PROTECTION AND PROMOTION OF CHILDREN’S RIGHT TO LIFE IN

UGANDA: A CASE STUDY OF HOIMA AND MBALE REFFERAL HOSPITALS

OWOR GOOD FRIDAH

2015/HDO3/2514U

MA (HUMAN RIGHTS)

A DISSERTATION SUBMITED TO THE GRADUATE SCHOOL IN PARTIAL

FULFILMENT FOR THE AWARD OF MASTER OF ARTS DEGREE IN

HUMAN RIGHTS OF MAKERERE UNIVERSITY

JANUARY 2019

DECLARATION

I Owor Good Fridah hereby declare that this Dissertation is my original work and to the best of my knowledge has never been published and/or submitted for any award to any University.

Signature……………………… Date: …….………………

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APPROVAL

This dissertation has been written under my supervision and is ready for submission

Supervisor Ass. Prof. Dr. A. B. Rukooko

Signature ……………………. Date: ……………………

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ACKNOWLEDGEMENT

I wish to extend my sincere gratitude to the Almighty God, for the gift of life, the wisdom and strength that he has given me which has enabled me to get the resources that have made me possible to complete this work. My great appreciation and gratitude goes to my supervisor Dr. Ass. Prof. A. B. Rukooko for his academic and professional guidance, inspirational instructions and encouragement throughout the course of preparing for and conducting the research which has been of great help towards the accomplishment of this work into its present state. I am grateful for the insightful comments he provided on the draft. May God almighty bless him abundantly! I am greatly indebted to my brother Semu Good without whose caring support especially in finance, moral and spiritual guidance, it would not have been possible. My extended appreciation to my children Annet Nyaketcho, Arnold John Odoi, Angelica Owor and my husband Martin John Owor who endured my absence during the study, there is no doubt in my mind that without their prayers and support I would not have completed this dissertation. My gratitude is also extended to my mother Mrs. Phidelis Good, my bothers Sam Bikundi, Semu Good and John Paul Busobozi for their constant encouragement and prayers. I also wish to thank the management and staff at Mbale and Hoima Regional Referral Hospitals for supporting and providing the required data for the study.

May God bless you all!

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TABLE OF CONTENTS DECLARATION ...... i

APPROVAL ...... ii

ACKNOWLEDGEMENT ...... iii

ABBREVIATIONS ...... vii

LIST OF FIGURES ...... viii DEFINITION OF KEY TERMS ...... ix ABSTRACT……………………………………………………………………………….xii CHAPTER ONE ...... 1 GENERAL INTRODUCTION ...... 1 1.0 Introduction ...... 1 1.1 Background to the Study ...... 1 1.2 Statement of the Problem ...... 5 1.3 Objectives ...... 5 1.4 Research Questions ...... 6 1.5 Significance of the Study ...... 6 1.6 Justification of the Study ...... 6 1.7 Conceptual Framework ...... 7 1.8 Scope of the Study ...... 8

CHAPTER TWO ...... 10 LITERATURE REVIEW ...... 10 2.0 Introduction ...... 10 2.1 Legal Framework for the Protection of the Right to Life ...... 10 2.2 Perceptions of health workers towards children‘s right to life in Hoima and Mbale Hospitals...... 16 2.3 Capacity of Duty-bearers to Protect and Promote Children‘s Right to Life ...... 19 2.4 Challenges Affecting the Realisation of Children‘s Right to Life ...... 21 2.5 Conclusion ...... 23 2.6 Summary...... 23

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CHAPTER THREE ...... 25 RESEARCH METHODOLOGY ...... 25 3.0 Introduction ...... 25 3.1 Research Design...... 25 3.2 Geographical Area and Population ...... 26 3.3 Sampling Procedures ...... 26 3.3.1 Estimated Sample size ...... 26 3.3.2 Sampling Techniques ...... 26 3.4 Data Collection Methods ...... 27 3.4.1 Interview ...... 27 3.4.2 Documentary Review...... 27 3.4.3 Survey ...... 28 3.5 Data Collection Instruments ...... 28 3.5.1 Interview Guide ...... 28 3.4.2 Questionnaire ...... 28 3.5 Research Procedure ...... 29 3.6 Data Quality Control ...... 29 3.7 Data Analysis Techniques ...... 29 3.7 Ethical considerations ...... 30 3.8 Limitations of the Study...... 31

CHAPTER FOUR ...... 32

DATA PRESENTATION AND INTERPRETATION...... 32 4.0 Introduction ...... 32 4.1 Perceptions of health workers towards children‘s right to life in Hoima and Mbale hospitals...... 32 4.2 Capacity of duty bearers to protect and promote children‘s right to life at Hoima and Mbale Hospitals ...... 39 4.3 Challenges to the realisation of children‘s right to life in Hoima and Mbale Hospitals ...... 45 4.4 Strategies Forward ...... 50 4.5 Summary ...... 52

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CHAPTER FIVE ...... 53 DISCUSSION OF FIELD FINDINGS ...... 53 5.0 Introduction ...... 53 5.1 Perceptions of health workers towards children‘s right to life in Hoima and Mbale hospitals...... 53 5.2 Capacity of duty bearers to protect and promote children‘s right to life at Hoima and Mbale Hospitals ...... 57 5.3 Challenges to the realisation of children‘s right to life in Hoima and Mbale Hospitals ...... 61 5.4 Conclusions ...... 68

CHAPTER SIX ...... 69 CONCLUSIONS AND RECOMMENDATIONS ...... 69 6.0. Introduction ...... 69 6.1 Conclusions ...... 69 6.2 Recommendations ...... 71 References ...... 74 APPENDICES ...... 83

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ABBREVIATIONS

CRC Convention on the Rights of the Child HIV/AIDS Human immune Virus/Acquired Immune Deficiency Syndrome HSSP Health Systems Strengthening Project ICCPR International Covenant on Civil and Political Rights ICT Information Communication Technology IDA International Development Association MGLSD Ministry of Gender, Labor and Social Development MOH Ministry of Health NHP National Health Policy PFP Private for Profit PNFP Private- Not for Profit RRHs Regional Referral Hospitals SPSS Statistical Package for the Social Sciences UDHR Universal Declaration of Human Rights UHSSP Uganda Health Systems Strengthening Project UNFPA United Nations Population Fund UNICEF United Nations Child‘s Fund USAID United States Agency for International Development WHO World Health Organisation WSSCC Water Supply and Sanitation Collaborative Council

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LIST OF FIGURES

Figure 4. 1: Responses to whether the hospital‘s priority is to protect children‘s right to life 33 Figure 4. 2: Responses on whether the hospital has enough personnel ...... 35 Figure 4. 3: Responses to whether hospital staffs adhere to legal instruments while treating children ...... 36 Figure 4. 4: Responses to whether staff members are held responsible for negligent acts that lead to children‘s loss of life...... 37 Figure 4. 5: Responses to whether staff members offer adequate support to ensure that children‘s right to life is protected ...... 38 Figure 4. 6: Presents responses on whether Hospital staff members are aware of all the legal instruments that protect children‘s right to life ...... 40 Figure 4. 7: Results on whether hospital staff members are well qualified ...... 41 Figure 4. 8: Responses to whether staff members have good experience (More than 5 years) ...... 42 Figure 4. 9: Staff members have adequate knowledge of human rights ...... 43 Figure 4. 10: Responses to whether staff members receive training in human rights and protection of child‘s right to life ...... 44 Figure 4. 11: Responses to whether diarrheal diseases are responsible for children‘s death .. 45 Figure 4. 12: Responses to whether Malaria is responsible for children‘s death ...... 46 Figure 4. 13: Responses to whether inadequate funding is responsible for children‘s loss of life ...... 47 Figure 4. 14: Responses to whether inadequate funding for technological equipment is responsible for children‘s loss of life ...... 48 Figure 4. 15: Responses to whether lack of enough personnel is responsible for children‘s death ...... 49

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DEFINITION OF KEY TERMS Child: According to General comment No. 15 (2013) on the right of the child to the enjoyment of the highest attainable standard of health, ―child‖ refers to an individual below the age of 18 years, and this is also in accordance with article 1 of the Convention on the Rights of the Child.

Right to life: The right to life is provided for in Article 6 of the Covenant on Civil and Political Rights. In General Comment No 6 paragraph 1 the committee has noted that ―It is the supreme right from which no derogation is permitted even in time of public emergency which threatens the life of the nation‖ (CCPR General Comment No. 6: Article 6 (Right to Life)). The committee on Human Rights has also noted that states parties shall put in place measure to avoid acts of violence, arbitrary deprivation of life, and to take all possible measures to reduce infant mortality and to increase life expectancy through adopting measures to eliminate malnutrition and epidemics. Children‘s Right to health: ―The UN Human Rights Committee interprets children‘s right to health as defined in article 24 as an inclusive right, extending not only to timely and appropriate prevention, health promotion, curative, rehabilitative and palliative services, but also to a right to grow and develop to their full potential and live in conditions that enable them to attain the highest standard of health through the implementation of programmes that address the underlying determinants of health‖ (General comment No. 15 (2013)).

Perception: According to Cambridge English Dictionary perception means ―a belief or opinion, often held by many people and based on how things seem‖. In this study, perception points to how medical workers identify with Government‘s failure or refusal to adequately fund the Ministry of Health and facilitate hospitals adequately to be able to save children‘s lives and how this contributes to their failure or success in saving children‘s lives. It also speaks to the impact this has on medical workers especially how it may affect their response to doing their job and how this affects the realisation of children‘s right to life in Hoima and Mbale referral Hospitals.

Duty Bearers: Before human rights duties can be fairly and justifiably allocated to specific duty bearers, the duty bearers must be identified as potential duty bearers. The duty bearers can be individuals or institutions as a party that exercises jurisdiction over the right holder (Besson 2015). While there remains arguments about whether individuals are the sole bearers ix of human rights duties or institutions this study takes duty bearers as both individuals and institutions of state. The individuals in this case are parents and medical workers and the institutions are the Ministry of Health, Public Service Commission, Ministry of finance and any other departments of government that work in relation to the realisation of children‘s right to health and the protection of the right to life.

According to Ljungman, whereas states are the primary duty bearers of human rights protection there are also non-state moral duty bearers. Among these are primary moral duty bearers and secondary moral duty bearers. Example of primary moral duty relevant to this study are parents to children and doctors and nurses for patients while secondary moral duty bearers relevant here are hospital administrations (2004).

Protection: Protection of human rights comes from the obligations of the state. In this case because the right to life and the right to health overlap in both Civil and Political Rights and Economic Social and Cultural Rights we shall take a general view of the meaning of the team. Protection of human rights refers to ―prevent others from interfering with the enjoyment of the right‖ (United Nations Human Rights-Office of the High Commissioner). ―The obligation to protect obliges the State and its agents to prevent the violation of rights by other individuals or non-state actors. Where violations do occur the State must guarantee access to legal remedies” (Ljungman, 2004). Protection is one of the minimum core obligations of the state in the realisation of human rights. The achievement of the protection obligation requires states ―to take steps‖ to the maximum of their available resources to achieve progressively the full realization of economic, social and cultural rights‖. Protection of human rights is also emphasised in General comment No 6 on the right to life with particular focus on the right to health and infant mortality. Article five states that, ―Moreover, the Committee has noted that the right to life has been too often narrowly interpreted. The expression ―inherent right to life‖ cannot properly be understood in a restrictive manner, and the protection of this right requires that States adopt positive measures. In this connection, the Committee considers that it would be desirable for States parties to take all possible measures to reduce infant mortality and to increase life expectancy, especially in adopting measures to eliminate malnutrition and epidemics‖.

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Promotion: The term promotion means ―to further or encourage the progress or existence of‖ something (Reverso Dictionary). In the context of human right and particularly the promotion of children‘s right to life, promotion refers to the furtherance and encouragement for the progress and realisation of the set objectives targeting the reduction of child and infant mortality in Uganda. The realisation of the right to life requires the establishment of mechanisms, policies and programmes to assist the duty bearers in carrying out their responsibilities.

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ABSTRACT

This study aimed at assessing the realisation of children‘s right to life in Hoima and Mbale Regional Referral Hospitals. The study set out to assess the perceptions of health workers towards the legal framework on children‘s right to life in Hoima and Mbale hospitals, to assess the capacity of duty bearers to protect and promote children‘s right to life in Hoima and Mbale hospitals and to identify and examine the challenges to the realization of children‘s right to life in Hoima and Mbale Hospitals. The assessment reviewed international, regional and national standards and policies. A case study research design was used employing both qualitative and quantitative techniques to collect and analyze data. A sample of 123 respondents and informants was used which included hospital management, medical staff, non-medical staff and parents/guardians of child patients. Data was collected through reviewing documents, use of questionnaires and interviews. The researcher collected field data on the perceptions of health workers towards children right to life, the capacity of duty bearers to realise children‘s right to life and the challenges that affect the realisation of children‘s right to life in Mbale and Hoima Hospitals.

The researcher found out that malaria is the main challenge to the realisation of children‘s right to life. Diarrhea, inadequate funding and inadequate personnel also affect the realisation of children‘s right to life. It inferred that Uganda still has a high child death rate especially for children of 0-5years of age. It was also found out that medical workers prefer to work in the private sector compared to government due to low pay, medical workers practice dual employment working in both government and private hospitals. In addition, the study found that duty bearers have capacity to protect and promote children‘s right to life however much this is sometimes limited by inadequate funding and inadequate personnel.

The study concluded that unless funding for health is increased, most of the challenges will not easily change. There is need to increase the number of medical staff and the Public service commission should hire more medical personnel and the Ministry of Finance, Planning and Economic Development should also allocate more funds to the ministry of health. The Ministry of Health should also work with the ministry of public service to be able to supervise medical personnel and prohibit the practice of dual practice where medical workers get two jobs, one in the public and another in the private sector. The study also concluded that the efforts that the Ministry of Health has put in place to fight malaria and diarrhea have not completely solved the challenge of child mortality and malaria has continued to claim infant life. The study recommends that the Ministry of Health should support recruitment of more personnel and Government should increase funding to hospitals in order to procure enough drugs and equipment. The study also recommends that government should make a policy that requires medical graduates who are sponsored by government to work in the public sector for at least two years after graduation. This will reduce the challenge of inadequate personnel. If the MGLSD and the Ministry of Health implement these recommendations, they will be able to improve the realisation of children‘s right to life.

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CHAPTER ONE

GENERAL INTRODUCTION

1.0 Introduction

This study aimed to assess the realization of the right to life of children in health centres in Uganda with specific reference to Hoima and Mbale Hospitals. The right to life is a universally recognized right of all human beings and it is a fundamental right which governs all other existing rights. In its absence, all other fundamental rights have no reason to exist. For children, the right to life is the chance to be able to live and have the possibility to grow, to develop and become adults (Baldrige, 2013). It is the role of the state and hospitals, beyond the responsibility of parents, to ensure that children have the possibility to develop in a healthy and normal fashion, under all circumstances. They must guarantee a protection that is suitable for all children, regardless of their social or ethnic origins. This chapter presents the background to the study, statement of the problem, objectives, research questions, significance of the study, justification of the study, conceptual framework and scope of the study.

1.1 Background to the Study

In a global context, children‘s right to life is given a wide definition with children special protection, enabling the progressive development of ―minor rights‖. For example, in France, since 1841 laws started to protect children in their workplace and the right to be educated (Baldrige, 2013). In Germany the health care system has remained the same with German Statutory Health Insurance (national health insurance) putting emphasis on strong government funding to support child health care programs (Ghatak, Hazlewood, & Lee, 2008). Children‘s right to life is further defined in the European Union context, going beyond the avoidance of accidents and prevention of disease to include all aspects of the children‘s well-being. The competence of the European Union to intervene in the field of children‘s right to life is defined by the provision in Article 153 (1 and 2), which authorizes the Council to adopt, by means of directives, measures that protect children‘s lives.

From the health perspective, Sub-Saharan Africa lags behind the rest of the world. Infant and child mortality rates are high in the region, resulting in over four million African children dying each year (Sanon, 2009). Although the global infant mortality rate has decreased from an estimated rate of 63 deaths per 1000 live births in 1990 to 32 deaths per 1000 live births in 1

2015, infant mortality rate remains particularly high at 61 deaths per 1000 live births in Africa. The reasons for poor child survival in Africa include social, economic and political factors which exacerbate common diseases that lead to death (Sullivan & Roskens, 2011). Infant and child mortality rates are high in the region, resulting in over four million African children dying each year (Sanon, 2009). Measles, pneumonia, respiratory infections, diarrhea and malaria remain the major causes of infant and child mortality globally (Kok, 2003). Improving the productivity and performance of health workers to ensure that quality health care on children‘s life is efficiently delivered continues to be a major challenge for African countries. The performance of a health organization depends on the knowledge, skills and motivation of individuals. It is therefore important for employers to provide suitable working conditions to ensure that the performances of employees meet the desired standards (WHO, 2004). African countries are trying to improve the functioning of health care delivery systems to ensure that the children receive timely quality care.

The right to life is protected in the International, Regional and National frameworks and systems. At the International level, the right to life is protected under the UDHR in Article 3 which states that, ―Everyone has the right to life, liberty and security of person‖. This is the most morally binding provision for the right to life in international law. This right is also provided for in the ICCPR in Article 6.1 which stipulates that, ―Every human being has the inherent right to life. This right shall be protected by law. No one shall be arbitrarily deprived of his life‖. This right is also protected under General Comment No. 36 on the right to life. There are also more specific provisions on the right to life, especially children‘s right to life. For Example, the CRC is an international Covenant dedicated to children‘s rights and Article 6 of this covenant stipulates that, 6.1. ―States Parties recognize that every child has the inherent right to life‖ and 6.2. ―States Parties shall ensure to the maximum extent possible the survival and development of the child‖.

