Applying Human Rights to Advocacy Campaigns for Access to Essential Medicines in Uganda Lessons from AGHA Sandra Kiapi Executive Director, Action Group for Health, Human Rights and HIV/AIDS (AGHA) Uganda

Outline What is the Right to Health Rights Based Approach Uganda human rights and other obligations/medicines Key Elements of the Right to Health Standards of the Right to Health 2. Health Financing in Uganda: Facts and Figures

What is the Right to Health

Rights Based Approach

Uganda human rights and other obligations/medicines

Key Elements of the Right to Health

Standards of the Right to Health

2. Health Financing in Uganda: Facts and Figures

1. Right to Health The Right to Health is a right to an effective and integrated health system encompassing health care and other determinants of health It is not: The Right to be Healthy It is not a limitless right to receive medical care for every illness/disability It is a right to enjoy a variety of facilities and conditions necessary for good health which include: Those necessary for health care Those relating to general conditions affecting health ie safe water, food, sanitation,

The Right to Health is a right to an effective and integrated health system encompassing health care and other determinants of health

It is not:

The Right to be Healthy

It is not a limitless right to receive medical care for every illness/disability

It is a right to enjoy a variety of facilities and conditions necessary for good health which include:

Those necessary for health care

Those relating to general conditions affecting health ie safe water, food, sanitation,

Rights Based Approach Human Rights are concern with the disadvantaged Resources given to those with the greatest need ie are resources going to those who least need them? What is the state doing for those rural and poor populations?

Human Rights are concern with the disadvantaged

Resources given to those with the greatest need ie

are resources going to those who least need them?

What is the state doing for those rural and poor populations?

Uganda’s Human Rights treaty & other Obligations in relation to access to medicines The Right to Health is enshrined in article 12 of the ICECSRs to which Uganda is a Party: provision of medicines is a core obligation Under General Comment 14-Obligation to provide Available, Accessible, Acceptable and Good Quality (AAAQ) Health Services ACHPRs- art.16 obliges states parties to take measures to protect the health of their people 1995 Constitution-state shall take practical measures to ensure provision of medical services to the population Alma Ata 1978, PHC Includes Provision of Essential Drugs Ouagadougou Declaration on PHC and Health Systems Strengthening Calls upon the Governments to set up sustainable mechanisms for increasingly available, affordability, and accessibility for essential medicines and other health supplies

The Right to Health is enshrined in article 12 of the ICECSRs to which Uganda is a Party: provision of medicines is a core obligation

Under General Comment 14-Obligation to provide Available, Accessible, Acceptable and Good Quality (AAAQ) Health Services

ACHPRs- art.16 obliges states parties to take measures to protect the health of their people

1995 Constitution-state shall take practical measures to ensure provision of medical services to the population

Alma Ata 1978, PHC Includes Provision of Essential Drugs

Ouagadougou Declaration on PHC and Health Systems Strengthening Calls upon the Governments to set up sustainable mechanisms for increasingly available, affordability, and accessibility for essential medicines and other health supplies

Key elements of the Right to Health Accountability: countries that sign treaties affirm the right to health and a state agrees to be accountable to the international community & citizens for the fulfillment of its obligations Participation: the right to participate in decision-making is a guiding principle: people must participate in the design and delivery of health services. Particularly the involvement of communities has been shown to increase likelihood that needs of communities will be met more effectively

Accountability: countries that sign treaties affirm the right to health and a state agrees to be accountable to the international community & citizens for the fulfillment of its obligations

Participation: the right to participate in decision-making is a guiding principle: people must participate in the design and delivery of health services.

Particularly the involvement of communities has been shown to increase likelihood that needs of communities will be met more effectively

Standards of the Right to Health: AAAQ Availability: public health and care services should be in sufficient quantities taking into account a country’s developmental and economic need; Accessibility has 4 dimensions: Non discrimination: health facilities, goods and services must be accessible to all especially the most vulnerable Physical accessibility: services must be within physical reach

Availability: public health and care services should be in sufficient quantities taking into account a country’s developmental and economic need;

Accessibility has 4 dimensions:

Non discrimination: health facilities, goods and services must be accessible to all especially the most vulnerable

Physical accessibility: services must be within physical reach

Standards cont’d (c) Economic accessibility: affordability (d)Information access: right to seek, receive and impart information concerning health issues Acceptability: health services are ethically and culturally appropriate ie respectful of individuals, minorities, peoples, and communities Quality: requires that health services must be scientifically and medically appropriate and of the highest quality

(c) Economic accessibility: affordability

(d)Information access: right to seek, receive and impart information concerning health issues

Acceptability: health services are ethically and culturally appropriate ie respectful of individuals, minorities, peoples, and communities

Quality: requires that health services must be scientifically and medically appropriate and of the highest quality

Financing the Health Sector in Uganda: the figures Population is 28 Million (last census), growing at 3.4% p.a= currently 31,000,000 31% of population live below poverty line (UBS, 2008) -9.3-10,000,000 million cannot fend for themselves at all Uganda spends 9.6% of its national budget on health-(trend down from two years ago at 11% next financial year, figures might be lower) (2009/10 state house 91 B, Mulago Hospital gets 41.87 B, Budget for military remains constant or Increases, yet Health fluctuates)

Population is 28 Million (last census), growing at 3.4% p.a= currently 31,000,000

