The Right to Health: Guarantees Under International Human Rights Law Vis-à-Vis Gambian Standards

ABSTRACT

This article explores the guarantees afforded to the right under international human rights law and critically assesses the extent to which these said guarantees translate municipally, having regard to The Gambia’s legal and policy frameworks on health. The paper begins with a critical survey of the international legal framework—instruments, precedents, and other soft law—defining and guaranteeing the right to health, in addition to pointing out the legal shortfalls in the 1997 Constitution as regards the right to health. The article further identifies The Gambia’s various obligations under international law with respect to the right to health and appraises The Gambia’s compliance with these obligations, having regard to specific relevant data. In addition, the article argues that the non-justifiability of the right to health is not justified and calls for the reform of the law in this respect. The article concludes by noting that, although The Gambia has registered successes in giving effect to the right to health, there still remains great challenges, and in this regard, proffers several recommendations.

Introduction

The right to health is fundamental human right that is recognised under international human rights law.[1] This right is guaranteed under several universal and regional human rights instruments.[2]

However, the right to health, being part of the socio-economic rights, is classified as a second generation right,[3] the legal effect of which is that the right’s enforcement is dependent on the available State resources.[4]

As such, many African States like The Gambia have excluded the right to health under the set of legally enforceable rights.[5] In The Gambia, there is no explicit provision under our Bill of Rights[6] that directly guarantees the right to health as a legally enforceable right.[7]

This right, aside the indirect protection by provisions such as Sections 21, 31 & 33 of the 1997 Constitution, is merely captured under the Directive Principles of State Policies.[8] Although Section 216 of the Constitution enjoins the State to endeavour to provide “adequate health and medical service”,[9] Section 211 of the same Constitution makes such non-justiciable.

Section 211 hinges the right on the notion of progressive realisation and, therefore, subjects the right to the “limits of the economic capacity and development of The Gambia.”[10] This notwithstanding, there is adequate authority under international human rights law to the effect that States must  give effect to second generation rights (i.e socio-economic rights), of which the right to health is one, at least to the minimum core.[11] I shall return to this later, but before then, I will first explore the legal framework on the right to health.

The international legal framework on the right to health

In his Droit International De La Sante, M. Belanger opined that the right to health is not part of customary international law.[12] However, the right, as Belanger rightly recognised, is protected under several international instruments,[13] such as the African Charter on Human and Peoples’ Rights (Art. 16), the International Covenant on Economic Social and Cultural Rights (Art. 12), the Convention on the Elimination of All Forms Racial Discrimination (Art. 5 (e) (iv)), the Convention on the Rights of the Child (Art. 24), the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families (Art. 28, Art. 43 (e) & Art. 45 (c)) and the Convention on the Rights of Persons with Disabilities (Art. 25). It is indeed noteworthy that The Gambia has ratified all the said instruments.[14]

My focus, however, shall be on the ICESCR and the African Charter. The ICESCR has been described as arguably the most eloquent on the protection of the right to health.[15] Article 12 of the ICESCR enjoins State Parties to the Covenant to “recognise the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”[16]

Paragraph 2 further requires State Parties to take steps to ensure the full realisation of the right to health, including provisions for the reduction of stillbirth rates and infant mortality, improvement of all aspects of environmental and industrial hygiene; prevention, treatment and control of epidemic, endemic, occupational and other diseases; and the creation of conditions which would assure to all medical service and medical attention in the event of sickness.[17]

At the regional level, Article 16 of the African Charter, which seems to be modelled on Article 12 of the ICESCR, speaks almost the same language. Article 16 of the Charter provides that every individual shall have the right to enjoy the best attainable state of physical and mental health, and that State Parties to the Charter shall take the necessary measures to protect the health of their populations   and ensure that they receive medical attention when they need.[18]

 As a State Party to both the ICESCR and the African Charter, The Gambia is bound to give effect to the provisions of both Article 12 of the ICESCR and Article 16 of the African Charter.[19] Although it has taken huge steps in terms of domesticating human rights instruments,[20] The Gambia, like many other States in the region, has failed to recognise the right to health as an enforceable right.[21]

Also, the effect of the right not being part of customary international (which is part of common law)[22] is that the right’s enforcement cannot be invoked by virtue of Section 7 (d) of the Constitution. However, and notwithstanding The Gambia’s dualist leaning, the Supreme Court, in The State v. Yankuba Touray,[23] noted that courts could have regard for contents of human rights instruments generally, even if not domesticated.[24]

Thus, the non-recognition of the right to health as an enforceable right and its subordination to a mere element of the Directive Principles does not make relevant provisions of international instruments and pronouncements of human rights bodies utterly immaterial in construing the right to health at the domestic level.