At the Regional level, the right to life is provided for under the African Charter on Human and People‘s Rights Article 4, African Charter on the Right and Welfare of the Child Article 5.1 provides that, ―Every child has an inherent right to life. This right shall be protected by law‖. General Comment No. 3 of the African Charter on Human and People‘s Rights is also a provision for the protection of the right to life at the regional level. Its preamble stipulates that ―The jurisprudence of the African Commission on Human and Peoples‘ Rights (the Commission) has widely recognized the right to life as a

2 foundational right. Without the right to life, other rights cannot be implemented‖. At the National Level, the right to life is protected in the Bill of Rights which is in Chapter IV of the Constitution of Uganda. Article 22 of the Constitution provides that, ―22. (1) No person shall be deprived of life intentionally except in execution of a sentence passed in a fair trial by a court of competent jurisdiction in respect of a criminal offence under the laws of Uganda and the conviction and sentence have been confirmed by the highest appellate court. (2) No person has the right to terminate the life of an unborn child except as may be authorised by law. Uganda has also put in place The Children Act to ensure the protection of children‘s rights.

However much all the above laws and provisions give guidelines on how to realise children‘s rights and the right to life, children still die from preventable diseases. Uganda ranks among the top 10 countries in the world for high maternal, newborn and child mortality rates accounting for 438 deaths per 100.000 live births. Child mortality rates per 1.000 live births in Uganda stand at 13 deaths on the first day, 20 deaths in the first week, 27 deaths in the first 28 days, 56 deaths in the first year and 90 deaths in the first five years. Malaria, diarrhea and infections like HIV account for more than 70% of under-five deaths (UNICEF, 2015).

Looking back at the statistics before 2010 on children‘s right to life, an earlier study by UNICEF in 2009 estimated that about 153,000 children die each year in Uganda, mostly from preventable causes such as diarrhea, measles, respiratory infection, malaria and malnutrition. AIDS, however, was expected to become a major cause of childhood death in the 1990s. A study of infant and child deaths in health units in Uganda found malaria the leading cause of death, responsible for 17.9% of the deaths (MoH, 1994). Malaria was followed by diarrhea, accounting for 9% of deaths; while acute respiratory infection and measles were responsible for 7% of the infant deaths and 9.9% of the under-five mortality. Article 22, (2) of the Uganda Constitution states that, no person has the right to terminate the life of an unborn child except as may be authorized by law. The Uganda Constitution further stipulates in Article 34, (3) of the Constitution states that ―No child shall be deprived by any person of medical treatment, which implies the constitution‘s emphasis on children‘s right to life. ―The Children Act-CAP 59 Laws of Uganda: The Act puts into effect the Constitutional provision on children and emphasizes the protection of the child by upholding the rights, protection, duties and responsibilities. This Article stresses the right of every child to life,

3 survival and development. It means that governments must ensure that health services are designed to protect the lives of children.

Hoima Regional Referral Hospital (RRH) is located approximately 190 kilometers from Kampala. Originally a health center for the Bunyoro-Kitara Kingdom, the hospital was upgraded to a district hospital, and in 1994 became one of the RRHs. Hoima hospital now serves Bunyoro (mid-western region) and part of central Uganda including Hoima, Masindi, Kiryandongo, Buliisa, Kibaale, Kyankwanzi, and Kiboga districts and a steadily increasing number of patients coming from eastern Democratic Republic of the Congo. It is also a teaching hospital for students pursuing medical professions in the region. According to Hoima District Annual report (2013), the risk of child death is caused by AIDS, malaria, pneumonia, malnutrition and diarrhea among others

Mbale Regional Referral Hospital is located in eastern Uganda about 240 kilometers away from the capital city Kampala and serves a population of approximately 3,500,000 million people from fourteen districts which include Mbale, Manafwa, Kapchorwa, Bukwo, Kween, Sironko, Butaleja, Bududa, Budaka, Tororo, Busia, Palisa, and Kibuku. It attained a regional referral status in 1994, became semi-autonomous in the same year. Staff members in both Hoima and Mbale hospitals are responsible for offering life-saving treatment and placing patients on file with their consent. In addition, they do not neglect or mistreat patients. Despite the attention paid to patients, particularly children during birth and after, MOH Annual Report (2015) showed that many mothers and ultimately children still lose their lives while in RRHs hospitals. The 14 Regional Referral Hospitals (RRHs) and 4 large Private Not for Profit (PNFP) hospitals assessed registered an increase in Standard Unit of Output (SUO) in 2014/15 compared to 2012/13 from 8,727,279 to 9,598,602. Mbale Hospital continues to lead in volume of outputs pushed by the very high number of admissions 70,183 (37% higher than 2013/14). Masaka retains the second slot registering a 36% increase compared to the year before. Hoima, St. Marys Lacor, Moroto all registered more than 20% increase. For reasons yet to be established Kabale had a 29% reduction in outputs compared to the year before. Hospital based deaths especially maternal deaths and fresh still births are indicators of quality of care. The total maternal deaths reported in 14 RRHs and 4 PNFP hospitals were 321 with a mean death of 18 mothers per hospital per year with a minimum of 2 in Mengo and a maximum of 37 in Mbarara RRH.

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1.2 Statement of the Problem

Whereas the Government of the Republic of Uganda has been working to improve the health of its citizens through a number of interventions including: the USD 130 million from the International Development Association (IDA) of the World Bank towards the cost of the Uganda Health Systems Strengthening Project (UHSSP) (UHSSP, 2011), the reaffirmation of commitments to the rehabilitation of the country‘s Regional Referral Hospitals and a whole range of Health Centre IVs in the financial year budget 2010/2011, the Water Supply and Sanitation Collaborative Council (WSSCC) funded Sanitation Fund programme (USF) and the National Health Policies I, II and III, which focused on health promotion and disease prevention, plus the Uganda National Minimum Health Care Package which has an obligation to provide basic health care combined with the Uganda National Expanded Program on Immunization (UNEPI) which mainly targets infants, children and women of childbearing age.

Uganda is still one of the 30 countries in the world with the highest number of deaths of children in the age group of 0-5 years (UNICEF, 2015). Hoima and Mable Regional Referral Hospitals are suffering an acute shortage of medical personnel. Consequently, the hospitals have been working under threat from the patients‘ attendants whose anger is aroused by the death of their dear ones—who mostly are children—in hospitals due to poor quality of service delivery (Odongo, 2015). Why do children continue to die at high rates yet the government has all the above programmes and funding to solve this problem?

1.3 Objectives

1.3.1 General Objective To assess the realisation of children‘s right to life in health centres with reference to Hoima and Mbale Hospitals.

1.3.2 Specific Objectives i. To assess the perceptions of health workers towards the legal framework on children‘s right to life in Hoima and Mbale hospitals. ii. To assess the capacity of duty bearers to protect and promote children‘s right to life in Hoima and Mbale hospitals. iii. To identify and examine the challenges to the realization of children‘s right to life in Hoima and Mbale Hospitals

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1.4 Research Questions

i. How does the legal framework and health workers‘ perceptions relate to the children‘s right to life in Uganda? ii. What is the capacity of duty bearers to promote and protect children‘s right to life in Hoima and Mbale Hospitals? iii. What are the challenges affecting the realization of children‘s right to life in Hoima and Mbale Hospital?

1.5 Significance of the Study

Study findings will benefit the hospital administration and staff members at Hoima and Mbale Hospitals to understand the reasons for the loss of children‘s life. The findings will also bring to attention that health workers need to be more cautious and save children‘s lives, and remind policy makers in Parliament, Ministry of Public Service, Ministry of Health as well as human rights activists in the field of the right to life about the need to focus more resources and time to the protection of children‘s right to life. It will also inform the academia of the challenges that need to be studied further to protect children‘s right to life. Not only is this study significant for only the purposes above. It has also helped the researcher to explore and understand more in the area of children's rights to life.

1.6 Justification of the Study

Statistics show that children have continued to lose their lives in government hospitals. The Infant Mortality Rate is at 54 deaths (UDHS 2011) per 1,000 live births and according to World Health Statistics series (2014) estimates are around 45 death per 1,000 live births. Both rates fall short of the Health Sector Strategic Investment Plan (HSSIP) target of 41 per 1,000 live births. Similarly the Under 5 Mortality Rate target of 69 per 1,000 live births fell short of the HSSIP target of 56 per 1,000. (UNICEF, 2015). Uganda is ranked 19th globally in under -5 deaths. Over 7 million children globally under -5 years of age die each year, mainly from preventable and treatable conditions. Pneumonia, diarrhea and malaria remain the leading cause of child mortality, and under nutrition contributes to more than one third of all deaths (Inter-parliamentary Union, Parliament of Uganda and The Partnership for Maternal and Newborn Health, 2011). This motivated the researcher to conduct a study to analyze the perceptions of health workers towards children‘s right to life, and its protection and promotion in Hoima and Mbale Hospitals. This study is intended to find out the causes of

6 children‘s death and suggest solutions in relation to health workers‘ perceptions and right to health policies in Uganda.

1.7 Conceptual Framework

A djunct variable Constraining Educate parents Variable about child Inadequate nutrition and health funds

Independent Implementation Bridging Dependent variable Variable variable variable To protect Provide adequate Parents take Children‘s children‘s right to child medical children to right to life life . facilities hospitals

Unintended Latent variable consequences Increased child Reduced child mortality rates mortality rates

In this conceptual framework, the promotion and protection of children‘s right to life can be achieved by providing adequate child medical facilities in hospitals or educating parents about child nutrition and health. These can be reinforced on the basis of legal instruments such as Children Act Cap 59 and the Ugandan Constitution and by parents taking their children to hospitals to receive medical care when they are sick.

Good nutrition also contributes to the realization of children‘s right to life. When parents are educated about child nutrition and health, they will feed their children properly, ensure a balanced diet with the required nutrients and thus children will have good immunity and live healthy lives.

However, attempts to promote and protect children‘s rights to life are often crippled by inadequate funds to hospitals, which results into unintended increased child mortality rates. Improving funding, providing of child medical equipment and sensitization of parents can

7 contribute towards the realisation of children‘s right to life and ultimately lead to very minimal child mortality rates.

1.8 Scope of the Study

1.8.1 Geographical Scope The study was carried out in Hoima and Mbale Hospitals. When contemplating a research on the right to life with focus on children, the researcher wanted to use regional referral hospitals that are not in the capital city, those that would do regional justice to the research and also give a representative picture of Government Hospitals. Hoima and Mbale Regional Referral Hospitals served this purpose excellently. Hoima hospital is located in western Uganda in Hoima District while Mbale Hospital is located in Eastern Uganda in Mbale District. The study was focused on assessing the realisation of Children‘s right to life in these two hospitals.

1.8.2 Content Scope In this study, the researcher will assess the perceptions of health workers towards the protection of children‘s right to life, the capacity of duty bearers to promote and protect children‘s right to life at Hoima and Mbale hospitals and will identify and examine the challenges affecting the realization of children‘s right to life in Uganda. After these assessments and examinations, the researcher will highlight some possible strategies for the realisation of children‘s right to life.

1.8.3 Time Scope The study period stretched from 2010 to 2016. This period was chosen because it is during this time that the trend in allocation of funds to the health sector showed that there was an increase in budget allocation towards the implementation of the Health Sector Strategic Investment Plan, which is the government strategic plan for improving performance in health (MOH, 2014/2015). The researcher was therefore interested in investigating the realisation of children‘s right to life during this period of time.

1.9 Conclusion Uganda is among the countries that still have a very high rate of child death in the whole world especially among children aged 0 to 5. This study assesses the realisation of children‘s right to life in Hoima and Mbale hospitals. The study is about the right to life, but alludes to the right to children‘s right to health so much too. This is because of the interrelatedness

8 between the right to life and children right to health. The study was carried out in Hoima and Mbale hospitals focusing on children‘s right to life from 2010 to 2016.

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CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

This chapter presents a review of the literature on protection and promotion of children‘s right to life. The literature review is based on themes derived from the objectives of the study and each objective is presented as a section under the literature review. In this review, the researcher presents the International Legal framework, the regional legal framework and the national legal framework on the protection of children‘s rights which includes children‘s right to life. The researcher then shows the perceptions of health workers towards the promotion and protection of children‘s right to life in Uganda from the available literature. In the section about perceptions, special attention is given to public health workers and public hospitals, though the private sector is also considered. This is because the study was focused on public/Government hospitals and public sector health professionals. After this is done, the researcher makes an assessment of the capacity of duty bearers (in this case, health workers) to protect children‘s right to life. The challenges to the realisation of children‘s right to life in Mbale and Hoima hospitals are then identified and examined.

2.1 Legal Framework for the Protection of the Right to Life

Universal Declaration of Human Rights (UDHR) 1948, Article 3 stipulates that, everyone has the right to life, liberty and security of a person. The realisation of this right is further reinforced by the provisions of Article 25 (1 and 2) which states that, Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection. What is essential to note about Article 25 is that it provides for the right to food without which the right to life cannot be realised. Article 25 also provides for medical care and the rights of children to enjoy social protection whether born in or out of the wedlock. This right combines major rights (right to food, right to medical care, and the right to social protection) which are important for the realisation of children‘s right to life.

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International Covenant on Civil and Political Rights (ICCPR) 1966, Article 6 (1) provides that, every human being has the inherent right to life. This right shall be protected by law. No one shall be arbitrarily deprived of his life.

International Convention on Economic, Social and Cultural Rights (ICESCR) 1966 Article 12 (1and 2) provides that, The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. 2. The steps to be taken by the States Parties to the present Covenant to achieve the full realization of this right shall include those necessary for: (a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child; (b) The improvement of all aspects of environmental and industrial hygiene; (c) The prevention, treatment and control of epidemic, endemic, occupational and other diseases; (d) The creation of conditions which would assure to all medical service and medical attention in the event of sickness. In this covenant, the researcher focuses on article 12 (2a) which is about the provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child.

General Comment No 36 on the right to life. This General Comment replaces earlier General Comments No. 6 (16th session) and 14 (23rd session) adopted by the Committee in 1982 and 1984, respectively). General Remark 2 stipulates that, Article 6 recognizes and protects the right to life of all individuals. It is the supreme right from which no derogation is permitted. The right to life has profound importance both for individuals and for society as a whole. It is most precious for its own sake, but also serves as a basic right, facilitating the enjoyment of all other human rights. General Remark 3 provides that, the right to life concerns the entitlement of individuals to be free from acts and omissions intended or expected to cause their unnatural or premature death, as well as their legitimate expectation to enjoy a dignified existence (OHCHR, General Comment No. 36). This General Comment emphasises the fundamental nature of the right to life and the interdependent value it carries in relation to the realisation of any other human rights. This is evident from the phrase ―it is most precious for its own sake‖ and the fact that all other rights cannot be realised if this right is not realised. General Remark 5 goes further to point out that deprivation of life resulting from medical malpractice is also unacceptable.

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The right to health is a fundamental part of human rights and of a life of dignity (UNAIDS, 2013). In this study, the right to life is discussed alongside the right to health because the study is particularly on children‘s right to life in Hoima and Mbale Regional Referral Hospitals. Due to the nature of this study that is carried out in two hospitals to assess the realisation of children‘s right to life, it will sometimes seem like the discussion is about the right to health, but readers should be reminded the study is on children‘s right to life in Hoima and Mbale Hospitals. For this reason, more emphasis on deprivation of life resulting from medical malpractice can be drawn from the Committee on the Rights of the Child General Comment No. 15 (2013) on the right of the child to the enjoyment of the highest attainable standard of health (art. 24). In this General Comment under the section of (IV) Obligations and Responsibilities, ―States have three types of obligations relating to human rights, including children‘s right to health: to respect freedoms and entitlements, to protect both freedoms and entitlements from third parties or from social or environmental threats, and to fulfil the entitlements through facilitation or direct provision. In accordance with article 4 of the Convention, States Parties shall fulfil the entitlements contained in children‘s right to health, to the maximum extent of their available resources and, where needed, within the framework of international cooperation‖ (General Comment No.15 (2013)). This makes it very clear that the primary responsibility of the right to health rests within the obligations of the state. Among the core obligations of the state under children‘s right to health is: Reviewing the national and subnational legal and policy environment and, where necessary, amending laws and policies; Ensuring universal coverage of quality primary health services, including prevention, health promotion, care and treatment services, and essential drugs; Providing an adequate response to the underlying determinants of children‘s health; and Developing, implementing, monitoring and evaluating policies and budgeted plans of actions that constitute a human rights-based approach to fulfilling children‘s right to health.

It should be noted that the right to health is a very essential prerequisite to the realisation of the right to life. It is one of the most important rights that must be realised if the right to life is to be safe. It is for this reason that emphasis is made on the right to health although the right under study is Children‘s right to life. This emphasis is further concretised in CESCR General Comment No. 14: The Right to the Highest Attainable Standard of Health (Art.12). Article 1 of this General Comment states that, Health is a fundamental human right indispensable for the exercise of other human rights. Every human being is entitled to the enjoyment of the highest attainable standard of health conducive to living a life in dignity.

