The use of the internet to advance sexual and reproductive health in Uganda
IntroductionDespite improving health outcomes, Uganda has high rates of maternal mortality. The overall maternal mortality rate is 360 per 100,000 live births, while the risk of a mother dying in a health facility during childbirth is 118 per 100,000 live births.1 Delay in seeking healthcare is partly the cause of this. Only 36.6% of women in 2014/2015 attended the minimum four antenatal care sessions, and only 52.7% delivered in health facilities. 2 The contraceptive prevalence rate is 30%.3
The internet has the potential to complement advocacy on sexual and reproductive health and to strengthen health systems. In 2014, internet penetration in Uganda was at 42.5%. 4 The increasing availability of mobile phones, with a penetration rate of 52% in 2014, has made the internet more accessible. 5 Monthly mobile phone data bundles cost between USD 4 to USD 8 for 500 MB to 1 GB. 6
Despite the increasing availability of the internet, it is only recently that its potential to galvanise citizens and to complement the advocacy that happens on the ground is being recognised. This report discusses the use of the internet in Uganda to advance sexual and reproductive rights.
will to achieve the right to health in Uganda
Uganda is a signatory to international instruments affirming the right to the highest attainable standard of physical and mental health.7 The right to health, like all economic, social and cultural rights (ESCRs), must be progressively realised, requiring the government to take steps to respect, protect and fulfil it including “appropriate legislative, administrative, budgetary and other measures.”8 It must also allocate the maximum of available resources and meet certain minimum obligations, including providing essential medicines, ensuring the right to reproductive, maternal and child healthcare, and addressing preventable mortality.9
There is insufficient political will to achieve the right to health in Uganda, which makes advocacy essential. Uganda’s constitution does not enshrine the right to health in the Bill of Rights, only guaranteeing access to health services in the National Objectives and Directive Principles of State Policy. 10 There is no legislation in place to provide a comprehensive framework for realising the right to health. The government has enacted a National Health Policy and the Health Sector Development Plan to guide the health sector. 11 However, the government is yet to allocate adequate resources for health. During the last five years, the national health budget has hovered between 7% and 9%, below the Abuja Declaration target of 15%. 12
Legislation and policies on access to the internet in Uganda
It is increasingly recognised that access to the internet is essential to realising rights and to development. 13 Recent resolutions have called for accessible, available and affordable internet and internet governance frameworks that are open and respect human rights. 14 Uganda has passed laws to regulate cyber frameworks 15 and has a national IT Policy (2012). 16
ICT interventions undertaken to improve health outcomes
The internet as a tool for advocacy
The internet is increasingly used to monitor and advocate for the right to health. The Initiative for Social and Economic Rights (ISER) 17 recruited volunteers from the community and trained them on the legal and policy framework on the right to health. The organisation also provided them with smartphones and trained them on the effective use of social media. They serve as Community Health Advocates (CHAs), monitoring the realisation of the right to health in their communities. Although based in different districts, using social media platforms, CHAs discuss the challenges their communities are facing in realising the right to health, and share results from their monitoring with each other, ISER and their communities. Their use of social media raises awareness about the gaps in healthcare systems, and provides ISER with real-time updates from the communities. ISER follows up on these issues during its engagement with the local government and Ministry of Health. ISER is planning to work with the CHAs to submit complaints to quasi judicial bodies like the Uganda Human Rights Commission 18 and to identify cases for strategic litigation.
The use of social media by these CHAs is salient because although participation is a right enshrined in the constitution, Ugandans, especially those in rural communities, rarely challenge the status quo to demand government accountability. Barazas 19 – initiatives by the Office of the Prime Minister designed to stimulate accountability by enabling communities to voice their complaints – often occur infrequently. Since they are general for every rights violation, they are insufficient platforms to enable the community to voice their concerns about the quality of healthcare.
