“Health rights are key in ensuring patient safety and enhancing patient empowerment.”
The preamble of the 1946 World Health Organisation, (WHO) constitution defines health broadly to mean a state of complete physical, mental and social well being of a person and not merely the absence of disease or infirmity.
The constitution further defines the right to health as the enjoyment of the highest attainable standard of health and enumerates some principles of this right as healthy child development, equitable dissemination of medical knowledge and its benefits; and government provided social measures to ensure adequate health.
Article 25 of the United Nations Declaration of human rights 1948 states that everyone has a right to a standard of living adequately for the health and well being of himself and of his family, including food, clothing and medical care and necessary medical services.
Article 16 of the African Charter reiterates the same principle of the highest attainable standard of health.
Furthermore General Comment no.14 which addresses the right to health makes a direct clarification that the right to health is not to be understood as a right to be healthy but instead the right to health is articulated as a set of both freedoms and entitlements which accommodate among other things the individual’s biological and social conditions.
The constitution of Uganda though does not expressly provide for the right to health, it is included in the National Objectives and Directive Principles of State Policy and courts have also make judicial decisions imputing the right to health from other civil and political rights for instance the right to life, freedom from torture and discrimination, right to receive information among others.
Patient refers to health care users, also known as health care consumers and patient rights are seen as a subset of human rights and can be substantive like right to information or procedural for instance a right to complain.
Patient safety is the freedom for a patient from unnecessary harm or potential harm associated with health care. It literally refers to a collective term which refers to strategies and protocols to minimize the risk of harm occurring to patients. Every year an estimated one million patients die in hospitals across the world because of avoidable clinical mistakes.
Thesaurus dictionary defines empowerment as the exertion of a strong influence or control over others in a variety of settings. Patient empowerment could therefore be defined as the process by which patients gain more control over their health and health care.
The Ministry of Health in a bid to promote patients awareness developed Patients’ Charter, which outlines patients’ rights and responsibilities. The rights in the Charter include: the right to medical care; prohibition of discrimination; participation in decision making; confidentiality and privacy; informed consent; and refusal of medical treatment and these rights are 19 in number listed in the Charter. The responsibilities of the patient include provision of information; compliance with instructions; and respect and consideration of other patients and health workers. The discussion below highlights health rights and how these rights ensure patient safety and enhances patient empowerment:
The right to information about the safety and quality of health services:
Article 41 of Uganda constitution provides that every person has a right to receive information even that in the hands of the government. This being a civil right has seen courts giving it interpretation to include right to health and health rights.
For instance in the case of The Center for Health, Human Rights and Development (CEHURD) and others V. the executive director Mulago National referral hospital and AG, court held that there was a violation of article 2 (a) & (b) of the protocol to the African Charter on Human and Peoples Rights of women in Africa which requires state parties to keep appropriate measures to provide adequate, affordable and accessible health services, including information, education and communication programs to women especially those in rural areas and now days the rampant development of slums in Uganda whose occupants require medical attention.
Communication between patients and health care providers, and the barriers many Ugandan patients face in this regard, has an important impact on quality, cost, and patient safety and may lead to misdiagnosis and inappropriate treatment leading to longer stays in hospitals or death. Therefore by upholding this right a change can be created and patients empowered.
Similarly in CEHURD V. Nakaseke District Local Government, the case was brought on behalf of a pregnant woman while awaiting obstetric care died in a hospital. It considers whether the hospital failed to provide appropriate obstetric and management thereby violating her rights as well as those of her surviving children. This case establishes principle that Ugandans can sue health workers for medical negligence and offers a mechanism to demand accountability from the government as to how it is investing in social and economic rights such as health care. Therefore such civil rights have been interpreted to include health right for the protection and empowerment of patients.
The right to informed consent and a patient to be given adequate and accurate information about the nature of their illness, diagnostic procedures and the proposed treatment for one to make a decision that affects one of these elements helps patients to make informed medical decisions hence ensuring patient safety and empowerment. The information should be communicated to the patient at the earliest possible stage in a manner that he/she is expected to understand in order to make a free, informed, and independent choice. However in certain situations the doctor may withhold the information where he believes that it will cause harm to the physical and mental wellbeing of a patient.
Treatment against a patient’s will may be provided under the following circumstances:
- If the patient has received information as required to make an informed choice.
- If the treatment is anticipated to significantly improve the patient’s medical condition.
- If there are reasonable grounds to suppose that after receiving treatment, the patient will give his/her retrospective consent.
Consent provides legal justification of care to avoid allegations of committing the tort of trespass to the person; Consent represents the legal and ethical expression to one’s autonomy and self-determination.
In the South African case of Christian Lawyers Association v Minister of Health and Others, the High Court considered informed consent in the context of termination of pregnancy. The court stated that the concept forms the basis of the doctrine of volenti non fit injuria that justifies conduct that would otherwise have constituted a delict if it took place without a victim’s informed consent. All this is aimed at promoting the health wellbeing of a person.
