HHr Health and Human Rights Journal

Decolonizing Health Governance: A HHR_final_logo_alone.inddCase 1 10/19/15 10:53 AM Study on the Influence of Political History on Community Participation moses mulumba, ana lorena ruano, katrina perehudoff, and gorik ooms

Abstract

This paper presents a case study of how colonial legacies in Uganda have affected the shape and breadth

of community participation in health system governance. Using Habermas’s theory of deliberative

democracy and the right to health, we examine the key components required for decolonizing health

governance in postcolonial countries. We argue that colonization distorts community participation,

which is critical for building a strong state and a responsive health system. Participation processes

grounded in the principles of democracy and the right to health increase public trust in health

governance. The introduction and maintenance of British laws in Uganda, and their influence over

local health governance, denies citizens the opportunity to participate in key decisions that affect them,

which impacts public trust in the government. Postcolonial societies must tackle how imported legal

frameworks exclude and limit community participation. Without meaningful participation, health

policy implementation and accountability will remain elusive.

Moses Mulumba, LLB, LLM, MPhil, is the Executive Director of the Center for Health, Human Rights and Development, , Uganda, and a doctoral researcher at the Faculty of Medicine and Health Sciences, Ghent University, Belgium. Ana Lorena Ruano, PhD, is an Associate Professor at the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Norway, and a researcher at the Center for the Study of Equity and Governance in Health Systems, Guatemala City, Guatemala. Katrina Perehudoff, PhD, LLM, MSc, is Senior Research Fellow and Co-Director of the Law Centre for Health and Life at the University of Amsterdam, Netherlands; a Post-Doctoral Assistant at the International Centre for Reproductive Health at Ghent University, Belgium; and a Fellow at the Amsterdam Institute for Global Health and Development, Netherlands. Gorik Ooms, LicJur, PhD, is a Professor in the Department of Public Health and Primary Care, Ghent University, Belgium. Please address correspondence to Moses Mulumba. Email: [email protected]. Competing interests: None declared. Copyright © 2021 Mulumba, Ruano, Perehudoff, and Ooms. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted noncommercial use, distribution, and reproduction.

JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal 259 m. mulumba, a. l. ruano, k. perehudoff, and g. ooms / general papers, 259-271

Introduction es true partnerships between communities and decision makers through empowerment cycles. Community participation is a critically import- Getting rid of the lasting impact of colonization ant component of building public trust in health calls for raising citizen awareness of rights and governance, as well as a key feature of the right to obligations and building collective action that health.1 It refers to the free, active, meaningful, and promotes self-determination through dedicated inclusive processes through which people make policy frameworks and incentives that help ensure decisions on issues that affect them, their families, the dispersion of decision-making power in health and their communities.2 Colonialism deeply affects policy.7 This diffuses decision-making power a country’s social fabric and inherently changes among more stakeholders and ensures that health social, cultural, political, and economic structures services reflect local needs, which increases com- in a way that continues to be felt decades after in- munities’ control over maintaining and improving dependence.3 Using elements of Jürgen Habermas’s their health.8 However, establishing these processes theory of deliberative democracy and the right to in contexts of exclusion and marginalization re- health as normative frameworks, this paper ex- quires time and sustained support that allows for amines the legacies of colonialism in Uganda and the reconfiguration of societal-level power dynam- how they have affected community participation ics.9 This is crucial for strengthening public trust in health system governance. We propose that in health governance, which is a central building health system requires embedding block of health systems’ ability to provide services community participation through policies that 10 incentivize historically marginalized and excluded efficiently, effectively, and equitably. groups to better disperse decision-making power, Like many countries in Sub-Saharan Africa which is a consequential first step in truly achiev- and around the world, Uganda struggles with a ing self-determination. recent colonial past and its legacy. In many former Colonization disrupts people’s connection to colonies, the effects of often brutal and forced colo- the land and forces a new country identity on exist- nization influence all aspects related to governance 11 ing cultures, communities, and families, and does well into postcolonial self-rule. Table 1 shows how so through policies that seek to control, stigmatize, many sub-Saharan countries were under colonial and intervene in their lives.4 Decolonization calls rule from as early as the late 1890s and began for the dismantling of several layers of complex achieving independence only in the 1960s. For and entrenched colonial structures, ideologies, South , this came as late 2011. Today, almost narratives, identities, and practices, as well a re- all low-income countries in Sub-Saharan Africa construction process that focuses on reclaiming have serious health governance challenges, and humanity, rebuilding bodily integrity, and reassert- most still struggle with their colonial legacies. ing self-determination.5 The political, economic, We argue that achieving the highest attain- social, and cultural control that was leveraged on able standard of health is intrinsically linked to an occupied nation breaks down local social fabrics Habermas’s theory of deliberative democracy. and creates inequality and public mistrust in the Communicative action, the power of speech, le- governance system. As a result, some populations gitimacy, and the principles of legitimacy and the become more and more excluded, and these his- public sphere shape community participation and torical cycles of disempowerment lead to further affect the way that communities engage with the exclusion.6 Colonialism also shapes the health health system and enjoy their right to health. Many system and all governance processes within, with a postcolonial societies with weak deliberative de- history of colonization acting as a key determinant mocracy values continue to struggle with democracy of health for many vulnerable population groups. because colonization impacted self-determination, Decolonizing health systems allows for a which limits popular sovereignty, especially in return of community participation that establish- context of extreme poverty and resource con-

