(Kampala) – The World Bank should not proceed with a US$90 million loan for strengthening the health care sector in Uganda without enforceable steps to end discrimination in care for marginalized groups, 16 Ugandan and international organizations said today in a letter to World Bank President Jim Kim. Health care for women and lesbian, gay, bisexual, transgender, and intersex (LGBTI) people should be included in non-discrimination measures, the groups said.
In February 2014, shortly after President Yoweri Museveni signed the Anti-Homosexuality Act, Kim announced the delay of the Uganda loan out of concern that it would support discrimination in Uganda’s health sector. He said that discrimination is bad for economies. In August, Uganda’s Constitutional Court nullified the law on procedural grounds. But the government immediately filed an appeal to the Supreme Court and convened a committee to consider whether the law should be returned to parliament for reconsideration.
“Even with Uganda’s Anti-Homosexuality Act no longer enforceable, discrimination is alive and well in health services for many groups including LGBTI people,” said Moses Kimbugwe, program director at Spectrum Uganda, a Ugandan human rights organization. “It is vitally important for the World Bank to work with the government of Uganda to get serious about fighting discrimination – starting with clear conditions attached to this $90 million health loan.”
Beyond increasing prison sentences for same-sex conduct – already criminal under Uganda’s colonial-era, anti-sodomy provisions – the new law endangered public health work by criminalizing “promotion of homosexuality.” For example, police raided a well-respected health clinic and medical research facility in April, accusing the clinic of conducting “unethical research” and “recruiting homosexuals.” The law lacked any definition of what behavior or speech might constitute “promotion.”
The World Bank’s $90 million loan would assist Uganda’s health ministry with a funding shortfall for the renovation of certain health care facilities.
The Ugandan government has not provided any enforceable assurances that it will work to prevent discrimination in health services or even monitor discrimination by health care workers, the groups said. The Health Ministry issued a non-legally-binding directive to health workers, which defines the care of LGBTI people as an “ethical dilemma” for healthcare workers – rather than a professional obligation and a fundamental human right. It does not require health workers to provide medical care and treatment without bias. Nor does it properly guarantee confidentiality to patients who are at risk of prosecution if, for example, a health worker reports them to police for same-sex conduct, which remains a criminal offense in Uganda.
In July Museveni signed the HIV Prevention and Control Act, which could further fuel fear and discrimination. The law criminalizes intentional HIV transmission, attempted transmission, and behavior that might result in transmission by those who know their HIV status. The law also allows for mandatory HIV testing for all pregnant women. It allows medical providers to disclose a patient’s HIV status to others, contrary to international best practices and violating fundamental human rights.
Women tested against their will or whose HIV status may be revealed against their will may be exposed to potential physical violence from partners who fear or blame them for infection. The well-documented impact of such punitive measures is to drive people away from services.
In the loan, the groups said, the World Bank should require the government to prohibit discrimination in healthcare delivery, including on the grounds of gender, sexual orientation, and gender identity and all other grounds articulated under international law. It should require the government to respect patient confidentiality, privacy, and informed consent to all treatment, including fully informing patients of the risks involved with medical procedures and medication. The government should also guarantee that it will not interfere with any independent group or other third-party monitoring of health institutions.
The World Bank should fund activities to promote all patients’ rights, including funding patient advocates and legal counsel for people who face discrimination, breach of confidentiality, or other abuses in health settings and training for Ugandan health workers to respect these rights. It should also fund robust supervision and monitoring, including by independent organizations, to identify instances of discrimination.
The World Bank should review the new HIV law, in close collaboration with Ugandan groups and independent experts, and publicly outline measures it will take to ensure that Uganda’s health system is strengthened and HIV objectives are achieved, given the discriminatory environment. The bank should publicly and privately at all levels urge the government to repeal all discriminatory laws and end discriminatory practices, emphasizing the importance of non-discrimination for health and development and emphasize that the government’s lack of progress in this area will increasingly call into question aspects of the government’s relationship with the World Bank.
“This loan to the health sector should signal an end to ‘business as usual’ between the World Bank and Uganda,” said Asia Russell, director of international policy at Health GAP, an international health advocacy organization. “Discrimination in health services violates human rights and puts already vulnerable people at greater risk. The World Bank has a duty to ensure the Ugandan government invests in mitigating the effects of discrimination in the health services.”