The right to medical care:
The UNESCO Declaration aims at the promotion of equitable access to medical, scientific and technological developments as well as the greatest possible flow and the rapid sharing of knowledge concerning those developments and the sharing of benefits with particular attention to the needs of developing countries. The Declaration calls for respect of human dignity, autonomy, consent and other human rights and the need to maximize benefits and minimize harm to patients, research participants, and other affected individuals. It recognizes the ethical principle of respect for persons including patients.
In Nalwendo Vs Attorney General, the plaintiff was shot by a policeman in kajjansi and taken to Mulago hospital for treatment but that to date; the hospital has declined to give her a medical report. In defense the defendant denied liability and averred that the Uganda Police Force paid for antenatal services and medication until her recovery and discharge from Mulago hospital after delivery of her baby. Court held that the defendant should pay the plaintiff medical expenses to go for further treatment in India since such medication is not available in Uganda. This decision ensured her safety especially from itching scars and she would get better treatment in India.
In FB v Princess Alexandra Hospital NHS Trust  EWCA Civ 334 (12 May 2017), it was the patient’s case that the doctor was negligent in: (i) failing to take an adequate history and (ii) failing to conduct an adequate examination…the history taking was not carried out to the standard to be expected of a competent SHO is inevitable. The doctor was in breach of duty and negligence is established. The court considered standard of care of hospital doctors in the context of their function and grade. This decision and many others act as deterrence to the doctors for fear of court actions and heavy penalties imposed on them hence ensuring patient safety and empowerment.
Prohibition of discrimination:
The Collins English Dictionary and Thesaurus defines the word “discrimination” as follows, “The singling out of a particular person, group, etc. for special favor or disfavor…” in case of medical care this involves discriminating patients and denying some individuals health rights especially those from poor economic ground. These health rights therefore protect patients from such kind of discrimination and despite their economic and social status. This guarantees patient safety and empowerment due to the fact that they are assured of treatment whenever necessary.
The Equal Opportunities Act 2007 ensures that no patient’s health rights are violated hence their safety from hospitals and it provides guidelines of redress including causing appearance to their tribunal over any form of discrimination against any person in need of medical treatment. This means that all persons despite their status, gender, religion are empowered to access medical treatment without any fear and in the exercise of their health rights.
The existence of racial and ethnic disparities in health and health care has not been well documented in Uganda. In USA, Institute Of Medicine, IOM’s Unequal Treatment was the first major report to highlight that in addition to racial and ethnic disparities in health, there is evidence of racial and ethnic disparities in health care. Patient safety efforts are now a central component of efforts to improve the quality of care for all patients. However, the role of language barriers and its impact on adverse events is less well documented. Health right are there meant to remedy such problems by relaying information to the patients in a clear and precise manner.
The right to participation of patients in decision making:
Patient safety is about designing strategies to protect patients from harm. It is a discipline on how to make patients safer. Patient participation in decision making leads to safe investigative space in case of any negligence, it reaffirms the statutory duty of candor on part of doctors and it rejuvenates the health care safety investigation branch. The patients no longer fear to bring up their claims against hospitals for violation of their health rights.
Patient participation also leads to transparency and better and efficient communication with authorities especially the doctors.
Patient participation is a major patient safety culture right to ensure that health and social care services provide people with safe, effective, compassionate and high-quality care. It encourages medical care service providers to be on an upward trajectory of improvement and at the same time protecting and empowering patients and the community at large.
The health right to confidentiality and privacy in ensuring patient safety and empowerment:
The Institute of Medicine (IOM) (USA) reportstates that patients should not be harmed by the care that is intended to help them, and they should remain free from accidental injury.
Confidentiality in health care refers to the obligation of professionals who have access to patient records or communication to hold that information in confidence. Rooted in confidentiality of the patient-provider relationship that can be traced back to the fourth century BC and the Oath of Hippocrates, this concept is foundational to medical professionals’ guidelines for confidentiality and protection of patient safety.
An example is the landmark Jaffee v. Redmond decision where the U.S. Supreme Court upheld a therapist’s refusal to disclose sensitive client information during trial (Beyer, 2000). In writing the majority opinion, Justice Stevens said:
Effective psychotherapy… depends upon an atmosphere of confidence and trust in which the patient is willing to make a frank and complete disclosure…The psychotherapist privilege serves the public interest by facilitating the provision of appropriate treatment for individuals suffering the effects of a mental or emotional problem.
The confidentiality provisions will improve patient safety outcomes by creating an environment where providers may report and examine patient safety events without fear of increased liability risk. Greater reporting and analysis of patient safety events will yield increased data and better understanding of patient safety events.
Privacy, as distinct from confidentiality, is viewed as the right of the individual client or patient to be let alone and to make decisions about how personal information is shared.