260 JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal m. mulumba, a. l. ruano, k. perehudoff, and g. ooms / general papers, 259-271 straints.12 This exclusion delegitimizes the public social justice.15 space, which is coopted by officials who were not Colonial governments’ dominance of their col- elected by the people. This weakens democracy and onies required achieving control over the territory, increases authoritarian leadership, hence impact- which in turn involved the erosion of self-determi- ing public trust in the health system’s governance.13 nation and the imposition of a rule rooted in the Democracy and human rights are co-original and colonizer’s beliefs and practices.16 Oftentimes, this can act in virtuous cycles of empowerment when translated into the enforcement of a foreign culture, they integrate previously excluded groups and lead religion, and social mores and customs through to the type of systemic change that dismantles the slave trade, misappropriated natural resources, colonial structures at the ideological and practical exploitative trade relations, and unfavorable means level. Finally, community participation is central of producing wealth.17 Such foreign systems of rule to the realization of the right to health, as stated of law limited local peoples’ self-determination in the United Nations Committee on Economic, and sovereignty, for subjected communities were Social and Cultural Rights’ General Comment beholden to laws that they had not participated in 14.14 By framing participation disparities as rights making. The repressive systems that crushed In- violations, public health advocates can draw on in- digenous legal and health systems also disregarded ternational legal standards to frame responsibilities local traditional values, which were then replaced and evaluate policies, shifting the analysis of health by those of the colonial rules. These systems in- reform from a focus on the quality of care to one on clude the health system, which was organized by

Table 1. Sub-Saharan countries and dates of their independence

Country Colonizer Independence date Benin France 1960 Burkina Faso France 1960 Belgium 1962 Central African Republic France 1960 Chad France 1960 Comoros France 1975 Democratic Republic of the Congo Belgium 1960 Eritrea Italy, , and Ethiopia 1993 Gambia United Kingdom 1965 Guinea France 1958 Guinea-Bissau Portugal 1973 Madagascar France 1960 United Kingdom 1964 Mali France 1960 Mozambique Portugal 1975 Niger France 1960 Belgium 1962 Senegal France 1960 Sierra Leone United Kingdom 1961 Sudan 2011 United Kingdom 1961 Togo France 1960 Uganda United Kingdom 1962 United Kingdom 1964 () United Kingdom 1980

JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal 261 m. mulumba, a. l. ruano, k. perehudoff, and g. ooms / general papers, 259-271 the colonizers based on their own ideas and beliefs health systems is important for allowing commu- around the type and number of services that should nity participation in health systems to thrive. be provided to the local population. Our analysis focused on understanding the As the Ugandan case study demonstrates, colonial period’s subrogation of community par- postcolonial countries continue to grapple with the ticipation and public trust in health governance. impacts of colonial values on their legal and health By applying the normative guidance provided by systems. Laws criminalizing abortion and same- Habermas’s deliberative democracy framework sex unions are just some examples. The missionary and the right to health framework, we uncovered hospitals and schools introduced during colonial the need for decolonization that emphasizes com- rule continue to account for almost 20% of Ugan- munity participation as part of building public da’s health and education systems.18 The values that trust in the health system. guide these systems, instituted through colonial rule, disregard current scientific knowledge and The Uganda case study human rights and represent key challenges to the delivery of empowering and liberating health and Uganda provides an opportunity for studying the education systems. Uganda provides a good case historical and political influences of colonialism on study on the influence of political history on com- community participation as an integral part of the munity participation. right to health and health governance generally. Uganda has transitioned through the precolonial, Methods colonial, and present-day periods of developing a democracy and a health system. The formation of This paper uses a qualitative, historical case-study its national development agenda in the post-colonial methodology and is guided by an analysis of the period and the rolling out of its decentralized health political history of community participation in system also offers an opportunity to examine the Uganda from the precolonial, colonial, and post- colonial influences on the structures for communi- colonial periods.19 The literature review included ty participation through the lens of constitutional publicly available documents located through provisions, local government legislation, and other online searches for academic articles, government policy frameworks that provide the foundation documents, nongovernmental organization (NGO) for operationalizing community participation. reports, and other gray literature. The publications Through into precolonial, colonial, considered were published in English and used and postcolonial, the history of the country allows rights-based approaches to health system strength- us to critically assess the extent to which community ening. Additionally, publications that described or participation was lost during the colonial period. contextualized the historical events that shaped This then provides a basis for examining the decol- Uganda’s political setup and health system were onization steps needed to bring back community included in the study. participation as part of good health governance. As We analyzed data through a content analysis we argue, it is difficult to separate Uganda’s current using two normative frameworks: (1) Habermas’s health system from its colonial and political history, concept of deliberative democracy and (2) the right as the latter continues to influence the architecture to health framework. Both frameworks center of the health system today. around the concept of community participation whereby people and communities are at the cen- Precolonial community participation ter of decision-making processes in health. These During the precolonial period, communities or- frameworks emphasize the tenets of the power of ganized around kingdoms, in which community speech, legitimacy, and the public sphere, and they participation was a key social tenet.20 For example, advance the argument that the decolonization of in the Kingdom, kingship was made into

262 JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal m. mulumba, a. l. ruano, k. perehudoff, and g. ooms / general papers, 259-271 a kind of state lottery in which all clans could par- enshrined in international human rights law. ticipate.21 The community consolidated its efforts behind a centralized kingship, and this provided Community participation during Uganda’s the community an opportunity to expand. Every- colonial period day life was organized around communal efforts. Uganda was a of the Social capital was critical for mobilization, which from 1894 to 1962, and although the economic, so- included rotating groups for labor sharing in the cial, and political landscape changed dramatically, clearing, planting, weeding, and harvesting stages the country retained a degree of self-government of agriculture, as well as emergency-oriented ar- that was uncommon.27 Different Indigenous com- rangements, such as local burial assistance groups munities now inhabiting the country were brought that provided material and psychosocial support together during the colonial period following the to bereaved families.22 Community participation declaration of a over Uganda evolved around self-help projects, which enhanced in 1894.28 Political dispensations unified traditional communities’ economic and social welfare through kingdoms that had enjoyed sovereign powers until a scheme called bulungi bwansi (“for the good of then. New lawmaking processes were developed in the community”).23 Community participation was Britain and enforced first in Buganda and quickly therefore interwoven into the fabric of precolonial expanded to other kingdoms. The period saw many Ugandan society. It also included some features of developments that would later shape the discussion deliberative democracy and the right to health. on community participation in health governance The practice of traditional medicine was the amid British rule and the continued influence of only health system that existed in Uganda during the kingdoms. the precolonial period.24 Traditional medicine prac- The colonial administration imposed its own titioners included herbalists, bonesetters, psychic system of administration through indirect rule, healers, birth attendants, faith healers, diviners, whereby the British administered the protectorate and spiritualists who used Indigenous knowledge through local chiefs and kings, who surrendered sov- to develop materials and procedures.25 Despite the ereignty in return for British protection. Because the colonial government’s suppression of traditional colonialists obliged certain communities to merge, medicine practitioners, traditional medicine sur- the uniformity of former autonomous chiefdoms vived colonization and continues to play a role in was lost along with traditional practices of commu- Uganda’s present-day health system. The question nity participation.29 The traditional discursive spaces of regulating these practices remains a major health were dismantled as the British enforced their rules governance issue for Uganda’s health system. Com- and introduced forced labor and exploitative tax munities have continued to demonstrate trust in systems. traditional healers, despite the documented public During this period, Britain signed a number health hazards that they have caused. of agreements with both Buganda as a kingdom The key lesson from this period is that in the and later Uganda as a protectorate that spelled out quest for a normative community participation governance issues between the colonizers and the structure that decolonizes health governance, In- colony.30 Through these agreements, Britain shaped digenous ideas and innovation should be taken into the structure of government, including provisional account. This is especially important when trying administrative decisions and the administration of to understand the public sphere and how culture, justice and maintenance of order.31 However, the attributes, beliefs, and norms can inform the nor- structures introduced were devoid of key elements mative structure of community participation.26 In of deliberative democracy, such as a public sphere. applying the human rights framework, validating Local communities were excluded from formal and empowering these Indigenous spaces is im- decision-making, which was now the exclusive portant for advancing the right to participation as competence of the colonial rulers. At the signing

JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal 263 m. mulumba, a. l. ruano, k. perehudoff, and g. ooms / general papers, 259-271 of the 1900 , for instance, the Article 15(1) of the 1902 Orders in Council Buganda signatories were allowed only to append established the judicial system, including the signatures, and there is no evidence of them being High Court, which was to have full civil and included in the development of the agreement it- criminal jurisdiction over all persons and matters self.32 Therefore, the Buganda Agreement was not a in Uganda. The court system is critical for health legitimate instrument when seen through the lens governance given the important role of litigation in of deliberative democracy. health issues, as witnessed in present-day Uganda. The agreement then became part of Uganda’s The relevance of courts in health governance is modern legal system. Interestingly, it also intro- visible in the important court decisions and pro- duced the concept of public interest, which was not nouncements in relation to accessing health care. discussed but mentions cursorily that government The Constitutional Court, for instance, has ruled was to be the custodian of resources on behalf of the that the government’s failure to provide adequate people. Today, the families and communities affil- maternal health services violates human rights iated with those who benefited from the Buganda protected in international treaties and the Ugan- Agreement continue to dominate land ownership. dan Constitution, including the right to health, the Given the centrality of land as a resource, a large right to life, the rights of women, and the prohi- amount of decision-making power is now concen- bition of inhuman and degrading treatment.37 The trated among a few families, and critical processes courts have also declared the criminal legislation such as the allocation of land for health facilities concerning mental health as violating rights and and leadership in community participation struc- have called for provisions that better enhance the tures are still separated from the people who would rights of persons with disabilities.38 The colonial benefit the most from them.33 These families act procedural challenges in the usage of courts to ad- as power centers and exert control in many gov- vance health have seen some of these cases take as ernance processes, including those related to the long as nine years to be decided. health system. Although the 1902 Orders in Council put in The next significant step that the British gov- place the basic elements and structures of gov- ernment took to solidify its rule in the Protectorate ernment, they did not further democracy in the of Uganda after the Buganda Agreement was the protectorate. Uganda remained under direct control establishment of the 1902 Orders in Council.34 The of the British, and there was no Indigenous repre- Orders in Council dealt with matters of constitu- sentation within the government. The concept of tional significance and were the benchmark against democracy calls for the representation of people in which many laws in colonial and postcolonial government, and their exclusion signals an absence Uganda were built, as they provided the first legal of it. The subjugation of community participation instrument for establishing a legal framework of and the direct importation of British laws denied government for the entire protectorate.35 Their Ugandans the opportunity to participate in key major limitation was that they brought in UK decisions that affected them. As Kwanele Asante legal frameworks without any adaptation to the has argued, a non-rights-based approach absolves local context. This was in complete disregard of the state parties of their duty to ensure that patients importance of community participation in legal de- (communities) are substantively involved in the cision-making for a country. Lord Denning, in the development of key health policies.39 We agree with case of Nyali Ltd. v. Attorney General, challenged Asante that diluted community inclusion not only this practice when he used an analogy of an oak absolves states of their human rights duties with re- tree and concluded that one cannot transplant an spect to the right to health and right to participate, oak tree from English soil and plant it on Kenyan but also renders communities unable to hold policy soil and expect it to flourish well like it did before.36 makers and governments accountable for inade-

