Medico-legal breaches: The silent epidemic in the Ugandan health system
The last about two decades have witnessed positive developments in the Ugandan healthcare system. Processes and outcomes of healthcare delivery have significantly improved, leading to better health gains. However, in recent years there have also been an increasing number of incidents related to medico-legal violation. Medico-legal covers a range of issues where the law intersects with medical practice and decision making. While some of these issues have been brought to light through public court cases and the media, a lot remains unknown. This blog builds our recent public lecture “Where law meets Public Health Policy: The Case of Maternal Health in Uganda.”
Focussing on maternal and newborn health, we know that a lot of deaths (85,000 every year and 230 per day) happen around childbirth – most preventable and many fall within the medico-legal category. The number of related cases continues to rise – overt and covert; intentional and inadvertent; person and system faulted. The scope and nature of these cases has widened and some present the most difficult conundrums as they are no robust provisions for them in the existing laws. Some of the cases include criminal negligence and extortion; operating unlicensed clinics, drugshops and training schools; pilfering public medicines for private sale; selling and dispensing expired medicines; fraud, fictitious documentation, embezzlement of public funds and chronic absenteeism from workstations.
A quick overview of the law in Uganda shows abundant legislation on health-related offences; however it still remains largely ineffective. The policy landscape for medico-legal is still weak and in need of further development. The Ministry of Health has no specific policy guidelines for the provision of medico-legal services – rendering existing services disjointed, haphazard and inconsistent. Building on legal frameworks such as Articles 33 and 34 of the 1995 Ugandan Constitution which spell out the rights of women and children respectively, the role of the state has been questioned by many.
Another bottleneck is the weak and ineffective penal sanctions; those cases with some mention seem to have obsolete recourses and consequences that are far from deterrent. For example in 2012 an attendant in a Kampala clinic selling expired and adulterated medicines was fined 2,000 Uganda Shillings or 3 months imprisonment according to the Food & Drugs Act (1959) – Section 2(3)(b). The Medical and Dental Practitioner’s Act (1998) section 47 mentions offence not to do with ethical practice but only on proceedings before UMC and registration. Article 170 of the Constitution under the Health Service Commission Act has a Code of Conduct (Sections 29-35); however it does not provide sanction or penalty for non-compliance. The Nurses and Midwives Act Cap 274 only states (Section 54) that anyone who contravenes the Act is liable to a penalty of 3,000 – 3,000,000 Uganda Shillings.
In light of the high stakes (maternal and newborn death), is this deterrent or even compensatory? While the majority of healthworkers maintain the highest level of service and integrity in a largely dysfunctional system, some few have displayed highly disappointing criminal behaviour. While some have been unfairly blamed and penalised, it would be helpful and in good faith – for justice to prevail – if the “clean and hardworking” clinicians stopped living in denial and defending their colleagues’ actions; rather focus should be on building critical mass of professionalism.
Medico-legal issues are attracting attention from across the board. Some issues are new and very complex with blurred lines around the nature and context of the crime. The Ugandan health system has a bearing on the prevention, occurrence and management of medico-legal cases. Most happen in the public sector, with few reported in private health facilities and even fewer from civil society organisations although this could also be a result or symptom of sub-optimal regulation and coordination. While civic renewal movements and activism have increased community awareness, they have also contributed to the growing divide and increased mistrust between lay people and professionals in health and the judiciary. Some of the vices (e.g. extortion leading to delayed service and/or death for mothers and newborns) are entrenched in the widespread corruption in most service sectors including health.
In conclusion I would like to reiterate that medico-legal issues cannot be ignored anymore. With increased public awareness, advocacy and growing interest in litigation the medico-legal landscape needs to be trodden more carefully than before. The unprecedented move towards a rights-based approach (skewed largely to patient rights!) means that healthworkers will find themselves in an increasingly vulnerable position and need multi-faceted support. Medico-legal cases have inflicted heavy damage on the health system and raised questions on pertinent healthcare issues including ethics, regulation, quality and safety. A deeper understanding of the professional, socio-cultural and geopolitical contexts within which medico-legal issues thrive is needed as policy and practice measures are undertaken using a multi-pronged approach.
*Written by Dr Gloria Seruwagi, a post-doctoral research fellow at the Makerere University Centre of Excellence for Maternal Newborn and Child Health.