Using the right to health framework to tackle non-communicable diseases in the era of neo-liberalism in Uganda

The main objective of this article is to reflect on how the right to health framework may be used to tackle non-communicable diseases in the era of neo-liberalism in Uganda. NCDs, also known as chronic or lifestyle diseases, cause many deaths. The risk factors for NCDs include the harmful use of alcohol, physical inactivity, salt intake, tobacco use, raised blood pressure, diabetes, obesity, as well as ambient and household air pollution. The article moves beyond the recognition of these important risk factors and interrogates the contribution of neo-liberalism to the prevalence of NCDs. The article argues that neo-liberalism, which emphasises the role of market forces in dealing with socio-economic questions, significantly contributes to the NCDs challenge in Uganda. The article concludes that the right to health can and should play a critical role in tackling the challenge of NCDs in Uganda. Unless policy challenges associated with neo-liberalism are tackled, current NCD prevention, control and management efforts that focus on individual behaviour or lifestyle approaches and place the burden of responsibility on the individual may not achieve the desired results.


Introduction
The main objective of this article is to reflect on how the right to health framework might be used in the prevention, treatment and control of non-communicable diseases (NCDs) in the era of neoliberalism in Uganda. As is the case in many countries, Uganda is party to human rights instruments that guarantee the right to health 1 and outline state obligations towards the realisation of the right, including the prevention and treatment of diseases. The Constitution of the Republic of Uganda further contains provisions with a bearing on the right to health. 2 Several public health policies and interventions are aimed at the promotion of the right. 3 Globally, the recognition of health as a human right has gained traction in certain areas, for example, in the field of sexual and reproductive health, including HIV. There is an increased recognition of the role of law, including human rights, in the struggle to tackle NCDs, also known as chronic or lifestyle diseases. The World Health Organization (WHO) recognises human rights as one of the primary approaches in the prevention and control of NCDs. 4 De Vos et al also advocate a right to health-based approach to the prevention and control of NCDs. 5 Magnusson and Patterson advocate human rightsinspired legal and governance reforms as part of a comprehensive global response to NCDs. 6  of human rights to NCD prevention and control remains nascent and there thus is a need for the infusion of human rights into NCD programme design, monitoring and evaluation. 8 According to the WHO, NCDs kill 41 million people annually, the equivalent of 71 per cent deaths globally. 9 Each year 15 million people in low and middle-income countries die from a NCD between the ages of 30 and 39 years. 10 Cardiovascular diseases account for most NCD deaths, or 17,9 million people annually, followed by cancer (9 million), respiratory diseases (3,9 million) and diabetes (1,6 million). 11 The 2030 Agenda for Sustainable Development recognises NCDs as a major challenge to sustainable development. 12 Goal 3 of the Agenda aims to 'ensure healthy lives and promote well-being for all' and outlines a number of objectives relevant to the response to NCDs. Target 4 addresses the reduction of premature mortality from NCDs and the promotion of mental health and well-being. Risk factors related to NCDs include the harmful use of alcohol, physical inactivity, salt or sodium intake, tobacco use, raised blood pressure, diabetes, obesity, ambient and household air pollution. 13 Bad food, nutrition and diet are closely linked to the increase in NCDs, 14 which not only affect adults. Children and adolescents, who are targeted by food and beverage companies through advertisements, may become victims of behaviour such as tobacco use, alcohol abuse and unhealthy diets. 15 In Uganda the incidence and prevalence of NCDs are increasing at an alarming rate. 16 The common types of NCDs in the country, which are precipitated by the above risk factors, include diabetes, cancer, cardiovascular disease such as heart attacks and strokes as well as chronic respiratory diseases. 17 The burden of NCDs is 8 S Gruskin et al 'Non-communicable diseases and human rights: A promising synergy' (2014) 104 American Journal of Public Health 773. 9 WHO 'Non-communicable diseases: Key facts' (2018), http://www.who.int/ news-room/fact-sheets/detail/noncommunicable-diseases (accessed 24 October 2018). 10 As above. 11 As above. 12 UN Transforming our world: The 2030 Agenda for Sustainable Development (2015). 13 As above. 14 C Lachat et al 'Diet and physical activity for the prevention of non-communicable diseases in low and middle-income countries: A systematic policy review' (2013) 10 Public Library of Science and Medicine 6. 15 J Proimos & JD Klein 'Non-communicable diseases in children and adolescents' (2012) 130 Pediatrics Perspectives 3. 16 Ministry of Health 'Non-communicable diseases', http://www.health.go.ug/com munity-health-departments/non-communicablediseases (accessed 24 October 2018). 17 As above. increasing in both urban and rural areas. 18 According to 2016 estimates, approximately 297 000 people died due to NCDs with cardiovascular disease accounting for 10 per cent of mortality; cancer 10 per cent; chronic respiratory disease 2 per cent; diabetes 2 per cent; and other NCDs 11 per cent. 19 As noted above, in Uganda, alcohol abuse, tobacco use, unhealthy foods and physical inactivity contribute to the burden of NCDs. 20 Several commentators have argued that neoliberalism has shaped and influenced NCD policy design and implementation in many countries. Battams argues that the neoliberal paradigm 'shapes the supply of unhealthy goods', contributing to the burden of NCDs. 21 She further argues that trade and development policies largely are influenced by neo-liberalism resulting in trade and economic development goals trumping health goals linked to NCDs. Lenchucha and Thow argue that in low-income countries such as Zambia, neo-liberalism conditions the policy environment in a way that promotes the use of tobacco, alcohol and other unwholesome goods. 22 They have further observed that economic sectors, including trade, industry and agriculture, do not pay attention to the health consequences of their policies. Glasgow and Schreker observe that most commentators view the challenge of NCDs as related primarily to individual choice and behaviour. 23 Yet, neo-liberalismfor example through trade liberalisation and marketing activities of transnational corporations (TNCs) -significantly contributes to the global burden of disease, including NCDs. 24 In Uganda public health messages target individual behaviour and prioritise the risk factors of smoking, alcohol abuse and physical inactivity. These messages are in concordance with the neoliberal paradigm, which underlines the values and virtues of the market, individual liberty, choice and freedom. 25 As Tarryn and Cella observe, such messages assume that people have the agency to make healthy choices. 26 Although messages targeting individual behaviour contribute to a reduction of NCDs in Uganda, there is a need to investigate the contribution of structural and systemic factors such as neo-liberalism, which may constrain the state's capacity to prevent and control NCDs.