The Supreme Court’s holding in Whalen v. Roe addressed the notion of balanced interest. In saying “disclosures of private medical information to doctors, to hospital personnel, to insurance companies, and to public health agencies are often an essential part of modern medical practice”, the court did not give individuals absolute control over sharing of their own health information.
This empowers patients to disclose their problems to doctors because they expect reciprocal duty of privacy from the doctors whereby if such information is disclosed it may lead to discrimination from the public and self hate by the patient.
The health right to healthy and safe environment:
Finally the right to healthy and safe environment can be read from article 39 of the Ugandan constitution and it is as well listed by the Charter to be observed and respected as a healthy right aimed at protecting patient safer and empowerment.
The healthy facilities are in sorry state and do not conform to healthy and safe environment standards. Some patients sleep on the floor after giving birth exposing them to more dangers of infections. Other hospitals with structures have no source of power to enable both operations at night as well as running of necessary equipments like refrigerators.
This has further exposed the lack of political will to improve our health sector and in total violation of international obligations like the Abuja Declaration of committing 15% of the budget to health sector. Patients have now developed a belief that whatever is provided is a favor from government and yet they are entitled to such services as of right.
It should however be noted that in certain circumstances these rights undermine patient safety and empowerment. For instance in Re T patient refused blood transfusion citing religious grounds in which case doctors had to respect the patient’s rights at the expense of putting the patient’s life in danger.
Similarly in Medical and Dental Practitioner tribunal V. Okwonkwo, patients refused blood transfusion citing the book of Leviticus in the Bible that man shall not take blood. The wife died and the doctor battled with proceedings for almost six months before being set free on appeal.
These decisions are based on established law for instance in Sideway V. Bethlehem Hospital, it was held that a patient can refuse treatment for rational, irrational or no reason at all if they are mentally capable. This however has not greatly impacted n doctors that go a head and prescribe treatment to save life. For example in the case of Njareketa where a doctor amputated a leg of the patient to stop further affecting the whole body, court on appeal awarded her a mere 1 cent after deliberating on the circumstance of the case.
From the foregoing discussion I therefore recommend the following to be done in order to promote healthy rights and patient safety:
- The Ministry of Health should establish and extensively publicize guidelines for patients to report cases of violation of their health rights.
- The Ministry should also enhance legal education of health workers and citizens, and provide legal assistance to abused patients.
- Inadequate resources for health promote unethical practices such as health workers demanding illegal fees and thus propagating the abuse of health rights.
- The Ministry should commit more funds to ensure availability of basic resources for implementing health rights issues, and improve supervision of health workers.
The realization of health rights in resource-constrained and patient-burdened public health care settings in Uganda remains an obstacle towards quality health care delivery, health care-seeking behavior and health outcomes.
Although the Uganda Patients’ Charter of 2009 empowers patients to demand quality care, inequitable access and abuse remain common. For instance in 2013, “African Journal of Primary HealthCare and Family care”, carried out research at Mulago Hospital assessing “the Awareness of, responsiveness to and practice of patients’ rights at Uganda’s national referral hospital.”
The results showed that at least 36.5% of patients faced a challenge regarding their rights whilst seeking health care. Most of the patients (79%) who met a challenge never attempted to demand their rights. Most patients (81.5%) and health workers (69.4%) had never heard of the Uganda Patients’ Charter. Awareness of patients’ rights was significantly higher amongst health workers (70%) than patients (40%). Patients’ awareness was associated with education level, employment status and hospital visits.
The results further indicate that Patients feel powerless to negotiate for their rights and fear being discriminated against based on their ability to bribe health workers with money to access care, and political, socio-economic and tribal status.
Unfortunately systems of checks and balances on the practice of health rights at the hospitals remain unclear to both patients and health workers, contrary to provisions in the Constitution that the State will take all efforts to ensure provision of health services to its population. This situation has led to many deaths in Uganda resulting from clinical mistakes or situations that could be prevented. It has also affected the lives of women by failing to provide adequate Emergency Obstetric Care services leading to countless casualties.
 Exploring patient participation in reducing health care related risks, WHO 2013
 Ministry of health patient charter 2009
 B.K Twinomugisha, ‘’Fundamentals of health Law in Uganda’’ (2015) Pretoria University Law Press, pp 192-229
 Civil suit no. 11 of 2012
 Article 12 b & c of the patients Charter
 Article 2(f)
 Articles 3-6
Civil suit no. 70 of 2013  UGHCCD 103 (13 July 2017).
John Tingle, Associate Professor Nottingham Law School, “Reverse Innovation and Patient Safety in transitioning and Developing countries”
 ‘’To Err is Human: Building Safer Health System’’
 Valerie Prater, University of Illinois at Chicago, “Confidentiality, Privacy and Security of health information: Balancing interests “December 8, 2014.
Jaffee v. Redmond, 1996, p. 9.
 “African Journal of Primary Health Care and Family care “research at Mulago Hospital assessing “the Awareness of, responsiveness to and practice of patients’ rights at Uganda’s national referral hospital.”