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Published online by Cambridge University Press: 28 January 2025
On 19 August 2020, the Constitutional Court of Uganda handed down a landmark judgment on maternal health rights in Uganda. This judgment held that the State of Uganda was responsible for violating the right to health, non-discrimination, life and inhuman and degrading treatment of women under international law and Ugandan constitutional law for its failure by omission to provide basic emergency obstetric care in public facilities. This article examines the contribution of the Constitutional Petition No 16 judgment to the strengthening of women's reproductive health rights. By rejecting the “lack of resources” defence when complying with minimum core obligations under progressive realization in the provision of emergency obstetric services, the court makes an important contribution to the limited but growing body of jurisprudence holding governments accountable for a failure to ensure the protection of women's sexual and reproductive rights at both domestic and international levels.
Assistant professor, Department of Public Law, Faculty of Law, CUNEF Universidad.
Assistant professor of human rights law, Faculty of Law, Universidad Pontificia Comillas.
Professor of law, Centre for Human Rights, University of Pretoria.
1 Center for Health, Human Rights and Development (CEHURD) and Three Others v Attorney General (Constitutional Petition No 16 of 2011) [2020] UGCC 12 (19 August 2020).
2 This article will focus on immediate obligations in EmOC and will exclude minimum core obligations in sexual and reproductive rights not specific to EmOC.
3 “Maternal deaths” (Global Health Observatory, World Health Organization), available at: <https://www.who.int/data/gho/indicator-metadata-registry/imr-details/4622#:~:text=Definition%3A,and%20site%20of%20the%20pregnancy> (last accessed 7 September 2022).
4 “Maternal mortality: Maternal mortality declined by 34 per cent between 2000 and 2020” (UNICEF), available at: <https://data.unicef.org/topic/maternal-health/maternal-mortality/> (last accessed 7 September 2022).
5 “Trends in maternal mortality 2000 to 2020. Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division” (2023, World Health Organization) at 37, available at: <https://iris.who.int/bitstream/handle/10665/366225/9789240068759-eng.pdf?sequence=1> (last accessed 4 January 2024).
6 “Maternal deaths fell 44% since 1990” (2015, The World Bank), available at: <https://www.worldbank.org/en/news/press-release/2015/11/12/maternal-deaths-fell-44-percent-since-1990#:~:text=Despite%20global%20improvements%2C%20only%209,%2C%20Rwanda%20and%20Timor%2DLeste> (last accessed 7 September 2022).
7 “Trends in maternal mortality 2000 to 2020”, above at note 5 at 38.
8 “Transforming our world: The 2030 agenda for sustainable development” (21 October 2015, UN General Assembly) A/RES/70/1.
9 “Global health expenditure database (2000–2018)” (World Bank), available at: <https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=ZG&most_recent_value_desc=true> (last accessed 4 October 2022).
10 Id at European dataset, available at: <https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=EU> (last accessed 13 November 2024).
11 Id at Latin American dataset, available at: <https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=XJ> (last accessed 13 November 2024).
12 Id at Sub Saharan Africa dataset, available at: <https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=ZG&most_recent_value_desc=> (last accessed 13 November 2024).
13 “What needs to be done to solve the shortage of health workers in the African Region” (24 August 2017, World Health Organization), available at: <https://www.afro.who.int/fr/node/8513> (last accessed 9 October 2022).
14 “Out of pocket expenditures (% of current health expenditure) in Sub-Saharan Africa” (The World Bank), available at: <https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS?locations=ZG> (last accessed 5 October 2022).
15 Perkins, M et al “Out-of-pocket costs for facility-based maternity care in three African countries” (July 2009) 24/4 Health Policy and Planning Bulletin 289Google ScholarPubMed at 298.
16 “Birth attendant by skilled health staff (% of total) – Sub Sahara Africa” (The World Bank), available at: <https://data.worldbank.org/indicator/SH.STA.BRTC.ZS?locations=ZG> (last accessed 10 October 2022).
