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Context

The following information concerns the context and system factors in Uganda that may have played a role in the response to COVID-19 and the maintenance of essential health services. Context and systems factors cannot easily be changed when an outbreak occurs, whereas policies or interventions can.

Exemplars in COVID-19 conceptual framework for assessing epidemic preparedness and response

Contextual factors

Though part of this research focused on the policy choices officials made during the early phases of the pandemic, a country’s ability to limit COVID-19 transmission and related mortality can also be attributed to contextual factors, including those below.

A country’s population demographics, such as age structure and population density, may contribute to pandemic outcomes, such as the number of cases and deaths (see figure below).1,2 Underlying population-level health characteristics that may have shaped Uganda’s experience in the early months of the COVID-19 pandemic include a relatively young population and relatively low prevalence of the comorbidities that have been associated with severe COVID-19 (described below).

Demographic indicators and pre-pandemic health context

IHME, World Bank

Age structure

Uganda has one of the world’s youngest populations. In 2020, 46% of Ugandans were between the ages of 0 and 14, 52% were between the ages of 15 and 64, and just 2% were 65 or older (see figure below).3,4

Elderly adults are significantly more likely to die from COVID-19 than younger adults and children.5 Countries around the world vary widely in their age structures: in some African countries, fewer than 2% of the population is 70 years or older, while in some European countries that share is more than 15%.6   Some research suggests that accounting for variation in age structure between countries may explain nearly 50% of the variation in COVID-19 mortality.7

 

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Age and sex distribution of COVID-19 cases and deaths in Uganda as of August 2021

Republic of Uganda COVID-19 Response Info Hub, https://covid19.gou.go.ug/statistics.html

Underlying health conditions

Prior to the COVID-19 pandemic, Uganda had a relatively lower prevalence of underlying health conditions that have been associated with severe COVID-19 outcomes, compared to the global average—including diabetes, heart disease, and stroke (see figure below).2,8

A variety of chronic health conditions like high blood pressure, diabetes, and cardiovascular disease are associated with greater rates of mortality from COVID-19.5 HIV can make individuals susceptible to infectious diseases because of how it impacts the immune system. Similarly, cancer and cancer treatments like chemotherapy frequently disrupt the immune system, leaving individuals vulnerable to severe infection.9

 

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Smoking prevalence and ambient air pollution

In Uganda, about 10% of adults—15% of men and 4% of women—use tobacco, a rate lower than in many of its neighboring countries.10

According to WHO guidelines, the country’s air quality is unsafe (though COVID-related lockdowns reduced air pollution substantially while they were in place).11,12,13,14 This is due in part to emissions from vehicles, manufacturing, and waste burning, as well as from the agricultural sector.15,16

Fine particulate matter, especially matter small enough to reach the deepest part of the lungs, causes chronic pulmonary injury and inflammation.5,17   Individuals exposed to these particles may be more likely to be infected with respiratory pathogens and to have more severe outcomes.

 

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Age-standardized prevalence of key risk factors for COVID-19 mortality in Uganda compared to Africa and global values

IHME

The World Bank classifies Uganda as a low-income country.18 ,19,20 In 2021, Uganda’s gross domestic product (GDP) per capita was about $858,*,21 and 41% of Ugandans live on less than $1.90 per day. Unemployment is low: only 2.9% of the labor force was unemployed in 2021.23 However, that number can be misleading. Most Ugandan workers (73% of all workers in 2019 and 80% of women workers24 ) have what economists call “vulnerable” employment, which one study defines as “inadequate earnings, low productivity, and difficult conditions of work that undermine workers’ fundamental rights.”25   Nearly three-quarters of the country’s paid workers are involved with agricultural labor.22

In 2020, Uganda scored about 0.4 out of 1 on the World Bank’s Human Capital Index,26 a metric designed to measure the amount of human capital (an estimate of the health and education that contribute to worker productivity) a child born today can expect to attain by the time they turn 18.27   This is among the lowest scores in the world.28

Uganda is a republic with a president (the head of state) and a prime minister (the head of government business). These executives share legislative power with the National Assembly. The ruling party during the COVID-19 pandemic, the National Resistance Movement, has been in power since 1986, and Yoweri Museveni has been president since then (as of December 2022).

