July 14, 2011

I. Background

The Ugandan Prison System

Uganda has 223 prisons countrywide. Designed to house 13,670, in March 2010 Ugandan prisons were at 224 percent of capacity, with 29,136 male and 1,278 female prisoners in custody.[2] The Uganda Prisons Service employs 6,700 staff, including 6 physicians.[3]

In addition to prisons run by the central government, prior to 2006, local governments administered independent prisons, at which conditions were reportedly grossly inadequate.[4] The Prisons Act of 2006 transferred the functions and administration of these locally administered prisons to UPS,[5] to create one nationwide system. Significant problems remain at the over 170[6] former Local Administration Prisons (LAPs).[7] Although approximately one third of Uganda’s prisoners were housed in former LAPs in March 2010,[8] prisoners in former LAPs constitute the majority of those not served by prison-based health facilities.[9]

Currently, UPS operates two official categories of prisons: reception centers and farm prisons. Although practice varies, in general, remandees and prisoners convicted of petty offences (with sentences less than one year) are kept at reception centers; male prisoners convicted to serve sentences over a few months but less than 10 years, or those with a short period of time remaining on their sentences, are sent to farm prisons. Remand or convicted prisoners facing or serving sentences over 10 years are sent to maximum security reception center prisons.Individual officers in charge (OCs) of prisons are empowered to decide which prisoners, including those undergoing medical treatment, to move to farm prisons; they do so without consultation with medical officials and their decisions are not subject to review.[10]

There is a separate juvenile justice system, with five facilities for children accused or convicted of criminal offences nationwide.[11] Though official statistics indicated no children held in prisons during 2009-2010,[12] in practice children are detained with adults in some.[13]

By law, UPS “shall be provided with adequate resources and facilities.”[14] UPS funding derives from the government of Uganda, donor funding, and “internally generated” revenue.[15] OCs set their budget priorities, which are reviewed and decided upon by prison headquarters in Kampala, with supplies coming almost exclusively in the form of the items requested. The receipt of these items is erratic and undersupply a general problem.[16]

Management of health in prisons is overseen by the Ministry of Internal Affairs, the line ministry for the UPS. UPS has calculated that it spends 17,073 Uganda shillings (US$6.96) per prisoner annually on health when dividing its health budget by the prisoners, staff, and staff dependents who use its services; that figure drops to 4,830 Uganda shillings ($1.98) annually per prisoner when factoring into the calculation the members of the neighboring communities who access prison-supplied health services.[17]

Officially, the total UPS health budget was increased by 55 percent between fiscal year (FY) 2009/10 and FY 2010/11.[18] Yet the overall proportion of the prison budget allocated for health services remained a flat two percent.[19] By comparison, the government provides roughly 9 to 10 percent of its national budget to healthcare.[20] In 2009, the commissioner general of prisons admitted to the media that lack of funding had led to deteriorating infrastructure and health in Ugandan prisons.[21]

Health services for the prisons are headed by a national directorate in Kampala. As of March 2011, 63 of Uganda’s 223 prison units had some level of healthcare worker. At the rest, prisoners were expected to rely on the health facilities in the neighboring communities.[22]

The national referral hospital for prisoners is at Murchison Bay Prison in Kampala. Murchison Bay Hospital treats prisoners temporarily referred from other prisons to receive inpatient or outpatient medical treatment,[23] and is the only medical facility in the prison system accredited to provide TB treatment and antiretroviral therapy for HIV treatment.[24] The UPS has established 10 regional health units intended to oversee delivery of healthcare services.[25] Forty-nine additional health “units” across the UPS have healthcare workers. But, in practice, the capacity of many of the facilities is limited: according to the prison medical authority, “we have no doctors at all in the upcountry units, we have zero.”[26]

The Ugandan Healthcare System

While the UPS often relies on community-based health services for prisoner care, healthcare for Uganda’s general population suffers from numerous problems. Uganda’s healthcare system ranks 186th out of 191 countries according to the World Health Organization (WHO).[27] Life expectancy is among the lowest in the world at 52 years; 1 in every 35 women dies as a result of giving birth.[28]

In national healthcare facilities, only half of all posts are filled.[29] Access to healthcare in poor rural areas is especially difficult. Around half of the population does not have any contact with modern healthcare facilities.[30] Some 70 percent of Ugandan doctors and 40 percent of nurses and midwives are based in urban areas, serving only 12 percent of the population.[31]

Healthcare centers,[32] often in dilapidated condition, frequently house patients together in wards, with no privacy regardless of gender or condition.[33] Medical equipment is lacking and where available, often there is no staff, electricity, or water.[34] The government does not supply sufficient drugs and equipment countrywide, leading to frequent drug stock outs and lack of basic supplies such as gloves or disinfectant.[35]

[2] Uganda Prisons Service (UPS), “Summary of UPS Prisoners Statistical Returns,” March 2010, http://www.prisons.go.ug/reports/0310.pdf (accessed March 24, 2011).