17 “Tanzania demographic and health survey and malaria indicator survey (TDHS-MIS) 2015–16” (2016, Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) (Tanzania Mainland), Ministry of Health (MoH) (Zanzibar), National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS) and ICF) at 172, available at: <https://dhsprogram.com/pubs/pdf/FR321/FR321.pdf> (last accessed 10 October 2022).
18 Id at note 13.
19 Ibid.
20 “Healthy mothers, healthy babies: Taking stock of maternal health” (2 June 2019, UNICEF), available at: <https://data.unicef.org/resources/healthy-mothers-healthy-babies/> (last accessed 8 November 2022).
21 Hanson, C et al “Access to maternal health services: Geographical inequalities, United Republic of Tanzania” (2017) 95/12 Bulletin of the World Health Organization 810CrossRefGoogle ScholarPubMed at 810.
22 “Uganda demographic and household survey” (2016, Uganda Bureau of Statistics) at 305.
23 “Maternal mortality ratio (model estimate per 100,000 live births): Uganda” (2023, The World Bank), available at: <https://data.worldbank.org/indicator/SH.STA.MMRT?locations=UG> (last accessed 17 April 2023).
24 “Uganda demographic and health survey 2022: Key findings” (2022, Uganda Bureau of Statistics - UBOS and ICF), available at: <https://www.health.go.ug/wp-content/uploads/2023/09/UDHS-2022-presentation-final.pdf> (last accessed 13 December 2023).
25 Ibid.
26 Ibid.
27 “Sustaining public sector investments in health sector: Uganda budget brief | financial year 2023/4” (2023, UNICEF), available at: <https://www.unicef.org/esa/media/13261/file/UNICEF-Uganda-Health-Budget-Brief-2023-2024.pdf> (last accessed 13 December 2023).
28 Constitutional Petition No 16 of 2011, above at note 1 at 15.
29 Id at 16.
30 Ibid.
31 Ibid.
32 Id at 4.
33 See Constitutional Appeal No 01 of 2013.
34 Id at 2.
35 Id at 11.
36 International Covenant on Economic, Social and Cultural Rights (1966), UN Treaty Series vol 993.
37 UN Committee on Economic, Social and Cultural Rights General Comment No 3: The Nature of States Parties’ Obligations (art 2, para 1, of the Covenant), 14 December 1990, E/1991/23, para 9. See also the Principles and Guidelines on the Implementation of Economic, Social and Cultural Rights in the African Charter (Nairobi Principles).
38 Ibid.
39 Ibid.
40 Ibid.
41 “An evaluation of the obligation to take steps to the ‘maximum of available resources’ under an Optional Protocol to the Covenant: Statement” (10 May 2007, CESCR) E/C.12/2007/1, para 8, available at: <https://www..ohchr.org/english/bodies/cescr/docs/statements/Obligationtotakesteps-2007.pdf> (last accessed 25 October 2024).
42 Ibid. The reasonableness standard is comparable to the reasonableness standard developed by the South African court in Grootboom. See Government of the Republic of South Africa v Grootboom and Others 2000 (11) BCLR 1169 (CC).
43 CESCR, ibid. See also CESCR General Comment No 3, above at note 37, para 2; CESCR General Comment No 14: The Right to the Highest Attainable Standard of Health (art 12 of the Covenant), 11 August 2000, E/C.12/2000/4, para 30.
44 “An evaluation of the obligation”, above at note 41, para 8. These criteria are similar to the ones adopted in Grootboom, above at note 42.
45 Robertson, RE “Measuring state compliance with the obligation to devote the ‘maximum available resources’ to realizing economic, social, and cultural rights” (1994) 16/4 Human Rights Quarterly 693CrossRefGoogle Scholar at 693.
46 Convention on the Elimination of All Forms of Discrimination against Women (1979), UN Treaty Series vol 1249.
47 UN Committee on the Elimination of Discrimination Against Women (CEDAW) General Recommendation No 24: Article 12 of the Convention (Women and Health), 1999, A/54/38/Rev.1, para 17.