The period between November 2020 and January 2021 was election campaign season in Uganda. During that time, rallies and protests drew crowds of people, which may have contributed to the spread of COVID-19.

Because of ongoing economic and political instability in neighboring countries such as South Sudan, Uganda also has the largest population of refugees in Africa. It is among the top five refugee-hosting countries in the world. 29 Uganda’s refugee communities were especially harmed by the pandemic: large numbers reported lost jobs, inability to access medicine and essential goods such as clean drinking water and sufficient food, and increasing mental health challenges.30 Researchers have also identified administrative and other barriers to vaccine access among Uganda’s refugee communities.31

All dollar amounts that appear in this narrative are given in U.S. dollars.

Uganda has considerable experience with large-scale public health emergencies, including recent outbreaks of infectious diseases with epidemic potential. According to the World Health Organization (WHO), Uganda has experienced seven outbreaks of Ebola between 2000 and 2019 (and another Ebola disease outbreak caused by the Sudan ebolavirus was declared in 2022). During that time, it also saw four outbreaks of Marburg32 along with outbreaks of Crimean-Congo hemorrhagic fever, yellow fever, Rift Valley fever, avian influenza, and measles.33 At the beginning of the COVID-19 pandemic in 2020, Uganda had just contained an Ebola outbreak in the Kasese District in southwestern Uganda, near the border with the Democratic Republic of Congo.34 

Malaria is also endemic in Uganda. The country has one of the highest malaria burdens in the world,35 with malaria as a leading cause of death.36 In 2020, WHO counted 20.4 million malaria cases and nearly 31,000 deaths from the disease in Uganda.37Many malaria patients die at home, however, so their deaths may go unreported.38

These experiences gave Ugandan health officials tools and systems they could use to respond quickly to the COVID-19 pandemic—especially when it came to coordinating pandemic response, testing, and surveillance activities.34 For instance, during the Ebola outbreak in 2019, Uganda’s government and partners invested nearly $20 million in training health workers and village health teams (VHTs) in high-burden areas on infection prevention and control, epidemic surveillance, and other aspects of outbreak response.39 Staff at border points of entry (PoE) were also trained to use infrared thermometers and thermo-scanners to detect incoming travelers with fevers. In fact, one of these workers at Entebbe International Airport detected the country’s first COVID-19 case on March 21, 2020.34,40 (Note that symptom screens and temperature checks have limited impact in the context of asymptomatic transmission.)

System factors

Beyond policy interventions, other modifiable factors under the short-term control of countries and governments that can help shape countries’ pandemic outcomes (such as testing strategies, disease surveillance, laboratory capacities, contact tracing programs, case management, mobility restrictions, and surge response coordination), it is also important to consider preexisting system factors, such as the strength and structure of a country’s health care system and supply chains, in any analysis of a country’s COVID-19 preparedness and response.

Prior to the pandemic, Uganda already had a centralized system for the distribution of purchased and donated health commodities. In the public sector, since 1993, supplies have come to health facilities from warehouses associated with the Ministry of Health’s National Medical Stores41; in the private sector, they come from Joint Medical Stores; and some development partners have established their own supply chains for individual programs.42,43 More recently, the country has established a centrally coordinated electronic laboratory information management system for tracking, ordering, and delivering key medical supplies.44

Uganda’s manufacturing economy was relatively small prior to the COVID-19 pandemic,44 with almost all health supplies imported from other countries. When the pandemic began, prices for key goods such as personal protective equipment increased considerably—sometimes by a factor of 15 or more.45 However, local manufacturers and importers did exist, and they were able to begin and expand the production of critical supplies, including surgical masks and KN95 masks, by mid-2020.46

 

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Since 2001, community health services such as health education, commodity distribution, basic case management, and follow-up care have been provided by village health teams (VHTs), whose members are selected by the communities they serve.46 Since 2015, VHTs have been placed in each of Uganda’s 112 districts.47

