This research and analysis was conducted by research partners at the Makerere University School of Public Health.

Introduction and Key Takeaways

Around the world, public health emergencies such as the COVID-19 pandemic can profoundly disrupt the delivery of routine or essential health services . For instance, they can reduce the supply of those services, such as by redirecting health care workers and resources toward the emergency response. Patients’ fear of infection in public places, especially health care facilities, can also depress demand for essential health services and keep people from receiving the care they need.

WHY DID WE STUDY UGANDA?

We selected Uganda for this study, alongside three other countries in sub-Saharan Africa, because together they demonstrate a wide and variable spectrum of COVID-19 response and outcomes, and they have recent experience managing public health emergencies (such as cholera, Ebola virus disease, and measles in Uganda). The strong partnerships these four countries have established between researchers and health officials also facilitate access to data and translation to action.

Uganda in particular, and especially before the end of 2020, was able to limit COVID-19 transmission very effectively. This success could be due, at least in part, to Uganda’s aggressive immediate response in March and April 2020, which reduced population mobility considerably.

Unfortunately, this reduction in mobility was also associated with a sharp decline in the use of essential health services and associated indicators such as childhood vaccine coverage and outpatient health facility visits. However, between the spring of 2020 and the summer of 2021, most essential health service indicators recovered from their initial dip. Because many interventions intended to reduce transmission were introduced around the same time, and because Uganda’s pandemic context has changed rapidly, it is difficult to parse which interventions were most effective. However, it seems clear that many show great promise and may be adapted going forward—both for Uganda and for other contexts.

KEY TAKEAWAYS

The COVID-19 pandemic and the behavioral and political response to it can cause reductions in the delivery and utilization of essential health services. Policy makers and decision makers in other contexts should be ready to mitigate these disruptions in context-specific ways. In Uganda, the decline in essential health services delivery and utilization (along with COVID-19 itself) had significant adverse effects on key public health indicators. Starting in 2020, Ugandan officials implemented a variety of interventions to mitigate supply- and demand-side obstacles to essential health services to improve public health outcomes. These interventions include:

  • Established district task force subcommittees on the maintenance of essential health services in the context of COVID-19, with weekly meetings chaired by the resident district commissioner
  • Worked with civil society organizations and the Gateway Bus Company to facilitate transportation of passengers and health workers to facilities
  • Decided at hospital and district levels how to effectively allocate health workers between frontline COVID-19 support and routine medical services
  • Established supportive supervision and mentorship for health workers on maintenance of essential health services via e-platforms or by telephone
  • Implementing partners transitioned from in-person to online training for health workers to strengthen capacity in family planning services
  • Continued some in-person training in accordance with infection prevention and control standards; some implementing partners transitioned from group mentorship sessions to individual sessions
  • Used social media platforms to communicate availability and continuity of health services
  • Processed orders for COVID-19 commodities using the electronic logistics management information system
  • The Uganda Ministry of Health developed a COVID-19 website to share information on services and increase access to sexual and reproductive health care
  • Transferred responsibility for antenatal and postnatal care and treatment for malaria and diarrhea to community health workers
  • Provided training to non-medical staff (e.g., security guards, plumbers) to conduct temperature screening
  • Trained community health workers to identify and refer patients, and generate demand for services through health promotion and social mobilization campaigns
  • Conducted special clinics for maternal and child health services
  • Provided patients with multiple months of medication (e.g., HIV and heart-related medicine)
  • Health workers rearranged service delivery schedules to ensure continuity
  • Designated certain regional facilities for COVID-19 treatment
  • Introduced young child clinics, special clinics for maternal and child health services, HIV services, and daily immunization services

What Was the Pre-Pandemic Context in Uganda?

Uganda’s Pre-pandemic Context

Various

PRE-PANDEMIC HEALTH SYSTEM INDICATORS AND ESSENTIAL HEALTH SERVICES IN UGANDA

At the national level, Uganda’s Ministry of Health (MOH) oversees health service delivery at national referral hospitals and regional referral hospitals. The MOH is responsible for policy formulation and analysis, strategic planning, standards and quality assurance, resource mobilization, coordination of health services, and research and monitoring and evaluation. At the regional level, district health structures oversee the planning and implementation of human resources for health policies, recruitment, and human resource management. At the local level, Village Health Teams help connect communities with health services. Village Health Team members, selected by the villages themselves, are responsible for health promotion and education, mobilization for health services and action, distribution of health commodities, and simple community case management of common infectious diseases.1 Uganda had about 180,000 Village Health Team members in 2015.