264 JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal m. mulumba, a. l. ruano, k. perehudoff, and g. ooms / general papers, 259-271 quately discharging their right to health duties. that affected mostly Europeans doing the postco- The control of sleeping sickness—the focal lonial work and Indians who had been brought in medical policy between 1900–1908—is an example to develop the infrastructure. Controlling venereal of the implications of the aforementioned colonial disease was a core medical policy of the colonial governance structures for health. Sleeping sick- government from 1908 until the 1920s.41 The Mulago ness is caused by the tsetse fly, commonly found health center was later developed into a general na- in tropical climates, including the region around tional referral hospital for venereal diseases. More in Uganda. Kirk Arden Hoppe re- hospitals and dispensaries were established in counts how from 1906 onward local ordinances provincial and district headquarters throughout devoid of community participation were imposed Uganda. These institutions were planned from the by British rulers under the guise of disease control. central level and without any community partici- For example, the Township Ordinance of pation. Moreover, the epidemic of venereal disease 1906 permitted the inspection and punishment of was an opportunity for the colonial government to Ugandan canoe owners and crew who were found exert social control and to impose notions about to have a tsetse fly on board. Punishment was in sexuality and Christian values brought by mission- the form of a fine or one month’s imprisonment. aries.42 These ideas, differing from local conceptions The 1907 Uganda Fishing Ordinance made it illegal of venereal disease, were later enshrined in the Ve- to fish on Lake Victoria and to possess or sell lake nereal Diseases Act of 1977.43 One example of how fish, which was an important source of nutrition the Venereal Disease Act violates the right to health and income for local Ugandans. In 1908 and 1909, is the requirement that a person with a sexually health regulations were issued to consolidate and transmitted disease identify the person who infect- later evict 33 island communities in Lake Victoria ed him or her. Such forced disclosure tears at the to the mainland. Although framed as a disease social fabric of a community. control initiative, these regulations were a covert However, it was also during the colonial method of strategically depopulating people from period that Uganda first witnessed a form of decen- an area (the Lake Victoria region) rich in hunting, tralization, when the British secretary for colonial fishing, and charcoal.40 administration made it colonial policy to promote These laws and regulations further mar- the creation of local governments. This decentral- ginalized Ugandans by depriving them of ization influenced Uganda’s health system through interdependent civil, economic, and social rights, the introduction of health subdistricts. including autonomy and the social determinants The colonial control systems equated the of health. Ugandans affected by these rules had no practice of traditional medicine with witchcraft. avenue for recourse to hold colonial decision-mak- As a result, the colonial government introduced the ers accountable, which is an essential component of Witchcraft Act in 1957, which had provisions for the right to health. However, by the time of inde- the prevention of witchcraft and punishments for pendence, Uganda had begun to witness some form persons practicing witchcraft. In this way, the law of democracy that would see citizens participate in attempted to strip Ugandans of the informal health decision-making on issues affecting them. system offered by traditional medicine. In 1997, the Supreme Court of Uganda, in the case of Salvatori Health governance in the colonial period Abuki and Richard Abuga v. Attorney General, held The colonial period saw the introduction of the section 7 of this legislation unconstitutional for formal health system through the establishment of permitting the banishment of persons convicted mission hospitals. By 1909, three health centers in of practicing witchcraft from their homes.44 This Mulago, Mengo, and Masaka were established for judgment is a good example of some of the efforts to the treatment of venereal diseases, a new epidemic decolonize legislation introduced during colonial

JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal 265 m. mulumba, a. l. ruano, k. perehudoff, and g. ooms / general papers, 259-271 times. The judgment emphasized the importance Postcolonial Uganda and community of measuring the colonial laws against Uganda’s participation constitutional values. Uganda gained independence on October 9, 1962, Much of the health-related legislation that with signs of constitutionalism.51 A constitution remains on the books today was imposed through had been worked out as a result of negotiation the doctrine of legal reception, in which the British among the major political actors.52 Direct univer- legal culture was transferred to Uganda. Laws such sal suffrage was put in place except for Buganda, as the Public Health Act (1935), the Mental Treat- where representatives to Parliament were indirectly ment Act (1938), the Venereal Diseases Act (1977), elected through the Council of Buganda. On the the Penal Code Act (1950), and many others still first anniversary of independence, the Constitution affect health governance in Uganda. Starting in the was amended by Parliament to provide for a cere- 1930s, the colonial government shifted its medical monial president to replace the governor-general.53 focus to public health policy.45 During this time, Overall, postcolonial Uganda had a mix of strug- many laws relating to public health were adopted gles to establish democratic structures and an early and have not been comprehensively reviewed since. turbulent time with civil wars and coups that saw Changing socioeconomic conditions call for legal the obliteration of the earlier democratic structures frameworks to be updated, and often strength- that would have facilitated community participa- ened.46 Some of these laws have been criticized for tion in the health system. The post-colonial Uganda being restrictive in the area of reproductive rights, descended into dictatorial regimes in the tenures of such as with regard to sexual orientation and access , , , and Godfrey to safe and legal abortion.47 In such cases, as part of Binaisa, a period that did not feature community decolonization, it is important to open a participa- participation in decision-making for the country. tory dialogue around legal review to address gaps In 1971, for instance, President Idi Amin Dada con- tradicted most of the constitutional provisions of between policy, law, and practice. 1962 and 1966. He denied Ugandan citizens democ- It is also important to note that while colonial racy and ruled by decree. laws have stayed on the books, a number of areas Developments in the health system included that these laws targeted—such as harmful practices the creation of the Ministry of Health, which had by traditional healers—continue today. For exam- been formed just before independence to replace ple, the recent wave of ritual , including the colonial medical department responsible for child sacrifice, have prompted Ugandan parlia- medical services.54 In addition, missionary health mentarians to call for a law regulating the activities organizations provided health services in rural and 48 and practices of traditional healers and herbalists. urban areas through cost sharing.55 The most im- Abortion practices criminalized in the colonial portant factors affecting the provision of socialized Penal Code Act continue to contribute 1,200 deaths health services were the prevailing economic and 49 out of the total 6,500 maternal deaths each year. political conditions in the country. There are also shared positive experiences and pref- The government and its Ministry of Health erences by the population to use traditional healers had an ambitious program to build 22 100-bed because of their easy access, the ability to pay in hospitals, which was feasible due to the country’s installments or in kind for services rendered, and economic prosperity between 1962 and 1971, during the kindness of traditional birth attendants.50 These the first tenure of President Obote.56 The country are important indications of the need to ensure had four recognized health care service types and community participation in the development of levels: (1) primary health care, consisting of centers new regulatory frameworks that could address the and clinics; (2) secondary health care, consisting of country’s current health governance needs. district hospitals; (3) tertiary health care, consist-