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These provisions about the right to health are to emphasise the necessity of living a dignified life, which all comes back to the protection of the right to life.

In the introduction of the same General Comment, it is noted that the provisions of this general comment are directed at the importance of approaching children‘s health from a child-rights perspective that all children have the right to opportunities to survive, grow and develop, within the context of physical, emotional and social well-being, to each child‘s full potential.

According to the Convention on the Rights of the Child (CRC) (1989) ―Article 2, states parties shall respect and ensure the rights set forth in the present Convention to each child within their jurisdiction without discrimination of any kind, irrespective of the child‘s or his or her parent‘s or legal guardian‘s race, color, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status. ―Article 6 Stipulates that States Parties recognize that every child has the inherent right to life and that they shall ensure to the maximum extent possible the survival and development of the child‖. As is clear from the statements above, the Convention on the Rights of the Child, including its preamble, establishes that every child has the inherent right to life and, due to his physical and mental immaturity, needs special legal protection and safeguards, without making any distinction between born and unborn children. Indeed, the Convention expressly points out that said protection covers every child, ―before as well as after birth‖ (CRC, 1989).

African Charter on Human and Peoples Rights (ACHPR) 1987 Article 4 states that, Human beings are inviolable. Every human being shall be entitled to respect for his life and the integrity of his person. No one may be arbitrarily deprived of this right.

African Charter on the Rights and Welfare of the Child (ACRWC) 1990 Article 14: Health and Health Services, Provides that, 14 (1) every child shall have the right to enjoy the best attainable state of physical, mental and spiritual health, (3) to reduce infant and child mortality rate; (4) to ensure the provision of necessary medical assistance and health care to all children with emphasis on the development of primary health care; (5) to ensure the provision of adequate nutrition and safe drinking water; (6) to combat disease and malnutrition within the framework of primary health care through the application of appropriate technology; (7) to ensure appropriate health care for expectant and nursing 13 mothers; (9) to integrate basic health service programmes in national development plans; (11) to ensure the meaningful participation of non-governmental organizations, local communities and the beneficiary population in the planning and management of basic service programmes for children (ACRWC, 1990 Article 14). All the above provisions are aimed at the right to health, but the important implication to note is that they are aimed at the realisation and preservation of life. They emphasise the need to promote the right to health in order to reduce child mortality and infant mortality which are both geared at the realisation of children‘s right to life.

At the national level, the constitution is the key legal document, although Uganda has a Children‘s Act and several strategies for the promotion and protection of children‘s rights. Article 22 of the 1995 Constitution of Uganda as amended in 2005 also protects the right to life. Article 22 provides that, no person shall be deprived of life intentionally except in execution of a sentence passed in a fair trial by a court of competent jurisdiction in respect of a criminal offense under the laws of Uganda and the conviction and sentence have been confirmed by the highest appellate court. No person has the right to terminate the life of an unborn child except as may be authorised by law (Uganda Constitution, 1995).

The Constitution of the Republic of Uganda (1995) Art.34; provides specifically the following rights of children: the right to know and be cared for by parents or other people; the right to basic education, the right not to be denied medical treatment or any other social or economic benefits, protection from all exploitation, and that orphans or other vulnerable children must be specially protected by the laws of Uganda.

The Children Act (1997) CAP 59, Part II (5) (1&2) states that: (1) It shall be the duty of a parent, guardian or any person having custody of a child to maintain that child and, in particular, that duty gives a child the right to—(a) education and guidance (b) immunisation; (c) adequate diet; (d) clothing; (e) shelter; and (f) medical attention. (2) Any person having custody of a child shall protect the child from discrimination, violence, abuse and neglect. This provision protects the rights of the child and in particular it gives a provision for the protection of the rights to immunisation, medical attention, shelter and adequate diet. The emphasis in subsection two is to highlight the necessity of all these rights and to show that all of them are necessary reinforcing each other and interdependent. The Act puts into effect the

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Constitutional provision on children and emphasizes the protection of the child by upholding the rights, protection, duties and responsibilities.

The Occupational Safety and Health Act (2006). The occupational safety and health act part II provides for administration and enforcement of the act, appointment of inspectors, administration of the act, duty of confidentiality by inspectors, powers of inspectors, occupier to accord facilities to inspectors, causing delay to, or obstruction of inspectors, powers of inspector to prosecute, establishment of the occupational safety and health board, advisory panels, and terms of service of members of advisory panels

The government has the obligation to realise all human rights and like all other human rights, the right to health imposes obligations on state parties: the obligations to respect, protect and fulfill. It is these obligations that call upon the government to put in place strategies so that the right to health can be realised in practical sense. In Uganda these strategies include laws and policies in the field of health. For example: Uganda has the National Health Policy (2010). The Goal of this policy was to attain a good standard of health for the people of Uganda. The priority areas were: Strengthening health systems in line with decentralisation; Reconceptualising and organising supervision and monitoring of health systems at all levels; Establishing a functional integration within the public and private sector; Addressing the human resource crisis; Universal Access to Uganda National Minimum Health Care Package, which includes promotive, preventative, curative, rehabilitative and palliative care (National Health Policy, 2010). National Development Plan (NDP) II 2015/16-19/20. This Development Plan outlines key health interventions to drive growth 2015-2020. These include: Scale up training of health cadres in short supply. Develop community structures for improved health education, promotion and disease prevention, including the Community Health Extension Workers strategy. Support implementation of primary health care. Improve effectiveness and efficiency in the delivery of health (NDP) II 2015/16-19/20).

Uganda also has the Health Sector Development Plan 2015/16-2019/20. This plan outlines a broad plan to realise the right to health for 20115/16-2019/20 and defines the long and medium term agenda for health. Health Sector development priorities include: Strengthening national health system including governance; Disease prevention, mitigation and control; Health education, promotion and control; Curative services; Rehabilitation; Palliative care

15 services; Health infrastructure development. (Health Sector Development Plan. 2015/16 - 2019/20).

Uganda has also put in place a Patient Charter which aims to ensure the rights of patients are protected as they seek health services and to empower them to demand quality health care. It seeks to enhance community participation and accountability (Patient‘s Charter, 2009). The Patients Charter is a result of joint effort by the Ministry of Health in partnership with Civil Society Organization led by the Uganda National Health Consumers Organization (UNHCO). The objective of the patients‘ charter is to empower health consumers to demand high quality health care, to promote the rights of patients and to improve the quality of life of all Ugandans and finally eradicate poverty nationwide. The patients charter and its constant review processes will enable health users‘ to contribute to the development and contribution of the overall health care system, guide and improve the capacity of health providers in the provision of high quality care. According to the principles on the rights of the child, referring to the principles that provide for the survival and development of the child, the rights referred to are rights to the resources, skills and contributions necessary for the survival and full development of the child. They include the rights to adequate food, shelter, clean water, formal education, primary health care, leisure and recreation, cultural activities and information about their rights. These rights require not only the existence of the means to fulfil the rights but also access to them. Specific articles address the needs of child refugees, children with disabilities and children of minority or indigenous groups. This is further legally provided for in the CRC Article 6 (2) as shown above.

The Parliament of Uganda has also enacted laws for the protection of public health professionals. For example, The Employment Act 2006, the HIV and AIDS Prevention and Control Act of 2014 plus an HIV/AIDS workplace policy. All these legal provisions, policies and development plans are supposed to protect the rights of children and most importantly the right to life which is the guarantee for the enjoyment of all other human rights.

2.2 Perceptions of health workers towards children’s right to life in Hoima and Mbale Hospitals.

While Uganda‘s population has been steadily growing at an annual rate of 3.2 percent, the number of health professionals remains relatively flat, complicating the delivery of health services. The additional workload has put pressure on health human resources, compromised

16 the quality of health care, and led to consumer claims of poor treatment from health workers. While government is responsible for enacting and implementing laws and policies, for example, In this USAID report on HealthCLIR: Uganda Health Business Legal and Institutional Reform Assessment 2010, USAID argues that, the policy implementation inefficiency has not only resulted into loss of health workers‘ lives and put pressure on those that remain but also affects the perceptions of health workers concerning working in the public health sector. Contributing to Uganda‘s health worker shortage, many medical doctors pursue public health careers as opposed to clinical disciplines. By choosing public health, medical personnel find jobs with higher salaries offered by the many Private and International Organisations in Uganda and outside Uganda. As a result, there are too few clinical health professionals to service the population. This is a result of Government negligence to implement the policies in place. For example, USAID has noted that, while the Code of Conduct and Ethics for the Uganda Public Service forbids a public officer from holding two jobs at the same time, in reality the majority of health professionals in Uganda engage in dual practice to supplement their low public sector salaries. According to most health practitioners, without officials turning a blind eye to dual practice in Uganda, the public health sector would crumble. Public health workers, unable to live on a public sector salary, would abandon the public health system and possibly the country altogether.

Regardless of the fact that officials have turned a blind eye to dual practice, the perception of Uganda‘s health workforce that they earn too little compared to the global standards and demand for health professionals has led them to still leave the country for better employment elsewhere. For example, Uganda experiences a significant level of movement of health workers across its borders. Higher salaries and better working conditions have attracted Ugandans to places like the United Kingdom and South Africa, as well as to neighboring countries such as Rwanda and Kenya. Realising that the migration of labor is inevitable and that the resulting remittances are desirable, the Ministry of Gender, Labor, and Social Development has established an External Employment Unit to help Ugandans go overseas legally.

Ministry of Public Services is responsible for setting salaries of health workers as well as schemes of service and performance evaluation systems. Despite a recent salary increase for public health workers, salaries remain low and are a de-motivating factor among the health workforce. Katongole et al (2015) have also noted that there is a need to have urgent attention 17 on factors which seem to affect the effective use of the nonmonetary human resource tools. The factors include; improving working conditions and staffing to reduce workload and avail enough resources to the workers to be motivated to carry out their work. The government‘s attempt to attract health workers to hard-to-reach areas with additional benefits has been largely unsuccessful. This can be explained by the perceptions and attitudes health workers have from the previous explanation above that health workers prefer to work for Private and International Organisations because they pay more than government (USAID, 2010). It is also simple to conclude that failure of government to find health workers to employ in the hard to reach areas is because of a shortage of workers since health professional prefer to work abroad or for NGOs than in Uganda where the nonmonetary human resource tools are almost nonexistent. The researcher is also inclined to think that since the government is reluctant to implement the policies that promote the safety of medical workers in the public sector, they would rather work in the private sector, earn more money and can take care of their challenges themselves or enjoy the serious policy enforcement in the private sector and better working environment.

The above conclusion is informed by the fact that the Ministry of Gender, Labor, and Social Development is collaborating with the MOH on a UNFPA-funded training program to ensure youth-friendly health service delivery. Responding to a teen pregnancy rate of 24.6 percent, as well as claims of ill treatment of young patients by medical personnel, the program aims to train health professionals ensuring appropriate treatment of young patients as well as privacy within the facility. The program has been active in a few districts and is under review. Compared to the above public health sector attitudes is the private sector health profession's attitudes—As previously mentioned, many health workers employed in the public sector also work in the private sector, at either large PFPs or in private practice. They are attracted by the prospect of profit as well as better working conditions and a workload which is less crushing than in the public sector. With an awareness that patients are paying for service, it is said that the same medical professionals adopt a more pleasant bedside manner when seeing patients in a private clinic.

Public health workers are often discouraged by poor working conditions, low pay, and a heavy workload. In addition, a lack of a career path for many contributes to low morale and high attrition. Medical personnel complain of continuous stress resulting from overwork and poor working conditions. Absenteeism in the public health sector is a large problem due to 18 lack of managerial oversight and a tendency for health workers to prioritize their private sector employment over their public sector positions. Forty percent of health workers are consistently not present at work, representing an annual loss of approximately 29.4 billion shillings. This is unfortunately not the only loss incurred, as the study sets out to investigate, this is suspected to also be one of the causes of loss of lives of children at birth due to lack of medical professionals helping the young mothers/teenagers who get pregnant. Even when the medical professionals are present, it is said that their treatment of these young patients is not up to the required health and professional standards (USAID, 2010). This can be seconded by the fact that a Medical Superintendent was quoted to have said, most health workers in government hospitals are like mercenaries who only do their job and wait for payments at the end of the month, unlike in PNFP hospitals where health workers have attachments to their organizations because of mainly their faith (Katongole et al, 2015).

To conclude this section on the perceptions of health workers towards children‘s right to life in Hoima and Mbale hospitals, the researcher would like to note that health workers‘ attitudes and perceptions are largely determined by the monetary benefits from their job, the work environment and the facilitation available in their places of work. From the above presentation of the perceptions, the researcher has also found out that all these incentives are very low in the public sector and most affected in government institutions which are supposed to be the ones that provide health services to the poor that cannot afford private health facilities.

2.3 Capacity of Duty-bearers to Protect and Promote Children’s Right to Life

Highly skilled physicians, nurses, administrators, and ancillary staff are critical to producing high quality outcomes and effective quality improvement, hence protection of children‘s right to life (Argote, 2010). There is a need for selective hiring of qualified staff. Successful recruitment and retention of staff is tied to empowerment of staff in human rights issues that must be treated as full partners in the hospital operation and given opportunities for advancement (Brown and Duguid, 2013). The hospitals need to place great emphasis on recruiting and retaining top level physicians and nurses, accompanied by an effort to encourage these professionals to form working teams, including case managers, pharmacists, social workers, and others, to promote quality (Brown and Duguid, 2003). To facilitate service quality for children‘s life, hospitals must implement effective human resource strategies involving selective hiring, retention of physicians and nurses and training them in

19 human rights matters (Cohen and Levinthal, 2011); monitoring of doctors on staff (or with privileges) and ensuring that they must continue to meet certain performance and practice standards to retain credentials (Crewson, 2004).

Strengthening health systems is critical for achieving the global aspirations reflected in the Millennium Development Goals and other efforts to improve health outcomes. Key among the efforts to strengthening health systems is the development of a committed, well-prepared, skilled, and knowledgeable public health workforce. This can be achieved through training health workers to increase their knowledge and skills to provide quality health services (Matovu et al, 2013). Unfortunately, In Uganda, while the situation at General hospitals is encouraging and doctors spend most of their time in patient care or supervision, at health centre IVs, where the most vulnerable patients may be the situation is worse. Doctors spend most of their time in non-patient care activities (USAID, Makerere University & Health Systems 2020, 2012). This makes the capacity of health workers to save children‘s life minimal and ultimately affects their potential to promote and protect children‘s right to life. It was also found out that there is a challenge of absenteeism which consequently affects the capacity of the health workforce. There is a 37 percent absenteeism challenge that costs government over UGX 25 billion a year. Given the constrained health budget to hire enough medical personnel, this is a big setback to the capacity of the health workforce to promote and protect children‘s right to life.

According to WHO (2012), health workers are not producing the desired output of health interventions in line with human rights. Many have echoed this concern, for example, the Ministry of Health during the fifty-second session of the WHO Regional Committee for Africa and other organizations and policy and decision-makers at the high-level forum on the Millennium Development Goals (High-Level Forum 2004, World Bank 2000). It was stated that insufficient health personnel, in terms of numbers and level of performance, is one major constraint in achieving the Millennium Development Goals (MDGs) for reducing poverty and diseases. This is why the question of the capacity of duty bearers ‗medical workers‘ is of significant importance. Health workers‘ capacity is a huge factor in being able to reduce infant and child mortality in hospitals and governments in this case the Ugandan Government through the Public Service Commission should make sure that hospitals are adequately staffed and the ministry of finance should allocate enough funds to pay enough healthy workers. 20

2.4 Challenges Affecting the Realisation of Children’s Right to Life

The right to life is usually used to refer to that primary and essential right without which no other right could exist. However, there are several factors that affect children‘s right to life in Uganda. Though the number of children‘s deaths in Africa due to AIDS-related illnesses was estimated have dropped by 22% between 2001 and 2012, the number of deaths still amounted to a significant share of the world total 70% of global deaths. Currently, Uganda‘s under five mortality rate is 131 per 1,000 live births, the highest rate in East Africa. Kenya‘s mortality rate is 107 per 1,000 live births, Tanzania, 122 while Rwanda is at 23. Uganda‘s statistics improved from 146 deaths per 1,000 births in 2005. However, the President of the Uganda Pediatrics Association, Jane Achan, said malaria, pneumonia, diarrhea, malnutrition and HIV/Aids are the major causes of child deaths in the country. Although most of these diseases are preventable, Achan said interventions have fallen short of universal coverage and many children are being left out. ―Mosquito net coverage is, for instance, at only 45 percent, few children are on oral rehydration therapy or Zinc for diarrhea and even fewer on PMTCT. We are not achieving any universal coverage for interventions and it needs to be scaled up and sustained,‖ she said (Daily Monitor, 28th December).

In 2012, more than 1.1-million children were thought to have died from AIDS-related illnesses in Africa, an 11.5% share of the regional tally. Deaths among HIV-positive children may be attributed to the contributing cause of death, such as tuberculosis, diarrheal diseases or lower respiratory tract infections (Africa check, 2014).