Of the nearly 7,000 health facilities in Uganda in 2018, just under half (45 percent) were government public facilities, 40 percent were private for-profit facilities, and the remaining 15 percent were private nonprofit facilities.2 Before the COVID-19 pandemic, in 2018, the country had about 200 intensive care beds—83 percent of which were located in Kampala City—and about 400 ambulances.3 (Each ambulance served more than 100,000 people; nearly half of the country’s districts had an ambulance.)

According to estimates of effective universal health coverage, Uganda ranks 132 of 204 countries and territories, meaning that about 60 percent of all countries perform better in provision of universal health care.4 Effective coverage measures a variety of indicators of delivery of essential health services including reproductive, maternal, newborn, and child health, and infectious and noncommunicable disease treatment. In Uganda, total health expenditures in 2020 were 6.4 percent of the gross domestic product (GDP) and US$48 per capita—far below the Abuja Declaration to spend at least 15 percent of GDP and below the World Health Organization (WHO) recommendation of US$86 per capita. In 2020, out-of-pocket (private) health spending was 40 percent of the total, much more than experts typically recommend.

Compared with other countries in sub-Saharan Africa, Uganda performs well on essential health services indicators such as routine childhood immunizations and treatment for lower-respiratory infections, whereas it struggles to provide sufficient antenatal and maternal care or treatment for noncommunicable illnesses such as cancers, stroke, and diabetes.

COVID-19 IN UGANDA

From March 21, 2020, when Uganda reported its first case of COVID-19, until the beginning of August 2020, Uganda recorded just 1,176 cases of COVID-19 (about 25 cases per million people). Experts believe the country was able to mitigate transmission and avert widespread community spread because of early actions taken by the government, including airport closures and population lockdowns.

As mobility began to increase over the summer and with the start of the political campaign season in the fall, case counts began to rise in August 2020. However, Uganda kept its incidence rates below one case per million people until the end of May 2021. That month, the country experienced a surge in cases that observers attributed to the spread of the more transmissible Delta variant (first identified at the end of April 2021); the relaxation of mobility restrictions, and low COVID-19 vaccination coverage (less than 2 percent of Ugandans were vaccinated at the end of June 2021).5 Case counts peaked at more than 30 cases per million in mid-June 2021, and by the end of that month about 80,000 cases had been reported since March 2020. This 2021 wave accounted for nearly 70 percent of the country’s 1,023 total reported deaths from COVID-19 through July 2021.6

Timeline of COVID-19 cases, deaths, and events in Uganda

Various

Non-pharmaceutical interventions, including public health and social measures, were a critical part of Uganda’s response to COVID-19. These interventions included:

  • Movement restrictions and physical distancing Days before the first COVID-19 case was reported in Uganda on March 21, 2020, the president closed the country’s airports and territorial borders. Shortly thereafter, officials suspended public transportation and declared a nationwide curfew, prohibiting all movement between 7 p.m. and 6:30 a.m.7, 8 On April 1, 2020, officials instituted a nationwide lockdown, banning all forms of public and private transportation and closing all businesses except for a few essential services.
  • Strategies to support mask-wearing On May 4, 2020, a declaration from the country’s president mandated face masks in public for all Ugandans six years and older. The police were empowered to enforce this policy.
  • Precautionary measures in public places On March 18, 2020, the government suspended all public gatherings—including worship services, concerts, rallies, and cultural gatherings—and closed public places such as bars and restaurants. All educational institutions were also closed indefinitely. At workplaces of essential workers, meetings including more than 20 people were banned.

As a result of these pandemic response measures, mobility decreased sharply during the first months of the pandemic, which in turn limited commercial activity, thereby decreasing incomes and reducing economic growth. (Mobility in Uganda has been lower than in the WHO African Region overall, potentially reflecting the aggressiveness of the initial response by the government.) In response to the pandemic surge in the early part of 2021, health authorities in Uganda developed a resurgence plan to cover the period between June 2021 and June 2022. As part of that plan, officials reintroduced COVID-19 control measures including a lockdown in June 2021 and restricted travel from high-risk countries.

Relative population-level mobility during the COVID-19 pandemic

IHME

What Effect Did These Measures Have on Essential Health Services?