[3] UPS, “Programme 04: Prisons Medical Services: Work Plan and Budget FY 2010/11,” August 2010, p. 1.

[4] See, e.g., Uganda Human Rights Commission, “Statement from the Uganda Human Rights Commission Presented at the 61st Session of the United Nations Commission on Human Rights by Mrs. Margaret Sekaggya,” April 2005, http://www.nhri.net/pdf/UG18b.pdf (accessed April 12, 2011).

[5] Prisons Act of 2006, sec. 116.

[6] The Republic of Uganda Office of the Auditor General, “Value for Money Audit Report of Uganda Prisons Service,” March 2010, http://www.oag.go.ug/uploaded_files/1273680950Prisons.pdf (accessed May 5, 2011), p. 1.

[7] Prison authorities wrote to Human Rights Watch, “Our budget is still low compared to the tasks at hand. The transfer of former Local Administration Prisons to the center by the Prisons Act 2006, has increased tasks before us.” Email correspondence from prison authorities to Human Rights Watch, May 19, 2011. See also U.S. Department of State, “2009 Human Rights Report: Uganda,” 2010, http://www.state.gov/g/drl/rls/hrrpt/2009/af/135982.htm (accessed August 10, 2010); Human Rights Watch interviews with prison medical authority, Uganda Prisons Service, Kampala, March 11, 2011; OC, Fort Portal Prison, November 15, 2010; OC, Muduuma Prison, November 12, 2010.

[8] Human Rights Watch estimates that in March 2010, approximately 20,448 prisoners were housed in former centrally administered prisons, and 10,137 in former LAPs. UPS, “Summary of UPS Prisoners Statistical Returns”; UPS and Covenant Word Ministries, “Uganda Government Prisons By District,” undated, http://www.cwm.or.ug/coverage.pdf (accessed May 4, 2011).

[9] Human Rights Watch interview with prison medical authority, UPS, March 11, 2011.

[10] Human Rights Watch interviews with OC, Fort Portal Prison, November 15, 2010; OC, Muduuma Prison, November 12, 2010; prison medical authority, UPS, March 11, 2011; prison medical authority, UPS, Kampala, November 18, 2010.

[11] Remand homes are located at Fort Portal, Gulu, Naguru (in Kampala), and Mbale. Children convicted of crimes are placed in the Kampiringisa National Rehabilitation Centre. In some, non-profit organizations provide educational or other services. Foundation for Human Rights Initiative, “Juvenile Justice in Uganda: Report for the Period January-July 2009,” undated. In accordance with international law, Ugandan law defines children as individuals under the age of 18 and prohibits their detention with adults. Children Act of 1997, sec. 2 & 89(8).

[12] Justice, Law, and Order Sector, “Annual Performance Report, 2009-2010,” September 2010.

[13] Foundation for Human Rights Initiative, “Juvenile Justice in Uganda,” pp. 9-10.

[14] Prisons Act of 2006, sec. 8.

[15] The Republic of Uganda Office of the Auditor General, “Value for Money Audit Report of Uganda Prisons Service,” p. 4. Between FY 2005/06 and 2008/09, the Ugandan government increased its contribution to UPS from 27.66 (US$11.28 million) to 45.99 billion Uganda shillings ($18.76 million). Donor funding fluctuated from a high of 4.13 billion shillings ($1.68 million) in 2006/07 to a low of 0.72 billion shillings ($0.29 million) in 2008/09. “Internally generated” revenue increased from 1.45 ($0.59 million) in 2005/06 to 1.95 billion shillings ($0.80 million) in 2008/09. Ibid. Overall, the UPS budget was 49.2 billion shillings (approximately $20 million) in FY 2009/10, and 63.48 billion shillings (approximately $26 million) in FY 2010/11.

[16] Human Rights Watch interviews with OC, Masaka Main Prison, November 23, 2010; OC, Masaka Ssaza Prison, November 22, 2010; OC, Fort Portal Prison, November 15, 2010; OC, Kitalya Farm Prison, February 28, 2011; OC, Jinja Women’s Prison, March 2, 2011; OC, Muinaina Farm Prison, March 3, 2011; OC, Mutufu Prison, March 7, 2011; OC, Masafu Prison, March 8, 2011; OC, Murchison Bay Prison, November 10, 2010; OC, Muduuma Prison, November 12, 2010; prison medical authority, UPS, March 11, 2011.