What is the right to health?

In The Gambia and elsewhere in Africa, people often reduce the right to health to the right to be healthy, the right to access healthcare or buildings of the hospitals and other medical infrastructure.

However, the right to health extends further, and covers all such factors that can help us lead a healthy life, which factors are often called the underlying determinants of health.[25] In 2000, the UN Committee on ICESCR issued General Comment No. 14, which has, over the years, become a leading interpretative authority on the right to health.[26]

According to the Committee, “the right to health is not to be understood as the right to be healthy.”[27] Instead, it entails each person’s entitlement to benefit from underlying determinants of health, such as access to safe and portable drinking water, adequate supply of food, healthy housing, safe occupational and environmental conditions, access to health-related education, and freedom from unwarranted medical treatment.[28]

Similarly, in its Guidelines and Principles on Economic, Social and Cultural Rights[29] codified in 2011, the Working Group of the African Commission made similar clarifications.[30] In Free Legal Assistance Group and Others v Zaire,^[31] the African Commission on Human and Peoples’ Rights noted that the failure of the State to provide basic services, such as, safe drinking water and electricity, and the shortage of medicine amounted to a violation of Article 16 of the African Charter.[32]

From the above, it could be legitimately maintained that the right to health extends further than the average Gambian thinks. Often, when Gambians talk about the right to health, they decry inadequate and sub-standard medical infrastructure, limited and incompetent personnel, and medical misconduct.

However, although all of the said issues touch on the right to health, the right to health must not be understood as squarely falling within those issues alone; it extends to the quality of our food, water, housing, environment, and health-related education.

In this regard, the Ministry of Health, although a principal agent, must not be seen as the sole State agency responsible for our health. Given the definition of the right to health under both General Comment No. 14 and the Guidelines, it is apparent that other State agencies such as the National Water and Electricity Company (NAWEC), the National Nutrition Agency (NaNA), National Food Safety and Quality Authority (FSQA), the Medicine Control Agency (MCA), the National Environment Agency (NEA), local government authorities, among other State agencies, all have a role to play in giving effect to the right to health.

Thus, the State may be in breach of the right to health if one of its agencies, say, NEA or a local government authority, pollutes or allows another person to pollute the environment, for example, with chemical substances or toxic fume.

The Gambia’s obligations with respect to the right to health

In Social Economic Rights Action Centre & Anor v. Nigeria,[33] the African Commission on Human and Peoples’ Rights noted at paragraph 44 that:

“internationally accepted ideas of the various obligations engendered by human rights indicate all rights—both civil and political rights and social and economic—generate at least [three level of duties] for a State that undertakes to adhere to a rights regime, namely the duty to respect, protect…and fulfil these rights. These obligations universally apply to all rights and entail a combination of negative and positive duties.”[34]

In light of the foregoing, The Gambia’s obligations with respect to the right to health are threefold, namely:

• obligation to respect;
• obligation to protect; and
• obligation to fulfil

Obligation to respect

The obligation to respect requires The Gambia to refrainfrom interfering directly or indirectly with the right to health.[35] In line with this, The Gambia is obliged to, for example, refrain from denying or limiting access to healthcare services as well as from withholding, censuring or misrepresenting health information.[36]

Obligation to protect

The obligation to protect requires The Gambia to prevent third parties, say, pharmaceutical companies and other private health service providers, from interferingwith the right to health.[37]

In line with this obligation, The Gambia is obliged to adopt legislative and other measures to ensure that private actors (eg. pharmaceutical companies, private medical establishments, private medical practitioners, etc) conform with human rights standards when providing health care services.[38]

The obligation to protect also requires The Gambia to control the marketing of medicines and medical equipment by private actors, and protect individuals from acts of third parties that may be harmful to their health.[39]

The enactment of the Women’s (Amendment) Act, 2015, prohibiting Female Genital Mutilation (FGM), and the establishment of the Medicines Control Agency and the Food Safety and Quality Authority under the Medicines and Related Products Act, 2014, and Food Safety and Quality Act, 2011, respectively, are all significant strides among many others in fulfilment of this obligation.