Diarrheal diseases cause most global deaths in children under the age of five. According to the WHO, there are an estimated 1.7-million cases of diarrheal diseases in the world each year, with 780,000 children dying from diarrhea. In sub-Saharan Africa, about 644,000 children died from diarrhea in 2012, accounting for 6.7% of deaths. Diarrheal diseases, generally caused by bacterial, viral or parasitic organisms, cause death through dehydration. Yet these deaths are preventable: according to the US Centers for Disease Control, 88% of diarrheal deaths are the result of unsafe water and inadequate sanitation and hygiene (Africa check, 2014). In 2012 malaria, a mosquito-transmitted, parasitic disease, killed 618,000 children around the globe – 568,000 or 92% of them in sub-Saharan Africa. The disease accounted for 5.9% of deaths in sub-Saharan Africa. Children are particularly vulnerable to malaria: in 2012, deaths in children under the age of five accounted for 41% of malaria deaths in sub-Saharan Africa (Africa check, 2014). An increase in malaria interventions – the

21 provision of insect-repellent mosquito nets and indoor spraying with insecticides, for example – has seen the number of children‘s deaths in sub-Saharan Africa fall from 812,000 in 2000 to 568,000 in 2012. Of 3.3-million lives saved through such interventions between 2000 and 2012, 3-million were of children under the age of five in Africa (UNICEF, 2012). According to the Ministry of Health, the proportion of children dying from malaria increased from 28% in 2011/2012 to 31% in 2012/2013 (MOH, 2013).

Michael (2009) observed that strategic funding entails the principle of diversified sources of funding and experience has shown that institutions with one source of funding will remain a captive and hospitalized children will most likely lose their lives. The health sector is a unique sector in their ability to pursue multiple and conflicting agendas and the only guarantee available for this sector to accomplish conflicting agendas is multiple sources of funding. The importance of funding is that it facilitates the pooling of financial risk across the population or a defined subgroup and can be used to train health workers in human rights related matters and procure enough equipment and medicine to promote and protect life.

Technology, specifically information and communication technology (ICT), enables a new approach to supply rural areas in Africa with access to medical services and protect the right to life. ICT Act has been useful in the sense that it encourages the use of telecommunication facilities and equipment in hospitals to communicate and save children‘s life. The combination of village health workers, telemedicine through mobile phones and mobile rather than stationary health clinics enables a new way to deliver health care services to rural populations in sub-Saharan countries (Knapp, Richardson, & Viranna, 2010). ICT is the enabler that makes such strategies viable and is spreading quickly through sub-Saharan. Technology for harnessing of Information and data play a critical role in the quality service delivery in hospitals (Allen, 2001). Investments in Technology that facilitate service assessment and improvement process is essential (Dutton and Starbuck, 2002). The hospital must show four main commitments: a willingness to invest in Information Technology; investments in Information Technology and in Quality Insurance departments with qualified staff that abstract medical records, analyze data, and facilitate the Quality Insurance process (Cibulskis and Hiawalyer, 2002). However, the Ministry of Public Services which is responsible for setting salaries of health workers as well as schemes of service and performance evaluation systems and despite the fact of the recent salary increase for public health workers, salaries remain low and are a de-motivating factor among the health

22 workforce. The government‘s attempt to attract health workers to hard to reach areas with additional benefits has been largely unsuccessful. There is also a less budgetary allocation to the Ministry of Health and this makes procurement of the above said ICT facilities impossible in government hospitals.

2.5 Conclusion

In the literature review, it has been found out that the Constitution of Uganda, the Children Act of 1997 cap 59, are the key instruments at the national level for the protection of children‘s right to life. There are also international and regional standards which include; the ICCPR Article 6, ICESCR Article 12, General Comment No. 36, General Comment No. 15 of 2013 and the CRC. The most serious challenges to the realisation of children‘s right to life were malaria, and inadequate funding that leads to other challenges. It was also found out that the capacity of medical worker to prevent children‘s loss of life is limited in many situations. Medical professionals also prefer to work in the private sector compared to the government sector.

2.6 Summary.

International, regional and national legal provisions protect children‘s rights. The Constitution of Uganda and Children‘s Act Cap 59 also target to promote and protect the rights of children in general which includes children‘s right to life. Some legal provisions at the international, regional and National levels are specifically in place to protect children‘s rights. For example, Uganda Children‘s Act 1997, the ACRWC, Child Rights Principles and the CRC. The literature revealed that, health workers perceive government jobs as less paying compared to the private sector and income-rich countries, government hospitals do not take measures to implement policy and this led health workers to perceive government as negligent. The literature also showed that the capacity of duty bearers in terms of personnel is low yet their skills and knowledge are critical in promoting and protecting children‘s life. This review also illustrates that the major challenge in keeping a motivated medical workforce is low pay/salaries by the government compared to the private sector and International Organisations. This demotivation was found to result in dual employment where public health workers also look for jobs in the private sector. Government laws are not proportionately implemented, this has created a gap between the law policy and implementation and this gap has in turn led to loss of lives. For example, while the HIV/AIDS Work Place Policy is in place, in many instances, the law is not being evenly

23 implemented yet health workers have suffered disproportionately from HIV/AIDS with an infection rate estimated at 6.7 percent of the general population. Malaria, pneumonia, diarrhea, malnutrition and HIV/AIDS remain the major causes of child death in the country while cchallenges related to illness and inadequate technology have also continuously been identified as causes of children‘s loss of life.

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CHAPTER THREE

RESEARCH METHODOLOGY

3.0 Introduction

This chapter explains the research design, population and sampling, research methods, research instruments, data analysis techniques, procedure, constraints and ethical considerations. The research design used in this study was a case study and the sample population was selected from the two hospitals that were studied as cases of reference and the sample size was chosen depending on the available number of respondents from the target population but also depending on the position personnel held in the case of key informants who were in management positions.

3.1 Research Design

The study used a case study research design, employing both qualitative and quantitative techniques to collect and analyze data. Amin (2005) urges that, the use of mixed research methods helps to investigate a problem from all sides. Usage of different approaches also helps to focus on a single process at a time and confirms the data accuracy. The research design being the conceptual structure within which the research is structured, it constitutes the blueprint for the collection and analysis of data (Kothari, 2004). Generally, if a researcher uses mixed methods, he/she will use a research design that employs both qualitative and quantitative data to answer the research questions. The combination of methods involves the collection, analysis and mixture of qualitative and quantitative data in one study. In this study, the point was to emphasise that mixed methods provide for the possibility of complementarity between methods which in turn gives the candidate a wide and better understanding of the research problem being investigated. This use of more than one method while studying the same dimension of a research problem and answering research questions helps to enrich the researcher and the conclusions he/she can arrive at (Biber & Nay, 2010). Creswell (2015) also noted that, ―a core assumption of (mixed methods) is that when an investigator combines statistical trends (quantitative data) with stories and personal experiences (qualitative data), this collective strength provides a better understanding of the research problem than either form of data alone‖ (p.2) In this case, mixed methods were used to investigate both qualitative and quantitative data and to combine the two to draw conclusions based on the strength of both data. In this case, the researcher used interviews

25 and questionnaires to collect field data and thereafter the data was sorted, coded and tabulated using Statistical Package for the Social Sciences (SPSS).

3.2 Geographical Area and Population

The target population was 180 respondents from Hoima and Mbale Hospitals who included hospital management, medical staff, non-medical staff and parents/guardians of children patients. This was because the employees and parents have knowledge of the situation of children‘s right to life. The researcher chose Hoima and Mbale hospitals because they are located in places that are familiar and of ancestral origin and also because the hospitals were reachable which made the research economically feasible.

3.3 Sampling Procedures

3.3.1 Estimated Sample size

The researcher estimated to get a sample size of 123, 113 respondents for the questionnaires and 10 informants for interviews. According to Krejcie and Morgan (1970) when the population size is 180 people, then, 123 is an appropriate sample size. The reason for using the Krejcie and Morgan table was because it is effective in determining the most reliable sample size. The sample size for each hospital was, 4 Hospital management personnel, 17 Medical staff, 19 Non-medical staff from both hospitals and 31 parents of children patients.

Table 3.1 Sample size for a subgroup

Respondents Target Sample Size Sample technique population Hospital management 10 08 Purposive Medical staff 40 34 Simple random Non-medical staff 22 19 Simple random Parents 108 62 Simple random Total 180 123

3.3.2 Sampling Techniques

The study used purposive and simple random sampling techniques to select hospital management, medical staff, non-medical staff and parents. This was because the key

26 informants in management were selected particularly because of the positions they held while the other respondents were selected randomly because they all had equal chances of participating in the study. A sample frame was constructed and the samples randomly selected from the sample frame. According to Amin (2005), simple random sampling ensures that every member has an equal chance of being recruited into the sample. This was found to be true and helpful since the researcher avoided personal views and chose respondents impartially.

3.4 Data Collection Methods

3.4.1 Interview

Interview provides a way of generating data by asking people to talk about their everyday lives. Their main function is to provide a framework in which respondents can express their own thoughts in their own words (Brewer & Miller, 2003). In this study, a number of open ended questions based on the topic areas that the researcher wanted to cover were used. The open ended nature of the questions defined the topic under investigation, and also provided an opportunity for the interviewer and interviewee to discuss some topics in detail. Interviews were held with Hospital management in both hospitals. These interviewees were treated as informants during the study and were chosen based on their availability and willingness to participate though those in management positions were chosen because of their positions and the information they were expected to hold on management issues. Interview questions were drafted to answer the research questions. The interview questions were open ended to allow informants to express their opinions and perspectives on children‘s right to life in both hospitals.

3.4.2 Documentary Review

This refers to critical examination of public or private recorded information related to the issue under investigation (Oso & Onen, 2008). Secondary data means data that are already available, that is to say, they refer to the data which have already been collected and analysed by someone else. When the researcher utilises secondary data, then he has to look into various sources from where he can obtain them (Kothari, 2004). This method was used to review textbooks, ministry reports, and other publications related to the protection and promotion of children‘s right to life. The researcher also reviewed government policies such as National Development Plans II 2015/16-2019/20 and National Health Sector Plan 2010— and library texts. The documents reviewed were obtained through the use of libraries and

27 internet sources, though some document like the constitution were owned in hard copy. The most used internet sources were the Ministry of Health and the Ministry of Gender, Labour and Social Development websites. The researcher carried out documentary review from Makerere University Main Library and the Makerere Institute of Social Research Library. The information obtained was used to provide supportive evidence to the findings obtained through interviews and the use of questionnaires.

3.4.3 Survey

Surveys are used for gathering information by means of interview or questioners. They are a means of collecting similar information from many people at the same time. These utilise standard instruments like questioners and are structured and set up fixed question and answer formats to gather quantitative data (Henn, Weinstein & Foard, 2006). Using surveys helps to collect data that gives the researcher large amount of data from the sample considered and in turn the opportunity to generalise and make conclusions about the social challenge of problem being studied and how to solve such a challenge.

3.5 Data Collection Instruments

The researcher used two instruments to collect both qualitative and quantitative data. An interview guide and a questionnaire were used to collect data. The questionnaire was delivered to the respondents and filled and thereafter collected by the researcher for analysis while the interview guide was administered by the researcher to the informants and responses written down for future analysis.

3.5.1 Interview Guide

Face to face interviews were conducted with 8 hospital management officials. The interview guide was administered and interview questions and follow up questions probing for more information asked, clarification and capturing facial expression of the informants was also done. This kind of interaction between the interviewer and interviewees gave the researcher an opportunity to revisit some of the issues that had been an oversight in other instruments and yet they were vital for the study.

3.4.2 Questionnaire

Questionnaires are used to get information from people in a non-threatening way (McNamara, 2002). They are used in both qualitative and quantitative research. A

28 questionnaire was used because it allowed definite answers that were required to answer the quantitative questions about the study. The questionnaire was administered to parents/guardians, medical personnel and non-medical staff members. In this study, the questionnaires were delivered by the researcher who later waited for one week for the respondents to give feedback. This questionnaire comprised of a number of close ended questions printed in a format that allowed answers to be directed at the research questions. These questions were supposed to be and were answered by the respondents on their own.

3.5 Research Procedure

An introductory letter was obtained from the Directorate of Research and Graduate Training Makerere University. This letter was presented to the hospital administration to seek permission to allow the researcher to carry out this study in Hoima and Mbale Hospitals. The aim of the cover letter was also to introduce the researcher and the research topic to the hospital administration and to neutralize any doubt or mistrust they may have about the researcher and the study, and to motivate them to allow the employees of the hospitals to participate and answer the questions.

3.6 Data Quality Control

Data Quality control was added in the methodology section. Data quality control was ensured through use of standardised data collection instruments which included a questionnaire, interview guide and reviewing secondary documents. These instruments were first tested to ensure validity and reliability. To ensure that the questionnaire and interview guide contents were valid and relevant, the researcher carried out a pilot study test on these instruments. This ensured that the data collected in the research was valid and relevant to answering the research questions raised by the study.

3.7 Data Analysis Techniques

The data collected was edited and sorted to ensure clarity and completeness. The quantitative data was then coded, classified and tabulated using SPSS computer progamme, as a percentage for easy presentation. Analysis was done to obtain the frequency and percentage distribution of respondents, with the findings presented in tables and figures, and detailed descriptions of the themes, extracts, and explanations of the study. In the analysis of the collected data, the researcher adopted a self-rating scale of 1-5. This scale indicated whether respondents agreed or disagreed with the statement presented in the questionnaire. This scale

29 was then used to find out whether the statement the researcher presented in the questionnaire was strongly agreed to, agreed to or strongly disagreed to or disagreed to, or whether the respondent was not sure. This was the basis of whether the duty bearers have the capacity to realise children‘s right to life. The scale also helped the researcher to identify the challenges to the realisation of children‘s right to life depending on the responses from the respondents. During analysis, respondents who agreed and those who strongly agreed were combined to form one category of agree, respondents who disagreed and those who strongly disagreed were combined to form a category of disagreed while those who were not sure formed a third category. In this scale, 1 represented strongly disagree and 5 reflected strongly agree.

On the other hand, data obtained from interviews was analysed using thematic analysis. Thematic analysis was largely used to analyse data from interviews and to find out the perceptions of health workers. It should also be noted that the 1 to 5 scale was in some cases also applied. The obtained data was categorized according to themes basing on the study objectives after which the patterns of responses were studied and presented to understand the identified themes.

Qualitative data, particularly data from secondary sources was critically analysed. The researcher drew comparisons, examples and statistical differences between the numbers obtained from primary and quantitative data and compared and contrasted, evaluated and assessed these to complement the finding from quantitative data.

3.7 Ethical considerations

Barnes (1979), defines ethical factors as those which: arise when we try to decide between one course of action and another not in terms of expediency or efficiency but by reference to standards of what is morally right or wrong. Ethical considerations place the research participants, rather than the researcher, at the centre of the research design when deciding what is appropriate and what is acceptable as ethical conduct in research. The researcher emphasized anonymity of the participants to guarantee their security and safety. It should also be noted that there was no need to seek individual consent since the hospital management introduced the researcher and requested the hospital employees who constituted the respondents to participate in the research, because there were no objections this was a form of group consent and because no respondents demanded individual consent forms thereafter, the researcher proceeded to interact minus presenting individual consent forms. The option to

30 abstain from participating in the research for those unwilling was also emphasised. For the child patients‘ parents, their participation was based on their desire to voice their concerns which they said they believed would be helpful, hence agreeing to participate in the research (p. 16).

3.8 Limitations of the Study

The major challenge was that some respondents would not cooperate and therefore not willing to give information. However, the researcher tried her level best to create friendly relationships with the respondents before asking them any questions related to the investigation thus preparing them to be receptive. The researcher also emphasised anonymity to make the respondents feel free that their information contributed to the study would not cause them any harm in the future. The expected responses were also not all received, out of the 113 questionnaires distributed, 79 were filled and returned. This made a 69.9 response. The researcher also conducted interviews with an 80% response from 8 informants out of 10 contacted hospital management personnel.

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CHAPTER FOUR

DATA PRESENTATION AND INTERPRETATION

4.0 Introduction

Chapter four presents the findings and interpretation of data in the investigation of protection and promotion of children‘s right to life in Uganda: a case study of Hoima and Mbale hospitals. The objectives from which the presentation and analysis are drawn are. To assess the perceptions of health workers towards children‘s right to life in Hoima and Mbale hospitals. To assess the capacity of duty bearers to protect children‘s right to life in Hoima and Mbale Hospitals and to identify and examine the challenges affecting the realization of children‘s right to life in Hoima and Mbale Hospitals.

Out of 113 questionnaires distributed, 79 were filled and returned, giving a percentage response of 69.9%. In addition, out of the 10 planned interviews, 8 were conducted giving a percentage response of 80%. The overall response was 70.7%. The majority of the respondents were aged between 31-40 years, which made 54%. They were followed by 20% aged 20-30 years and 18% aged 41-50 years while the rest 8% were aged 50 years and above. Of all these respondents, 53% were female while 47% were male.

4.1 Perceptions of health workers towards children’s right to life in Hoima and Mbale hospitals.

In order to assess the perceptions of health workers towards children‘s right to life, the researcher used open ended interview questions in both hospitals. The researcher also included, in the questionnaire, questions about adherence to legal instruments in the two hospitals while treating children. This question was intended to find out whether health workers know the instruments and whether they later follow these instruments. Among the interview guide questions, a question about whether hospital workers treat human rights as important, a question on whether they have enough personnel and whether these staff respect rights of children, especially the right to life and a question about what instruments the hospitals rely on for the protection of children‘s right to life were asked. A conclusive question about whether staff members offer adequate support to ensure that children‘s rights are respected was also asked. These questions were used to assess the

32 perceptions of the health workers towards children‘s right to life in Hoima and Mbale hospitals. Thematic analysis was used to assess the perceptions of health workers towards the legal framework on children‘s right to life. The 1 to 5 scale adopted in the methodology was also helpful since some data was from the questionnaires. The scale helped the researcher to determine whether respondents agreed or disagreed depending on the score one awarded to a particular statement. For example, when the researcher asked the informants — medical staff — whether children‘s rights are important, doctors from both hospitals noted that; there is a pediatric department specifically meant to treat children according to their illnesses.