Along with the COVID-19 pandemic itself, the precautionary measures taken to mitigate the pandemic created supply- and demand-side barriers to maintaining essential health services in Uganda.

Supply-Side Barriers

Leadership and Governance

The government of Uganda deployed police and other security personnel to ensure adherence to movement restrictions, which prevented some health care providers from being able to travel to work and perform their jobs. There were media reports that some abused their power and misinterpreted the rules—for instance, by preventing people from seeking routine health care even when it was allowed.9 This might have affected health-seeking practices among the public.

Finances

At the end of March 2020, Uganda’s parliament approved a US$30.7 million (104 billion Ugandan Shillings) budget for the COVID-19 response, and the MOH mobilized financial resources from government and other international agencies to support the response. Because Uganda has limited resources for health care in general, these loan obligations and budgetary allocations undermine access to other programs and types of care, for example, by delaying the disbursement of funds intended for specific essential health services such as tuberculosis control.

Health Workforce

More than 10 percent of COVID-19 cases are asymptomatic and many COVID-19 symptoms (e.g., fever, cough, and sore throat) mimic those of other diseases, especially malaria, the most common cause of outpatient department visits in Uganda. Unlike COVID-19, malaria is not spread via person-to-person transmission, and therefore some health workers did not always carefully observe COVID-19 prevention practices such as masking and social distancing. This oversight sometimes resulted in infections and fatalities among frontline health care workers, reducing the number of workers available to care for COVID-19 patients or provide essential health services.10

Movement restrictions also affected health care workers, resulting in disruption of service delivery—for instance, when health workers did not report to work on time or at all.

In addition, there were reports of COVID-19 infection among health workers.11 As a result, there was a perception among the public that health facilities were hotspots for transmission of COVID-19,12 which led to fear among health workers and the closure of some health facilities due to staffing shortages.11

The Uganda National Tuberculosis and Leprosy Program also noted that the COVID-19 outbreak and subsequent lockdown affected travel related to its capacity-building and training events. The MOH Department of Emergency Medical Services likewise noted that the COVID-19 pandemic exacerbated existing shortages in human resource capacity for emergency care at all levels of the health system, as personnel were reassigned to work on COVID-19-related tasks.

Infrastructure and Commodities

The COVID-19 pandemic and subsequent global movement restrictions resulted in delays and stockouts of many essential health commodities, including personal protective equipment and many other health commodities, particularly those that are imported. The MOH Pharmacy Division noted delays in delivery of supplies and reagents by the National Medical Stores, which resulted in disruptions in blood collection, testing, and processing. For the same reason, supplies were often rationed and redirected. For instance, the National Tuberculosis and Leprosy Program noted stockouts of critical reagents and real-time PCR diagnostics (GeneXpert cartridges) at some health facilities because they were repurposed to support the COVID-19 response.13 Likewise, a global reduction in the supply of some vaccines (such as HPV) led to rationing of doses.

Health Service Delivery

The COVID-19 pandemic and response efforts affected patient transportation and referrals, led to the suspension of immunization and other outreach clinics, reduced outpatient visits due to a fear of contracting COVID-19, and caused the delay or suspension of mass health campaigns such as mosquito net distribution and indoor spraying in malaria high-burden districts. The repurposing of space to create isolation units for patients with COVID-19 also affected access to other types of essential care in both public and private health facilities. The 2019/2020 Annual Health Sector Performance Report noted that mental health units were being used as COVID-19 treatment units, which undermined the delivery of mental health services.14

Health Information Systems

The COVID-19 pandemic and restriction measures affected health data reporting across the board. The Uganda Population-Based HIV Impact Assessment, a routine national survey for HIV surveillance, was scheduled for the first half of 2020 but postponed until movement restrictions were lifted. This was also true for the Uganda Demographic Health Survey. The pandemic and associated control interventions also affected the rollout of revised health management information tools for data reporting, which in turn affected timely reporting of key program performance indicators at the facility level.11 The subsequent decline in data reporting rates led to difficulties in monitoring the delivery and maintenance of essential health services.11

Demand-Side Barriers

Reductions in health-seeking behaviors proved to be another major barrier to the delivery of essential health services in Uganda, especially during the first months of the pandemic. Among households that needed medical care in the first six months of the pandemic, more than half delayed or skipped care, with about 30 percent delaying or skipping care through February 2021. In Uganda, the most frequently cited reasons for skipping health care visits unrelated to COVID-19 were lockdown-related mobility restrictions and transport challenges. (Many also cited cost as a barrier, but it was unclear if this barrier was greater during the pandemic; however, it is plausible that lockdowns and business closures substantially reduced household incomes.) The most commonly skipped medical needs were treatment for communicable diseases, diagnostic services, general visits, and reproductive, maternal, and child health.