Against the backdrop outlined above the article argues that neoliberalism, which emphasises the role of market forces in dealing with socio-economic questions, significantly contributes to the prevalence of NCDs in Uganda. The article further argues that some of the challenges posed by neo-liberalism are surmountable through a holistic and comprehensive application of the right to health framework. The article is divided into five parts. The first part is this introduction. In the second part I examine the right to health framework at the international, regional and national levels. I tease out the normative scope and content of the right with specific reference to interpretation by the Committee on Economic, Social and Cultural Rights (ESCR Committee). 27 The third part of the article examines the contribution of neo-liberalism to the NCD challenge in Uganda. I commence with an examination of neo-liberalism and proceed to illustrate how it adversely impacts on the struggle to tackle NCDs. I argue that neo-liberal policies, such as privatisation and liberalisation, significantly contribute to the NCDs trajectory in the country. The fourth part of the article explores the role that the right to health framework can and should play in tackling the NCD trajectory. In this part I argue that the right to health framework, with its emphasis on both health care and the social determinants of health, can and should play a fundamental role in tackling the risk factors related to NCDs that are exacerbated by neo-liberalism. Part 5 offers concluding remarks.

Right to health framework
The WHO, which defines health as a 'state of complete physical, mental and social well-being and not merely the absence of disease and infirmity', recognises the right to health as a fundamental human 25 On the market's sacrosanctity, see M Friedman Why government is the problem: Essays in public policy (1993 Building on the definition in the Ottawa Charter, Huber et al suggest a new concept of health in terms of the ability to adapt and to self-manage in the face of social and emotional challenges. 34 Jambroes et al observe that by looking at health as 'a complete state', the definition is static, does not take into account the changing patterns of morbidity, and has contributed to the medicalisation of society. 35 The challenge with these definitions is that they reproduce the biomedical model of disease that largely emphasises biological and behaviourial factors. As Yamin has observed, health is not simply 'a question of divine or genetic fate, of random biological events, or individual behaviour', 36 but a matter of justice -a product of social relations as much as biological or behavourial factors. It is the inequities in these social, and inherently Thus, there is a need to move beyond the above definitions, including those by the WHO, and interrogate the underlying social, economic, political and cultural factors that shape the health and well-being of individuals and populations. The Universal Declaration of Human Rights (Universal Declaration), which 'laid a foundation for the human rights movement', 38 guarantees every person 'the right to a standard of living adequate for the health of himself and of his family, including food … medical care and necessary social services'. 39 The International Covenant on Economic, Social and Cultural Rights (ICESCR) guarantees everyone the right to 'the highest attainable standard of physical and mental health'. 40 The ESCR Committee, which monitors state compliance with ICESCR, has provided an authoritative interpretation of this right 41 and noted that 'good health cannot be ensured by a state' 42 and that 'genetic factors, individual susceptibility to ill health and the adoption of unhealthy or risky lifestyles may play an important role with respect to an individual's health '. 43 The ESCR Committee further interpreted the right to health 'as an inclusive right extending not only to timely and appropriate health care but also to the underlying determinants of health', 44 including access to safe water, food, a clean and healthy environment, relevant education and information and participation of individuals and communities in health interventions. 45 Indeed, most of the risk factors for NCDs outlined above are attributed to individual life styles, and may be tackled through education and information. However, as the ESCR Committee observed, there are 'formidable structural and other obstacles resulting from international and other factors' 46 that may inhibit the realisation of the right to health by many state parties, including Uganda. Some of these obstacles might be perpetuated by neo-liberal policies of international financial and trade institutions According to the ESCR Committee, the right to health contains a number of 'interrelated and essential elements', 48 namely, the availability, accessibility, acceptability and quality of public health facilities, goods and services. 49 The facilities, goods and services should be physically and economically accessible to everyone without discrimination. There should also be sufficient information about these facilities, goods and services, which should be respectful of medical ethics, culturally, scientifically and medically appropriate. 50 ICESCR requires state parties to take steps to ensure the 'creation of conditions which would assure to all medical service and medical attention in the event of sickness'. 51 According to the ESCR Committee this requirement includes 'the provision of equal and timely access to basic preventive, curative, rehabilitative services and health education'. 52 Thus, in addition to preventive measures, including education, information, communication and screening procedures, which are critical in the struggle against NCDs, the state should ensure that treatment options, including palliative care, for the various NCDs are available, accessible, acceptable and of good quality. Pursuant to its obligation to fulfil human rights, the state should ensure that those who are unable, through their own means, to access treatment for NCDs, are provided with the necessary treatment. 53 As in the case of other human rights, the state has three types of obligations: to respect, protect and fulfil the right to health. 54  interfering directly or indirectly with the enjoyment of the right to health'. 55 A state party violates the obligation to respect if it fails 'to take into account its legal obligations regarding the right to health when entering into bilateral or multilateral agreements with other states, international organisations and other entities, such as multinational corporations'. 56 Pursuant to their obligation to protect, states should take measures that prevent non-state or private actors from interfering with the enjoyment of the right to health. 57 The obligation to protect is violated where the state fails to take all necessary measures to safeguard persons within its jurisdiction from deleterious activities of private persons, including corporations. 58 An example of an omission is a 'failure to regulate the activities of corporations in order to prevent them from violating the right to health'. 59 The state may further violate the right to health where it fails to take measures to discourage the production, marketing and consumption of tobacco, narcotics, and other harmful substances such as unhealthy foods, 60 associated with NCDs.