Social media and advocacy on the internet are also used to build momentum for strategic litigation. When filing a case on maternal mortality, the Center for Health, Human Rights and Development 20 extensively used the internet and social media to draw attention to violations in health facilities. Although there is still no victory in the legal sense,21 this campaign highlighted the deplorable conditions in health facilities that result in preventable maternal deaths and made the government pay increasing attention to maternal mortality. There has been a 40% reduction in maternal mortality between 2011 and 2014 in part due to improvements in health facilities. 22 Similarly, when filing a petition challenging clauses of the HIV Act 23 that violate human rights,civil society organisations used social media to mobilise a public protest to accompany the filing of the petition and started a discussion on HIV and the need to respect human rights while addressing public health concerns.
Strategic litigation is only successful when it is followed up by mobilisation and advocacy. 24 In both these cases, engaging with social media enabled the organisations to reach people that were not familiar with the cases and the human rights implications raised by them and to broadly disseminate their advocacy message.
The internet as a tool to strengthen health systems
Access to health information
The internet, particularly social media, has become an important platform to disseminate health information. The Facebook page called Mama Tendo25 discusses sexual and reproductive health and disseminates health information in an easy-to-understand manner. A group for mothers to share their stories, it has also become an open platform of over 12,000 members who share information concerning sexual and reproductive health. This is especially critical given the limited health information provided by healthcare providers . The website also enables mothers to share information about malpractice by doctors and health centres, in this way promoting accountability.
The Rwenzori Center for Research and Advocacy 26 project “Converging ICTs for saving mothers giving life” uses information technology to disseminate primary healthcare information and improve maternal health and child mortality outcomes through facilitating better record-keeping processes and enabling communication between the community and health facilities. It enables Village Health Teams with Java-enabled mobile phones to register new patients and confirm follow-up visits for pregnant women. It also has an e‑learning system that provides basic information and education on health through mobile phones, which volunteer Village Health Teams disseminate. 27
The government is also increasingly harnessing technology to disseminate health information. In 2011, a maternal health project was launched in the districts of Kamuli, Luweero and Lyantonde. Pregnant women are registered through the use of mobile phones and reminders are sent to them to attend the required four scheduled antenatal care visits and to encourage them to deliver in health facilities. Community members are also able to provide anonymous feedback on this platform, which enables these districts to follow up issues affecting health service delivery. 28
These interventions are important because the lack of knowledge or what is often termed “health-seeking behaviour issues” – usually related to the woman’s delay to seek help – are the major underlying cause for maternal deaths. 29 The distance and lack of transport from home to health facilities also prevent mothers from reaching the health service point to access health information and services. 30 By bringing the information closer to the community through technology, these interventions result in increased clinic attendance, particularly for pregnant women and mothers with children under five. 31
Digitised health records that result in better record keeping and can result in disaggregated data
The health sector in Uganda often lacks disaggregated data. 32 The use of the internet to digitise health records improves data collection and analysis. The Ministry of Health uses the District Health Information Software (DHIS2) system for data entry and analysis. DHIS2 is a web-based Java application that can be used to collect, validate and present data, and Uganda is the second country in Africa to implement it countrywide. Village Health Teams use mobile phones to report data, which is collated on a central server at the Ministry of Health that provides weekly and monthly reports. 33 This allows timely access to and verification of data. For example, Village Health Teams report death rates of women of reproductive age and infants, enabling the teams to audit this information. Through the DHIS2 mobile, Village Health Teams can receive information on maternal and child health campaigns. 34
As a result of the DHIS2, all systems combine the disaggregated data and report facility aggregate data online, with reporting rates of 85%.35 Access to national data results in more informed management decisions that enable effective responses to disease outbreaks and shortage of medications.36
The internet can be used to provide health information, strengthen data collection, promote accountability, and complement the advocacy happening on the ground. However, Uganda cannot harness the full potential of the internet to advance the right to health unless it addresses the limitations below.
Government has broad power to procure surveillance equipment and regulate internet content. 37 The Data Protection and Privacy Bill (2015) , 38 while a positive step forward for privacy, has broad and vague conditions that allow personal data to be collected, leaving discretion for abuse.
