Mukono Health Center IV provides relatively better services and is usually crowded. Image Source: Report by Initiative for Social and Economic Rights on Monitoring the Right to Health
The Global Information Society Watch (GISWatch) 2016 focuses on economic, social, cultural rights (ESCRs) and the link it has to the internet. Does the internet enable or disable the realisation of ESCRs? The internet is often linked to issues such as censorship, privacy and cyber bullying. But very few question whether the internet could actually be linked to everyday basic needs. In a world that is rapidly moving online we need to ask what role does the internet play in relation to healthcare, housing, shelter, food and education – all these things we cannot go without. For many no link is seen as they do not have access to the necessary technology and also they do not see how the internet may make things easier.
In this article GenderIT.org writer, Tarryn Booysen, has a chat with Allana Kembabazi, author of the 2016 GISWatch Uganda report.
In a world that is rapidly moving online we need to ask what role does the internet play in relation to healthcare, housing, shelter, food and education – all these things we cannot go without. For many no link is seen as they do not have access to the necessary technology and also they do not see how the internet may make things easier.
Allana Kembabazi from Uganda has written a very informative report entitled The use of the internet to advance sexual and reproductive health. As I sit down to have a chat with her, we look at various policies and processes that have been put into place to deal sexual and reproductive rights. We also have a look at the laws and context in Uganda in comparison to South Africa, and then the greater sphere of Africa. Times are changing and as the internet grows we start seeing how the way we do everyday tasks is also changing. However, this new online explosion can leave some people behind.
The context of Africa
Sexual and reproductive health rights in Africa remain largely unrealized despite the fact that these rights are expressed in many international documents and national laws. These rights are often misunderstood by many African leaders. The report Why Realizing Sexual and Reproductive Rights in Africa Remains a Dream gives background as to why this is so, including that ideas about ownership of the body (by the individual or community) might differ in parts of Africa from the dominant paradigm as postulated by international law.
In South Africa where I live, the Constitution protects the rights of all people to make their own decisions regarding their reproduction, and gives them security in, and control over, their bodies. Women have the right to access appropriate healthcare services and the Constitution recognises that the decision to have children is fundamental to a woman’s physical, psychological and social health, and that complete access to reproductive healthcare services are needed. The State is responsible for providing reproductive healthcare in safe conditions to all citizens.
In the GIS Watch report on Uganda, it is stated that Uganda is a signatory to international instruments that ensure the right to health of all citizens, and yet the rate of maternal mortality is extremely high. In the recent years there has been growing access to internet and related services, but can these limited ICT tools be put to any use to resolve the concerns around health, especially those related to lack of information and basic healthcare.
Tarryn Booysen: Hi Allana, it is such a privilege for me to be having this interview with you as sexual and reproductive rights is something I personally feel quite strongly about. It is great to see people from Africa making their voices heard.
Could you tell us a bit about why you chose to focus specifically on sexual and reproductive rights (SRH) and its link to the internet?
Allana Kembabazi: Access to the internet has increased in Uganda with the increasing proliferation of mobile phones. The use of social media has also increased. As the use of the internet is fast growing in Uganda, there is need to leverage its potential in the promotion and protection of economic social rights, particularly given the slow progress in government action in the fulfilment of these rights.
The internet also serves as a key avenue for people in Uganda, especially young people, to express their dissatisfaction with the socio-economic situation in the country. At the Initiative for Social and Economic Rights (ISER), we work to advance economic social rights, and we know that women are detrimentally affected when economic social rights are not realised. As an organisation, we focus on the right to the highest attainable standard of physical and mental health, which includes sexual reproductive health. ISER uses the Internet to engage in research, awareness raising and advocacy around ESCRs in Uganda and internationally. While there has been some research on the use of mobile phones to improve health outcomes, there is very little research on how the internet can advance the right to health and sexual reproductive rights.
TB: What is the current state of sexual and reproductive rights in Uganda at the moment?
AK: Despite improving health outcomes, Uganda has high rates of maternal mortality. Delay to seek health care is partly the cause of this. Only 36.6% of women in 2014/15 attended the minimum four antenatal care sessions (ANC) and only 52.7% delivered in health facilities. The contraceptive prevalence rate is 30%. Although the reproductive health guidelines state that spousal consent is not required for women to access family planning services, in practice this is not the case because of discriminatory social cultural norms. Poor and rural women disproportionately lack access to comprehensive sexual and reproductive services. According to the most recent Uganda Demographic Health Survey(1), 46% of married women living in urban areas used some method of contraception, as opposed to only 27% of married women located in rural areas. 44% of married women with a secondary level or more of education used contraceptives as compared to only 18% of those with no education.