4.1.1 Hospitals’ priority is to protect children’s right to life This section presents respondents‘ responses on whether the hospital‘s priority is to protect children‘s right to life. On the question about whether the hospital took the protection of children‘s right to life as a priority, it was established that both hospitals‘ priorities were to protect children‘s right to life. This was supported by 92% of the respondents in Hospital A and 100% of the respondents in Hospital B although 8% in Hospital A were not sure. The results imply that both hospitals are in total support of protecting children‘s right to life. Further illustration is presented in figure 4.1 below.

Figure 4. 1: Responses to whether the hospital‘s priority is to protect children‘s right to life

During the analysis of the collected data that supplemented the above findings, the researcher noted that an interviewee from hospital A also confirmed the above findings when he noted;

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“We have a pediatric department specifically meant to provide treatment to children suffering from different ailments such as malaria, diarrhea, anemia, tuberculosis, premature children and children with HIV AIDS”. A doctor from hospital B also notes that; “We divide the children according to their illnesses to avoid further infection”. Prematures are so vulnerable to infection and contracting illnesses, even the very young ones. That‟s why we separate them according to their illnesses.

This shows that the hospitals treat child protection as a priority. On the follow up question on what shows that hospital workers respect children‘s rights, two respondents from hospital A said that, “We have a lock-in system which reports the time of arrival and departure — this doctor also said that — we put up posters advocating for no bribes to help give all children the same rights even when their parents have no money. When doctors and nurses take bribes, they will prioritise patients whose parents can give them money and therefore we do not encourage it. We want this to stop because it will cause discrimination”. This was further supplemented by another doctor who also mentioned that, “we give every child an equal right to treatment and in most cases we emphasise first come first serve except on occasions when a child is brought in a critical condition. We attend to children according to how they come and the medical service they need and of course on whether we have the drugs”.

Three doctors from hospital B also put emphasis on communication and information sharing. One had this to say “we explain child medications to the parents/guardians and advise them to come back if there are side effects that affect the child, if the medication has not responded and thus make the health fail to improve”. The second doctor said that, “I share clear information about drugs with the parents hoping that this will help them on how to take care of the sick children. This helps reduce errors like over and under dosage of the prescribed drugs which may lead to a child loosing life or more complications”. The third doctor also noted that, “I consider drug costs while making prescriptions, in most cases we have no option but to prescribe drugs the poor people can afford otherwise they will buy half dose of the expensive drugs or even not buy at all due to the costs involved because the majority of the patients we have here are peasants from rural areas who cannot afford expensive drugs and as a result if the medication is not taken as prescribed this can prolong the sickness which may lead to a child loosing his/her life”.

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These five informants coupled with the fact that the hospitals have a pediatric department each are an illustration that they respect children‘s right to life and take it as a priority.

4.1.2 The hospital has enough personnel

Figure 4. 2: Responses on whether the hospital has enough personnel

During the study, it was established that 83% of the respondents in hospital B and 54% in hospital A disagreed that the hospitals have enough personnel. Only 35% in hospital A and 15% in hospital B agreed with the statement while 11% in Hospital A and 2% in hospital A were not sure. The results imply that both hospitals do not have enough personnel which affects the hospitals‘ abilities to adequately promote and protect children‘s right to life. This was further supported by informants from hospital A and B who had this to say; “We are understaffed yet we receive many patients even from neighboring districts. We work sometimes throughout for 24hours that is, from 8am to 8am the next day" a doctor noted. He also insisted that, “We need more doctors otherwise we cannot finish all the work each day due to exhaustion because we are also human beings. Some patients remain unattended to on a daily basis just because we are not enough”.

“We are few nurses in the ward compared to the number of children in need of the services, we work from when we come in until we leave, no minute to rest not even having time to eat and yet the body needs the energy”, a nurse also noted.

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The issue of understaffing was also further confirmed by two doctors from hospital B who said that, “We are understaffed, the number of child patients we receive is overwhelming compared to the number of doctors and nurses. Even children who need the service are so many and doctors are few”. The other doctor insisted that, “there is a lot of work and we are few. This is why we over work and some people leave because it is so hectic and cannot contain the pressure of going through the same situation day in day out. There is even no time to have lunch”.

All these responses combined highlight that, the hospitals do not have adequate personnel to attend to all patients among whom children belong.

4.1.3 Hospital staff adherence to the legal framework of the protection of children’s right to life in Uganda This section presents the data on whether the hospital staff adhere to the legal framework of the protection of children‘s right to life in Uganda.

Figure 4. 3: Responses to whether hospital staffs adhere to legal instruments while treating children

Results in Figure 4.3 show that hospital staff adhere to legal instruments while treating children. This was confirmed by 78% of the respondents in hospital A and 88% in hospital B who agreed with the statement. Only 14% in hospital A and 5% in hospital B disagreed while 8% in hospital A and 7% in hospital B were not sure. This shows that hospital staff adhere to

36 legal instruments while treating children in order to protect and promote children‘s right to life. This adherence was also confirmed by some of the key informants. For example, a doctor in hospital B when asked about what legal instruments the hospital staff refer to, to protect children‘s right to life. He had this to say; “The constitution, and the code of ethics and conduct are what we rely on” this was further confirmed by another doctor in the same hospital who said that, “we follow the constitution, policies and procedures then Acts. For example, Nurse‟s Acts and codes of ethics and conduct”. The third doctor and the last to tell the researcher about legal instruments simply mentioned that, “we follow the code of ethics”. When the researcher posed this question about which legal instruments hospital staff refer to in hospital A, One doctor said, “We follow the constitution and the professional code of conduct, the constitution is the law hospitals follow, and those who break the law could end up in jail”. The second informant who was a nurse said that, “we use Uganda clinical guidelines” the third who was a doctor mentioned that, “we refer to the ethical code of conduct and clients charter”.

The above revelation shows that there are legal instruments which hospital staff adhere and refer to in a bid to promote and protect children‘s right to life.

4.1.4 Staff members held responsible for negligent acts that lead to children’s loss of life.

Figure 4. 4: Responses to whether staff members are held responsible for negligent acts that lead to children‘s loss of life.

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During the study, it was established that 68% in hospital A compared to 36% in hospital B of the respondents agreed that staff members are held responsible for negligent acts that lead to children‘s loss of life. On the other hand, 59% in Hospital B compared to 27% in hospital A disagreed that staff members are held responsible for negligent acts that lead to children‘s loss of life while 5% were not sure for each hospital- A and B. The results imply that more staff members in hospital A are held responsible for negligent acts which compels them to be more cautious to ensure that children‘s right to life is promoted and protected while this is not the case for hospital B. This lack of accountability for their negligence that results in children‘s loss of life was further confirmed by a doctor in hospital B who said that, “We need to have a mechanism to reprimand/punish errant officials for example there are some doctors who are supposed to be on their duty stations but prefer to first do their private business and some doctors are supposed to be on call but even when they call them they do not show up. Some people do things that result in children‟s loss of life and they are not punished”.

4.1.5 Staff members’ ability to offer adequate support to ensure children’s right to life is protected.

Figure 4. 5: Responses to whether staff members offer adequate support to ensure that children‘s right to life is protected

Results in Figure 4.5, show that 76% in hospital A and 83% of the respondents in hospital B agreed that staff members offer adequate support to ensure children‘s right to life is

38 protected. On the other hand, 11% in hospital A and 12% in hospital B disagreed while 13% of the respondents in hospital A and 5% in hospital B were not sure whether staff members offer adequate support to ensure children‘s right to life is protected. This was supported by a respondent during face to face interviews when he said; “Staff members at this hospital offer adequate support to ensure children‟s right to life is protected because those who work in the pediatric ward are specifically employed to ensure that children receive the required medical support.”1 This shows that staff members in both hospitals endeavor to make sure that children‘s right to life is protected.

4.2 Capacity of duty bearers to protect and promote children’s right to life at Hoima and Mbale Hospitals

In order to assess the capacity of duty bearers to protect and promote children‘s right to life, the researcher presented five statements in the questionnaire that represented questions to be responded to by the respondents. Some of these questions related to the open ended questions in the interview guide were intended to obtain qualitative data. The interview guide questions used to assess the capacity of duty bearers were: Are hospital staff aware of the instruments that protect children‘s right to life? How do you understand children‘s right to life? Do hospital staff receive trainings in children‘s right to life in the Hospitals or elsewhere? Does the hospital have some library for human rights and other facilities for implementing human rights? The same scale as used in analysing the perceptions of health workers and assessing the capacity of duty bears to protect and promote children‘s right to life was used. The responses obtained are presented below;

4.2.1 Hospital staff members’ awareness of all the legal instruments that protect children’s right to life A question was set to investigate whether staff members are aware of the legal instruments for the protection of children‘s right to life. However much this question was close ended, an open ended question was also included in the interview guide questions asking the informants whether staff are aware of the instruments that protect children‘s right to life. It was noted when the researcher discussed with the informants, that, most medical personnel and hospital staff did not know the legal instruments. Most of those that knew the instruments for the

1 This was said by an administrator in hospital B. A pediatrician who works with children. He also notes that there are some doctors who are hired because they are experts in child ailments and the hospital relies on these doctors to treat children. He also noted that however much these are not many because the hospital cannot afford hiring many the few available are focused on treating children. 39 protection of children‘s right to life knew the instruments by name and nothing more. The data is illustrated in percentages in the graph below:

Figure 4. 6: Presents responses on whether Hospital staff members are aware of all the legal instruments that protect children‘s right to life

During the study, it was established that the majority (64%) of the staff members in Hospital B compared to 32% in Hospital A were not aware of all the legal instruments for the protection children‘s right to life. On the other hand, majority 52% of the staff members in hospital A compared to 24% of the respondents in hospital B agreed that they were aware of the legal instruments that protect children‘s right to life while 16% in hospital A and 12% in hospital B were not sure. This shows that more staff members in hospital A compared to staff members in hospital B are aware of all the legal instruments that protect children‘s right to life. In general, the researcher concluded that hospital staff members know very little about legal instruments that protect children‘s right to life.

From the interviews, two informants from Hospital B said that “we use the constitution and the code of ethics and conduct to protect children‟s right to life‖. Another doctor from Hospital B also said that, “we know of the constitution, policies and procedures as well as Acts for example the Nurse‟s Act and codes of ethics and conducts” and the last informant also said that, ―we know the code of ethics.‖

Other informants from Hospital A had these to say; One doctor said “We know of course, the constitution and the professional code of conduct, the constitution gives the rules for equal

40 rights for everyone including children”. Another doctor said that, ―we use the Ethical code of Conduct and the Clients Charter. The client‟s charter also describes patients‟ rights and health workers should follow these while also treating children” a nurse in the same hospital said that, “we follow the Uganda Clinical Guidelines”.

This made a total of 3 informants out of 8 who were aware of the constitution and used constitutional provisions as their guidelines for the protection of children‘s right to life. Other informants did not know the legal provisions. In general the researcher infers that the hospital staff know very little about instruments for the protection of children‘s right to life, especially regional and international instruments since no one, including those who knew some documents mentioned an international standards document.

4.2.2 Hospital staff members are well qualified

Figure 4. 7: Results on whether hospital staff members are well qualified

According to results in figure 4.7, staff members in both hospitals are well qualified. This was revealed by 86% in hospital B and 89% of the respondents in hospital A. Only 14% of the respondents in hospital B and 3% in hospital A disagreed with the statement while 8% of the respondents in hospital A were not sure whether hospital staff members are well qualified while all respondents from hospital B either agreed or disagreed. This shows that both hospitals have qualified staff members who are capable of treating children to ensure that their right to life is promoted and protected. This was further confirmed during face to face interviews when five out of 8 key informants had this to say;

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“The hospital has qualified staff members because all health workers are professional medical practitioners with certificates, diplomas, Bachelor‟s Degrees, and Masters Degrees among others”. Similarly, a medical officer was quoted saying; “No one can be allowed to work in this health facility if they are not qualified, except support staff who provide non- medical help and student interns still undergoing medical training”

All key informants from Hospital A and B said that, “Qualification is the requirement for anyone to be recruited by the hospital‟. One doctor from hospital B also said that, “work experience is a good indicator so we also look for this, those who have good work experience easily know how to deal with challenges compared to those who are fresh from school. This is good for us because the challenges with treating children are many”. Work experience was also emphasised by another doctor from hospital A who said that, “when you have work experience, you can easily get the job compared to those who don‟t have”. Two doctors from hospital A also said that, “doctors with a practicing license are considered as well”. This implies that having a practicing license is a critical factor for a doctor to be recruited in Hoima or Mbale hospital and definitely individuals have to be qualified.

4.2.3 Staff members have good experience (More than 5 years)

Figure 4. 8: Responses to whether staff members have good experience (More than 5 years)

Study findings revealed that majority of the respondents; 81% in hospital A and 79% in hospital B agreed that staff members have good experience. Those who disagreed were 5% in hospital A and 19% in hospital B while 14% in hospital A and 2% in hospital B were not

42 sure. The results imply that staff in both hospitals have good experience and are therefore able to promote and protect children‘s right to life.

It was also noted during interviews when the researcher asked the informants what are the major factors taken into consideration when recruiting staff members in these two hospitals that experience was a key advantage when applicants apply for jobs. One of the nurses in hospital B also noted that, “Experience in child health is very good because doctors are confident when working on children.” „All doctors from both hospitals also said that, good medical experience is always an added advantage when it comes to practice and dealing with real medical situations‟

4.2.4 Staff members have adequate knowledge of human rights

Figure 4. 9: Staff members have adequate knowledge of human rights

According to results in figure 4.9, majority 57% of the respondents in hospital B and 49% in hospital A agreed that staff members have adequate knowledge of human rights. Those who disagreed were 38% in hospital B and 22% in hospital A. Results further show that 29% in hospital A and 5% in hospital B were not sure whether staff members have adequate knowledge of human rights.

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4.2.5 Do hospital staff members receive training in children’s right to life

Figure 4. 10: Responses to whether staff members receive training in human rights and protection of child‘s right to life

When respondents were asked whether staff members receive training in human rights and protection of children‘s right to life, 33% of the respondents in hospital A compared to 57% in hospital B agreed to have received training in human rights and child protection. On the contrary, 35% in hospital A and 36% in hospital B disagreed while 32% in hospital A and 7% in hospital B were not sure. The results indicate that staff members in hospital B access more training in human rights and child protection compared to staff members in hospital A.

The above findings were further confirmed by an informant who had this to say; “The hospital rarely organizes training in human rights and protection of children‟s right to life. Therefore, most staff members have not accessed such training”.

Those who received some training got this from international organistions and NGOs working in the field of the right to health and children. This was confirmed by a doctor in Hospital B who said that, “We get training form International organisations, for example, UNICEF and other NGOs in Uganda. UNICEF provides training on the rights of children, on how to handle children, how to communicate with children and seeking the opinions of children on how they feel” NGOs like USAID provided funds to train doctors and nurses in child rights principles and HIV/AIDS prevention”.

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The above findings also confirm that these hospitals do not have a library for human rights. There were no trainings provided by the hospitals. Only international and Non-Governmental Organisations funded trainings were said to have taken place

4.3 Challenges to the realisation of children’s right to life in Hoima and Mbale Hospitals

On the first question about the major cause of children‘s loss of life, the major causes were identified to be malaria, diarrhea, infections, severe anemia, sickle cell anemia and acute malnutrition. Other questions included a question about whether Hoima and Mbale hospitals are adequately funded and if not, whether inadequate funding affects the implementation of children‘s right to life. The researcher also posed a question about whether lack of enough personnel leads to children‘s loss of life? During the study, the researcher also presented five statements to the respondents that represented the questions the researcher needed to answer about the challenges affecting the realisation of children‘s right to life. The scale of 1-5 that the researcher used in assessing the perceptions and the capacity of duty bearers was also adopted to identify and examine these challenges affecting the realisation of Children‘s right to life in Hoima and Mbale hospitals. The responses are presented below;

4.3.1 Diarrheal diseases are responsible for children’s death

Figure 4. 11: Responses to whether diarrheal diseases are responsible for children‘s death

During the study, it was established that diarrheal diseases are responsible for children‘s death. This was revealed by 59% in hospital A and 81% of the respondents in hospital B. Respondents who revealed that diarrheal diseases were not responsible for children‘s death were 22% in hospital A and 17% in hospital B although 19% in hospital A and 2% in hospital

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B were not sure. This implies that diarrheal diseases are the major diseases responsible for children‘s death in both hospitals. This was supported by one informant from hospital A who said that; “Diarrhea is one of the leading causes of children‟s death because it dehydrates children and they excessively lose water from the body”. Children are not strong and diarrhea can make them vulnerable very fast. This is why it kills them if parents take long to bring them for treatment”.

The researcher also reviewed documents and from this review, it was also noted that according to the President of Uganda Pediatrics Association, diarrhea and HIV/Aids are among the major causes of children‘s death in the country (USAID, 2010).

