watsemwa & anor v Attorney general (CS NO. 675 OF 2006) (2006) UGHCCD 16 (20 February 2015). Watsemwa, mother to baby DavidGosetline sued Mulago Hospital for negligently handling her deliverywhere her son’s brain was irreversibly damaged, after which he wasdiagnosedwithsevereasphyxia.Thiswasduetodelaysof40to50minutesandnon-supervisionwhenitwasrealisedthatacordhadprolapsed.Shewastakentothetheatreforoperationasaresult.JudgeElizabethMusokeinherjudgmentonthe20/02/2015awardedtheplaintiffsthesumofShs.450,000,000= (Uganda shillings four hundred fiftymillion only) as anappropriateawardforthepain,sufferingandlossofamenitiesforthebaby,whileawardingShs.50millionforthepainandsufferingofthemother.

Source: Author analysis

Civilsocietyorganisations(CSOs)alsosetaprecedentontherighttohealththroughPetition16thatcompelledthegovernmenttoprovideessentialandqualitymaternalhealthservicestoUgandansandcompensatematernaldeathvictims.Other advocacy efforts included petitions for budget reallocationof39.2billion for recruitmentandtheenhancementof salaries forhealthworkers, where over 5,000 health workers were recruited and salariesenhancedfordoctorsatHCIVs(40).


f ) Prioritising the vulnerable and marginalised

TheConstitutionofUgandaanddevelopmentplansarticulatethefocusonthevulnerablegroupssuchaswomenandchildren,youth,theelderlyandthepoor.Severalotherinitiativeshaveafocusonthepoor(seeChapter2onsocialprotection).Povertyreductionstrategies,suchasSocialAssistancefortheElderly (SAGE), theYouthLivelihoodProgramme,OperationWealthCreation,theNationalAgriculturalAdvisoryServicesanduniversaleducationwereintroducedtocaterforthelessprivilegedinsociety.However,thesuccessofthesemaynotbeoptimal.Otherinitiativesincludegendermainstreamingingovernmentplanningandprogrammes.Inaddition,voucherprojectshavebeen implemented to facilitate access tomaternal, child and reproductivehealthservices,especiallyamongthepoor.SpecialpreventionandtreatmentprogrammeshavebeenimplementedforpopulationsmostatriskofacquiringHIV/AIDS.Thenorthern regionhas received special support for itspost-conflictrecoveryefforts(41).

Despitetheefforts,challengesstillexist.Transportcostsstillundermineaccesstohealthservices.Governmentfinancingisinput-basedanddoesnottake into account localitieswithmoreburdenofdisease and theneed forservices(42).Arecentstudyfoundthat“healthaidwasmostbeneficialtoindividualswholivedclosesttoaidprojectsandaidtendedtonotbetargetedtolocalitieswiththeworstsocioeconomicconditions”(43)(1).Theproposednational insurance does not clearly specify how to include the poor andindigentanditsprioritisationoftheformalsectoremployeeswillaccentuateinequities(15).

Implications and practical ways of anchoring UHC in the right to health discourse in Uganda

There is acommonunderstanding thatUHCis in tandemwith the rightto health perspective.TheRights-BasedApproach (RBA) is amechanismtoadvanceUHCasitisdesignedtopromoteequityandaddressdisparitiesamongcitizens;itisalsodesignedtoempowerthecitizensandpositionthemtotakechargeoftheirhealthdestinyandwell-beingandattainsustainabilityforUHC.

Progress has been made over the last 15 years to advance the sixprinciplesoftheRTH.TheConstitutionofUgandaandotherinternationallegalinstrumentsthatUgandaisasignatorytospecifytheobligationsofthegovernmenttoensurethehighestattainable levelofhealthfor itscitizens.


Thereisaperception,however,thattherighttohealthisnotwellarticulatedintheconstitution.ThislendscredencetothecallstoamendtheconstitutiontoexplicitlyincludetheRTH.Thisisenvisagedtofosterotherprocesses,suchasdefininghealth carefinancingmechanisms, including anationalhealthinsuranceschemeandaccountability,asaprincipleofgoodgovernance,aswellasUHCpillars.ThiswillimplylegalisationoftheRTHandputinplaceenforcementmechanismstosupporteffortsbytheUgandaHumanRightsCommissionformonitoringandreportingtoParliamentannuallyandenablecitizenstoconsequentlyseekredresswhenevertheirrightsareviolated.Thecaveat,though,thatthegovernmentcanonlyactwithinthemeansoftheircapacity should attenuate expectations that legislation will guarantee theright tohealth.There isoften adifferencebetween legal entitlements andmaterial provisions (44).The principle of progressive realisation and shareresponsibilitypromisesopportunitiesforconcertedeffortstowardsUHC.

PrioritisationofPrimaryHealthCare(PHC)wouldensureinvestmentin low-cost interventions that would benefit the majority of Ugandans.Thisapproachshouldbepeople-centred–puttingtheneedsofpeopleandcommunities,notdiseases,atthecentreofhealthsystems,andempoweringpeople to take charge of their own health (45). The ideal design of thehealth system should, therefore, harness the population’s capacity fordiseasepreventionandshouldbeorganisedaroundpeople,notthediseases.It would ensure that services respond to people’s voices and meet theirneeds and aspirations.For the right tohealth tobecome a reality, policy-makers must strive for a healthy physical and social environment (e.g.safe drinkingwater and good sanitation, adequate nutrition andhousing,safe and healthy occupational and environmental conditions and genderequality, as recommended by the SustainableDevelopmentGoals) (2, 8).Thiswoulddefinitelyrequireinter-sectoralcollaborationtoaddressthesocialdeterminants of health(45, 46). Efforts to streamline the governance ofrelevantsectorsmustbeprioritised(47).