48 P Alston and G Quinn “The nature and scope of states parties’ obligations under the International Covenant on Economic, Social and Cultural Rights” (1987) 9/2 Human Rights Quarterly 156 at 177.
49 “The right to contraceptive information and services for women and adolescents” (2010, UNFPA and Center for Reproductive Rights) at 22, available at: <https://www.unfpa.org/sites/default/files/resource-pdf/Contraception.pdf> last accessed 25 October 2024.
50 CESCR General Comment No 3, above at note 37, para 10. On the essence of human rights law see: M Scheinin “Core rights and obligations” in D Shelton (ed) The Oxford Handbook of International Human Rights Law (2013, Oxford University Press) 527; P Thielbörger “The ‘essence’ of international human rights” (2019) 20/6 German Law Journal 924.
51 J Tasioulas “Minimum core obligations: Human rights in the here and now” (research paper, 2017, The World Bank) at V, available at: <https://openknowledge.worldbank.org/bitstream/handle/10986/29144/122563-WP-Tasioulas2-PUBLIC.pdf?sequence=1&isAllowed=y> (last accessed 10 February 2023).
52 A Müller “Limitations to and derogations from economic, social and cultural rights” (2009) 9/4 Human Rights Law Review 557 at 579–83.
53 CESCR General Comment No 3, above at note 37, para 10.
54 Ibid.
55 “Technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal mortality and morbidity” (2 July 2012, UN Human Rights Council) A/HRC/21/22, para 21.
56 Ibid.
57 The identification of a minimum core obligation is contentious. See id at 492–95.
58 The Convention on the Rights of the Child (CRC) and ICESCR do not cover safe delivery or confinement. Art 24(2)(d) of the CRC requires that state parties “shall take appropriate measures … To provide appropriate pre/natal and post/natal care for mothers”. Similarly, art 10(2) of the ICESCR provides that: “Special protection should be accorded to mothers during a reasonable period before and after childbirth”.
59 MA Freeman, C Chinkin and B Rudolf “Article 12” in MA Freeman, C Chinkin and B Rudolf (eds) The UN Convention on the Elimination of All Forms of Discrimination Against Women (Oxford Commentaries on International Law, 2012, Oxford University Press) 311 at 329.
60 CEDAW General Recommendation No 24, above at note 47, para 27.
61 African Union Protocol to the African Charter on Human and People's Rights on the Rights of Women in Africa, 11 July 2003.
62 CESCR General Comment No 3, above at note 37, para 10.
63 Ibid.
64 CESCR General Comment No 14, above at note 43, para 43.
65 Id, para 44(a).
66 UN Committee on Economic, Social and Cultural Rights (CESCR) General Comment No 22 (2016) on the right to sexual and reproductive health (article 12 of the International Covenant on Economic, Social and Cultural Rights), 2 May 2016, E/C.12/GC/22.
67 Id, para 49.
68 Id, para 49(c).
69 Programme of Action adopted at the International Conference on Population and Development Cairo, 5–13 September 1994 20th Anniversary Edition, para 7.6, available at: <https://www.unfpa.org/sites/default/files/pub-pdf/programme_of_action_Web%20ENGLISH.pdf> (last accessed 23 October 2024).
70 Id, para 8.17.
71 Id, para 8.22.
72 Ibid.
73 Guidelines for Monitoring the Availability and Use of Obstetric Services (1997, UNICEF, WHO and UNFPA), available at <https://www.publichealth.columbia.edu/file/10730/download?token=LzW5VePB> (last accessed 23 October 2024). An updated version of the 1997 guidelines was published in 2009: Monitoring Emergency Obstetric Care: A Handbook (2009, WHO et al) available at: <http://apps.who.int/iris/bitstream/handle/10665/44121/9789241547734_eng.pdf;jsessionid=3F8EF3ED942E517C20DC99953631D9FB?sequence=1> (last accessed 23 October 2024).