4.3.2 Malaria is responsible for children’s death

Figure 4. 12: Responses to whether Malaria is responsible for children‘s death

When respondents were asked whether malaria is responsible for children‘s death, 87% of the respondents in hospital A and 86% of the respondents in hospital B agreed. Only 5% in hospital A and 2% in hospital B disagreed while 8% in hospital A and 12% hospital B were not sure. This shows that malaria is responsible for children‘s death in both hospitals. This was also confirmed by an informant from Hospital A who said, “Complicated malaria is a big problem, it causes convulsion and severe anemia. This makes the children‟s immunity weak and they can die fast”. Another informant from Hospital B added that, “malaria” is the major problem, it makes the body vulnerable and even other diseases attack the body hence

46 the children will lose their immunity and die”. Other doctors simply mentioned that “malaria” is the biggest problem without pointing out any particular effects

4.3.3 Inadequate funding is responsible for children’s loss of life

Figure 4. 13: Responses to whether inadequate funding is responsible for children‘s loss of life

Results in Figure 4.13 show that 51% of the respondents in hospital A and 79% in hospital B agreed that inadequate funding is responsible for children‘s loss of life. On the other hand, 41% of the respondents in hospital A compared to 17% in hospital B disagreed with the statement. Results further show that 8% of the respondents in hospital A and 4% in hospital B were not sure whether inadequate funding is responsible for children‘s loss of life. In line with the above statistics, three out of the 8 key informants from hospital B had this to say;

“Inadequate funding is responsible for children‟s death because the hospital is unable to purchase all the required medicine and sundries yet supplies from National Medical Stores are sometimes not enough”.

It was also found out through the interviews from hospital A that “regular stock/supplies such as medicines and sundries are never enough sometimes there are stock out of certain drugs. And that there was overcrowding in the ward which also suggested lack of enough hospital beds”. All these denoted that the hospitals were not adequately funded and this ultimately resulted in loss of children‘s lives.

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4.3.4 Inadequate funding for technology equipment is responsible for children’s loss of life

Figure 4. 14: Responses to whether inadequate funding for technological equipment is responsible for children‘s loss of life

Results in Figure 4.14 show that when respondents were asked whether inadequate technological equipment is responsible for children‘s loss of life, 46% in hospital A compared to 17% in hospital B agreed with the statement. On the other hand, 78% in hospital B compared to 35% in hospital A disagreed. Results further show that 19% in hospital A and 5% in hospital B were not sure. This shows that inadequate technological equipment is more responsible for children‘s loss of life in hospital A compared to hospital B. This was confirmed by a doctor from hospital A who had this to say; “Inadequate funding for technological equipment is responsible for children‟s death because the hospital is unable to purchase the necessary equipment to prevent children‟s death. For example, most of the heart surgery cases have to be done outside Uganda in countries such as India because we do not have adequate funds to procure the equipment that works on heart complication cases”.

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4.3.5 Lack of enough personnel is responsible for children’s death

Figure 4. 15: Responses to whether lack of enough personnel is responsible for children‘s death

Study findings in Figure 4.15 show that majority 64% of the respondents in hospital B and 49% in hospital A agreed that lack of enough personnel is responsible for children‘s death. On the other hand, 38% of the respondents in hospital A and 29% in hospital B disagreed with the statement, although 14% in hospital A and 7% in hospital B were not sure. This implies that lack of enough personnel is responsible for children‘s death in both hospitals. One informant from hospital A also noted that, “the available staff are overworked”.

“We work for 24 hour shifts that is from 8:00am to 8:00am the next day”, a doctor noted. This led the researcher to conclude that there was a shortage of staff. This conclusion was later confirmed by nurses in Hospital B who insisted that, “they should increase on the number of caregivers to make our job more efficient and easier and prevent loss of children‟s lives, the work is so much compared to available nurses”.

However much, diarrheal diseases, malaria, inadequate funding, inadequate funding for technological equipment and lack of enough personnel are the major challenges to the realisation of children‘s right to life, there are other causes that were identified by the informants. During face to face interviews, for example, a doctor from hospital B said that; “ignorance of parents to make the right decisions makes children die and negligence of health workers” another doctor from hospital A also said that, late referrals lead to children‘s

49 loss of life, in his own words, “late referrals, that is to say; parents stay with ill children longer and sometimes apply traditional medicines before they come to the hospital”—this doctor also noted that—“absence of blood transfusion especially during holidays and inadequate medicine in the hospital lead to loss of children‟s life”. It was also noted by another doctor from hospital A who said that, “Parents are ignorant, they run away from the hospital when the children are still on medication yet this makes diseases keep coming back. And children eventually die because their body is too weak to deal with the diseases any more”. Other diseases mentioned by the informants in hospital A to be a challenge to realising children‘s right to life are; ―sickle-cell anemia, severe pneumonia, ceptisemia, and the condition of malnutrition and acute malnutrition”.

Of all the challenges to the realisation of children‘s right to life as given by the informants, Malaria has the highest score in both hospitals for those who agree that it is responsible for children‘s death. The score is 87% in hospital A and 86% in hospital B. inadequate funding for technological equipment has the lowest score on those who agree that it is the cause of children‘s loss of life. The score is 46% for hospital A and 17% for hospital B.

4.4 Strategies Forward

A doctor from hospital A proposed that; “Government should put in place a policy strategy which demands that all medical professionals that study on government scholarship should work for government for at least two years”. (Government sponsored students should be retained by government for two years after the completion of their studies). This way, government hospitals will have medical professionals that have studied on government scholarship which can reduce the shortage of health workers in government hospitals resulting from their preference to work with and for the private sector and international organisations or income rich countries.

Hoima and Mbale hospitals both have pediatric wards for treatment of children. As noted from the informants, the challenge was overcrowding and late admission of sick children. The hospitals do not have enough space where they can attend to all children and some children are brought to the hospital when it is too late. On the issue of overcrowding two doctors from hospital B and a nurse from hospital A said that;

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“If the pediatric wards are expanded and government hires more medical personnel, this would help solve the problem of many patients in a small place with few medical personnel to attend to them”.

Another informant from hospital B suggested that the parents/ guardians should emphasise ―the consistent use of long lasting insecticide treated nets, spraying of houses and prompt treatment of fever whenever it occurs”.

From the researcher‘s perspective, parents should also be sensitised on the importance of taking their children to hospital in time and those who do not comply should be punished by law if their negligence leads to loss of a child‘s life.

It was also proposed by the informants that there should be a form of punishment for errant officials who lead to loss of children lives. Punishment can range from suspension, imprisonment and cancelation of their practicing license, they suggested. A nurse from hospital A said that; “sometimes children lose their lives because medical workers make mistakes or come late”.

The researcher also noted that, the government needs to take more serious measures on implementation of the already existing policies. For example the HIV/AIDS Workplace Policy. This was because it was discovered that many health workers have lost their lives in government hospitals as a result of HIV/AIDS and this has increased the workload of those who remain and this affects the quality of care medical personnel provide to patients and also ends up resulting in health workers leaving government hospitals for the private sector. This exposure puts them at risk of acquiring occupational related diseases, including psychological stress, which can lead to mental illness, absenteeism and job dissatisfaction.

Hoima and Mbale Hospitals health workers are willing to figure out how to reduce the death of children. The most noted intervention in this effort was their insistence on the need for government to provide adequate funds and to improve the technological equipment available to the hospitals, especially in the pediatric wards so that the health workers can do their best to save children‘s lives without lacking essential supplies.

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4.5 Summary

It should be noted that out of the 113 questionnaires distributed, 79 were filled and returned. This made a 69.9 response. The researcher also conducted interviews with an 80% response from 8 interviewees out of 10 contacted medical personnel. From these questionnaires and interviews, an assessment of the perception of hospitals and health workers on the legal framework for the protection of children‘s right to life, an assessment of the capacity of duty bearers to protect and promote children‘s right to life in Hoima and Mbale hospitals and identifying and examining the challenges affecting the realisation of children‘s right to life in Hoima and Mbale hospitals.

It was found out that, the health workers perceive government hospitals as less paying which was actually true considering that donors and private sector pay much more than government. Health workers also valued the Ethical Code of Conduct more than any other instrument, although they frequently mentioned the constitution. It was also found out that the hospitals have a limited capacity to protect children‘s right to life. Most respondents also noted that, there was lack of adequate equipment, under staffing and overworking the medical personnel. The respondents also insisted that putting in place mechanisms to punish errant officials would be a good measure for the protection and promotion of children‘s right to life.

The researcher also discovered that adherence of hospital staff to the legal framework of children‘s right to life was largely successful. Apart from the noted ethical code of conduct, staff also adhered to the Patient‘s Charter. However much, the hospitals did not prioritise children because they were specifically not children's hospitals, the researcher noted that the hospitals had pediatric departments. Hence the hospitals still paid good attention to children‘s right to life.

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CHAPTER FIVE

DISCUSSION OF FIELD FINDINGS

5.0 Introduction

In this section of the study, the researcher discussed the findings. The findings discussed in this section are derived from the findings presented in chapter four. The discussion follows from what the researcher found out in the field and the already existing literature in relation to children‘s right to life in Hoima and Mbale hospitals. In the discussion, the researcher presents particular information from the findings and makes a detailed analysis on what was discovered in the field and from the reviewed documents. This discussion features literature from Ministry of Health Reports, Poverty Eradication Programme reports and policy reviews, Uganda Periodic Review report, Uganda Health Sector Plans and Special Rapporteur reports. This helped the researcher to compare the field findings with the available information in order to give more emphasis to the findings in the discussion.

Findings are discussed from the perceptions of health workers towards children‘s right to life, the capacity of duty bearers to protect and promote children‘s right to life and the challenges to the realisation of children‘s right to life in Hoima and Mbale hospitals.

5.1 Perceptions of health workers towards children’s right to life in Hoima and Mbale hospitals.

The perceptions of health workers were assessed using the questions of whether medical staff treat children‘s right to life as important, a question on whether staff offer adequate support to children and by reviewing literature on perceptions of health workers towards children‘s right to life.

When the researcher asked the informants (medical staff) whether children‘s rights are important, the response was that, they have a pediatric department that is specifically for treating children and to them this is a way of attaching importance and respect for children‘ right to life. The researcher confirms that this is the case. The hospitals have pediatric departments where children are treated for different illnesses. Children are treated and in different sections according to their illness to avoid infection of other diseases. However much this is the case, the researcher notes that, this is not enough to guarantee respect for children‘s life. The presence of a pediatric department does not necessarily mean

53 that the hospitals treat children‘s right to life as important. For example, when one informant from hospital B was asked what the major causes of children‘s death are, this informant who was a doctor said that, “negligence of health workers some time causes children to lose their lives”. Given the responses from all informants, the researcher believes this to be true, although it is not a representative view on which a general conclusion can be deduced.

Negligence was also identified as one of the causes of loss of children‘s life in Hoima and Mbale Hospitals. Negligence has also been noted in other hospitals in Uganda. For example, in 2014, a couple dragged Case Medical Centre to court accusing its workers of declaring their baby dead yet it was still alive. In their complaint filed with the High Court the couple accuses the hospital for failing to determine whether their baby was still alive or dead at birth. While case Medical Centre declared the baby dead, the couple discovered that their baby was alive when they took it for burial at Kisubi the same day. They rushed the baby to kisubi hospital where it was pronounced alive but later referred to Nsambya Hospital for better management. The records indicate that the baby was put in an incubator but later died after 18 hours since it had spent more than five hours wrapped in four bedsheets. The plaintiffs seek Shs127m in damages from the hospital for allegedly suffocating their baby to death. This violated the baby‘s right to life and the right to the highest attainable standard of health. (Daily Monitor, Monday January 27th 2014). This kind of negligence has led to loss of children‘s lives and is ultimately a challenge to realising the rights to life provided for in the CRC, the Children Act and other children‘s rights provided for at the National, Regional and International levels.

Negligence has however not gone unpunished in Uganda. In 2015, the High Court in Kampala awarded Shs450 million in costs and damages to a mother whose baby suffered brain damage during delivery at Mulago National Referral Hospital. The Judge ruled that Mulago Hospital should compensate Sarah Watsemwa Goseltine because its medical workers negligently handled the baby. The court heard that a nurse put Watsemwa Goseltine on labour induction drip without explaining to her what it was for, mishandled the delivery, and the doctor delayed to attend to her for about 40 minutes after the nurses had noticed that delivery was botched. Their actions and omissions led to irreversible brain damage to the baby (The Independent, June 7, 2015). While this was awarded, it remains the case that many cases are never reported and the responsible medical personnel go unpunished. Though there are no exact statistics of people who die as a result of medical negligence, many are victims

54 of wrong diagnosis, treatment, and surgery but the incidents are rarely reported. This form of negligence is a direct violation of the right to the highest attainable standard of health as provided for in general comment No. 14 and the right to life as provided for in general comment NO. 36 on the right to life and ultimately impedes the capacity of health workers to work towards the realisation of children‘s right to life.

Adequate support is a critical element to the life of every child, all international legal instruments on the rights of children emphasise the need to protect children for proper development. For example, the preamble of the CRC paragraph five provides that, “childhood is entitled to special care and assistance” (Convention on the Rights of the Child, 1989). This assistance is both to the healthy and the sick. During the study, it was established that staff members offer adequate support to ensure children‘s right to life is protected. Staff members at the hospital offer adequate support to ensure that children‘s right to life is protected because those who work in the pediatric department are specifically employed to ensure that children receive the required medical support. This is in agreement with the Patients Charter of (2009), and the Patients‘ Rights Act of (1996). The Patient Rights Act puts patients‘ rights under the responsibility of the directors of medical facilities and Health Workers. It requires that the directors of medical facilities ensure the observance of patient rights by designating a person to be in charge and provide them the required support. Health workers are required to provide such support as giving advice and assistance to a patient as to the realization of his rights under this Act; receiving, investigating, and processing patients‘ complaints – complaints regarding the quality of medical care shall be referred to the attention of the facility director; educating and instruction of all medical and administrative staff in the facility in all matters regarding the provisions of the Act. These provisions not only demand that medical workers give support to patients among whom are children, but also describe the conditions under which patients may be treated without valid consent, for example children. The Patients Charter provides that, ―A health provider may give medical treatment without informed consent of the patient if: (b) ―it is impossible to obtain the consent of the patient‘s representative or of the patient‘s guardian, where the patient is a minor or an incapacitated person‖. This implies that health workers provide enough support to children.

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In relation to the above, the researcher notes that there is a challenge of inadequate personnel where the number of children patients is too big compared to what the available personnel can handle per shift. This challenge impedes the good will and commitment of health workers in Hoima and Mbale hospitals to provide adequate support to children. “We are understaffed”, a doctor from hospital B said. As earlier noted, medical staff work very long shifts. An informant from hospital A told the researcher that they work for 24 hours that is from 8am to 8am the next day and still fail to complete the work.

From reviewing literature, it was found out that, health workers prefer to work for Donors and the private sector compared to working for the Government. This was attributed to low pay in government/public sector compared to the private sector. A study by USAID in 2010 also found out that, health workers in Uganda lose their lives to HIV/AIDS while the Occupational Safety and Health Act, 2006 which governs safety standards and several other policies that have been put into place to enhance the experience for health workers, including the HIV/AIDS workplace policy, are in many instances not evenly implemented. Health workers have suffered with HIV/AIDS, with an infection rate estimated at 6.7 percent of the general population, the disease has taken the lives of many health workers in Uganda, while increasing the workload of those who remain (USAID, 2010). This kind of experience has made the working conditions in Government hospitals so unfavorable that health workers leave and go to work in the private sector. It has also resulted in health workers refusing to work in the hard to reach areas. Hence children lose their lives because these hard to reach areas have inadequate medical personnel. Hoima and Mbale hospitals are not in hard to reach areas although it should be noted that rural-urban migration of health workers also affects these regional referral hospitals. This is because, although the 2004/5-2007/8 Poverty Eradication Action Plan included amongst its health priorities the recruitment and deployment of health workers, including pay reform on general wages and hardship allowances, by 2016 the Uganda periodic review of Economic, Social and Cultural rights still indicated that the health sector was still consistently underfunded at less than 15% of the National Budget as recommended by the Abujah Declaration (E/CN.4/2006/48/Add. R, Uganda Periodic Review Report 31st Oct-11th Nov. 2016). It was noted that inadequate staffing was a result of inadequate funding for health and also one of the major causes of children‘s loss of life since the reform programme to employ health workers in hard to reach areas and provide them with allowances was largely unsuccessful.

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In relation to perceptions, especially in the case of parents seeking the help of a professional at the time of giving birth, there have been cases of reported mistrust by some women. For example,

A section of mothers in Moroto District, Karamoja sub-region have shunned giving birth at Moroto Regional Referral Hospital citing rampant mortality rates at the facility. Desperate mothers say they have now resorted to traditional birth attendants (TBAs) for help, claiming that services at the hospital are not up to standard. Ms. Grace Lemukol, one of the residents, told Daily Monitor last week that they lost their colleague Sarah Chelain, who passed on with her baby at the hospital. Ms. Lemukol said most mothers currently fear delivering from Moroto hospital because of unexplained death of mothers especially during labour‖. ―As mothers, we believe it is better to deliver at the hands of the traditional birth attendants than going to Moroto hospital where someone is not sure of her life, she added.