However, and quite displeasingly, the death of at least seventy-three (73) children who allegedly consumed a contaminated syrup manufactured by Maiden Pharmaceuticals Ltd and allegedly imported into The Gambia by Atlantic Pharmaceuticals leaves an apparent and indelible stain on The Gambia’s full fulfilment of the duty to protect.

Obligation to fulfil

In addition to the above obligations, The Gambia also has an obligation to fulfil the right the right to health; this implies that The Gambia is obliged to adopt legislative, administrative, judicial, budgetary and other measures to ensure the full realisation of the right to health.[40]

In line with this obligation, The Gambia must, for instance, ensure the provision of health care services (including immunisation programmes against infectious diseases), and must also ensure equal access for all to the underlying determinants of health, including but not limited to safe and nutritious food, portable water, sanitary living conditions,[41] etc. The Gambia has taken remarkable steps in terms of ensuring equal access to healthcare as well as making available portable water and sanitation.[42]

However, we must not lose sight of the challenges; as at 2021, the public health sector’s health workforce index for skilled health human resource nationally stood at 1.53/1000pop or 15.3/10000 pop against WHO’s 4.45/1000 pop.[43]

As regards to immunisation, the 2021 Annual Service Statistics Report shows “that all of the antigens have national coverage above 80% in 2021 except for the first dose of Measles-Rubella vaccine which was 79.5%.”[44] This is apparently below the 90% target for vaccination in children,[45] and WHO has observed that this resulted in an estimated 15,391 under-immunised children and 15,391 zero-dose children.[46]

In light of this, it has been submitted that is important for The Gambia to increase its vaccination coverage through routine immunization while also considering how to implement catch-up vaccination strategies in the country to ensure that no children are left unprotected from vaccine-preventable diseases into the future.[47]

The right to health & the minimum core

The Committee on Economic, Social and Cultural Rights noted that, although States are to progressively ensure the realisation of the right to health, they are nonetheless to ensure that the right is fulfilled at least to the minimum core.[48] The Committee recognised that the right to health imposes obligations on States to ensure the availability, acceptability, accessibility, and quality of healthcare services for all, particularly the vulnerable (eg. children and women) and marginalised groups.[49] In this regard, the Committee identified the minimum core obligations of the right to health to include at the very least obligations to:

1. Ensure the right of access to health facilities and services on non-discriminatory basis, particularly for vulnerable and marginalised groups;[50]
2. Ensure access to minimum essential food which is nutritiously adequate and safe;[51]
3. Ensure access to basic shelter, housing and sanitation, and an adequate supply of safe and portable water;[52]
4. Provide essential drugs, as from time to time defined under the WHO Action Programme on Essential Drugs;[53] and
5. Ensure equitable distribution of all health facilities and services.[54]

On access to health facilities and services, a study by Health Policy Plus indicates that all of the population in The Gambia lives in close proximity to a fixed health facility and most have road access, though this could be impeded during the rainy season.[55]

However, 28% of the women responding to The Gambia Demographic and Health Survey 2013 reported that “distance to health facility was a barrier to accessing [health] care.”[56] The survey further indicates that only about 40% of rural villages have access to services by a community health worker.[57]

On access to essential food, The Gambia National Food Security Survey 2023 indicates that three (3) households out of ten in The Gambia (29%) are food insecure, representing a 3% increase from 2022.[58] The survey further reveals that food insecurity is significantly higher in rural areas (52%) compared to urban areas (21%).[59]

