Center for Health, Human Rights and Development (CEHURD), Prof. Ben Twinomugisha, Rhoda Kukiriza, Inziku Valente v. Attorney General - Constitutional Petition No. 16 (Maternal Health Care)

This case holds the Ugandan government accountable for persistently high rates of maternal mortality as a violation of the right to health, life, and the rights of women under the Ugandan Constitution.

Date of the Ruling: 
Aug 19 2020
Constitutional Court
Type of Forum: 

Petitioners challenged the Ugandan Government’s failure to provide basic maternal health services in violation of (1) the right to health, (2) the right to life, and (3) the right of women, under the Constitution.

The cases concerned the preventable deaths of two women, Ms. Nalubowa and Ms. Anguko. When Ms. Nalubowa arrived at the hospital for maternal care, nurses asked her mother-in-law for money and supplies, but the family did not have the amount requested. When Ms. Nalubowa began bleeding, a doctor never arrived to attend her. Ms. Anguko went into Labor at 11am and started bleeding at 2pm. Nurses instructed family members to stop the bleeding with old pieces of cloth. She was left unattended, and a doctor was not called until 7:30pm. Both women died.

First, the Court found that the state’s failure to attend to a patient due to the absence of a doctor and the Government’s failure to provide a clean and healthy environment violated the constitutional right to health (Articles 8A, 39, 45, and objectives XIV and XX of the constitution). While the Court acknowledged that the provision of services is often dependent on available resources, it held this does not excuse the failure to provide basic lifesaving services that are free of cost. In addition, the Court found that it is the Government’s responsibility to harness the resources needed to meet constitutional demands. Unimplemented policies and strategies, it reasoned, are not steps towards the realization of the right to health. According to the Court, the Government’s attempt to address omissions in basic maternal health services had been largely performative and had not led to any meaningful reductions in the leading causes of maternal death.

Second, the Court found that the Government’s failure to adequately provide basic maternal health care services in public health care facilities—as highlighted by the high mortality rate due to pre- and post-partum complications—violated the right to life (Article 22 of the Uganda Constitution). Persuaded by the holding of Justice Mumbi Ngugi of the High Court of Kenya in P.A.O. v. Attorney General, High court of Kenya Petition No. 409 of 2009(2012) eKLR, the Court concluded that “[t]here can be no argument that without the right to health, the right to life is in jeopardy.” The Government’s failure to implement well-known, affordable, and effective approaches used to reduce preventable maternal death rendered it liable for the deaths of Ms. Anguko and Ms. Nalubowa.

Third, the Court ruled that the Government’s omission to adequately provide basic maternal health care services in public health care facilities violated the rights of women (Articles 33(1), (2), and (3) of the Constitution). The Court found that (1) high out of pocket expenditures, (2) the lack of mama kits,[1] (3) the high levels of mothers dying during labor due to a lack of basic maternal health commodities, (4) the lack of staff with expertise and staff shortages, as well as (5) the Government’s inaction in implementing a roadmap to accelerate the decrease of maternal mortality (per World Health Organization guidance), violated the rights of women under the constitution. The Government was liable for the inadequate maternal services caused by scarce drugs, negligent professional care, and ill-equipped facilities.

Fourth, the Government’s omission to adequately provide emergency obstetric care in public health care facilities violated the right to health, life, and rights of women under articles 8A, 22, 33(1), (2) and (3), 45, 283 (read with objectives XIV and XX) of the constitution. The deaths of Ms. Anguko and Ms. Nalubowa were a result of the unavailability of basic maternal health services and negligent care, which the Court found to be cruel, inhuman or degrading treatment and a violation of human dignity under Article 24 of the Constitution.

Uganda’s rate of emergency obstetric care (EMOC) data suggest that over 40% of women giving birth in Uganda have need for EMOC, though only 11.7% of them give birth in facilities that offer such services.

[1] Mama’s kits are the basic supplies needed for clean and safe delivery.

Enforcement of the Decision and Outcomes: 

The Court awarded both compensatory and punitive/exemplary damages to the petitioners. The Court also ordered the implementation and enforcement of the following policies:

  1. Budget: In the next financial year, the Government should prioritize and allocate sufficient funds in the national budget towards maternal health care.
  2. Training: Through the Ministry of Health, the Government must ensure that all staff providing maternal health care services in Uganda is fully trained, and that all health centers are equipped within the next two financial years (2020-2022).
  3. Audit: Through the Ministry of Health, the Government must compile and submit to Parliament (with copy to this Court) a full audit report on the status of maternal health in Uganda at the culmination of each of the next two financial years.
  4. Progress Report: At the end of the first financial year (2020-2021), the Attorney General must submit a report detailing the progress and implementation of the above orders.
Significance of the Case: 

The judgment recognizes the right to health and access to basic maternal health care despite the same not being expressly recognized under the 1995 Constitution of the Republic of Uganda. With this decision, the Court acknowledged that access to proper maternal health care and emergency obstetric care is fundamental to ensuring women’s constitutional rights to health and life.

The decision also extends provision of basic maternal health care to women across all public health facilities, including lowest area units. Previously, only health facilities at the top of the referral chain could provide maternal health services.