266 JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal m. mulumba, a. l. ruano, k. perehudoff, and g. ooms / general papers, 259-271 ing of general referral hospitals; and (4) quaternary During this postcolonial period, a number health care, consisting of two national referral of colonial laws have been successfully challenged hospitals.57 There were regional referral hospitals before Ugandan courts as unconstitutional and in throughout the country. The role of health in Ugan- violation of human rights standards. For instance, da’s development was one of high priority. The section 130 of the Penal Code Act has been held country’s planning strategies had health services unconstitutional insofar as it refers to persons with and education as one of three important develop- mental disabilities as idiots and imbeciles.61 In this ment goals.58 case, the petitioners successfully argued that the Uganda’s health system was going through Penal Code subjected persons with mental disabili- some important reforms, but there is no evidence ties to inhuman and degrading treatment, contrary of community participation in the making of the to articles 24 and 35 of Uganda’s Constitution. policies or the implementation of health reforms during this period. The challenges that resulted Discussion from this nonparticipation were the adoption of reforms based on technical considerations without This paper has demonstrated that understanding a the integration of community perspectives. As a country’s historical context is key for decolonizing result, some of the health governance structures its health governance. Through the Ugandan case (such as health unit management committees) do study, we have identified key events that are central not respond to community needs, and communi- in defining a basis for decolonizing governance ties do not view them as “theirs.” This approach in health systems. The colonial legacy in Uganda advances a colonial legacy of focusing on commu- imposed values and systems that undermined nities as passive beneficiaries. self-determination and sovereignty, which eroded The political and economic turmoil of the even the most cherished precolonial systems that 1970s and 1980s also severely curtailed community would provide a base for community participation engagement in the health systems. Social services, as part of health governance. including health, broke down.59 The working envi- While there was no defined formal space for ronment in the health sector became hostile, and participation in the delivery of health services in many physicians migrated to other countries for precolonial Uganda, the few existing informal security and economic reasons. Medicines, equip- spaces for community participation demonstrate ment, and hospital facilities were in limited supply, the importance of community participation in de- and the quality of health care fell drastically. At the cision-making on issues that affect them. However, same time, an unregulated private sector mush- during colonial times, there was clear subjugation of roomed rapidly to fill the services gap created by community participation in Uganda’s governance, the poorly functioning government facilities that which left a legacy that problematized precolonial dominated the colonial health system architecture. arrangements; failed to appreciate and uphold This situation dashed any hopes of building a health the strength of Indigenous systems; created a system grounded in community participation. conflicting situation within Ugandan society; and After independence in 1962, efforts to diminished public trust in health governance. strengthen national and cultural identities began There are still some practices of community joint to reemerge. For instance, it is now clear that the work through bulungi bwansi that are still visible government is interested in providing support to even in other postcolonial countries such as Rwan- the practice of traditional medicine. The repeal of da, which takes the form of Umuganda.62 the 1968 Medical and Dental Practitioners Act in The precolonial systems that brought com- 1996 created a situation in which traditional practi- munities together were particularly important for tioners are tolerated as long as they do not claim to vulnerable groups such as women, who had spaces be registered medical practitioners.60 for addressing their social issues, including health.

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The introduction of laws such as the Buganda Law Reform Commission should create public Agreement took away key land resources from spheres as spaces for discussing the areas of weak- the communities, severing their means of welfare ness in these laws. The parliamentary lawmaking and access to the social determinants of health. process should equally have opportunities for peo- This agreement also made them subject to royal ple to speak and deliver opinions on aspects that rule, eroding their autonomy, community systems the laws should address. The outcome should be of health governance, and voice in health deci- laws that meet the test of legitimacy as guided by sion-making. This marginalized many Ugandans, Habermas’s views of deliberative democracy. made them vulnerable to ill-health, and imposed The current model of delivery of health ser- barriers to forming, contributing to, and accessing vices is still built largely on the colonial model. health care. These challenges continue to exist Missionary hospitals dominate the provision of among landless communities. health care, delivering care aligned with religious The direct importation of British laws and values, which permeate training schools orga- the continued influence of Britain in Uganda’s nized by religious groups that were introduced by governance denied Ugandans the opportunity to colonizers. participate in key decisions that affected their health. The colonial period also introduced mis- Laws were devoid of the legitimacy envisioned by sionary NGOs that deliver health care through a Habermas, and the previous spaces of community cost-sharing mechanism that has persisted as part participation in precolonial Uganda were eroded. of Uganda’s health system. These NGOs remain a The imposition of a judicial system through the major force in promoting religious-values-based Orders in Council not only undermined the Indig- health care delivery and have in many cases openly enous justice system but also introduced a judicial opposed the implementation of progressive sexual system that still adjudicates on right to health cases and reproductive health and rights policies. Such with procedural complexities. The current legal efforts have impeded the implementation of a technicalities that undermine the enforcement of human rights-based approach as part of Uganda’s the right to health and limit judicial interpretation health governance. Part of the decolonization pro- of justice issues in the health system at the national cess would require that Uganda, as a postcolonial level can be traced from the colonial legacy. country, revisit its NGO policies and ensure a regu- A number of colonial laws are still being ap- latory framework that insulates NGO mission work plied, and while some laws have been amended, from a biased model of delivery of health services a number of them have not been subjected to the based solely on religious values. This process could discursive test as advanced by Habermas. The most include a deliberate effort to build, support, and contested aspects of sexual and reproductive health include the work of Indigenous NGOs that advance and rights—such as access to safe and legal abor- a science- and rights-based approach to health ser- tion, sexual orientation, comprehensive sexuality vices delivery and advocacy as part of government education, access to family planning, and control programming. Such Indigenous NGOs can provide of venereal diseases—are still regulated through a forum for community participation in the de- colonial legislation such as the Penal Code Act of livery of health services and in decision-making 1950 and the Public Health Act of 1935. These laws around priorities for the health system. perpetuate colonial attempts at social control and The current structure of Ugandan health the degradation of Indigenous community fabrics. facilities is still rooted in the architecture of the co- The decolonization process requires that lonial masters, and the upgrading of hospitals and Uganda undertake a legal audit of all its laws and other health facilities has been slow. The division policies to assess them through the lens of human between the delivery of physical health and the de- rights and current scientific evidence. The Uganda livery of mental health introduced during colonial