In 2019, Uganda’s total health expenditures were 3.8% of GDP48 and $32 per capita49 —far below the 15% of GDP that the African Union’s 2001 Abuja Declaration pledged50 and below the WHO 2009 recommendation of $86 per capita. In 2020, out-of-pocket (private) health spending was nearly 40% of the total.51

In 2018, Uganda had nearly 7,000 health facilities. Government public facilities comprised 45% of these; of the remainder, 40% were private for-profit facilities, and 15% were private nonprofit facilities.52   That year, the country had about 200 intensive-care beds, most of which (83%) were in Kampala,53,54 and about 400 ambulances (fewer than one for every 100,000 people).55

Historically, many Ugandans have received a comparatively limited amount of routine or essential health services (EHS).53 According to estimates of effective universal health coverage, which measure a variety of indicators including reproductive, maternal, newborn, and child health and the treatment of infectious and noncommunicable diseases, Uganda ranks 132 out of 204 countries and territories worldwide (see figure below).56

Universal health coverage index for Ugandan health services

GBD 2019 Universal Health Coverage Collaborators

 

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Since 2001, Uganda has used the Integrated Disease Surveillance and Response (IDSR) strategy to detect, monitor, and report on high-priority diseases.57 The IDSR is a way for countries to measure their implementation of WHO Member States’ International Health Regulations (IHR), updated in 2005, which balance the prevention of infectious and noninfectious diseases with the promotion of international travel and trade.55 ,58 WHO’s 2017 Joint External Evaluation (JEE) of Uganda’s IHR core capacities found that Uganda had strengthened its capacities in surveillance, laboratory testing, emergency response operations, and risk communication—all of which would be essential to the country’s response to the COVID-19 pandemic.59

For example, Uganda adopted a free short message system (SMS) reporting platform in 2011 to replace older systems (a combination of paper-based and telephoned reports, radio calls, and emails) for transmitting weekly public health surveillance data.60 Officials and health care providers were already familiar with this system, known as mTrac: more than 50,000 health workers at nearly 6,000 health centers around the country used it in 2018,61 and developers anticipated that the database would expand to 300,000 users, including VHTs, by 2020.57 The mTrac system expanded in 2020 to include key COVID-19 functionalities, including contact tracing, case reporting, and the timely sharing of test results.62

 

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Uganda had an early warning system in place for indicator and event surveillance; well-equipped national reference laboratories; an efficient transport system for delivering diagnostic samples to laboratories across the country; and an active nationwide Public Health Emergency Operations Centre.60  It also honed its capacity for international collaboration in response to health security threats.

However, Uganda did not have the infrastructure it needed for comprehensive communication across and among sectors, nor for thorough surveillance at PoE. It also lacked standard operating procedures, plans, guidance, and tools for emergency preparedness and response. Most crucially, the JEE report recommended that Uganda create an emergency fund that would enable officials and health workers to promptly investigate disease outbreaks and enable a comprehensive emergency response.60

In 2021, an internal assessment of Uganda’s progress in implementing the JEE recommendations found the country had increased its scores across 18 indicators and had especially improved its capacity in three major technical areas in which its scores had been quite low.63

Uganda’s 2021 assessment found that it had lifted its scores “out of the red” (the lowest of five scores in the JEE tool) in three key categories: National Legislation, Policy and Financing; Emergency Preparedness; and Points of Entry.64,61

 

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Some of these improvements shaped Uganda’s COVID-19 response; others were shaped by it. For instance, the report noted that Uganda had used COVID-19 funding to improve the infrastructure and resources for screening and testing travelers at PoE.61 These new capacities—including thermal scanners, staff, laboratories, and equipment—have served Uganda’s ongoing response to COVID-19, but they also boost its capacity to respond to other diseases.61

 

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Outbreak factors

From March 21, 2020, when Uganda reported its first case of COVID-19, until August 1, 2020, Uganda’s COVID-19 case count was among the lowest in the world: just 1,176 confirmed cases, or about 26 cases per million people compared to the global average of over 2,300 cases per million over the same time period (see figure below).65 Experts attribute this low number to the country’s ability to avert community spread of COVID-19 early on, possibly due to the quick and intensive actions its government took to limit population mobility.