On access to water and sanitation, The Gambia Multiple Indicator Cluster Survey 2018 indicates that 90.4% of households in The Gambia have access to improved sources of drinking water[60] and 61.8% of the population has access to improved sanitation.[61] However, Escherichia coli (E. coli) bacteria has been detected in the drinking water of 73.2% of households,[62] with risk ranging from low (<1 E. coli per 100 mL), to moderate (1-10 E. coli per 100 mL), high (11-100 E. coli per 100 mL) and very high risk (>100 E. coli per 100 mL).[63] On housing, the housing shortage was estimated to be 128, 874 dwelling units by 2021.[64]

Equitable distribution of health facilities and services has been a challenge in The Gambia. The 2021 Service Statistics Report indicate that there were eight (8) hospitals and six (6) major health centres and a total of forty (40) minor health centres spread across the regions.[65] Although it is believed that health facilities are concentrated in the Greater Banjul Area, I do not have the data to back such claim. However, what remains undisputed is that qualified medical personnel and equipment are concentrated in the Greater Banjul Area.[66]

Non-justiciability of the right to health: how justified?

As noted earlier, The Gambia, merely classifies the right to health as an element of the Directive Principles under Section 216 of the 1997 Constitution and these Principles are not justiciable by virtue of Section 211 of the Constitution. Some scholars have made a case in favour of the classification of the right to health (and other socio-economic rights) as part of the Directive Principles on the ground that these rights are not amenable to judicial interpretation.[67]

Scholars such as Fuller have justified the non-justiciability of the right to health on the basis that it is a positive right that requires the State to invest substantial resources to ensure the realisation of the right.[68]

To this end, it has been argued that courts are not competent to adjudicate on socio-economic rights (of which the right to health is one) since they require the raising and spending of State resources,[69] which duty is budgetary and constitutionally of the National Assembly.[70] Those that share this view, therefore, maintain that adjudicating socio-economic rights will undermine the doctrine of separation of powers.[71]

However, a potent counterargument (which I believe to hold so much weight) is put forward by E. Durojaye;[72] the learned author rightly observed (and I quite agree) that the implementation of civil and political rights is NOT LESS EXPENSIVE than the implementation of socio-economic rights.[73] The learned author quite aptly posited thus:

“[T]he right to a fair hearing requires equipping the police system, building courts and recruiting competent judicial officers to dispense justice. All of this requires a substantial amount of resources [so much as, if not more than, the right to health and other socio-economic rights do].”[74]

Recommendations

While recognising the significant strides The Gambia has made in giving effect to the right to health in recent years, it must equally be appreciated that there still remains some fundamental gaps. It is with this in mind that I humbly recommend as follows:

The right to health be made justiciable under the Constitution

While this may sound too ambitious in light of The Gambia’s apparent economic constraints, I believe that the right to health may not be more expensive than some of the rights made legally enforceable under the Constitution.

Just like E. Durojaye argued, the resources required for the fulfilment of the right to health may not be more than those required to give effect to the right to fair trial, for example.[75] In Africa, South Africa[76] and Kenya,[77] for instance, recognise the right to health as enforceable in their respective Constitutions. Making the right justiciable enhances its protection, as the courts can in that case be approached for the right’s interpretation and enforcement.[78]

This recommendation would be taken care of if The Gambia’s Draft Constitution, 2024 is promulgated into law; the Draft Constitution recognises the right to health under Section 54 (which seems to be modelled on Article 27 of the Kenyan Constitution, 2010),[79][80] the right of the elderly under Section 55, and the right of the sick under Section 58.

Support the relevant entities such as the MCA, FSQA, etc

In addition to the above, the Government of The Gambia should increase its support to key stakeholders such as the Medicines Control Agency, the Food Safety and Quality Authority, and the National Environment Agency, among others; these entities should be supported with the necessary equipment and staffed with the right personnel to effectively discharge their respective mandates.

The MCA should, for instance, be equipped with the right instruments and given the need facilities in order to enable the Agency carry out its mandate of regulating the efficacy, quality, and safety of medicines and related products as well as regulate the importation, manufacture, labelling, sale, storage and distribution of medical products.