Delay in health care seeking during the pandemic

PERC with Ipsos

Reasons for and types of delayed or skipped health care

PERC with Ipsos

Together, these supply- and demand-side barriers had grave consequences for public health in Uganda. For example:

  • The number of infant vaccines, such as the diphtheria-tetanus-pertussis vaccine, that were delivered decreased significantly in the first few months of the pandemic but recovered later in the year.
  • Early in the pandemic, health facility births significantly decreased and maternal mortality significantly increased, but both returned to pre-pandemic levels later in 2020.
  • Outpatient health center visits of all types significantly decreased at the start of the pandemic. Outpatient visits for diabetes and malaria were significantly lower than expected from March to the end of 2020.
  • The country’s AIDS Control Program reported a 30 percent reduction in the rate of initiation of antiretroviral therapy for people living with HIV between April and June 2020, compared with the previous quarter. This reduction is likely a result of interventions such as movement restrictions implemented to control the spread of COVID-19.11
  • These movement restrictions also interfered with active case finding of tuberculosis within outpatient departments, one of the strategies implemented by the National Tuberculosis and Leprosy Program to identify tuberculosis cases to initiate treatment. COVID-19 control measures likely reduced the number of people who would have been initiated on treatment.
  • Patients newly diagnosed with chronic conditions like cancer could not start treatment, while others missed their regular hormonal treatment refills. Both delays in initiating treatment and interruption of treatment cycles contributed to increased stress, faster disease progression, recurrence, and early death.15
  • COVID-19 lockdowns resulted in canceled blood drives, which reduced the amount of donated blood available for transfusions in Uganda. As a result, there was a severe shortage of blood for maternal, injury, and trauma care.14

What Interventions Did Uganda Put in Place to Ensure the Maintenance of Essential Health Services?

With the support of local and international partners, Uganda has implemented several interventions to overcome these supply- and demand-side barriers to essential health service delivery during the COVID-19 pandemic. In part because many were implemented around the same time, it is difficult to measure which were most effective—but the interventions featured below may be successful if replicated or adapted elsewhere.

The following findings are organized according to the Health Systems Building Blocks framework.

INTERVENTIONS AT THE NATIONAL LEVEL

  • Attention to the maintenance of essential health services.
  • Uganda’s MOH organized its COVID-19 response via committees centered around eight pillars, one of which is the continuity of essential health services.
  • Guidelines for the maintenance of essential health services: In April 2020, the MOH published guidelines for maintenance of essential health services 16 and established a national committee on the topic. This guidance included a list of priority essential health services to be maintained, including the prevention, management, and control of communicable and noncommunicable diseases and maternal, child, and adolescent health. The MOH revisited these guidelines in August 2021 and revised them based on interim findings from our research as well as other emerging evidence.
  • COVID-19 Resurgence Response Plan: In July 2021, Ugandan health officials published a COVID-19 Resurgence Response Plan that focused in part on continued access to essential health services. The plan includes activities such as national and subnational coordination, availability of commodities, data reporting and monitoring, health workforce capacity strengthening, and occupational safety of health workers with respect to COVID-19 risk. The plan allocated US$31 million to the continuity of essential health services between June 2021 and June 2022.
  • Risk communication and health promotion: The MOH conducted media campaigns encouraging people to continue to safely access essential health services (such as maternal and child health services) and discouraging the stigmatization of people recovering from COVID-19.17

"Every week we were on radio talking about COVID but also talking about other medical services available in the hospital. At the beginning people thought that the hospitals were only treating COVID patients and then the others were not welcome. So, we took advantage of the availability of media space to talk to people not only about COVID but also other medical services available in the hospital."

- Key Informant Interview, Regional Referral Hospital
  • Enhancing triage: The MOH provided guidance on triaging people seeking health services during the COVID-19 pandemic to enable rapid identification and isolation of cases. Screening people for COVID-19 increased public confidence and trust in the health care system.17

Unfortunately, poor communication between the eight COVID-19 response pillars and poorly attended and facilitated meetings have undermined the success of Ugandan officials’ efforts to maintain essential health services during the COVID-19 pandemic. An overwhelming focus on maternal, newborn, and child health and HIV/AIDS programs has also diverted resources and attention from other disease programs like mental health, diabetes, and non-infectious outpatient care.