Cumulative confirmed COVID-19 cases per million people in Uganda, Africa, and the world, March 2020–December 2021

Our World in Data and Uganda Ministry of Health

As mobility began to increase over the last two quarters of 2020, and especially with the start of the political campaign season and associated crowds and gatherings between November 2020 and January 2021, case counts began to rise. Still, Uganda kept its case counts comparatively low (just more than 1,000 cumulative cases per million people) until the end of May 2021.65

In the second half of 2021, however, the cumulative case counts tripled and the number of reported deaths from COVID-19 increased ninefold.65 Observers attributed this surge to the spread of the more transmissible delta variant of COVID-19, which was first identified in Uganda at the end of April 2021,66 and to the relaxation of mobility restrictions.

 

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During the delta wave in 2021, Uganda’s government reimposed travel and community restrictions it had previously lifted or relaxed. It stopped the phased reopening of schools and institutions of learning, restricted community gatherings, limited the capacity and hours of operation of public transport, imposed longer curfews, and required strict mask wearing and hand hygiene in public places.67 ;It also strategized to boost the country’s comparatively low vaccination rates. (Fewer than 2% of Ugandans were vaccinated by the end of June 2021, but nearly 20% were vaccinated by the end of that year.64 ) For more information, see “Case study: COVID-19 vaccine uptake in Uganda” below.

The delta wave began to slow by August 2021. By the end of that year, however, routine sequences of COVID-19 samples had alerted Ugandan officials to the emergence of the new omicron variant among travelers arriving at the Entebbe International Airport from Kenya, Nigeria, and South Africa.68 In response to this pandemic wave, which peaked in early January 2022, officials resumed mandatory self-funded testing of all travelers arriving at land borders, whether or not they had been vaccinated or taken a COVID-19 test at home.69The Ugandan government also empowered private-sector laboratories to support overwhelmed government testing centers.70 As of December 31, 2021, Uganda had confirmed a total of about 140,000 COVID-19 cases, or about 3,000 confirmed cases per million people—still relatively low compared to many other countries worldwide. By the end of 2021, nearly 3,300 people were confirmed to have died from the disease.64 (See figure below.71 )

Cumulative confirmed COVID-19 deaths per million in Uganda, Africa, and the world, March 2020–December 2021

Our World in Data, Uganda Ministry of Health

 

The relative importance of the drivers of outcomes of interest during an epidemic or pandemic will depend on the nature of the specific pathogen. In the case of the COVID-19 pandemic, the SARS-CoV-2 virus is characterized by respiratory transmission from both symptomatic and asymptomatic individuals. The virus disproportionately affects older adults and those with compromised immune systems and comorbidities. Although vaccines and therapies to reduce severe disease and fatal outcomes from SARS-Cov-2 were developed relatively quickly, this is not always the case for other pathogens with epidemic and pandemic potential.

For more information, please see How does COVID-19 compare with past epidemics and pandemics?

Global and regional factors

Uganda has a warm, humid equatorial climate.72 The country is situated on the East African plateau at an average elevation of 1,100 meters above sea level.4 It is not yet possible to conclude whether these conditions played a role in the spread of COVID-19 in Uganda.

Uganda is one of the top five refugee-hosting countries in the world, with the largest population of refugees in Africa. 29 Uganda’s densely populated refugee communities were particularly affected by the pandemic.30

Respiratory viruses spread more easily through thin, dry air (and consequently at higher elevations) than through humid air.73In different climates, outdoor temperature ranges can lead to increased congregating in climate-controlled indoor settings that can increase viral transmission potential.5 All these factors may influence how rapidly COVID-19 spreads in different countries and at different times of the year.

As climate change worsens, the risk of infectious disease outbreaks has increased, with climatic conditions becoming increasingly fertile ground for pathogenic transmission.74 Research has shown that many infectious diseases are susceptible to climate variability, flooding, droughts, and the animal and human migratory impact of a changing climate, leading to a rise in vector-, food-, and water-borne illnesses.75

 

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