31% of population live below poverty line (UBS, 2008) -9.3-10,000,000 million cannot fend for themselves at all

Uganda spends 9.6% of its national budget on health-(trend down from two years ago at 11% next financial year, figures might be lower) (2009/10 state house 91 B, Mulago Hospital gets 41.87 B, Budget for military remains constant or Increases, yet Health fluctuates)

Health financing cont’d Uganda spends US $ 7.84 per capita on health, yet to meet the UNMHCP, at least US$ 28, and 40 are needed when ARVs are included Health Sector needs US $ 6.5-8 per capita to cover EMHS In 2006/2007, only US $ 0.72 was availed by GOU: donors topped up to US $ 4.06 On a positive note: 2008/2009 60 billion allocated to procurement of ARVs and Arteminsin Based Combinations In the past few months, there is a shortage of medicines for Malaria and Tuberculosis which has been going on since October last year

Uganda spends US $ 7.84 per capita on health, yet to meet the UNMHCP, at least US$ 28, and 40 are needed when ARVs are included

Health Sector needs US $ 6.5-8 per capita to cover EMHS

In 2006/2007, only US $ 0.72 was availed by GOU: donors topped up to US $ 4.06

On a positive note: 2008/2009 60 billion allocated to procurement of ARVs and Arteminsin Based Combinations

In the past few months, there is a shortage of medicines for Malaria and Tuberculosis which has been going on since October last year

Case Study: A Promise Unmet: Access to Medicines in Rural Uganda General objective: To track the availability of essential medicine in rural districts health facilities: Do the most disadvantaged have access to medicines? Specific objectives 1) To assess the trends of drug availability in health facilities in the new districts 2) To explore the challenges faced by health workers in getting drugs at the health facility level

General objective:

To track the availability of essential medicine in rural districts health facilities: Do the most disadvantaged have access to medicines?

Results: Trends of drug stock-outs Key Finding: There were frequent stock-outs of essential malaria and antibiotic drugs at all health centres. For example: CoArtem, the Ministry of Health mandated first line treatment for malaria, was often unavailable in health clinics in all three districts. For the first month of the study, 60-80% of clinics in Ibanda had no access to the 4 major antibiotics traced by this study

Key Finding: There were frequent stock-outs of essential malaria and antibiotic drugs at all health centres.

For example:

CoArtem, the Ministry of Health mandated first line treatment for malaria, was often unavailable in health clinics in all three districts.

For the first month of the study, 60-80% of clinics in Ibanda had no access to the 4 major antibiotics traced by this study

From Research to Policy Launch event targeting Members of Parliament, Ministry of Health officials, and health professionals Presented findings & policy recommendations Address Budget Gaps Reform drug purchasing and distribution Improve monitoring and evaluation Address HRH issues Build better communication systems Follow-up meetings in districts with policy makers

Launch event targeting Members of Parliament, Ministry of Health officials, and health professionals

Presented findings & policy recommendations

Address Budget Gaps

Reform drug purchasing and distribution

Improve monitoring and evaluation

Address HRH issues

Build better communication systems

Follow-up meetings in districts with policy makers

Stop-Stock-Out campaign The Civil Society Organisations want the government to: Ensure availability of essential medicines at all public health institutions. Ensure that there is sufficient funding for the medicines within minimum healthcare package. Give representation of civil society on the board of the National Medical Stores. Enhance transparency in medicines supply management. Provide a dedicated budget line for essential medicines. Live up to their commitments to spend 15% of national budgets on health care.

The Civil Society Organisations want the government to:

Ensure availability of essential medicines at all public health institutions.

Ensure that there is sufficient funding for the medicines within minimum healthcare package.

Give representation of civil society on the board of the National Medical Stores.

Enhance transparency in medicines supply management.

Provide a dedicated budget line for essential medicines.

Live up to their commitments to spend 15% of national budgets on health care.

Results of this campaign The Media reported extensively on the current drug shortage especially the TB medications (PHR website: http://phrblog.org/blog/2009/03/24/uganda-faces-tb-drug-shortage-on-world-tb-day/ > Pressure on the Government and Ministry of Health (MOH) came out openly to announce that there was a drug shortage WHO has procured some TB Medications GFTAM signed agreement with GOU to fulfill their undelivered commitment under previous grants LPO for malaria Drugs from Quality Chemicals a Local Pharmaceutical Company

The Media reported extensively on the current drug shortage especially the TB medications (PHR website: http://phrblog.org/blog/2009/03/24/uganda-faces-tb-drug-shortage-on-world-tb-day/ >

Pressure on the Government and Ministry of Health (MOH) came out openly to announce that there was a drug shortage

WHO has procured some TB Medications

GFTAM signed agreement with GOU to fulfill their undelivered commitment under previous grants

LPO for malaria Drugs from Quality Chemicals a Local Pharmaceutical Company

“ Under-funding of the health sector is tantamount to deliberately giving an under-dose of medication to a patient and hoping that he will still get better. Government needs to commit to the 15 percent to help alleviate these issues.” – Honorable Dr. Francis Epetait, Member of Parliament Keeping the Promise

“ Under-funding of the health sector is tantamount to deliberately giving an under-dose of medication to a patient and hoping that he will still get better. Government needs to commit to the 15 percent to help alleviate these issues.”

– Honorable Dr. Francis Epetait,

Member of Parliament