According to the most recent Uganda Demographic Health Survey(1), 46% of married women living in urban areas used some method of contraception, as opposed to only 27% of married women located in rural areas.
Uganda has high teenage pregnancy rates with over 24% of teenagers pregnant. Rural teenagers continue to start child bearing at an earlier age than their urban counterparts, with 24% of teenagers in rural areas pregnant compared to 21% in urban areas.# Women without the means to control their fertility are more likely to have unplanned pregnancies and pregnancies after short intervals, which makes them more vulnerable to maternal mortality.
TB: In your report you mention issues of digital literacy, how would you say this effects the country moving forward?
AK: Digital literacy is very important. The internet has opened up borders and put information on people’s finger tips. However, we live in a country in which there are high illiteracy levels. Even for those that are literate, few are digitally literate which prevents them from exploiting the full potential of the internet. This disproportionately affects women who due to levels of poverty, employment, literacy are more likely to be digitally illiterate and to face obstacles to accessing the internet.
TB: Has Uganda and Africa been moving with the times? Do you see us on a global scale when it comes to internet and ESCRs? If so how? If not, which steps do you believe we should take to improve our stances?
AK: In some ways, we are moving with the times as a country. However, the critical question is whether the poor, people in rural areas and the vulnerable can also access the internet and are empowered to use it. The internet must be accessible and affordable to all. A January 2015 survey by the Uganda Communications Commission found rural and urban users still find internet access expensive. Internet enabled devices remain expensive for the majority of Ugandans who are poor or vulnerable to falling back into poverty. Despite an overall decline in absolute poverty, 18% of Ugandans are chronically poor, living on less than USD1.20 per day and 43% of the population is poor or vulnerable to falling back into conditions of poverty. 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.
Moreover, those living in remote areas continue to lack access to electricity. According to the 2014 Poverty Status Report, access to electricity in the rural areas is only 7%. The government in partnership with private actors need to do more to ensure there is infrastructure to facilitate access to high speed internet, particularly in rural areas.
Despite the internet’s potential to advance economic, social and cultural rights, the lack of digital literacy prevents people from fully exploiting its potential. ISER has volunteer community health advocates who monitor the right to health in their communities and use the internet and social media in their monitoring and documentation but they had to be trained on the use of email, social media. Many opened emails for the first time when ISER provided them with internet enabled phones.
Despite the internet’s potential to advance economic, social and cultural rights, the lack of digital literacy prevents people from fully exploiting its potential.
TB: Would you say the internet is key in progressing SRH rights and why?
AK: I would say it has a critical role to play since it makes sexual reproductive health information readily available online, and this is information that might not be so easily accessible otherwise in Uganda.
It can be a powerful tool for advocacy. We saw it with the advocacy on petition 16 which dealt with mothers who died because the health centres lacked basic maternal health commodities. Civil society organisations organised on social media and formed list serves to strategise on advocacy. This also happened with the case challenging discriminatory provisions of the HIV and AIDS Prevention and Control Act, 2014. The increasing availability of the internet and the move to digitize health records has also resulted in disaggregated health data.
TB: In many countries it is still seen as taboo to speak about issues of sexual and reproductive rights, how do you suggest we change this?
AK: Training on rights is very critical and including men in this training is pivotal. Adolescents are afraid to seek out sexual reproductive health information and services because they are not expected to have sexual encounters. I was in Karamoja where we were told by health workers that free condoms at the health centres were almost expiring because the population would not use them. Yet when we held focus group discussions with that community, particularly with adolescent young men, they mentioned they had barely heard about condoms and did not believe their health centres offered sexual reproductive services. After offering these condoms to young men who were initially reluctant to take them, they opened up that it was taboo to speak about sex and they thought condoms promoted promiscuity and were afraid their women would think they slept around. They also had a number of questions around how this affected their manhood. After a lengthy dialogue with them, they eventually took some home.
In a different district, we were told by the District Health Officer’s office that when women received implants as a contraceptive measure, their husbands forcibly removed them when they found out. The men refused to use condoms. They did not understand the benefits of family planning to them. More troubling, they did not understand that women have the right to self-determination including the right to determine the number and spacing of children.
When women received implants as a contraceptive measure, their husbands forcibly removed them when they found out. The men refused to use condoms. They did not understand the benefits of family planning to them. More troubling, they did not understand that women have the right to self-determination including the right to determine the number and spacing of children.
TB: Many people, women especially, still feel ashamed and unaware of their rights. What steps need to be taken or are already in place for citizens to feel comfortable in speaking up and demanding the necessary information? How has the lack of access to internet played a role in this?
AK: This is very true. There has to be training on what human rights are. People cannot demand for what they do not know they are entitled to.