In 2016, the government blocked social media during the presidential elections and during the swearing in of the new president, in response to what it dubbed a “security threat”, based on the fear that social media would be used to mobilise people to protest perceived election irregularities.
Unfortunately, social media shut-downs during the presidential elections reflect broader attempts to censor dissenters. 39 The government has arrested individuals for posting critical comments on social media. 40 In 2015, the Uganda Police Force’s Cyber Crimes Unit publicly acknowledged that cracking down on cybercrimes includes “threats that could destabilize the country” on social media. 41
These routine shut-downs engender self-censorship of critical commentary, including commentary that highlights gaps in the government’s provision of health services.
Lack of availability and ease of access in remote rural areas
Although internet penetration has increased in Uganda, less than 1% of the population had access to fixed broadband in 2014. As mentioned, mobile phone penetration was only 52% in 2014. Only 12% of the population in 2014 accessed the internet via mobile broadband. 42 Moreover, internet speeds still remain very slow, discouraging people from using the internet and limiting the dissemination of health information videos over e‑learning web platforms.
Low literacy levels and the lack of digital literacy
Only 71% of Ugandans over the age of 10 are literate, with only 66% of people in rural areas literate. 43 This limits the ability of communities to engage with the health information they find online, which is also predominantly in English. Moreover, a number of Ugandans, especially the elderly, are not digitally literate, preventing advocates from exploiting the full potential of the internet as a tool in their advocacy. When ISER recruited its CHAs, it trained them on the use of the internet and social media. Some of the CHAs opened an email address for the first time during our training.
High levels of poverty and high cost of smartphones
Despite an overall decline in absolute poverty, 18% of Ugandans are chronically poor, living on less than USD 1.20 per day 44 and 43% of the population is poor or vulnerable to falling back into poverty. 45 In the rural areas, 70.2% of people remain poor or at risk of falling back into poverty, compared to 38.5% in urban areas. This makes the high cost of internet-enabled devices like smartphones – they cost an average of USD 50 – expensive for the majority of Ugandans. 46 A January 2015 survey by the Uganda Communications Commission found that rural and urban users still find internet access expensive. 47 Moreover, th ose living in more remote areas often lack electricity, and this makes it difficult to charge their devices unless they have access to solar energy panels, which are not always readily available. Access to electricity in the rural areas is only 7%. 48
In order to harness the potential of the internet, government, civil society and private providers need to work together in the following ways:
- Use the internet to disseminate health information in an easy-to-understand manner and in Ugandan languages.
Regulate internet service providers, encouraging them to reduce cost and improve network efficiency. Encourage the private sector to deploy telecommunication infrastructure by adopting policies that lower barriers to market entry, and form public-private partnerships to establish critical networks.
Invest in improving digital literacy by launching an “IT for the masses” programme, such as the one proposed in India 49 by the Ministry of Information Technology with the aim of improving digital literacy by 2020. 50 India designed this programme to target individuals between the ages of 14 and 60, to train them on how to use IT and related applications, including using video content for those who cannot read or write. A similar programme in Uganda could ameliorate the challenges faced in accessing the internet as a result of low digital literacy.
Allow for a free and open internet. As noted in the African Declaration on Internet Rights and Freedoms , “unlawful surveillance, monitoring and interception of users’ online communications by state or non-state actors fundamentally undermine the security and trustworthiness of the Internet.” 51
Invest in capacity building to increase digital literacy on internet platforms.
Use social media to teach people about their rights.
Harness the use of the internet in advocacy, with a particular focus on social media platforms.