A check on corruption

As a societal menace, corruption does not spare the health sector too. Durojaye pointed out that in many African countries, resources meant for social development and wellbeing of the people are either misappropriated or stolen by officials, thereby contributing to the poor quality of health care.[81]

In The Gambia, for instance, in 2022, “[t]he National Audit Office…revealed indications of mismanagement of Covid-19 response funds, noting that proper processes and procedures were not followed in the procurement and distribution of medical and food items.”[82]

According to the Transparency International 2023 Corruption Perceptions Index,[83] The Gambia is ranked the 98^th least corrupt nation out of 180 countries.[84] While this ranking suggests a marked improvement as compared to the 2022 ranking, it apparently shows that corruption is still prevalent in The Gambia.

A report[85] has shown that in countries where corruption is prevalent, the poor and the people who live in the rural areas tend to experience longer waiting hours in hospitals or even access medical attention.[86] Also, a 2011 study analysing data from 178 countries estimated that the deaths of approximately 140, 000 children per year could be indirectly attributed to corruption.[87] With this in mind, The Gambia Government, consistent with its obligations under international law, should adopt the appropriate measures to combat corruption.

Decentralise health facilities and services

In the 2021 Annual Service Statistics Report, the Health Management Information System Unit critically pointed out that “in [The] Gambia, the majority of qualified medical personnel are concentrated in the Greater Banjul Area, with only a few specialists ready to work in rural areas. This factor, combined with a lack of medical equipment, is compromising safe delivery services in remote areas.”[88]  

In light of the foregoing, the Gambia Government should intensify its efforts to decentralise health facilities and services by constructing more health facilities in rural Gambia and should equip these facilities with qualified personnel, including those capable of providing specialist services and conducting complex medical procedures, particularly in cases of emergency.

Sensitisation

The citizens and the key stakeholders should be enlightened about the right to health and the various obligations it engenders on the part of the State as duty-bearer. As is the case with other rights, an enlightened citizenry is necessary for upholding the right to health.

Conclusion

In conclusion, the above analysis shows both challenges and progress. Although The Gambia has taken significant steps in meeting its obligations under international law as regards the right to health, the lapses remain manifest; shortage of medical personnel, limited infrastructure, poor sanitation, corruption, among other factors, continue pose a challenge to the full realisation of the right to health.

Apparently, a close examination of the minimum core obligations of the right to health vis-à-vis the prevailing health realities suggests the need for improvement. With this in mind, I call on the Government of The Gambia to consider swift and comprehensive legal reforms, increase its support to key stakeholders, bolster its stance against corruption; and continue to enlighten the citizenry about their basic rights, particularly the right to health, the obligations it genders, and all that it entails.

REFERENCE:

1. Municipal Legislations
   • Constitution of the Republic of The Gambia, 1997
   • Constitution of the Republic of South Africa, 1996
   • Constitution of the Republic of Kenya, 2010
   • The Medicines and Related Products Act, 2014
   • The Food Safety and Quality, 2011
   • The Women’s Act, 2010
2. International Instruments
   • The International Covenant on Economic, Social and Cultural Rights
   • The African Charter on Human and People’s Rights
   • The Convention on the Elimination of All Forms Racial Discrimination
   • The Convention on the Rights of the Child
   • The International Convention on the Protection of the Rights of All Migrant and Members of Their Families
   • The Convention on the Rights of Persons with Disabilities
3. Precedents
   • The State v. Yankuba Touray SC. NO CR/001/2020
   • Social Economic Rights Action Centre & Anor v. Nigeria 47(2001) AHRLR 60 (ACHPR 2001) 
   • Free Legal Assistance Group and Others v Zaire (2000) AHRLR 74 (ACHPR 1995)
   • Minister of Health Others v Treatment Action Campaign and Others 2000 11 BCLR 1169 [CC]
4. General Comments/ Principles/ Guidelines/ Pronouncements of HR Bodies
   • General Comment No. 14. Geneva: UN Committee on Economic, Social and Cultural Rights. 2000
   • Principles and Guidelines on the Implementation of Economic, Social and Cultural Rights in the African Charter on Human and Peoples’ Rights (African Commission Principles and Guidelines), adopted in 2010 and formally launched in 2011. Available here 31^st August, 2024
   • Office of the United Nations High Commissioner for Human Rights, Fact Sheet No.31 (The Right to Health)
5. Books
   • J. H. Curie, Public International Law (2nd Edn., Irwin Law Inc. (2008)
6. Reports
   • The Transparency International 2023 Corruption Perception Index available here accessed on the 1st September, 2024
   • The National Human Rights Commission State of Human Rights in The Gambia—2020 Report available here accessed on the 31st August, 2024
   • The Gambia Bureau of Statistics, The Gambia National Food Security Survey Report 2023
   • The Gambia Bureau of Statistics, The Gambia Multiple Indicator Cluster Survey Report 2018
7. Articles
   • Sine, J., P.P. Saint-Firmin, and T. Williamson, Assessment of the Health System in The Gambia: Overview, Medical Products, Health Financing, and Governance Components (Washington, DC: Palladium, Health Policy Plus, 2019)
   • L. Fuller, The forms and limits of adjudication (Harvard Law Review (1978) 92)
   • E. Durojaye, The Approaches of the African Commission to the Right to Health under the African Charter (Community Law Centre, University of the Western Cape)
   • M. Belanger, Droit international de la santé, Paris, 1983
   • G. Pascale, The Human Right to Health under the African Charter on Human and Peoples’ Rights: An Evaluation of Its Effectiveness (University of Bergamo)
   • A. Thoronka, Gambia Audit Office Reveals Mismanagement of Covid-19 Response Funds (The Fatu Network, 22^nd April, 2022) available here/ accessed on the 1^st September, 2024