TB: Should the digital literacy education be implemented in schools or taught within the households and why should this be the case?
AK: Absolutely. Schools are a useful starting point particularly for the young since they are learning how to use computers. However, the education should extend beyond schools to households, especially to ensure the older generation that was in school before the internet and for people who have not gone to school to learn about the internet.
But also in relation to digital literacy, what makes it a challenge is the fact that most of the information is in English. Only 71 % of Ugandans above ten years are literate while only 66% of the people in rural areas are literate.
TB: What more could mainstream media do to improve the state of SRH rights?
AK: The media can play a valuable role in advocacy by galvanising the public and drawing attention to sexual reproductive rights violations. It can also debunk stereotypes and attitudes that prevent people from accessing sexual reproductive services. I also think the mainstream media needs training on sexual reproductive rights as a human rights issue.
TB: Health care is vital for every human being, and especially for pregnant women. Having the necessary information therefore is important but how does it work alongside the actual provision of health care, especially primary health care to all?
AK: They work hand in hand. We cannot discuss sexual reproductive rights without discussing the state of health care in Uganda. Women continue to face barriers that inhibit their access to quality health services. Despite policies in place that should ensure access to healthcare, women still have to walk long distances to the nearest health centre, sometimes in areas that do not have accessible and reliable public transportation. This affects their ability to access emergency obstetric care services.
We cannot discuss sexual reproductive rights without discussing the state of health care in Uganda. Women continue to face barriers that inhibit their access to quality health services. Despite policies in place that should ensure access to healthcare, women still have to walk long distances to the nearest health centre, sometimes in areas that do not have accessible and reliable public transportation.
The government has not allocated enough resources to the health sector and systematic underfunding of the health sector has resulted in poor health outcomes. Healthcare in Uganda is supposed to be free but persistent drug stock outs and the poor quality of healthcare in health facilities (a third of all posts in the public health sector were unfilled in 2014/2015, only 36%% of health facilities in rural areas surveyed by the World Bank followed clinical guidelines) results in people having to seek out private health facilities which have high out-of-pocket costs. These high out-of-pocket costs disproportionately affect poor and vulnerable households, resulting in many forgoing health services. This in turn obviously affects health outcomes, which are worse in rural areas and among the poor. Without quality health care that is accessible and affordable to all regardless of socio-economic status and geographic location, we cannot improve health outcomes.
While the internet could be mode for providing basic information and care, there are no policies that link the State’s obligation to provide adequate sexual reproductive rights, and policies on the internet, whether censorship or services providing information.
TB: Information cannot replace the need for doctors or hospitals, so what are the concrete ways in which you think that information on SRH will help?
AK: You are right that information cannot replace need for doctors and hospitals and we need to have health centres provide sexual reproductive health information. However, in a country in which sexual reproductive health information is not always available either because the nearest health centre in some places is far or the health centres do not provide it (there are concerns that sexual reproductive health information will be banned in schools), the internet provides information that is not readily available.
In a country where sexual reproductive health information is not always available, either because the nearest health centre in some places is far or the health centres do not provide it (there are concerns that sexual reproductive health information will be banned in schools), the internet provides information that is not readily available.
TB: 30% of South African women still don’t know that they have a right to safe, legal reproductive health services, including abortion. Abortion is legal in South Africa and has been since the Choice on Termination of Pregnancy Act was passed in 1996. In Uganda, are they legal, or illegal, and is it reasonably priced and accessible to all?
AK: Abortion is not legal in Uganda, although the law provides for mental and physical health exception and when there is risk to the life of the mother. Moreover basic sexual reproductive health services are not accessible to all. People who abort often do so illegally and with dangerous service providers.
For more on Uganda’s law on abortion read: Facing Uganda’s law ON Abortion. The legal framework in Uganda leaves women that seek to abort no choice but to do it with providers that might be dangerous.
In conclusion, the report states that governments need to work together in providing essential medicines, reproductive maternal and child healthcare. There is insufficient political drive to achieve the right to health in Uganda, and this makes advocacy essential, which relies to some extent on access to social media and internet. But add to that a number of Ugandans are not digitally literate, only 1% have access to broadband (2014), high levels of poverty, high costs of smart phones and that most of the content online (and on SRH) is largely in English – all this is preventing activists from using the full potential of the internet as a tool for advocacy.
A number of Ugandans are not digitally literate, only 1% have access to broadband (2014), high levels of poverty, high costs of smart phones and that most of the content online (and on SRH) is largely in English – all this is preventing activists from using the full potential of the internet as a tool for advocacy.
1. Uganda Demographic Health Survey (2011) at Page 67.