74 AE Yamin and DP Maine “Maternal mortality as a human rights issue: measuring compliance with international treaty obligations” (1999) 21/3 Human Rights Quarterly 563 at 593.
75 Id at 592–93.
76 Ibid.
77 Id at 563–607.
78 Id at 572.
79 Id at 573.
80 Id at 568.
81 Guidelines, above at note 73 at 22.
82 Id at 7.
83 Yamin and Maine “Maternal mortality as a human rights issue”, above at note 74 at 573; Guidelines, id at 10.
84 Yamin and Maine, id at note 74 at 578; Guidelines, id at 10–11.
85 Guidelines, id at 10.
86 Id at 11.
87 As major complications, the Guidelines include hemorrhage, prolonged and obstructed labour, postpartum sepsis, complications of abortion, severe pre-eclampsia and eclampsia, ectopic pregnancy and ruptured uterus: id at 19.
88 Ibid.
89 Id at 17.
90 Id at 18.
91 Id at 21.
92 Ibid.
93 Id at 25.
94 Ibid; Yamin and Maine “Maternal mortality as a human rights issue”, above at note 74 at 580.
95 Guidelines, ibid.
96 Id at 31.
97 Yamin and Maine “Maternal mortality as a human rights issue”, above at note 74 at 581.
98 Guidelines, above at note 73 at 31.
99 Yamin and Maine “Maternal mortality as a human rights issue”, above at note 74 at 581.
100 Guidelines, above at note 73 at 34.
101 Ibid.
102 Ibid.
103 Id at 36.
104 Ibid.
105 Ibid.
106 CESCR General Comment No 22, above at note 66, para 49(g); CESCR General Comment No 14, above at note 43, para 43(d).
107 R Gill, B Ganatra and F Althabe “WHO essential medicines for reproductive health” (2019) 4/6 e002150 BMJ Global Health 1 at 1.
108 Ibid. See “WHO model list of essential medicines - 22nd list, 2021” (2021, World Health Organization) at 50, available at: <https://www.who.int/publications/i/item/WHO-MHP-HPS-EML-2021.02> (last accessed 23 October 2024).
109 RJ Cook “Human rights and maternal health: exploring the effectiveness of the Alyne decision.” (2013) 41/1 Journal of Law, Medicine & Ethics 103 at 112.
110 Alyne Da Silva Pimentel v Brazil CEDAW/C/49/D/17/2008 10 August 2011.
111 Id, para 7.4.
112 Health Workforce Requirements for Universal Health Coverage and the Sustainable Development Goals (2016, WHO) at 12, available at: <https://aps.who.int/iris/bitstream/handle/10665/250330/9789241511407-eng.pdf> (last accessed 23 October 2024).
113 Id at 21.
114 F Bustreo et al “Ending preventable maternal deaths: The time is now” (2013) 1/4 Lancet Global Health e176 at e176–77.
115 J Tobin The Right to Health in International Law (2012, Oxford University Press) at 289.
116 Ibid.
117 CESCR General Comment No 14, above at note 43, para 43(e); CESCR General Comment No 22, above at note 66, para 49(c); CEDAW General Recommendation No 24, above at note 47, paras 2, 11 and 29.
118 CESCR General Comment No 22, id, para 49(c); CESCR General Recommendation No 24, above at note 47, paras 2, 11 and 29.
119 The Maputo Protocol, art 14(2)(a).
120 CESCR General Comment No 22, above at note 66, para 43(a).
121 Freeman, Chinkin and Rudolf “Article 12”, above at note 59 at 320; CEDAW General Recommendation No 24, above at note 47, paras 11, 14 and 27; RJ Cook “State responsibility for violations of women's human rights” (1994) 7 Harvard Human Rights Journal 125 at 165.