1 The government target is 131 per 100,000 live births overall. Ministry of Health. (2015). Annual Health Sector Performance Report 2014/2015. www.health.go.ug/download/file/fid/553
3 Data from 2011/2012. Ibid.
4 Uganda Bureau of Statistics. (2015). Statistical Abstract 2015 . www.ubos.org/onlinefiles/uploads/ubos/statistical_abstracts/Statistical%20Abstract%202015.pdf
5 Freedom House. (2015). Freedom on the Net 2015: Uganda . https://freedomhouse.org/sites/default/files/resources/FOTN%202015_Uganda.pdf
6 Uganda Bureau of Statistics. (2015). Op. cit.
7 Article 12 of the International Covenant on Economic, Social and Cultural Rights (1966) (ratified in 1987); Articles 11 (1)(f), 12 and 14 (2)(b) of the Convention on the Elimination of All Forms of Discrimination against Women (1979) (ratified in 1985); Article 24 of the Convention on the Rights of the Child (1989) (ratified in 1990); Article 25 of the Convention on the Rights of Persons with Disabilities (2006) (ratified in 2008). Regionally it is bound by the African Charter on Human and Peoples’ Rights (1981) (ratified in 1986), which enshrines the right to health in Article 16, and the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa, which Uganda signed in 2003 but has not yet ratified.
8 Article 2(1) of the International Covenant on Economic, Social and Cultural Rights (1966) (ratified in 1987); Article 4 of the Convention on the Rights of the Child (1989) (ratified in 1990); Article 4(2) of the Convention on the Rights of Persons with Disabilities (2006) (ratified in 2008).
9 Committee for Economic, Social and Cultural Rights, General Comment No. 14: The right to the highest attainable standard of health (Art. 12) (2000) at para 14. www.ohchr.org/Documents/Issues/Women/WRGS/Health/GC14.pdf
10 The right to health can also be derived from other articles of the constitution. These include article 39, which recognises the right to a clean and healthy environment; article 8A, which affirms that the Bill of Rights should be read with the National Objectives; article 45, which recognises that the Bill of Rights does not exclude other rights; and article 287, which affirms Uganda’s respect for its binding international obligations. See also Mbazira, C. (2013). The Status of Economic, Social and Cultural Rights in Uganda: The Huge Potential. ESRA Brief , Issue 1. iser-uganda.org/images/downloads/ISER_ESRA_brief_october_2013.pdf
11 Ministry of Health. (2010). National Health Policy II ; Ministry of Health. (2015). Health Sector Development Plan 2015/16-19/20 . health.go.ug/content/health-sector-development-plan-201516-201920
12 Ministry of Finance, Planning and Economic Development. (2016). Background to the Budget (FY 2011/12 – FY 2016/17).
13 The Human Rights Council resolution on “The promotion, protection and enjoyment of human rights on the Internet” ( A/HRC/20/L.13), signed by 85 countries, recognises “the global and open nature of the Internet as a driving force in accelerating progress towards development in its various forms.” https://daccess-ods.un.org/TMP/6083592.17643738.html. Although not binding, the 10 Internet Rights and Principles launched by the Internet Rights and Principles Dynamic Coalition in 2011 recognise that “everyone has an equal right to access and use a secure and open Internet” (Principle 3). internetrightsandprinciples.org/site
14 Regionally, the African Declaration on Internet Rights and Freedoms, in its preamble, recognises “that the Internet is particularly relevant to social, economic and human development in Africa.” It underscores “that the Internet is a vital tool for the realisation of the right of all people to participate freely in the governance of their country, and to enjoy equal access to public services.” It calls for accessible, available and affordable internet and lays out a strategy to achieve that. It also reiterates that “the Internet governance framework must be open, inclusive, accountable, transparent and collaborative” and “governed in such a way as to uphold and expand human rights to the fullest extent possible.” africaninternetrights.org/articles
15 Electronic Signatures Act (2010) www.ict.go.ug/sites/default/files/Resource/UGANDA%20Electronic%20Signatures%20Act%20No.%207%20of%202011.pdf; Electronic Transactions Act (2011) www.ict.go.ug/sites/default/files/Resource/UGANDA%20Electronic%20Transac... Computer Misuse Act (2011) www.ict.go.ug/sites/default/files/Resource/UGANDA%20Computer%20Misuse%20...
21 Constitutional Court Petition No. 16. The case is yet to be resolved after being initially dismissed on the political question by the Constitutional Court and has now been remanded to the Constitutional Court by the Supreme Court.