This kind of mistrust results in parents refusing to take their children to hospital or even seeking help of a medical professional for proper delivery of children. This has resulted in both maternal and child mortality and a violation of both rights to health and right to life (The Daily Monitor, June 13, 2017).

5.2 Capacity of duty bearers to protect and promote children’s right to life at Hoima and Mbale Hospitals

The capacity of duty bearers to protect and promote children‘s right to life in Hoima and Mbale hospitals was assessed using the following questions; Are hospital staff aware of the instruments that protect children‘s right to life?, How do you understand children‘s right to life? This question was asked as a background question to establishing whether hospitals have a human rights sensitisation mechanism; Do hospital staff receive trainings in children‘s right to life in the Hospitals or elsewhere? , Does the hospital have some library for human rights and other facility for implementing human rights? In addition to these interview guide questions, a set of statements was also set out in the questionnaire to find out whether duty bearers had the capacity to promote and protect children‘s right to life in Hoima and Mbale hospitals. These statements were meant to answer the research question about whether Hoima and Mbale regional referral hospitals had the capacity to protect and promote the life of children that come to them.

The findings of the study indicate that the majority (64%) of the staff members in Hospital B compared to 32% in Hospital A were not aware of all the legal instruments for the protection of children‘s right to life. On the other hand, majority 52% of the staff members in hospital A

57 compared to 24% of the respondents in hospital B agreed that they were aware of the legal instruments that protect children‘s right to life while 16% in hospital A and 12% in hospital B were not sure. This implies that a total of 95% of the respondents did not know all the legal instruments for the protection and promotion of children right to life compared to 76% who agreed that they knew the legal instruments for the protection and promotion of children‘s right to life. The researcher therefore notes that the majority of the staff member in Hoima and Mbale Hospitals do not know the legal instruments for the protection and promotion of children‘ right to life. Given the fact that the right to life is protected under international, regional and national law, the unawareness of the duty bearers of these laws that protect children‘s right to life is a major impediment to their capacity to protect and promote children‘s right to life.

When the respondents were asked whether health workers were qualified, the majority of the respondents agreed that hospital workers are qualified because qualification is a required assessment criteria for anyone to be hired by the hospital. One informant from hospital B also said that experience is an essential element, those who have work experience are preferred while hiring staff. It should however be noted that, although Hoima and Mbale hospitals hire qualified staff, the lack of enough of these due to health workers‘ preference to work in high paying countries and the private and donor sectors at the national level still impedes the capacity of the hospitals to protect and promote children‘s right to life. The researcher also noted that, since the hospital staff largely did not know the instruments for the protection and promotion of children‘s right to life, they possibly received no or very limited training in human rights in these hospitals and elsewhere. This is true with the exception that some informants received some human rights training from NGOs. The researcher also inferred that since hospital staff only got some human rights training from NGOs, they definitely could not have good knowledge of human rights. This is because good knowledge of human rights can only be acquired through extensive training and senstisation since there are so many documents and many laws that cannot just be known by having a few training sessions. It therefore requires a planned system of senstisation and capacity building in human rights through periodic refresher programmes that can equip health workers with good human rights knowledge and guidelines.

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Although medical training in Uganda dates back to 1924, it was not until 1963 that the first graduates of the then Makerere University College were awarded recognized degrees of medicine. Training for the degree in Uganda, like in many countries in sub-Saharan Africa, follows a system introduced by the former European colonial powers. Following high school, one has to undertake 5 years of undergraduate training in a medical school and, upon passing university examinations, is awarded a bachelor‘s degree in medicine and surgery (MBChB). This is followed by a minimum of a year of supervised practice (internship) in a referral hospital. After completing this process, the doctor is licensed to practice medicine as a ―medical officer‖ and may be employed by the government in a district hospital or health center. Others are employed by private health facilities or set up their own clinical practice after securing a license. In Uganda, like in many other countries in the region, medical officers make up the largest cadre of doctors and perform much of the clinical duties in hospitals and clinics, including emergency. One may remain at this level of training indefinitely or may return to medical school for a 3-year postgraduate study in a discipline of their choice (residency) leading to a Master of Medicine degree (equivalent to board certification). An alternative to a 3-year residency is 18 months of postgraduate study that leads to a Master of Public Health degree. (Ssenyonga & Seremba, 2007).

The Uganda Health Sector Plan 2015/16-2019/20 notes that, with health information, research and evidence generation, the country was able to transition to District Health Information System (DHIS)-2, which is an electronic web based reporting mechanism and revised reporting tools to ensure information disaggregation. The inadequate supply of the revised HMIS tools in all facilities is still hampering data collection and reporting. A data quality manual was developed and data validations were conducted in a number of districts. Surveys and facility assessments specifically for some high burden conditions (HIV, TB prevalence, malaria, NCDs) were successfully initiated/conducted. The mechanisms for evidence generation and oversight, however, need to be streamlined and strengthened to avoid scenarios where data generation is resource driven, as opposed to need driven. This is a clear indication that duty bearers are not only not knowledgeable in human rights but also lack the necessary information needed to make the right management decisions (Uganda HSDP, 2015/16-2019/20).

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While the capacity of duty bearers remains an issue of concern, it is unfortunate that there is government sponsored brain drain of medical workers in Uganda. According to recent data from Uganda‘s Parliament, the country has 1 doctor per 24,725 people and 1 nurse per 11,000 people, both well below guidelines from the World Health Organization. By contrast, Trinidad and Tobago have 12 doctors and 35 nurses per 10,000 people. So why is the Ugandan government advertising and recruiting to send more than 250 ―highly qualified‖ health workers to Trinidad? The Ugandan government is not sending short-term humanitarian aid workers, or even longer-term technical assistance. It‘s the middleman, screening and recruiting technically skilled health workers for private sectors jobs in a middle income country. In 2014, Ugandan activists who believed that the recruitment violated the right to health and puts Ugandan lives in jeopardy by depleting the country of much-needed personnel sued the government. ―A novel legal case filed in December 2014 is set to challenge the government‘s action of facilitating the ―brain drain.‖ The Institute for Public Policy and Research, a Ugandan think tank, was seeking an injunction to stop the recruitment, arguing that it violates international human rights law and Uganda‘s constitution, and is an ―unauthorized reversal of the national health policy objective of health system strengthening.‖ While medical workers in Uganda prefer to work for the private sector or leave the country to middle income states, it is unfortunate that the government participates in the brain drain that has already impaired the capacity of health workers to save the lives of Ugandans including children. This is indeed against the right to the highest attainable standard of health and puts the lives of Ugandans in jeopardy due to a very constrained health system in terms of medical personnel and capacity to handle the big numbers of patients (Human Rights Watch, 2015). This leaves pregnant mothers and children who are the most vulnerable exposed to the danger of losing their lives which affects the realisation of children‘s right to life.

The medical brain drain is not restricted to Uganda – the problem is common across sub- Saharan Africa: a 2011 study found, for example, it was found out that 77% of physicians trained in Liberia were working in the US. The consequences in Uganda are clear: the doctor to patient ratio was estimated at 1:24,725 in 2013, with a nurse to patient ratio of 1:11,000. The World Health Organisation (WHO) recommends one physician per 1,000 people. Trinidad, with 1.3 million people, has a doctor to patient ratio 12 times better than Uganda, with 35 million people. WHO ranks Trinidad‘s health system at 68 and Uganda‘s at 149.

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Each year, about 320 medical students graduate from Ugandan universities, more than in any other east African state. In the public health system, a doctor can expect to earn on average 700,000 shillings ($245) a month, compared with Sh3.8m earned by a civil servant and Sh2.4m by an accountant. In Kampala, the cost of living is not cheap. Rent for three-bedroom house in a good neighbourhood costs about Sh450.000 a month. A fairly cheap kindergarten charges Sh750.000 per pupil per term (three months). All this is before electricity, water, transport and food costs are included. It is perhaps little wonder that after completing their studies, most students relocate to Rwanda, Kenya, South Africa and the global north, where they are paid much more. (The Guardian, 2015). This brain drain that is primarily a result of low pay to medical personnel in Uganda has led to shortage of human resource and the challenge of dual practice which all lead to poor service delivery and increase child and maternal mortality all which make it difficult to realise children‘s right to life in Uganda.

5.3 Challenges to the realisation of children’s right to life in Hoima and Mbale Hospitals

The perceptions of health workers towards children‘s right to life and the assessment of the capacity of duty bearers (health workers) to protect and promote children‘s right to life bring us to the question of challenges. If we know the perceptions of health workers towards children‘s right life, and we also know the capacity of duty bearers to protect and promote children‘s right to life. Then, what challenges impede this capacity that is born of the way health workers perceive children‘s right to life in Hoima and Mbale hospitals.

The challenges to the realisation of children‘s right to life were identified and examined using a set of questions that included; what are the major causes of children‘s loss of life in Hoima and Mbale Hospitals? Are hospitals adequately funded? Do you think inadequate funding affects the implementation of children‘s right to life in Hoima and Mbale Hospitals? Does lack of enough personnel lead to children‘s loss of life? In the same fashion as in assessing perceptions and capacity, a set of statements was included in the questionnaire with the goal of finding out whether respondents agreed or disagreed with the truth or falsity of these questions.

However much the findings of the study indicated that malaria was one of the major causes of children‘s loss of life, the Uganda Health Sector Strategic Plan III noted that, Child morbidity and mortality are still high in Uganda although malaria was not identified among the major causes. The plan indicates that Neonatal deaths contribute 38% of all infant deaths, which is a

61 significant proportion given that these deaths occur in one month out of the twelve months of infancy. This proportion has largely remained the same over the past 15 years, (36.7% in 2000, 36.8% in 1995). Febrile illness is the major cause of under-five mortality in Uganda. Neonatal mortality is mostly caused by septicemia/pneumonia (31%), asphyxia (26%), prematurity (25%), congenital abnormalities (7%), tetanus (2%), diarrhea (2%) and other conditions (7%). Infections, birth asphyxia and complications of preterm delivery account for 82% of all newborn deaths. Over a half of the total newborn deaths occur during the first week of life, mainly in the first 24 hours of life. The majority of newborn deaths result from infections, asphyxia, birth injuries and complications of prematurity. Low birth underlines 40-80% of newborn deaths. The Uganda National Household Survey (2016/2017) notes that malaria/Fever accounts for 26% and is among the major causes of illness/injury among the population.

Malaria has been ranked the number one killer disease in Uganda, according to the 2013 Ministry of Health sector performance report. 80,000 people die of malaria every year and the most vulnerable according to Myers Lugemwa, the Officer in Charge of the Malaria Control Programme at the Ministry of Health, women and Children are the two most vulnerable groups affected by malaria and people living with HIV. ―For the children, their immunity is just developing; as such they lack the passive immunity which comes as a result of several malaria infection exposures in adults. This makes them too weak to fight the infection and that‘s why they get severe malaria in most cases,‖ (Daily Monitor 25th April 2014)

Uganda ranks sixth among African countries with high malaria-related mortality rates, and has one of the highest reported malaria transmission rates in the world. The World Health Organisation (WHO) reports that globally malaria is a major cause of ill health and deaths, with approximately 16 million cases and over 10,500 deaths reported in 2013. According to the Uganda Demographic Health Survey (UDHS) 2011, malaria accounts for 30%-50% of outpatient visits and 15%-20% of hospital admissions. Everyone in Uganda is at risk of malaria, although pregnant women and children under five years are mostly affected. Malaria has a major social-economic impact on individuals, families, and communities regarding out- of-pocket expenditures for consultation fees, drugs, transport, and subsistence at a distant health facility. It has a significant negative impact on Uganda‘s economy due to loss of workdays resulting from sickness, decreased productivity, and high school absenteeism. A single episode of malaria costs a family on average 9 US dollars, or 3 per cent of annual

62 income. In addition, severe malaria impairs children‘s learning and cognitive ability by as much as 60%, consequently affecting the performance of the educational system (MOH, 2015).

Inadequate funding remains the major challenge to the realisation of children‘s right to life. For example, a doctor from hospital A said that inadequate funding for technology results into failure to have the right equipment to save children‘s lives. A 2016 state of Economic, Social and Cultural Rights in Uganda and Emerging Issues report by Uganda Coalition on Economic, Social and Cultural rights noted that consistent inadequate budget allocation to the health sector affects the quality of health. During the 2011 Universal Periodic Review (UPR), Uganda agreed to raise the health care budget to 15% in line with the Abuja Declaration target. Uganda‘s health sector remains significantly under-funded, at 8.6% of total government expenditure and this subsequently impacts on access to quality health care services. This consistent inadequate funding has resulted in failed projects as noted on the issue of information technologies financing, dilapidated old hospital health centres and general hospitals, lack of adequate personnel, failed reforms on human resource issues and this has led to corruption and siphoning of the few available drugs. All these issues combined lead to children‘s loss of life.

Uganda is heavily underfunded where it matters -healthcare. Hospitals are costly and for those who can‘t afford it, they don‘t get it. Patients are left to search for cheap herbal remedies or wait until their pain subsides. Most of the health issues that arise in Uganda can be linked to the lack of water available for families. Without a proper source of clean water, Ugandans are at risk of contracting various illnesses or parasites that can potentially lead to death. More than 50% of Ugandans have no clean water source, which means they are at a higher risk for waterborne diseases. Various small health care programs in Uganda have been implemented to help with these issues including, The Water Project, which constructs wells in rural villages. Aside from bringing a reliable source of clean water, they give lectures on sanitation. UNICEF Uganda has also implemented a similar program that serves to inform the families of issues that arise from unclean water sources and also offers health services for free. This program called Family Health Days is one of many that are currently being put in effect with the partnership of faith-based organizations. Family Health Days is offered at various places of worship, advertised on the radio and spread through word of mouth. Several

63 families bring in their children to get immunizations or de-worming checks. Mothers are able to get assistance with antenatal care and blood pressure readings. Counseling is also given to foster a healthy lifestyle for the entire family. Programs such as Family Health Days and The Water Project truly make a difference in the lives of hundreds in the rural villages of Uganda. They work with the community and bring awareness to health issues of the poor. The Water Project, Family Health Days and numerous small programs offer hope for a country whose own government has repeatedly been under scrutiny for misusing international relief aid. (Martez, 2013). This kind of partnership between the Government, International Aid Agencies and communities has contributed so much to the protection of human rights and in this case the rights to health of mothers and their unborn or newly born children. It has also provided immunisation facilities to children which is a crucial factor in busting their immunity and health. All these interventions combined have rendered a very important contribution in the realisation of the right to life in situations where the Government lacked adequate funds to provide the necessary services and personnel in the rural areas.

As noted earlier, there is inadequate funding for technological equipment and this impedes the protection and promotion of children‘s right to life. This inadequate funding does not only stop at failure to facilitate the acquisition of data desegregation technologies but also affects the infrastructure that houses general hospitals and health centres. For example, the ministry of health has noted that with health infrastructure, physical access to health facilities (proportion of the population living within 5 km of health facility) is currently at 72%. All the 112 districts in Uganda either have a hospital or HC IV or both. This however includes some old and dilapidated infrastructure, mainly at General Hospitals (GHs) and some lower level health facilities. There were limited improvements in facility infrastructure.

Information & communications technologies (ICTs) are continually viewed as having the potential to address several challenges in Africa including in the health sector. For Sub- Saharan Africa, ICTs could offer a great deal of benefits since health care is one of its fundamental needs. Health challenges in Africa include both the diseases and supporting facilities in terms of human resource and physical infrastructure. For instance, HIV/AIDS, Malaria, Cholera, typhoid, and yellow fever are reported to kill several people in Africa each year. The government of Uganda endeavors to incorporate ICTs into the health sector through several policies. For example through the National ICT Policy, where the government of

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Uganda considers the incorporation of ICTs into the health sector, through the Poverty Eradication Action Plan (PEAP) which identifies ICTs as key to the country‘s modernisation and development and through the Ministry of Health (MOH)‘s Health Sector Strategic Plan (HSSP) where the government embraces ICT as a tool for enhancing the quality of health care service delivery, and a health sector ICT policy, strategies and action plans have been developed. However, there are challenges that hinder the incorporation and these includes the costs of ICT equipment, the workable conditions, level of awareness and skills of the potential users, technology compatibility and policy provisions amongst others. The poor ICT infrastructure status in Uganda currently is unable to adequately support the potential benefits of ICTs in the health sector. Very few hospitals are computerised, and when they are, internet access is limited. Most hospitals, including big national hospitals like the Mulago hospital, still use manual systems of recording and storing patient information. Cost of accessing the internet, maintaining the equipment and buying new ones is also a challenge. In other cases costs of installing internet facilities and maintaining it is also as challenge for poor countries like Uganda. In addition to the costs and status of infrastructure, several hospitals fail to work together because of the incompatibility of equipment and software. Related to this is the presence and availability of experts in real time. In cases where consultations have to be made across continents, there is also the issue of time difference and presence of experts when they are required. (Litho, 2010). This affects the realisation of children‘s right to life. Sometimes mothers die in labour due to lack of blood and there is no way of knowing which hospitals have surplus in store, yet there is sometimes blood in a nearby health Centre. The failure to fund ICT in Health adequately also impedes communication between hospitals and expert, between Uganda and other countries and leads to unnecessary referrals and untimely death of mother and their children which all drag back the efforts to reduce infant mortality and child mortality leading to loss of life.