122 Convention on the Elimination of All Forms of Discrimination against Women, 18 December 1979, A/RES/34/180, para 37.
123 Alyne da Silva Pimentel, above at note 110.
124 Id, paras 7.6 and 7.7.
125 Guidelines, above at note 73 at 13.
126 Id at 14.
127 Ibid.
128 Ibid.
129 CESCR General Comment No 22, above at note 66, para 49(d).
130 Joint General Recommendation / General Comment No 31 of the Committee on the Elimination of Discrimination against Women and No 18 of the Committee on the Rights of the Child on harmful practices, CEDAW/C/GC/31-CRC/C/GC/18, 4 November 2014 analyses the risks posed to the sexual and reproductive rights of women or girls who have been or are at risk of being subjected to harmful practices; UN Committee on the Elimination of Discrimination Against Women (CEDAW), CEDAW General Recommendation No 19: Violence against women, 1992, paras 19 and 20.
131 CESCR General Comment No 22, above at note 66, para 49(d).
132 C Shalev “Rights to sexual and reproductive health: The ICPD and the convention on the elimination of all forms of discrimination against women” (2000) Health and Human Rights 38 at 45–46. On dignity and autonomy see: C McCrudden “Human dignity and judicial interpretation of human rights” (2008) 19/4 European Journal of international Law 655 at 685–86.
133 CESCR General Comment No 3, above at note 37, para 4.
134 UN Human Rights Council “Technical guidance”, above at note 55, para 35.
135 CESCR General Comment No 3, above at note 37, para 11; UN Human Rights Council “Technical guidance”, id, para 26.
136 UN Human Rights Council “Technical guidance”, id, para 27.
137 CESCR General Comment No 14, above at note 43, para 43(b); CESCR General Comment No 22, above at note 64, para 49(f); UN Human Rights Council “Technical guidance”, id, paras 30 and 43.
138 CESCR General Comment No 14, id, para 53; UN Human Rights Council “Technical guidance”, id, para 29.
139 CESCR General Comment No 22, above at note 66, para 49(f).
140 CESCR General Comment No 14, above at note 43, para 43(b); CESCR General Comment No 22, id, para 49(b).
141 UN Human Rights Council “Technical guidance”, above at note 55, para 28.
142 CESCR General Comment No 14, above at note 43, para 53.
143 UN Human Rights Council “Technical guidance”, above at note 55, para 33 on essential interventions that should be included in the plan.
144 Id, para 34 on essential medicines for improving maternal health.
145 Id, para 39.
146 Id, para 42.
147 Id, para 35.
148 “Such ex-ante impact assessment should particularly consider the impact on vulnerable and excluded populations, including but not limited to women with disabilities, racial and ethnic minorities, conflict-affected and displaced women, adolescents and other marginalized groups, according to national context” (id, para 36).
149 CEDAW General Recommendation No 24, above at note 47, para 30.
150 Freeman, Chinkin and Rudolf “Article 12”, above at note 59 at 325.
151 Ibid.
152 UN Human Rights Council “Technical guidance”, above at note 55, para 45.
153 Ibid.
154 Id, para 47(c).
155 Id, para 46.
156 Id, para 48.
157 Id, para 51.
158 Id, para 49.
159 Constitutional Petition No 16, above at note 1 at 6.
160 Id at 23.
161 Id at 25.
162 Id at 29.
163 Id at 27.
164 Id at 29.
165 Id at 30.
166 Ibid.
167 Id at 33.
168 African Union African Charter on Human and Peoples’ Rights (27 June 1981).
169 Constitutional Petition No 16, above at note 1 at 24.
170 Id at 44.
171 Id at 46.
172 Id at 44.
173 Id at 17.
174 Id at 16.
175 Id at 29.
176 Id at 17.
177 Id at 42 and 44.
178 Id at 17.
179 Id at 44.
180 Id at 21 and 44.
181 Id at 31.
182 Id at 46.
183 Id at 18.
184 Id at 44.
185 Id at 36.
186 Id at 37.
187 The judgment referred to Alyne da Silva Pimentel v Brazil, above at note 110 and Laxmi Mandal v Deen Dayal Harinagar Hospital & Others Writ Petition No 8853/2008 (2010): id at 1.