Under the obligation to fulfil human rights, states should 'adopt appropriate legislative, administrative, budgetary, judicial, promotional and other measures towards the full realisation of the right to health'. 61 The state violates the obligation to fulfil human rights where it fails to enact or adopt and implement necessary legal and policy frameworks for the realisation of the right to health. Health policy frameworks should identify appropriate right to health indicators and set benchmarks in relation to each indicator. 62 Insufficient expenditure or the misallocation of public resources may also result in a violation of the right to health. 63 According to the ESCR Committee the state's obligations are to be progressively realised in accordance with available resources. 64 The ESCR Committee observes that, although ICESCR 'provides for progressive realisation' 65 and recognises 'constraints due to the limits of available resources', 66 there are obligations 'which are of immediate effect'. 67 These obligations are 'the guarantee that the 55 Para 33. 56 Para 50. 57 As above. 58 Para 51. 59 As above. 60 As above. 61 As above. 62 Paras 57 & 58. 63 Para 52. 64 Art 2(1). 65 Para 30. 66 As above. 67 As above. right will be exercised without discrimination of any kind'; 68 and 'the obligation to take steps … towards full realisation' 69 of the right. The steps taken by the state 'must be deliberate, concrete and targeted towards full realisation of the right to health'. 70 According to the ESCR Committee, the concept of progressive realisation 'should not be interpreted as depriving states parties' obligations of all meaningful content'. 71 Thus, state parties 'have a specific and continuing obligation to move as expeditiously and effectively as possible' 72 in order to ensure the full realisation of the right to health. Retrogressive measures are not permissible unless the state justifies that it took the decision 'after the most careful consideration of all alternatives'. 73 The ESCR Committee has affirmed that '[s]tates parties have a core obligation to ensure the satisfaction of, at the very least, minimum essential levels of each of the rights' 74 in ICESCR. These core obligations include ensuring access to health facilities, goods and services for vulnerable and marginalised groups; 75 'access to the minimum essential food which is nutritionally adequate and safe, to ensure freedom from hunger to everyone'; and access to an adequate supply of safe and potable water. 76 Indeed, there is a link between nutrition and NCDs, and effective public health nutrition is required in order to curb the prevalence of the diseases. 77 These core obligations also include the provision of essential drugs. 78 The ESCR Committee lists what it calls 'obligations of comparable priority', which include taking 'measures to prevent, treat and control epidemic and endemic diseases'. 79 Although other treaties address human rights of everyone, the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) specifically addresses women's human rights in the context of equality and non-discrimination. 80 State parties are enjoined to 'take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on a 68 As above. 69 As above. basis of equality of men and women, access to health services'. 81 State parties are called upon to pay special attention to rural women and ensure that among other things they have access to adequate health care, 82 including, for example, facilities for testing diabetes, blood pressure, and screening for breast and cervical cancer.
The Convention on the Rights of the Child (CRC) guarantees every child the 'enjoyment of the highest attainable standard of health and for the facilities for the treatment of illness and rehabilitation of health'. 83 State parties are called upon to take appropriate measures to ensure children access to both preventive and curative health services. 84 The Convention on the Rights of Persons with Disabilities (CRPD) guarantees persons with disabilities 'the right to the enjoyment of the highest attainable standard of health without discrimination on the basis of disability'. 85 State parties are enjoined to 'take all appropriate measures to ensure access for persons with disabilities to health services that are gender sensitive, including health related rehabilitation'. 86 At the regional level, the African Charter on Human and Peoples' Rights (African Charter) guarantees everyone 'the right to enjoy the best attainable state of physical and mental health'. 87 State parties are obliged to 'take the necessary measures to protect the health of their people and to ensure that they receive medical attention when they are sick'. 88 The Protocol to the African Charter on Human and Peoples' Rights on the Rights of Women in Africa (African Women's Protocol) obliges state parties to 'ensure that the right to health of women, including sexual and reproductive health, is respected and promoted'. 89 The treaty enjoins state parties to take appropriate measures to 'provide adequate, affordable and accessible health services, including information, education and communication programmes to women especially those in rural areas'. 90 It also guarantees women the 'right to live in a healthy and sustainable environment'. 91  calls upon state parties to 'ensure greater participation of women in the planning, management and preservation of the environment and the sustainable use of natural resources at all levels'. 92 It enjoins state parties to 'protect and enable the development of women's indigenous systems'. 93 State parties are also called upon to 'provide women with access to clean drinking water, sources of domestic fuel, land, and the means of producing food', 94 and to 'establish adequate systems of supply and storage to ensure food security'. 95 The African Charter on the Rights and Welfare of the Child (African Children's Charter) guarantees every child 'the right to enjoy the best attainable state of physical, mental and spiritual health'. 96 State parties are enjoined to take measures 'to ensure the provision of necessary medical assistance and health care to all children with emphasis on the development of primary health care'; 97 to 'ensure provision of adequate nutrition and safe drinking water'; 98 and 'to combat disease and malnutrition' 99 among children.
The Bill of Rights in the Ugandan Constitution does not expressly provide for the right to health. However, it calls upon the state to promote the social well-being of its people and in particular to ensure that all Ugandans enjoy rights and opportunities and access, among others things, to education, health services, clean and safe water, and food security. 100 The state should take all practical measures 'to ensure the provision of medical services to the population'. 101 The Constitution enjoins the state to take appropriate measures to encourage people to grow and store adequate food; to establish adequate food reserves; and to 'promote proper nutrition through mass education and other appropriate means in order to build a healthy state'. 102 In addition to the right to a clean and healthy environment, 103 the Constitution obliges the state to take all possible measures to 'prevent or minimise damage and destruction resulting from pollution'. 104 The Constitution includes an inclusive provision that renders justiciable other rights, such as the right to health, which are not expressly provided for in the Bill of Rights. 105 In the next part I interrogate the contribution of neo-liberalism to the challenge of NCDs in the country.