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[1] Art. 16 of the African Charter on Human and Peoples’ Rights; Article 12 of the International Covenant on Civil and Political Rights; Article 24 of the Convention on the Rights of the Child

[2] ibid

[3] J. H. Curie, Public International Law (2^nd Edn., Irwin Law Inc. (2008)) pp. 420-432

[4] Office of the United Nations High Commissioner for Human Rights, Fact Sheet No.31 (The Right to Health) p. 5 available here accessed on the 31^st August, 2024

[5] E. Durojaye, The Approaches of the African Commission to the Right to Health under the African Charter (Community Law Centre, University of the Western Cape) p. 400

[6] Chapter IV of the 1997 Constitution of The Gambia contains the various enforceable rights

[7] The right to health is not captured under Chapter IV of the 1997 Constitution; it is merely captured as part of the Directive Principles under Section 216 of the 1997 Constitution

[8] Section 216 of the 1997 Constitution

[9] ibid

[10] ibid, at Section 211

[11] ibid, supra note 4, at p. 25

[12] M. Belanger, Droit international de la santé, Paris, 1983; G. Pascale, The Human Right to Health under the African Charter on Human and Peoples’ Rights: An Evaluation of Its Effectiveness (University of Bergamo) p. 2

[13] ibid, supra note 1

[14] The National Human Rights Commission of The Gambia, State of Human Rights in The Gambia—2020 Report (available here accessed on the 31st August, 2024)pp. 11-12

[15] ibid, supra note 11, at p. 9; also see E. Durojaye, The Approaches of the African Commission to the Right to Health under the African Charter (Community Law Centre, University of the Western Cape) p. 395

[16] Article 12 of the International Covenant on Economic, Social and Cultural Rights

[17] ibid, at Article 12 (2)

[18] Article 16 of the African Charter on Human and Peoples’ Rights

[19] ibid, supra note 14

[20] See the Long Title of the Women’s Act, 2010, for example.

[21] ibid, supra note 7

[22] In Yankuba Touray SC. NO CR/001/2020, the Supreme Court noted that “[t]he common law, which by Section 7(d) of the Constitution and Section 2 of the Law of England (Application) Act (Cap.5:01 Laws of The Gambia) is applicable to The Gambia, recognizes that customary international law is part and parcel of the common law, in so for as it is not inconsistent therewith or with local statute law.”