188 Constitutional Petition No 16, id at 22.
189 Id at 25.
190 Id at 43.
191 Id at 51.
192 Citing Juan Mendez report of February 2013 “Failure by the prison authorities to provide regular antenatal and prenatal care to women who required it amounted to inhuman treatment by the prison”: id at 53.
193 Ibid.
194 Cook, RJ, Dickens, BM and Fathalla, MF Reproductive Health and Human Rights: Integrating Medicine, Ethics, and Law (2003, Clarendon Press)CrossRefGoogle Scholar at 56.
195 Fathalla, MF et al “Sexual and reproductive health for all: A call for action” (2006) 368/9552 The Lancet 2095CrossRefGoogle ScholarPubMed at 2098.
196 Ibid.
197 T Riley et al “Adding it up: Investing in sexual and reproductive health 2019—methodology report” (2020, Guttmacher Institute), available at: <https://www.guttmacher.org/sites/default/files/report_pdf/adding-it-up-investing-in-sexual-reproductive-health-2019-methodology.pdf> (last accessed 23 October 2024).
198 M Schäferhoff et al “Funding for sexual and reproductive health and rights in low- and middle-income countries: threats, outlook and opportunities” (The Partnership for Maternal, Newborn & Child Health, Open Consultants and The Center for Policy Impact in Global Health) at 18–19, available at <https://pmnch.who.int/docs/librariesprovider9/meeting-reports/srhr_forecast.pdf?sfvrsn=d6d8c47c_3&download=true> (last visited 23 October 2024).
199 Constitutional Petition No 16, above at note 1 at 19.
200 CESCR General Comment No 3, above at note 37, para 10.
201 Constitutional Petition No 16, above at note 1 at 20.
202 Ibid.
203 Ibid.
204 Id at 23.
205 Id at 49.
206 Id at 47.
207 Id at 48.
208 Id at 50.
209 Ibid.
210 Ibid.
211 Id at 43.
212 Ibid.
213 Id at 32.
214 Ibid.
215 Id at 47.
216 Ibid.
217 Ibid.
218 Id at 49.
219 Id at 32.
220 Cook “Human rights and maternal health”, above at note 109 at 106.
221 Ibid.
222 Constitutional Petition No 16, above at note 1 at 35–36.
223 Id at 27.
224 Parliament of Uganda “MPs call for adequate financing of maternal health” (25 May 2023), available at: <https://www.parliament.go.ug/news/547/mps-call-adequate-financing-maternal-health> (last accessed 13 December 2023).
225 Twinomugisha, BK “Exploring judicial strategies to protect the right of access to emergency obstetric care in Uganda” (2007) 7/2 African Human Rights Law Journal 283Google Scholar at 296–301. See also “Review of constitutional provisions on the right to health in Uganda: A case study report” (2018, CEHURD), available at: <https://equinetafrica.org/sites/default/files/uploads/documents/CEHURD%20Constitutional%20Review%20Sep2018.pdf> (last accessed 23 October 2024).
226 Constitutional Petition 16, above at note 1 at 18.
227 Id at 18–42.
228 The judgment refers mainly to the Delhi High Court case, Laxmi Mandal v Deen Dayal Harinagar Hospital & Others writ petition no 8853/2008 (2010).
229 A similar approach has been adopted by Indian courts. While the right to health is not specifically recognized by the Indian Constitution, the courts have upheld this right by relying on other recognized rights such as life and dignity in constitutions. See for instance, Paschim Banga Khel Mazdoor Samiti v State of West Bengal 1996(4) SCC 37.
230 Constitutional Petition 16, above at note 1 at 56.
231 Id at 58.
232 Ibid.
233 Ibid.