3 Deciphering the contribution of neo-liberalism to non-communicable diseases

Understanding neo-liberalism
The political context, which includes neo-liberal policies, has an enormous influence on the health of the population and on poverty and inequality. 106 Neo-liberalism, which has significantly contributed to creating and deepening poverty and inequalities, 107 may be traced to the regimes of Jimmy Carter and Ronald Reagan in the United States of America (USA) at the end of the 1970s and 1980s and Margaret Thatcher of the United Kingdom (UK) in the early 1980s. 108 The neo-liberal paradigm advocates a reduction in the role of the state in all economic and social spheres in order to unlock the potential of market forces. It calls for the elimination of all barriers that hinder the expansion of capitalism. Neo-liberalism is manifested in the policies of international financial institutions -the World Bank and the IMF -and the WTO, the leading global trade institution. These institutions believe that neoliberal policies promote economic conditions that will spur economic development, and integrate the local and global economies. 109 In Uganda, as in most African countries, the World Bank and the IMF imposed structural adjustment programmes (SAPs) that emphasise liberalisation, deregulation, privatisation and the compression of state budgets, foreign direct investment, and an increased role of international aid, allegedly to lift populations out of poverty. 110 According to these financial institutions, SAPs would open and liberalise trade whereby all forms of barriers are minimised or removed. African governments, including that of Uganda, were required to adopt an export-led growth strategy that would ostensibly put the countries on the road to recovery. Privatisation was touted as the main driver of growth. 111 The World Bank and the IMF imposed on these countries market-driven policies such as the privatisation of public enterprises, including water and power utilities and other socio-economic services, 112 which are critical for the realisation of the right to health. Privatisation, which included the retrenchment of civil servants, led to massive job losses and higher prices of goods and services that were unaffordable for the majority of citizens. Since the imposition of SAPs, Uganda has implemented neo-liberal policies that are market-oriented and export-led and characterised by the commercialisation or privatisation of public sector functions, 113 including health, water and agriculture. SAPs, which are based on the neo-liberal model of economic growth and development, have produced adverse consequences for health. They have largely been blamed for sacrificing public health and health care, especially for the rural and urban poor. 114

Neo-liberalism, health and non-communicable diseases
If well implemented, neo-liberal policies may lead to economic growth. However, what are the implications of neo-liberalism for health? Neo-liberal policies, which stress a reliance on the market, may lead to the increased commodification of basic social services such as health care, food, water and energy, thereby making them unaffordable for the majority of the population. 115 Neo-liberal policies adversely affect health and quality of life. Neo-liberalism, which focuses on markets for health care, ignores the fact that health moves beyond health care and encompasses social determinants of health. An emphasis on the dominance of the neo-liberal market reinforces the trend toward restricting socio-economic rights, including health. Neo-liberalism, with its emphasis on the role of the market in solving socio-economic questions, erodes the role of the state as a guarantor of these rights and converts rights into individual responsibilities and has a deleterious impact on health. As Brezis and Wiist observe: 116 The free market can harm health and health care. The corporate obligation to increase profits and ensure a return to shareholders affects public health. Such excesses of capitalism pose formidable challenges to social justice and public health. The recognition of the health risks entailed by corporation-controlled markets has important implications for public policy. Reforms are required to limit the power of corporations.
One of the tenets of neo-liberalism is that people should be responsible for most aspects of their health with minimal or no state intervention. 117 Health is viewed as an individual good to be accessed through individual or family and private health providers. As Chapman observes: 118 The neoliberal paradigm views health systems and services as commodities, that is, inputs to productivity and economic growth and sources of potential revenue, rather than as public and social goods. Neoliberal ideology also advocates for a minimal government with most social services provided by the private sector.
Although Uganda over the years has had an impressive economic growth, averaging 6 per cent, which may be attributed to neo-liberal policies implemented by the state, these policies have significantly contributed to an increase in economic and health inequalities. 119 A study by Oxfam found that the over-liberalisation of the economy is one of the key drivers of income inequality in the country. 120 Economic growth has largely been non-inclusive and, as a result, income inequality has significantly increased since the 1990s. According to Oxfam, trends in inequality indicate that Income inequality is manifested in poor people's inability to access socio-economic services, including health care. Some people with NCDs suffer in silence because they may not be able to afford the high cost of care. The responsibility for NCDs, especially their treatment and management, is left in the hands of individuals with little intervention by the state. Public health systems, which are accessible by the poor, are on the verge of collapse. 122 Private health care is accessible only by particular individuals and groups who may afford the high cost of care. 123 Neo-liberal policies, especially privatisation and liberalisation, have promoted investment in the private health sector. 124 However, private healthcare facilities largely promote curative care, with little attention being paid to primary health care, health promotion and disease prevention. The policies also promote limited individual and community participation in design and implementation, which would have revealed the actual socio-economic challenges faced by the people in accessing health care. I have argued elsewhere that neo-liberal policies, which are devoid of grassroots participation, are antithetical to the realisation of socio-economic rights of the poor, including the right to health. 125 Focusing on medical care, in my view, without tackling the structural causes of ill-health, including the socio-economic determinants of health, may in the long run be counterproductive. The government may deliver the best medical care for the treatment of diseases, including NCDs, but if it does not tackle the underlying causes of the population's poor health status, including miserable living conditions, all interventions will be in vain. The government must tackle the social determinants of health, which in effect are the conditions in which people live and work, which affect their opportunities to lead healthy lives. As Mooney correctly observes, health care must be viewed as a social institution where key social determinants of health, such as primary health care, education, food security and public sanitation, are promoted in a holistic and integrated fashion. 126  1,6 per cent. 133 It is even possible that some cigarettes and other tobacco products exported to developing and least developed countries may be of poor quality. For example, Deutsch reports that cigarettes sold in Africa are more toxic than those smoked in Switzerland. 134 International trade law thus has opened up developing country markets to tobacco exports from developed country markets. Cigarette smoking is promoted as part of the 'sophisticated' and 'cute' Western culture. Although the government has attempted to domesticate the WHO Framework Convention on Tobacco Control by enacting the Tobacco Control Act, 2015, the legislation has not been actively implemented.