22 Ministry of Health. (2015). Op. cit.
23 Constitutional Court Petition No. 24/26.
24 Berger, J. (2008). Litigating for Justice in Post Apartheid South Africa. In V. Gauri & D. M. Brinks (Eds.), Courting Social Justice: Judicial Enforcement of Social and Economic Rights in the Developing World. Cambridge: Cambridge University Press.
25 https://www.facebook.com/Mama-Tendo-Foundation-181933331888027 ; the group’s website can be found at www.mamatendo.org
27 Rwenzori Center for Research and Advocacy. (2015, 4 June). Accelerating access to ICTs to improve maternal health in Uganda. NetHope. solutionscenter.nethope.org/case_studies/view/accelerating-access-to-icts-to-improve-maternal-health-in-uganda
29 Ministry of Health. (2015). Op. cit.
31 As a result of this project, health care workers and Village Health Teams were able to pay more visits to pregnant women and mothers, resulting in increased clinic attendance. There were 381 visits by healthcare workers to pregnant women resulting in an 18% increase in clinic attendance and 255 visits by village health workers to mothers with children under five resulting in a 23% increase in clinic attendance. Rwenzori Center for Research and Advocacy. (2015, 4 June). Op. cit. Similarly, results from the government project reveal an increase in the number of women attending antenatal visits.www.mtrac.ug
32 Ministry of Health. (2015). Op. cit.
33 ITU Telecommunication Development Sector. (2013). ICT for Improving Information and Accountability for Women’s and Children’s Health . www.itu.int/en/ITU-D/ICT-Applications/eHEALTH/Pages/Women_and_Children.aspx
34Ibid. Similarly, the mTrac system that the Ministry of Health is rolling out enables real-time data collection and basic data analysis for each district. Data is collected by healthcare workers and Village Health Teams which report on certain indicators on a weekly basis by sending an SMS from their mobile phones to a code each week and then submit the data through SMS texts with coded key words based on the existing Health Management Information System (HMIS) paper form 033b. The community, through an anonymous SMS hotline that is widely advertised at health facilities, also reports on the quality of health care including issues like drug stock-outs and absenteeism of health workers. District Health Teams access the data on an online dashboard where it is aggregated, tabulated and graphed. Using a computer and modem provided by the Ministry of Health, district teams, together with pre-selected national stakeholders, cross check, review and approve all data submitted for their district before submitting it to the ministry. The Ministry of Health Resource Centre reviews the data and investigates and responds to the anonymous SMS reports. See: www.mtrac.ug
35ITU Telecommunication Development Sector. (2013). Op. cit.
37 For example, the Anti-Terrorism Act (2002) has vague provisions.
39 In 2011, in response to the “walk to work” protests over rising food prices, the national regulator issued a directive to ISPs ordering them to temporarily shut down citizens’ access to Facebook and Twitter, a directive which most ISPs did not comply with. Freedom House. (2015). Op. cit.
40 Freedom House. (2015). Op. cit. In February 2015, Robert Shaka was arrested for allegedly running a popular Facebook account, Tom Voltaire Okwalinga (TVO), which was critical of the government and how it handles corruption. In 2014, four individuals were arrested for their involvement with Facebook pages that were critical. In November 2014, three activists from western Uganda were arrested on allegations of inciting violence on a Facebook group, Masindi News Network (MANET). The popular Facebook group often demanded accountability from government.
43 Uganda Bureau of Statistics. (2015). Op. cit.
46 Freedom House. (2015). Op. cit.
47 Uganda Communications Commission. (2015). UCC Access and Usage Survey 2014 . www.ucc.co.ug/files/downloads/20150130-UCC-access-usage-dissemination.pdf
48 Ministry of Finance, Planning and Economic Development. (2014). Poverty Status Report 2014: Structural Change and Poverty Reduction in Uganda . www.finance.go.ug/index.php?option=com_docman&Itemid=7&task=doc_download&gid=423