[23] SC. NO CR/001/2020

[24] The Supreme Court noted that “[u]nincorporated treaties may not however be totally irrelevant to the domestic legal order.  They may, particularly those relating to human rights, be referred to as aids to the interpretation of the local law, to fill in gaps and also clear ambiguities in such law.”; also see. the Privy Council decision in Higgs and Anor vs. Minister National Security and others (Times December 23, 1999)

[25] General Comment No. 14. Geneva: UN Committee on Economic, Social and Cultural Rights. 2000

[26] ibid, supra note 15

[27] ibid, supra note 25

[28] ibid

[29] Principles and Guidelines on the Implementation of Economic, Social and Cultural Rights in the African Charter on Human and Peoples’ Rights (African Commission Principles and Guidelines), adopted in 2010 and formally launched in 2011 available here accessed  31^st August, 2024

[30] ibid, at para. 78

[31] Free Legal Assistance Group and Others v Zaire (2000) AHRLR 74 (ACHPR 1995)

[32] ibid

[33] 47(2001) AHRLR 60 (ACHPR 2001) 

[34] ibid, at para. 44

[35] ibid, supra note 12

[36] ibid

[37] ibid, at p. 26

[38] ibid

[39] ibid

[40] ibid, at p. 27

[41] ibid

[42] UNICEF, Water, sanitation and hygiene available here accessed on the 16th October, 2024

[43] Health Management Information System (HMIS) Unit, Annual Service Statistics Report 2021 at p.16

[44] ibid, at p. 95

[45] World Health Organisation, Country Disease Outlook 2023 at p. 63

[46] ibid

[47] ibid

[48] ibid, at p. 25

[49] ibid, at p. 26

[50] ibid, supra note 27, at para. 43

[51] ibid

[52] ibid

[53] ibid

[54] ibid

[55] Sine, J., P.P. Saint-Firmin, and T. Williamson, Assessment of the Health System in The Gambia: Overview, Medical Products, Health Financing, and Governance Components (Washington, DC: Palladium, Health Policy Plus, 2019) p. 14

[56] ibid

[57] ibid

[58] The Gambia Bureau of Statistics, The Gambia National Food Security Survey 2023, at p. 3

[59] ibid

[60] The Gambia Bureau of Statistics, The Gambia Multiple Indicator Cluster Survey 2018, at p. 364

[61] ibid, at pp. 366 & 390

[62] ibid, at p. 378

[63] ibid, at p. 365

[64] CAHF, Housing Finance in Gambia available here accessed on the 30^th October, 2024

[65] ibid, supra note 43, at p. 23

[66] ibid, at pp. 83-84

[67] ibid, supra note 6, at pp. 400-401

[68] L. Fuller, The forms and limits of adjudication (Harvard Law Review (1978) 92) pp.  353-409 

[69] ibid, supra note 53

[70] See. Section 152 of the 1997 Constitution

[71] ibid, supra note 68

[72] ibid

[73] ibid

[74] ibid, at p. 400

[75] ibid

[76] See. Section 27 of the  Constitution of the Republic of South Africa, 1996

[77] See. Article 43 of the Kenyan Constitution, 2010

[78] Minister of Health Others v Treatment Action Campaign and Others 2000 11 BCLR 1169 [CC] 

[79] Section 54 provides: “(1) Every person has the right to –

(a) the highest attainable standard of health, which includes the right to health care services, including reproductive health care;

(b) accessible and adequate housing, and to reasonable standards of sanitation;

(c) be free from hunger, and to have adequate food of acceptable quality;

(d) clean and safe water in adequate quantities; and

(e) social security.

(2) A person shall not be denied emergency medical treatment.”

[80] Section 25 (2) of the Draft Constitution subjects 54 of the Draft Constitution to the doctrine of progressive realisation.

[81] ibid, supra note 67, at p. 403

[82] A. Thoronka, Gambia Audit Office Reveals Mismanagement of Covid-19 Response Funds (The Fatu Network, 22^nd April, 2022) available here/ accessed on the 1^st September, 2024

[83] The 2023 Corruption Perceptions Index available here accessed on the 1st September, 2024

[84] ibid, supra note 81

[85] ibid

[86] ibid

[87] K. Hussmann, Health Sector Corruption (U4 Anti-Corruption Resource Centre) p. 1

[88] ibid, supra note 64, at pp. 83-84

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