Neo-liberalism, especially the liberalisation of trade in food, has contributed to a proliferation of fast food restaurants and outlets such as Kentucky Fried Chicken, Café Javas, Chicken Tonight and Java House, which serve potato chips, sausages, kebabs, chaps, fried eggs, chicken and all sorts of oil-filled food. Some of these foods, which are predominantly consumed in urban areas, have been linked to the emergence of NCDs. 135 These outlets also sell sugar and calorie-loaded chocolate and soft drinks of all types. In my view, the promotion of so-called 'zero sugar' sweetened soft or alcoholic drinks by food and beverage companies not only is deceptive, but a farce aimed at convincing consumers to purchase their products. Yet, the marketing of processed products contributes to negative changes in the dietary habits of the people. 136 Food and beverage industries promote consumerism through mass media and commercial marketing. In my view, these industries are largely interested in the maximisation of profits to meet the expectations of their shareholders and not necessarily the promotion of the population's health. The consumption of these foods may lead to obesity in children and young people, who are largely targeted by these companies through advertisements. Type 1 diabetes, which has been linked to fast food consumed by children, is on the increase in the country. 137 There is no doubt that nutrition is an important ingredient of good health. Good nutrition directly contributes to improved health and well-being. 138 However, neo-liberal agricultural policies, such as the Plan for Modernisation of Agriculture, which promotes the commercialisation of agriculture and not self-sufficiency in food, significantly contribute to persistent malnutrition and hunger in the country. 139 These policies promote land-grabbing, which has resulted in thousands, if not millions, of people driven off their lands. 140 The policies also promote the use of technology in agriculture, which largely favours large-scale farmers to the detriment of small-scale farmers who are displaced from their lands. 141 In most developing countries, including Uganda, there is an increased use of pesticides, herbicides and chemical fertilisers in commercial and small scale agriculture, allegedly to increase agricultural productivity. 142 However, the use of these pesticides and fertilisers, especially when not used properly, may have deleterious consequences for the environment and human health. 143 The majority of farmers who spray the crops, whether on individual holdings or in commercial farms, do not use safety masks, gloves and other protective gear, thereby enabling access of the pesticides in the blood stream. According to Kumari et al, 'chemical fertilizers and pesticides used over a long period of time have adverse toxic effects on the production potential of the land and the ultimate consumers of the agricultural products'. 144 For example, in Vietnam researchers found that pesticide use in agriculture was linked to NCDs. 145 Researchers found that there was illegal business in pesticides with false labels, as well as the marketing of expired or poor quality products in stores, which had adverse health consequences for the population. 146 Uganda has enough land to provide everyone with an adequate diet but, in my view, the main challenge is the unequal distribution and use of land. Instead of encouraging the population to grow organic healthy foods on the available land, the government has overly promoted the growing of cash crops such as sugar cane, coffee, tea and cotton at the expense of food production, ignoring 139 BK Twinomugisha 'Challenges for realisation of the right to food in Uganda' the fact that people cannot eat these crops. Overly concentrating on cash crops for export rather than those that feed the country's population may be counter-productive. Indigenous food crops in Uganda, such as millet, are becoming extinct in some areas of the country, because of the drive to produce cash crops. Geneticallymodified seeds, which are manufactured by Mosanto, and are promoted in developing countries to the detriment of indigenous seeds, may not be affordable to the poor. 147 The National Forest Authority (NFA) has also promoted the establishment of tree plantations such as eucalyptus and pine, which are owned by the rich and wealthy, including foreign investors, whose major interest may not be environmental conservation as such but profit maximisation from the sale of timber. These foreign tree species have a deleterious impact on the environment. For example, eucalyptus has been found to induce soil degradation and adversely affect biodiversity, sustainable cropping, and water conservation. 148 This tree species has replaced native forests and lands where communities have been growing organic foods, which have been found to be more nutritious, healthier and safer than their conventional counterparts, which have less antioxidants and more frequent pesticide residues. 149 Organic foods, including fruits, vegetables and grains, are more beneficial to the environment, as well as humans and animals that inhabit it. 150 In the next part of the article I explore the extent to which the right to health framework may be employed in efforts to tackle NCDs in the country.

Tackling the non-communicable disease trajectory: What role can and should the right to health framework play?
The right to health framework is so broad that this article does not claim to engage all its components in the discourse of NCDs in the era of neo-liberalism. However, I believe that a combination of key aspects of the right, namely, the use of juridical measures, community participation, and the gender perspective, might go a long way in 147  alleviating the NCD burden, provided that there is a strong political will on the part of government actors.

Legislative measures
Law plays a critical role in the promotion of public health. 151  The obligation to fulfil the right to health further enjoins the state to take steps, including legislative measures, to prevent, treat and control epidemics such as NCDs. The obligation to protect the right to health also requires the state to take appropriate measures, including legislation, to ensure that activities of private actors, including corporations, do not compromise the enjoyment of the right.