268 JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal m. mulumba, a. l. ruano, k. perehudoff, and g. ooms / general papers, 259-271 times continues to be the model today. This sepa- Conclusion ration has led to mental health being undermined and overlooked in mainstream programming. The In conclusion, for the decolonization of health governance in postcolonial countries, a conceptu- decolonization process requires that the design al framework combining deliberative democracy and capacities of national referral hospitals, re- and the right to health is needed. Decolonization gional referral hospitals, and other health facilities calls for arrangements that strive for community be upgraded from the colonial estimations that participation, Indigenous ideas, and national sov- were based on Uganda’s population and public ereignty. This process should also take into account health needs then. In undertaking this process, Habermas’s concept of deliberative democracy, the government should end the practice of making which emphasizes the importance of focusing on plans and decisions in technical offices without the tenets of power of speech, legitimacy, and the engaging local communities. The design of such public sphere. health facilities should be infused with ideas of the As part of the conceptual framework context-specific needs of the communities where grounded in the right to health and deliberative such health facilities are being proposed. This will democracy, decolonizing community participation in many ways help ensure that health facilities are must be premised on the recognition of each per- designed for and embraced by the communities son as a valid speaking partner with a unique and they serve. valuable knowledge to contribute. Thus, respect for The colonial training models for health pro- the inherent dignity of persons and self-determi- fessionals have continued to guide medical training nation must inform all participatory processes and in Uganda. Colonial high schools and post-high strategies, and each person’s expertise, experience, school institutions continue to dominate Ugan- and input must be valued. Local ownership and da’s education system. In many of these schools, community context should inform decision-mak- future health professionals receive training based ing in the health sector. This calls for efforts to on religious values that were imposed by colonial examine the history and diversity of the commu- governments. The danger of such an approach has nity as important elements for shaping effective been the churning out of health professionals and and efficient community participation as part of policy makers who base their decisions on religious the right to health. Respecting local knowledge, the values as opposed to science and human rights. The ability of communities, and their potential is key decolonization process requires that the education for decolonizing health systems that are participa- system be scrutinized through a comprehensive tory. Overall, participation should go beyond mere stakeholder consultation process to ensure the consultation and should build community capacity maximum participation of all those affected. Im- and foster public mobilization and awareness. pacts of the colonial legacy should be expunged This paper has illustrated how Uganda’s his- and replaced with the present needs. The various tory and political context has shaped the nation’s training curricula should be revised and upgrad- current system of health governance. We have ed to address current training needs that result in argued that when decolonizing a postcolonial professionals who base their decisions on evidence- country’s health governance, its health system can- and rights-based approaches. Training of trainers’ not be divorced from its political setup. It is thus modules and workshops should be undertaken to important that the political history is mapped to examine the best postcolonial methodologies for identify opportunities for operationalizing decolo- training health professionals. Such methodologies nization in health governance. should be grounded in contextual needs to ensure This paper has also demonstrated that a com- relevancy. bination of deliberative democracy and right to

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