The study also found out that Hoima and Mbale hospitals lack enough personnel and that this shortage makes the workload too much for the available staff. This results in health workers working very long shifts while the patients are so many. The ministry of health has also noted that, the health workforce is still a key bottleneck for the appropriate provision of health services, with challenges in adequacy of numbers and skills, plus retention, motivation, and performance challenges. Efforts by the GoU and Partners have facilitated recruitment of much-needed staff increasing the proportion of approved posts from 56% in 2010 to 69% in 2013/2014. There is improvement in recruitment of health workers, largely driven by efforts 65 in 2012 to improve staffing at HC III and IVs. There are however variations by district, facility type and by cadres. Only 45% of positions at HC II are filled, as compared to 70% / 71% at HC III and IV respectively. The effort to improve the availability of health workers at HC III and IV is commendable, though it may have had the unintended consequence of reducing attraction and motivation of staff at HC IIs and the general hospitals. Additionally, there are still variations in staffing levels by district with only 28% of positions filled in Kiruhura district, compared to 91% of posts in Iganga district. Plus, the current numbers per level are still too low for the health care delivery. There are an estimated 1.55 health workers per 1,000 persons, which is below the WHO cut off of 2.28 / 1,000 persons below which the country is considered as having a critical shortage. (Uganda HSSP III, 2010/11-2014/15). As noted earlier, a doctor noted that they worked for 24 hour shifts. This implies that according to the WHO, Uganda was having a critical shortage of health workers in the year 2014/2015. It is also justifiable to conclude that this shortage still exists in 2017 since Uganda had not increased the percentage of funds in terms of budgetary allocation by December 2016.

Apart from Hoima and Mbale Hospitals, the ‗lack of personnel‘ has also been identified in other hospitals in the country. For example, in 2016, an aggrieved couple sued Mengo Hospital for the death of their new born baby whom they claimed was wrongly injected by a student nurse. ―Court documents indicate that after the successful caesarian section, Sophie Namuli, a student nurse, came into her room holding a tray with two syringes; one big and another small‖. The student nurse then administered some drugs to the baby using the big syringe and the mother with the small one. After this, the baby turned dark and started crying and gasping while the student nurse stood confused. The baby is said to have died at around 3pm and a postmortem showed that the cause of death was hypoxia. The couple through their lawyer now hold Mengo Hospital liable for the death of their child on grounds that there was no supervision of the student nurse which resulted in the tragic loss of their child (Daily Monitor, Tuesday July 2016). Such mishandling of patients and drug administering is a violation of their right to the highest attainable standard of health and ultimately leads to violation of the right to life of the child as stipulated in the CRC, the 1995 Constitution of Uganda and the Children Act (Cap 59). It is also important to note that due to a strain on the few medical personnel, hospitals rely on interns to do some of the work and this has resulted in fatalities in situations where there is minimal or no supervision buy senior medical personnel.

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A similar situation (case) was reported by Uganda Radio Network on their website in 2012. It reported that, ―Judith Nansubuga died at Rubaga Hospital on March 5th due to what family members call negligence by the medical staff at the maternity ward. The family says medical workers at the Hospital failed to control her blood pressure leading to the loss of the unborn baby‖. A sister to the deceased is said to have requested a referral to another hospital but the midwives at Rubaga Hospital told her to wait for Dr. Jumba Mukasa, a consultant who was not on duty. In this case, the death of the mother and the baby was due to lack of personnel and negligence on the part of Rubaga Hospital. It is important to note that there is a shortage of medical experts in the country and consultants are strained with a lot of work. This leads to delays to receive medical attention even for patients with critical situations. In this case, this delay resulted in the violation of the right to life of both the mother and the child and the denial of the right to adequate medical care. Both violations are in contraventions of the right to the highest attainable standard of health and most notably the right to life (Uganda Radio Network, March 9th, 2012).

Health professionals have an indispensable role to play in the realisation of the right to health. Presently Uganda employs and retains too few health professionals to deliver a basic level of health services and protection to the entire population. It is important to note that those who need health services and the protection of health professionals most are the most vulnerable among which children are on top of the list. It should be noted that this kind of shortage is not just a post 2015 phenomenon. Between 1990 and 2002, there were five doctors per 100.000 people. Qualified staff fills only 42% of approved posts. In 2000, only 40% of health units had trained staff. Each year only 60 to 120 doctors graduate from medical, school, and only some 10 to 20% of them are assimilated (E/CN.4/2006/48/Add. R). To its credit, the Ministry of Health recogonises that, there are not enough trained health workers to implement HSSP and that they are unevenly distributed with most going to the urban areas and well placed districts. PEAP 2004/5-2007/8 includes among its health priorities the recruitment and deployment of health workers, including pay reform on general wages and hardship allowance. It is however unfortunate that this pay reform failed. In 2010, USAID noted that the pay reform and hardship allowances programme was almost a total failure. The former Special Rapporteur on the right to the highest attainable standard of health Paul Hunt, also noted in 2006 that, Uganda‘s human resource issue was one of a multi-dimensional nature and an urgent one. The issues that made Uganda‘s health human resource issue a critical one include; inadequate health budget allocations that precludes the appointment of a sufficient 67 number of health professionals; the application of a rigid ceiling on the health budget; the ―skills drain‖ from Uganda to income-rich countries, as well as rural to urban migration with in Uganda; poor terms and conditions; lack of human rights training for health professionals; the corrupt practice of some health professionals for example, siphoning public drugs to the private sector or referring patients to their personal private clinics.

5.4 Conclusions

It was found out that, the hospitals have trained personnel although they are inadequate in number. There is also a challenge of inadequate funding for both salaries and procurement of adequate medical equipment. This analysis also found that, medical workers are not adequately informed in regards to the rights of children, there is a problem of dual employment because most medical workers hold two jobs — one in the private and another in the public sector — because government jobs pay less. It was also found out that the pediatric departments of Hoima and Mbale Regional Referral Hospitals are congested and lack essential facilities and care takers.

It was also found out that negligence is a big challenge to the realisation of children‘s right to life. Whereas, this study focused on Hoima and Mbale Hospitals, the researcher concluded that negligence is a general problem even in other hospitals. Cases of negligence can be found in legal suits ranging from cases against the National Referral; Hospital ‗Mulago Hospital‘, major hospitals like Rubaga and Mengo and private health centres like Case Medical Centre which are all major hospitals in the country. Such degree of negligence has a very serious impact on the realisation of the right to life especially for babies since their health requires much attention and vigilance than older people.

In general, the researcher has come to conclude that, perceptions, capacity and challenges are inter-related. For this reason, perceptions affect capacity and this in turn has a serious contribution to the persistence of the challenges to realising children‘s right to life.

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CHAPTER SIX

CONCLUSIONS AND RECOMMENDATIONS

6.0. Introduction

This chapter presents the conclusions and recommendations of the study. Conclusions and recommendations are drawn from the themes that were investigated. Recommendations are drawn from the identified gaps, the literature reviewed and the analysis of the field findings. Conclusions are presented as the end inferences drawn by the researcher while recommendations are the ways forward to address the identified challenges to the realisation of children‘s right to life. The conclusions and recommendations follow from the objectives of the study, respectively.

6.1 Conclusions

Basing on findings from the study, these conclusions were arrived at;

Health workers prefer to work for donors and the private sector because Government pays less salary. This does not only end with them preferring the private sector. It was also noted that health workers, especially doctors do not respect the Code of Conduct and Ethics for the Uganda Public Service which forbids a public officer from holding two jobs at the same time. The majority of health professionals in Uganda engage in dual practice to supplement their low public sector salaries. It was also noted that if doctors from the private sector stopped taking jobs in the public sector, it would actually crumble.

The study also found out that the Government does not implement the existing policies. It was noted that while health workers continued to lose their lives to HIV/AIDS, the HIV/AIDS Workplace Policy was not being implemented. The researcher therefore concluded that this led health workers to prefer the private sector where regulations may be much more effective and workplace safety is guaranteed.

It was also found out that the hospitals take children‘s rights as important. This was due to the fact that each of the hospitals had a pediatric ward. This made it clear that there was prioritization of children‘s rights. It was however pointed out by the informants in both hospitals that the lack of adequate funds and equipment still impedes their dedication to

69 saving children‘s lives. The study thus concludes that shortage of equipment still leads to loss of children‘s live in Hoima and Mbale Hospitals.

On the objective of whether the duty bearers, in this case—health workers—had the capacity to promote and protect children‘s right to life, it was concluded that hospital staff are aware of the legal instruments for the protection of children‘s rights. This awareness was largely of the codes of conduct and the patient Charter.

It was further concluded that hospital staff members were not aware of all (international and regional frameworks) the legal instruments that protect children‘s right to life. Only one doctor mentioned human rights standards and three had knowledge of the constitutional provisions and the children Act.

Health workers in Hoima and Mbale hospitals complained that sometimes—which had become most times recently—they are overwhelmed by the numbers of children patients because the health workers are few. It was also found out that the pediatric ward was overcrowded due to these increasing numbers of children. Although the hospitals were willing to protect children‘s right to life this challenge impeded their capacity in a one way or another.

The study also concluded that staff members in both hospitals are well qualified and have good experience which implies that although they are not enough compared to the numbers of patients, they are able to do their best to save children‘s lives all the time.

The researcher also concluded that few staff members receive training in human rights and child protection and that Hoima and Mbale hospitals did not have libraries where human rights policies and documents would be or were kept for reference or refresher training.

According to study findings, malaria and diarrheal diseases were the major causes of children‘s death in Hoima and Mbale hospitals. While respiratory infections account for 18% and are one of the major causes of illness and injury among Ugandans, malaria/fever accounts for 26% of the major causes of illness and injury to the Ugandan population and remains the major impediment to the protection of life and health (UNHS, 2016/2017). This

70 was coupled with a lack of enough personnel and increasing number of patients which was also a big challenge.

It was found out that inadequate funding was also responsible for children‘s death. Inadequate funding led doctors to leave government hospitals for the private sector, or work two jobs, which resulted in dual practice. This lack of adequate funding also led to lack of the necessary supplies to treat children. As also noted by UNHS (2016/2017), unavailability of medicines/supplies stands at 23%. This implies that there is limited provision of necessary medicines and this matches the situation in Hoima and Mbale hospitals where health workers said that there were stock outs of drugs and this led to loss of children‘s life.

The researcher also concluded that patients buy medicines from private pharmacies and clinics because the hospitals lack medicines and supplies. This was also confirmed by the 2016/2017 UNHS which notes that, between 2012/3 to 2016/7 the proportion of the population seeking health care from government health facilities has remained the same while the number of those seeking care from pharmacies has doubled over the same period.

It was also concluded that negligence of health workers is one of the major challenges to the realisation of children‘s right to life. Even though the context so much relates to right to health, the consequence of loss of the fundamental right to life for the child is a serious human rights violation.

6.2 Recommendations

From the conclusions, the researcher came up with recommendations. These recommendations also draw a lot from the strategies presented after the findings in chapter four.

The study recommends that compulsory service provision for two years by medical professionals that have studied on government scholarship can be adopted. This will solve the challenge of lack of enough personnel in government hospitals.

The study recommends that, children‘s right to life in Uganda can be studied by way of health research in relation to the available international, regional and national legal frameworks to establish whether these frameworks meet their intended goals of protecting

71 children‘s right to health and providing the environment necessary to realise children‘s right to life.

The study recommends that the government should put more emphasis on promulgation of the available laws and policies. On this issue, the government should also put much emphasis and allocate more funds to the implementation of the policies. For example, the HIV/AIDS Work Place Policy and the codes of Ethics and Conduct that require health works not have two jobs, one in the public sector and another in the private sector.

The researcher also recommends that the Government-Public service commission and the Ministry of Finance should increase the salaries of health workers to a scale that matches the salaries of their counterparts in the private sector. This will help solve the problem of dual employment that results into shortage in the public sector.

It was also noted that the government needs to provide human rights refresher courses to the health workers in the public sector so as to improve their knowledge and skills on human rights. This should be reinforced with a library facility where health workers can continuously improve their understanding of children‘s right to life in both Hoima and Mbale hospitals.

The study recommends that hospital administration receive and carry out awareness trainings for hospital staff members on legal instruments for the protection of children‘s right to life and the conceptual context of the right to life itself. This is because most staff members were not aware of all the legal instruments that protect children‘s right to life.

The study further recommends that the Ministry of Health should support recruitment of more health workers since both hospitals reported that they do not have enough personnel to protect and promote children‘s right to life.

The study recommends that Government of Uganda through the Ministry of Health should provide more funding to hospitals in order to procure enough drugs for Malaria and diarrhea as well as hire more medical personnel to improve the protection and promotion of children‘s right to life.

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The study also recommends that further study should be carried out on the effects of health financing on the right to health and ultimately children‘s right to life in Uganda. The impact of human right education in the realisation of children‘s right to life and the relationship between human rights training and capacity of health workers to promote and protect children‘s right to life.

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APPENDICES

Appendix i: Questionnaire Dear respondent, I am FRIDAH GOOD OWOR, pursuing a Master of Arts Degree in Human Rights of Makerere University. I am carrying out an academic study about Protection and promotion of Children‘s right to life in Uganda a case of Hoima and Mbale hospitals. In your position, you have useful information to contribute to the success of the study. You can readily contribute this information by answering the questions in this instrument. All information given will be treated confidentially for purely academic purposes and please do not indicate your name anywhere on the questionnaire. Thank you for your cooperation. SECTION A: BIO-DATA Please tick or circle.

1. Age: 20-30 31-40 41-50 Above 50

2. Sex: Male Female

3. Highest level of education Diploma Bachelors Masters PHD

Tick the number that best indicate your opinion on the questions using the following scale. Scale 1 2 3 4 5 Strongly disagree Disagree Neutral Agree Strongly agree

SECTION B: Legal protection of life Sl Statement SA A NS D SD 1 Hospital staff adhere to legal instruments 5 4 3 2 1 while treating children 2 The hospital‘s priority is to protect 5 4 3 2 1 children‘s right to life 3 Hospital staff members are aware of all the 5 4 3 2 1 legal instruments that protect children‘s right to life 4 Staff members offer adequate support to 5 4 3 2 1 ensure children‘s right to life is respected

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5 Staff members are held responsible for 5 4 3 2 1 negligent acts that lead to children‘s loss of life.

SECTION C: Capacity of duty bearers SL Statement SA A NS D SD 1 The hospital has enough personnel 5 4 3 2 1 2 Hospital staff members are well qualified 5 4 3 2 1 3 Hospital staff members have good 5 4 3 2 1 experience 4 Staff members have adequate knowledge 5 4 3 2 1 on human rights 5 Staff members receive training in human 5 4 3 2 1 rights and child protection

SECTION D: Challenges affecting the realization of children‘s right to life Statement SA A NS D SD 1 Diarrheal diseases are responsible for 5 4 3 2 1 children‘s death 2 Malaria is responsible for children‘s death 5 4 3 2 1 3 Inadequate hospital funding is responsible 5 4 3 2 1 for children‘s loss of life 4 Inadequate technological equipment is 5 4 3 2 1 responsible for children‘s loss of life 5 Lack of enough personnel is responsible 5 4 3 2 1 for children‘s death

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Appendix ii: Interview Guide

To assess the perceptions and attitudes of hospitals and health workers regarding children‘s right to life in Uganda Do hospital workers treat human rights as important? Do they have enough personnel? What shows that they respect human rights and children‘s right to life? Is there any human rights agenda in the hospital (projects, practice or events)? What legal instruments does the hospital refer to to protect children rights?

To assess the capacity of duty bearers to protect children‘s right to life in Hoima and Mbale Hospitals Are hospital staff aware of the instruments that protect children‘s right to life? How do you understand children‘s right to life? Do hospital staff receive trainings in children‘s right to life in the Hospitals or elsewhere? Does the hospital have some library for human rights and other facility for implementing human rights?

To identify and examine the challenges to the realisation of children‘s right to life in Hoima and Mbale Hospitals What are the major causes of children‘s loss of life in Hoima and Mbale Hospitals? Are hospitals adequately funded? Do you think inadequate funding affects the implementation of children‘s right to life in Hoima and Mbale Hospitals? Does lack of enough personnel lead to children‘s loss of life?

Strategies How does the hospital plan to promote and protect children‘s rights, what programmes are in place? Does the hospital punish hospital staff who violate children‘s rights, especially right to life? What is the hospital doing or planning to do to implement, promote and protect children‘s right to life?

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Appendix iii: Table for determining sample size from a given population N S N S N S N S N S 10 10 100 80 280 162 800 260 2800 338 15 14 110 86 290 165 850 256 300 341 20 19 120 92 300 169 900 269 3500 346 25 24 130 97 320 175 950 274 4000 351 30 28 140 103 340 181 1000 278 4500 354 35 32 150 108 360 186 1100 285 5000 357 40 36 160 113 380 191 1200 291 6000 361 45 40 170 118 400 196 1300 297 7000 364 50 44 180 123 420 201 1400 302 8000 367 55 48 190 127 440 205 1500 306 9000 368 60 52 200 132 460 210 1600 310 10000 370 65 56 210 136 480 214 1700 313 15000 375 70 59 220 140 500 217 1800 317 20000 377 75 63 230 144 550 226 1900 320 30000 379 80 66 240 148 600 234 2000 322 40000 380 85 70 250 152 650 242 2200 327 50000 381 90 73 260 155 700 248 2400 331 75000 382 95 76 270 159 750 254 2600 335 100000 384 Note: ―N‖ is population size ―S‖ is sample size.

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