Parliament has the overall responsibility of making laws in the country. 154 In order to 'promote the health of persons and reduce tobacco-related illnesses and deaths', 155 and 'to protect persons from the socio-economic effects of tobacco production and consumption', 156 Parliament enacted the Tobacco Control Act, 2015 which, among others, stresses the right to a tobacco-free environment 157  advertisement, promotion and sponsorship. 158 The government has a duty to enforce this law and 'protect the public against the influence of and interference by commercial and other vested interests of the tobacco industry'. 159 Although this legislation, which seeks to fulfil Uganda's obligations as a party to the WHO Framework Convention on Tobacco Control, is progressive, there is limited enforcement of the law. There is an urgent need for government to mobilise resources for the enhanced enforcement of the law to ensure compliance. Another area requiring regulation is alcohol production and consumption. Studies have found that alcohol abuse is increasing in both rural and urban areas. According to Ndugwa et al, 164 the level of alcohol use among adults in Uganda is high and almost 10 per cent of the adult population has an alcohol abuse-related disorder. 165 Uganda has one of the highest levels of alcohol consumption in the East African region with an annual per capita alcohol consumption of 9,5 litres. 166 Alcohol abuse has been linked to NCDs and accidents. Most of the laws on alcohol use, such as the Enguli (Manufacture and Licensing) Act, 167  and mid-1960s, are outdated and outmoded and need to be revised or repealed. There is a need for alcohol control legislation that explicitly states government's public health objectives for passing the legislation. The legislation should aim at regulating affordability, hours and days of trading in alcohol, alcohol marketing, setting a minimum purchase age of alcohol, and taxation measures, drawing lessons from other jurisdictions. 169 In this vein, Betty Nambooze who introduced a private member's Bill -the Alcohol Control Bill 2016 -should be applauded and supported. Government should also actively enforce the 2017 ban on the production of alcohol in sachets.
The food and soft drinks industries also need to be regulated. The Food and Drugs Act 170 is outdated and outmoded. Legislation that promotes self-sufficiency in food, the establishment of national food reserves, and proper public health nutrition is urgently required. Local governments should also develop bye-laws on effective agricultural practices, food production, storage and processing, such as occurred in the 1960s. The Food and Nutrition Bill 2009 should be urgently resuscitated and discussed in Parliament in order to address the right to food, in a holistic fashion, taking into account NCD food-related challenges. The Bill recognises the right to food as a fundamental human right and aims, among others, at providing a legal basis for implementing the Food and Nutrition Policy. 171 The Bill creates an obligation on the government to ensure that food is available, accessible and of good quality especially for vulnerable groups, such as children, pregnant women and the elderly. 172 It also enjoins the government to ensure participation of the people in the design and implementation of food-related policies. 173 Government is also enjoined to ensure the provision and maintenance of sustainable food systems. 174 Unregulated food advertising may also contribute to the challenge posed by NCDs. Various commentators have advocated the regulation of food advertising, especially because of its link to obesity in children. 175  , which came into force on 1 July 2019, every food business operator and marketeer is prohibited from using words such as natural, fresh, original, finest, best, authentic, genuine and real. 178 The regulations prohibit companies from encouraging or condoning the excessive consumption of a particular food. In South Africa, regulations made pursuant to the Foodstuffs, Cosmetics and Disinfectants Act provide maximum limits for food, including bread, breakfast cereal and porridge, processed meat, savoury snacks and potato chips. 179 In 2016 Chile implemented a law which was directed at children below the age of 14 years. 180 The law required front-package labels, restricted advertising directed at children, and banned the sale in schools of all foods and beverages containing added sugars, sodium or saturated fats that exceeded set nutrient or calorie limits. 181  exceeding cut-offs decreased from 90,4 per cent to 15 per cent in 2016. 183 Thus, Uganda needs legislation that controls or regulates the pervasive advertisement and marketing of sugar-sweetened beverages and other unhealthy food. Higher taxes should also be imposed on these food and beverages to make them less affordable.
Some of the food and beverages on the market may also be counterfeit. A recent study by the Uganda National Bureau of Standards (UNBS) found that 54 per cent of products on the Ugandan market, including food and cosmetics for women, are either counterfeit or substandard. 184 Parliament should debate and pass the Anti-Counterfeit Bill, 2015, after addressing concerns by civil society organisations that the proposed law may limit access to generic drugs which, because of their relative affordability, are essential in the treatment of NCDs. In order to enhance access to medicines, Parliament should also engage the government to utilise TRIPS flexibilities such as compulsory licensing and exploitation of patents by government, which were incorporated in the Industrial Property Act, 2014. 185 Parliament indeed can play a significant role in the promotion of the right to health by legislating against supply factors that exacerbate the NCD challenge. However, as the WHO and the United Nations Development Programme (UNDP) caution, legislators should be aware of the lobbying power of large tobacco, alcohol, food and beverages companies that are likely to thwart any efforts by Parliament to curtail their activities. 186 The WHO and the UNDP have outlined essential elements of legislation on tobacco control, the harmful use of alcohol, an unhealthy diet, physical inactivity and an unhealthy environment. 187 These include increasing taxes on tobacco, alcohol, and sugar-sweetened beverages; regulating advertising, the promotion and sponsorship of ultra-processed foods and beverages; and nutrition labelling on proceed foods and beverages. 188 Civil society organisations (CSOs) engaged in tobacco control must hold government accountable to ensure that it resists Tobacco control advocates should also be aware of the fact that tobacco companies are well-resourced and are litigious. Thus, there is a need for defence lawyers -usually government lawyers or state attorneys -to anticipate the likely arguments and strategies of the tobacco industry and to adequately prepare to counter them at an early stage. In order to augment efforts by government lawyers, CSOs, engaged in tobacco control advocacy, may also apply to court to be joined as parties to the suit. A person or professional, with experience in tobacco control strategies, may also apply to court for leave to join the suit as an amicus curiae. CSOs should engage the media to ensure that any 'shady' or suspect transactions involving the tobacco industry in respect of the suit are duly investigated and exposed. CSOs should sensitise judicial officers and lawyers about the provisions of the WHO Framework Convention on Tobacco Control and the Tobacco Control Act.