[17] UPS, “Work Plan and Budget,” p. 6.

[18] The health budget increased from 0.87 billion Uganda shillings ($355,139) in FY 2009/10 to 1.35 billion Uganda shillings ($551,727) in FY 2010/11. UPS, “Work Plan and Budget,” p. iv. Prison authorities report that the recurrent non-wage budget of the prison health services increased by 90 percent between FY 2009/10 and FY2010/11 (from 0.39 billion shillings ($149,460) to 0.74 billion shillings ($283,559), and will again be increased by 56 percent in FY 2011/12 (to 1.15 billion shillings ($441,414)).

[19] Human Rights Watch interviews with prison medical authority, UPS, March 11, 2011; UPS, “Work Plan and Budget,” p. 6. Reportedly, prison health services may approach three percent of the overall prison budget in FY 2011/12. Human Rights Watch interview with prison medical authority, UPS, March 11, 2011.

[20] UPS, “Work Plan and Budget,” p. 28.

[21] Isaac Khisa, “Funding Blamed for Deterioration of Uganda’s Prisons,” East Africa in Focus, October 5, 2009, http://www.eafricainfocus.com/2009/10/04/funding-blamed-for-deterioration-of-uganda%E2%80%99s-prisons/ (accessed August 11, 2010).

[22] Human Rights Watch interview with prison medical authority, UPS, March 11, 2011; Letter to Human Rights Watch from prison authorities, June 29, 2011.

[23] Human Rights Watch interviews with OC, Murchison Bay Prison, November 10, 2010; doctor, Murchison Bay Hospital, November 10, 2010.

[24] Human Rights Watch interview with prison medical authority, UPS, March 11, 2011.

[25] These units are located at Fort Portal, Masindi, Mbarara, Masaka, Jinja (M), Mbale, Gulu, Moroto, Arua and Kigo.

[26] Human Rights Watch interview with prison medical authority, UPS, November 18, 2010.

[27] World Health Organization, “Country Cooperation Strategy Uganda,” WHO/CCS/2, 2000, http://www.who.int/countries/en/cooperation_strategy_uga_en.pdf (accessed April 25, 2011).

[28] WHO, “World Health Statistics,” 2010, http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf (accessed April 25, 2011); WHO et al., “Trends in Maternal mortality 1990-2008: Estimates developed by WHO, UNICEF, UNFPA and The World Bank,” 2010, http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf, p. 26 (accessed May 19, 2011). Non-provision of maternal health services and commodities in public healthcare facilities in Uganda remains a major issue. See, e.g., Center for Health, Human Rights and Development et al. vs. The Attorney General, petition to the Constitutional Court of Uganda, 2011.

[29] Uganda Human Rights Commission, “12th Annual Report,” 2009. In 2010, per 10,000 people, there was one physician, less than one dentist, and 13 midwives. WHO, “World Health Statistics.” Foundation for Human Rights Initiative, “The Right to Healthcare in Uganda,” 2010, http://www.fhri.or.ug/executive%20summary%20research%20report.pdf (accessed April 25, 2011) (reporting that as a result of understaffing, patients waited for four to six hours to see a nurse at health centers).

[30] World Health Organization, “Country Cooperation Strategy Uganda”; World Health Organization, “Country Profile: Uganda,” 2009, http://www.who.int/tb/publications/global_report/2009/pdf/uga.pdf (accessed April 25, 2011).

[31]Annie Kelly, “Healthcare a Major Challenge for Uganda,” The Guardian, April 1, 2009.

[32]There are not enough community health centers or hospitals. In theory, there are supposed to be healthcare facilities at the parish, sub-county, and county levels, as well as a hospital at the district level. Richard Kavuma, “Uganda’s Healthcare System Explained,” The Guardian, April 1, 2009. However, at least 26 districts in Uganda do not have a hospital, and patients must walk 12 kilometers in order to reach the nearest community health center. Foundation for Human Rights Initiative, “The Right to Healthcare in Uganda.” On average, rural residents live 5.2 km and urban residents 2.9 km from the nearest health center. Uganda Bureau of Statistics, “National Service Delivery Survey,” 2004, http://openmicrodata.wordpress.com/category/uganda/ (accessed April 25, 2011).

[33] Foundation for Human Rights Initiative, “The Right to Healthcare in Uganda.”

[34] Richard M. Kavuma, “Unhealthy Returns,” The Guardian, February 12, 2010; Foundation for Human Rights Initiative, “The Right to Healthcare in Uganda.”

[35] Foundation for Human Rights Initiative, “The Right to Healthcare in Uganda.”