Why was Uganda selected?

Executive summary

Several key interventions helped Uganda delay the spread of COVID-19 and mitigate its effects in the early months of the pandemic. An aggressive early response and the country’s ability to apply existing tools for disease response, testing, and surveillance may have limited case counts between March and August 2020. Strong, centralized public health leadership used data to make informed decisions and acted quickly to enforce preventive measures and prioritize the maintenance of essential health services (EHS).

How did we select the countries we studied?

Differences in testing, surveillance capacities,¹ and reporting criteria have made it difficult to quantify² and compare the impact of COVID-19 in countries around the world. Yet some countries were able to build and sustain health system capacity, maintain EHS, and target public health and social measures (PHSMs, also known as nonpharmaceutical interventions) to mitigate the overall impact of the COVID-19 pandemic. Identifying the strategies, policies, and practices that enabled these successes can give us a better understanding of health system resilience, adaptive health policies, and emergency response strategies that could be applied to other countries and future infectious disease outbreaks.

To select positive outlier countries with transferable lessons for pandemic preparedness and health system resilience, the Exemplars in COVID-19 Response research project used data from March 2020 through the end of 2020 to identify countries with best-practice responses to the early phases of the pandemic. It is a snapshot in time; it does not account for subsequent waves of the pandemic, nor for the later availability of COVID-19 vaccines in the selected countries.

The six positive outlier countries were selected by evaluating COVID-19 indicators (including age-standardized death rate, cases per million, and testing rate) and EHS indicators (including disruption to routine immunization) after screening for the availability of high-quality data and the transferability of the findings. After identifying potential Exemplar countries, we completed validation research comprising an examination of the COVID-19 epidemiological curve over time, testing policies and strategies, interventions to maintain EHS, survey data, and interviews with local and regional health experts. The final six countries were selected after considering linguistic, demographic, and geographic diversity as well as government structure and data availability. (See figure below.)

For Uganda and the other five selected countries (Costa Rica, Dominican Republic, Ghana, Sri Lanka, and Thailand), we conducted a literature and policy review, key informant interviews, qualitative analysis, and quantitative analysis. We synthesized findings to develop key recommendations on health system resilience and pandemic preparedness. This country selection process reviewed indicators through the end of 2020, but the Exemplars research itself covers the time period through the end of 2021. It is important to note that the performance of the selected proxy indicators does not reflect the entire health system’s performance.

Key insights: Uganda

Several key interventions, summarized below and detailed in the following pages, contributed to Uganda emerging as a positive outlier in the early phases of the COVID-19 response and the maintenance of EHS. Like all countries, Uganda also faced substantial challenges.

Intensive early response

From March 21, 2020, when Uganda reported its first case of COVID-19, until August 1, 2020, Uganda recorded just 1,176 cases of COVID-19 or about 26 cases per million people (compared to an average of 700 cases per million in Africa over the same period).^3,4 While surveillance and reporting issues resulted in undercounting globally, Uganda’s early response was impressive. Even before March 2020, officials had imposed stringent PHSMs to prevent the spread of the virus. Experts believe the quick and intensive actions officials took to limit population mobility may have helped the country avert broad community spread during those early months.

Preexisting disease response capacities

Uganda’s comparatively recent experience with previous diseases that carried epidemic potential, such as Ebola and Marburg, meant that it had infrastructure and strategies it could adapt in response to the COVID-19 emergency. These included structures for coordination, laboratory work, surveillance, and digital health; specialized laboratory networks that had been built for HIV and tuberculosis and could be repurposed for COVID-19 diagnostics; trained village health teams for rapid response in local communities; and tools and processes for Integrated Disease Surveillance and Response (IDSR).

Leadership and governance

Early in 2020, the Ugandan Ministry of Health activated its Public Health Emergency Operations Center, along with a National Task Force—chaired by the country’s president, and composed of political and technical leaders from across the government—to support and coordinate new and adapted strategies for COVID-19 preparedness and response. These centralized structures for public health leadership enabled officials to act quickly, implementing (and ensuring adherence to) preventive measures such as lockdowns and mask mandates.

Essential health services maintenance

As was the case in many countries, the early actions Ugandan officials took to control the spread of COVID-19, such as suspending public gatherings and implementing curfews, were associated with a sharp decline in the supply of, and demand for, EHS. However, officials quickly identified these obstacles and acted to mitigate them, along with other unintended consequences of COVID-19 PHSMs. Strategies included shifting tasks to VHTs; multimonth drug dispensing; broad and diverse risk communication efforts informing the public about strategies and interventions for EHS maintenance; and using technology for telemedicine and supervision. Most key health indicators recovered from their initial dip by early 2021.

Challenges

Uganda is a low-income country with multiple pressing public health concerns and limited resources for sustaining pandemic prevention and response interventions. COVID-19 vaccination rates have been comparatively low—by the end of December 2021, just 3% of Ugandans had received a complete dose of the COVID-19 vaccine, and 15% were partially vaccinated⁵ —leaving the country vulnerable to future waves.

The efficacy of some of the interventions Uganda implemented to prevent the spread of COVID-19 and mitigate the pandemic’s consequences was limited. Some, like the recruitment of health workers to regional referral hospitals, were temporary; others, such as the provision of cash and food to the vulnerable, were applied inequitably and may not always have reached everyone who needed them.

Other interventions had adverse effects. Lockdowns and movement restrictions undermined the delivery of key EHS. Similarly, the unintended consequences of school closures (Uganda had the longest school closure in the world⁶), such as learning loss, increasing educational inequality, and rising rates of teenage pregnancy, are still being evaluated.

After a strong early response, the emergence of new variants also overwhelmed Uganda’s health system. In the second half of 2021, the cumulative case counts tripled and the number of reported deaths from COVID-19 increased ninefold.⁷Observers 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 2021,⁸ and to the relaxation of mobility restrictions.

As fatigue associated with intense and prolonged restrictions grew, along with their unintended social and economic results, rates of adherence to some PHSMs slipped. Information gaps, misinformation, and limited community engagement affected public trust in health officials and preventive measures.