Constitutional rights litigation
Using examples from India, Columbia and the United States, Magnusson et al illustrate how constitutional rights provisions may be used to challenge actions or omissions by governments and corporations, which are harmful to health. 189 Litigation may be used to hold the relevant industry actors to account for harm caused by their health-related products. 190 The Constitution confers a right on any person who claims that a fundamental right or other freedom guaranteed under the Constitution has been infringed or threatened to petition a competent court for redress, including compensation. 191 The Human Rights Enforcement Act, 2019, permits such a person to apply to the High Court for redress. 192 Indeed, some public-spirited individuals and organisations have challenged violations of health-related rights. 193  the rights to life and health. The Constitutional Court dismissed the petition on the ground that it raised political questions into which the Court could not inquire. However, on appeal 195 the Supreme Court referred the case to the Constitutional Court to be determined on its merits. It held that courts have the constitutional mandate to inquire into socio-economic human rights such as the right to health beyond the strict interpretation of the doctrines of separation of powers and political question, and that courts can adjudicate matters of social policy decided by the political branches of the state, namely, the executive and the legislature.
Activities of tobacco companies have also been challenged through litigation using the right to a clean and healthy environment. In 196 the applicants alleged that the activities of the first respondent, which included tobacco processing, the emission of tobacco smoke, dust and smell, violated their right to a clean and healthy environment, which is guaranteed by the Constitution. 197 Counsel for the respondents raised a preliminary objection that there was no cause of action since the applicants had not suffered personal injury. The Court cited the cases of British American Tobacco Ltd v The Environmental Action Network 198 and Advocates for Development and Environment v 199 where the Court held that the purpose of article 50(2) of the Constitution is to enable an individual or organisation to protect the rights of others, especially the indigent and vulnerable, although they have not suffered personal injury or a violation of their rights. 200 The Court dismissed the preliminary objection and held that the respondents had violated the applicant's right to a clean and health healthy environment.

Asiimwe & Others v Leaf Tobacco and Commodities (U) Ltd & Another
In yet another case, that of BAT Uganda Limited v Attorney-General and Centre for Health, Human Rights and Development, 201 the petitioner, a tobacco company, challenged the constitutionality of several provisions of the Tobacco Control Act, 2015, including those requiring large picture health warnings, the banning of smoking in public places and workplaces, the banning of all tobacco advertising, promotion and sponsorship, and the prohibition of the sale of tobacco products in specified places. The petitioner argued that these provisions, among others, violated the right to practise a lawful trade, business or occupation. 202 The Court held that the petitioner's rights were not absolute since they can be limited in the public interest, which includes the protection of public health. 203 Owiny-Dollo DCJ held as follows: 204 This petition, I have no doubt in my mind is part of a global strategy by the petitioner and others engaged in same or related trade to undermine legislation in order to expand the boundaries of their trade and increase their profits irrespective of the adverse health risks their products pose to human population … The petitioner admits that its products when used in accordance with their instructions result into serious adverse effects to their users and others. They also concede that the products they manufacture and sell cause death. Legislation such as the Tobacco Control Act that seeks to protect the public from the adverse effects of the petitioner's products cannot be said to be unconstitutional.
There have also been attempts at challenging the activities of food and beverage companies. In Centre for Food and Adequate Living v Attorney-General & Another, 205 which has not yet been decided, the applicants allege that the government's failure and omission to restrict the marketing, broadcasting and advertisement of unhealthy foods to children is a violation of the rights to adequate food, health and safety of the children. The applicants are asking the Court for orders, among others, banning the marketing, broadcasting and advertisement of unhealthy food to children.

Community participation in the prevention and treatment of non-communicable diseases
Participation, which is a cardinal component of the right to health, is recognised in various international, regional and national human rights instruments. 206 Participation in the context of this discussion means that citizens have genuine ownership and control over NCD policy development processes at all stages: analysis, design, planning, implementation, monitoring and evaluation. Participation entails active and genuine involvement of citizens in identifying their problems and designing appropriate interventions through collaboration with different stakeholders, including government and its relevant agencies. Thus, participation in the prevention, treatment and management of NCDs does not mean that citizens should depend entirely on their own resources without external support. Government should marshal, invest and direct financial, human and other resources, including seeking international assistance, for integrated preventive and curative care in the context of NCDs and in the spirit of primary health care. Building on their resilience, ingenuity and agency, citizens should be empowered with relevant public health education and information so that they may demand accountability from the state and non-state actors involved in NCDrelated programmes. Genuine and active participation should promote citizens' consciousness and awareness of their human rights, including the right to health, to enable them to express their views, interests, grievances and concerns towards the state and other duty bearers.
The challenges posed by neo-liberalism in the context of NCDs are not insurmountable. Building on the philosophy informing the Alma-Ata Declaration, 207 government should look at neo-liberal economic policies not only in terms of how they promote economic growth but how they impact on the health and welfare of the people. It should devise health policies that lead to the empowerment of the population and facilitate their active participation. However, as the experiences of China 208 and Mexico 209 illustrate, for a community participation approach in tackling NCDs to be effective, there should be enhanced support for education, information and communication interventions in the community. Community health centres, especially Health Centres III and IV, should be utilised in NCD detection, diagnosis, treatment and management. The government should create incentives, including transport costs and accommodation, in order to attract a greater number of qualified health professionals at all levels, including in areas that are difficult to reach. Village health teams, which are focused largely on infectious diseases and maternal-child health, might be utilised by health professionals in 207 Alma-Ata Declaration (n 206 community prevention and the management of NCDs. 210 There should be an increased investment in public healthcare goods and services, including essential medicines, at all health centres. This entails that government should increase its expenditure on health to the target of 15 per cent as agreed in 2001 by African Union (AU) countries in Abuja to ensure that primary health care is prioritised. 211 The right to participation additionally requires that communities should be able to determine which food to produce and the farming methods and techniques. Participation implies that food sovereignty, and not necessarily the commercialisation of agriculture, should be promoted. Food sovereignty has been defined as the right of peoples to healthy and culturally appropriate food produced through ecologically sound and sustainable methods, and [people's] right to determine their own food and agricultural systems. It puts the aspirations and needs of those who produce, distribute and consume food at the heart of food systems and policies rather than the demands of markets and corporations. 212 Food sovereignty goes beyond ensuring that people have enough food to meet their physical needs. 213 People should be empowered to produce and enjoy healthy and culturally-appropriate food. Their local production systems should be promoted and supported. Rural women should have power over the seed and be able to pass it over from one generation to the next. Trade liberalisation of seed production, which favours transnational corporations such as Mosanto, should be revisited. Fast food may be dangerous to a person's health. Thus, local, traditional and organic food production and consumption should be prioritised, encouraged, promoted and supported. The state should, through land reform, ensure that peasants and landless people have access to land. They should be empowered to demand seeds and access to water as a public good.