Inpractice,contextisveryimportant.Alltheserequireheavyinvestmentand commitment on systems improvement, including community healthsystems.ForUgandatomoveonthepathtoUHC,thereisneedtoutiliseresources at the global level, which will enable knowledge transfer andresources management. Although the 2010 World Health Report notesthat low-income countries need international assistance to achieveUHC,itdoesnotmentionthatthisassistanceisamatteroflegalobligation.Moreattentionneedstobepaidtodevelopmentsintheglobalhealtharchitecture


andtoadaptingtotheirinfluencesontherighttohealthandUHCeffortsinUganda.

AsalludedtoearlierinChapter4,theinfluenceofgovernanceontherighttohealthcannotbeoverstated.Governancedefinesrolesandresponsibilitiesfordutybearersandrightsholders;andensuresaccountabilityforresourcesandqualityofoutputsand,ultimately,healthforall.Unfortunately,Uganda’scitizens havenot been fully engaged in governance of thehealth systems.Thevarious citizenengagementapproaches and social accountability tools(CommunityScoreCards,CitizenReportCards,Barazas)havebeenusedsporadically and remain un-institutionalised (48). However, in view ofthe important principles of participation, the contribution and roles ofbeneficiariesisnotwellarticulatedbyUHCframeworks(49).Itis,therefore,imperative to integrate thebeneficiaryresponsibilitiesalongside therights.WhereasUHCpaysparticularattentiontocitizens’entitlements,itpromoteslaxity among the citizens to contribute to the required resources, whichshould be the citizens’ responsibility. Legal mechanisms can be used toclaimentitlementsfromthegovernmentbutcouldalsobeameansforthegovernmenttoenforcepublichealthinitiatives.

Citizens’participationshouldleadtothemobilisationofresourcesforhealth,thepreventionofillhealthandbehaviourchange.Thishasenormousbenefitsforthewell-beingofsocietyandtheeconomicgrowthofthecountry.Citizens’involvementrightfromtheplanningstagetohealthservicedeliveryand the application of accountability approaches is key to empoweringthemandstrengtheningtheirvoicetomeaningfullyparticipateanddemandqualityservices.Thiswillconsequentlyenhancecitizens’ownershipandtheresilienceofthehealthcaresystem.

Importantly, “not all potential paths to a universal health system areconsistentwithhumanrightsrequirements.Simplyexpandinghealthcoverage,especiallyifitcontinuestoexcludepoorandvulnerablecommunities,isnotsufficient from a human rights perspective” (50).Health policy loopholesand human resources for health challenges have led to inequitable andsub-optimal health outcomes, reflected by the high rates of preventablecommunicable diseases and the upsurge of non-communicable diseases.UHC provides for the protection of citizens against financial hardshipsbroughtaboutbycatastrophicspendingonhealth,puingcitizensbelowthepovertyline.TheproposedNationalHealthInsuranceScheme,however,islikelytoinstitutionaliseinequitiesbetweengroupsandschemes.Itprioritises


thewell-off and the bill has no explicitmention of how to integrate theinformalsectorandthepoor.

Policy recommendations for the UHC agenda

Achievinguniversalhealthcoverageimpliesthatallpeoplehaveaccesswithoutdiscrimination, to nationally determined sets of the needed promotive,preventive, curative and rehabilitative basic health services.These servicesshould be essential, available, accessible, affordable, safe and effective andofacceptablequality,whichisabasisforhealthrights,whileensuringthattheusersoftheseservicesdonotexperiencefinancialhardship,especiallythepoor,vulnerableandmarginalisedsegmentsofthepopulation(8).Therefore,thefollowingpolicyshiftsandrecommendationsshouldbemade:

1. ToachieveUHC,citizens’rightsandtheirresponsibilitiesshouldbeputat thecentreof thehealthservicedeliverysystemthroughtheenactmentofaPatients’RightsandResponsibilitieslawwhichwillencouragecitizenstotakechargeoftheirbehaviourandlifestyle,andthepreventionandmanagementoftheirdiseaseconditionsandwell-being.The law should also promote voice and accountability andenhancestrongcommunityhealthsystemsandresilience.

2. ForUgandanstoenjoytherighttohealthandhealthforall,thecon-stitutionmustembracearobustandstrategiclegalframeworkthatoperationalisesthepro-poorNationalHealthInsuranceScheme,andequalopportunitiesforall,sothathealthgoodsandservicestranslateintoclaimableentitlementsthatgovernmentcanprovide.

3. Topromote sustainedprogressonUHC, state agreements/mecha-nisms on clear targets and shared responsibilities among differentactorsshouldbesoughtonthebasisofjustice,solidarityandhealthrights.

4. Explicitprioritisationofthevulnerableandmarginalisedshouldbemainstreamed into allUHC-related reforms to ensure consistencywiththerighttohealthperspective.


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