A gender perspective in non-communicable disease prevention and management interventions
According to Vlassof, the concept of gender 'refers to the array of socially-constructed roles and relationships, personality traits, attitudes, behaviours, values, relative power and influence that society ascribes to the two sexes on a differential basis'. 214 The WHO defines gender in terms of 'the roles, behaviours, activities, attributes, and opportunities that any society considers appropriate for girls and boys, and women and men'. 215 The gender perspective is critical in analysing how public health challenges such as NCDs affect women and men in the era of neo-liberalism. The perspective is also crucial in assessing how government responds to these challenges. In fact, the ESCR Committee has urged states parties to integrate a gender perspective in their health-related policies, planning and research in order to promote better health for both women and men. A gender-based approach recognizes that biological and sociocultural factors play a significant role in influencing the health of men and women. The disaggregation of health and socio-economic data according to sex is essential for identifying and remedying inequalities in health. 216 Studies have found that women and men have different levels of exposure and vulnerability to NCD risk factors. 217 The WHO observes that NCDs are the leading cause of death among women globally and are responsible for two in every three deaths among women annually. 218 The role of women in the household may expose them to air pollution -an important contributing risk factor to NCDs. 219 According to the WHO, household air pollution causes NCDs, including respiratory disease and lung cancer. 220 According to USAID, 'due to their domestic roles, women and girls tend to be more exposed to the smoke, dust and soot caused by cooking solid fuels'. 221 They are exposed to second-hand smoke, which is a known risk factor for NCDs. 222 Pregnant women may also experience a series of NCDs related to their reproductive functions, for example, an increase in blood pressure. 223 USAID has observed that gender relations 'affect accessibility to preventive care and treatment for NCDs'. 224 The underlying 'genderrelated power inequalities have implications for NCD treatment, as women and girls may depend on their husbands or partners for health care decision-making, access and expenditures'. 225 Although studies reveal that women are more likely to seek health care than men, other factors such as income poverty may inhibit their access to health care. 226 Women experience fewer apparent symptoms of cardiovascular diseases than men and, consequently, are less likely to be diagnosed and treated. 227 The majority of the world's poor are women, who are least able to afford funds for NCD treatment. When a household has money available for health care, these funds may be spent on men's health needs. 228 Women may also have an unequal say in decisions pertaining to health expenditures. 229 Women often are sole caregivers for those with NCDs and their care-giving and other types of informal work are unpaid or underpaid. This situation may be exacerbated by neo-liberal policies that impose charges for health care, including NCD prevention, treatment, care and support.
Thus, integrating a gender perspective in health interventions is critical since NCDs affect men and women differently. There are even gender-specific NCDs, which require specifically-designed interventions. For example, while some women suffer from cervical cancer, prostate or testicular and penile cancers are specific to men. Thus, as USAID has recommended, it is critical that data should be collected for men and women disaggregated by sex, and analysed through a gender perspective. 230 Policies and other interventions based on this data should address the different NCD prevention, screening, treatment and management needs of men and women. All these policies and interventions should be guided by the right to health framework.

Conclusion
The main objective of the article was to reflect on how the right to health framework may be used to tackle non-communicable diseases in the era of neo-liberalism in Uganda. The state has obligations to respect, protect and fulfil the right to health. As part of its obligation to protect human rights, the state should ensure that activities by private persons, including tobacco, alcoholic, food and beverage industries, do not adversely affect the realisation of the right to health. The state should devise juridical, administrative and other appropriate measures to ensure that activities of these industries do not escalate the NCD trajectory in the country. Such measures should target unhealthy commodity industries as the major drivers of NCDs through regulation, taxation, pricing, product bans, and restrictions on advertising and sponsorship.
Current prevention, control and management efforts that frame the question of NCDs as apolitical by focusing primarily on individual behaviour or lifestyle changes are likely to fail unless structural factors that shape the NCD burden are tackled. Prevention measures through lifestyle changes are critical for the patient and health system. A person's choice and behaviour play a crucial part in explaining the outset of NCDs. However, the political, economic and social context in which the diseases are located and reproduced cannot be ignored. The role of the social determinants of health, including poverty, gender and social inequalities, the level of education, nutrition, and environmental conditions, should be recognised. The contribution of processes such as trade liberalisation and the marketing activities of transnational corporations to the burden of NCDs should also be recognised.
Under neo-liberalism, public health has been moved into the private sphere. The state must intervene and reclaim its place in the socio-economic sphere. Neoliberal policies of privatisation and liberalisation should be revisited. In the absence of social protection measures and other safety nets, there is an urgent need to treat health as a public good especially for the poor and vulnerablethose who cannot by their own means afford the high cost of NCDrelated care. Heavily-subsidised universal health insurance may also be considered. The production and consumption of locally-produced organic foods should be promoted. Thus, the food sovereignty of the people should be promoted. Small-scale farmers should be supported with the necessary agricultural implements to enable them produce sufficient food for their families. The government may even consider the delicate and complex question of land redistribution to ensure that peasants, rural women and landless people have access to and control of land for food production.
Gender relations affect accessibility to preventive care and treatment for NCDs. The underlying gender-related power relations and inequalities have implications for NCD prevention and treatment. Thus, a gender perspective should be incorporated in all health policies and other interventions since NCDs may affect men and women differently. Communities should be empowered to ensure that they may meaningfully participate in NCD related interventions.