INTERVENTIONS AT THE NATIONAL LEVEL

  • Continued disbursement of essential health service funds: Maintaining essential health services required leveraging resources from international partners, particularly UNICEF and WHO, and resources from the other seven COVID-19 response pillars. Because the funding was directed to essential health services specifically and not public health in general, it was not diverted to COVID-19 care. Health facilities therefore continued to receive necessary quarterly funding on time and in full, which minimized disruption to most essential health services.

“We normally get our PHC [funds for primary health care] and we continued to get it, there was no shortage of funds, the funding was as it used to be.”

- Key Informant Interview, General Hospital

INTERVENTIONS AT THE NATIONAL LEVEL

  • Development of guidelines and protocols: Clear guidelines and protocols helped give health care workers confidence about working safely during the COVID-19 pandemic. For example, Mulago Women’s Referral Hospital set up a virtual hospital for staff training and sensitization, and the MOH developed guidelines for managing health care workers who contracted COVID-19 while on duty.
  • Virtual platforms for support, supervision, and capacity-building: In adherence to COVID-19 restrictions, health worker support and supervision was provided via e-platforms or by telephone. For instance, to strengthen the capacity of health workers providing family planning services, implementing partners transitioned from in-person to online training starting in September 2020. Some in-person trainings continued with social distancing protocols in place.17
  • Provision of personal protective equipment, support, and other non-financial incentives: The MOH directed district local governments to provide transportation and psychosocial support to infected and otherwise affected staff; the MOH also undertook risk communication targeting health care workers about the key actions required to stay safe and healthy. Public-private partnerships with nongovernmental organizations, private companies, and foreign governments enabled health workers and facilities to obtain essential goods. For example, the NGO Living Goods  provided 4,300 community health workers with personal protective equipment, Absa Bank Uganda provided 160 medical oxygen cylinders, and the German government provided digital X-ray machines through the TB or not TB project.

INTERVENTIONS AT THE SUBNATIONAL AND COMMUNITY LEVELS

  • Staff redeployment and recruitment: In some districts, staff were recruited and redeployed to maintain essential health service, while others were assigned to provide care at COVID-19 facilities.

“…in allocation we redeployed the midwives to handle facilities that on average handled three deliveries every 24 hours and that time we also moved some of the nurses to where there were many cases of emergency…”

- Key Informant Interview, District Health Officer
  • Engaging and protecting community health workers: MOH guidelines recommended shifting tasks such as temperature and symptom screening and referral for case management of childhood illnesses to Village Health Teams (a subset of community health workers) whenever possible. To this end, officials provided protective gear to the Village Health Teams, which ensured the maintenance of community-based services such as indoor residual spraying for mosquito control and integrated community case management of childhood illnesses.
  • Providing safe places to stay for health workers: To address the challenge of movement restrictions for health workers, some health facilities provided accommodations for staff. Eventually, the government provided movement permits so that health workers could circumvent the lockdown.

“We had to identify a house to provide extra accommodation for our staff who were working so much and we did not want them to travel to their homes to transmit the disease to their family members.”

- Key Informant Interview, Senior Medical Officer
  • Leveraging the availability and skills of non-medical staff: In health facilities, health care providers leveraged the availability of non-medical staff such as guards to do non-technical jobs, including temperature screening for COVID-19.

“As I said we multitask, and we find people like even cleaners and askaris [janitors] are given extra tasks like taking temperatures at the gate apart from their other ordinary job of guarding.”

- Key Informant Interview, General Hospital

INTERVENTIONS AT THE NATIONAL LEVEL

  • Emergency orders of essential products: In the event of stockouts of essential supplies—such as personal protective equipment, antiretroviral drugs, and laboratory diagnostic tools—national distribution mechanisms allowed for making emergency orders and transferring goods from one health facility to another. By July 2021, Uganda had shifted to a system of centralized commodity monitoring, warehousing, and distribution to all public health facilities.
  • Frequent review of supply and procurement plans and use of e-platforms: To avoid stockouts and ensure the availability of drugs and medicines for essential services, the MOH Pharmacy Division reviewed supply and procurement plans for infection prevention and control materials and used the electronic logistics management system to process orders for Ebola Virus Disease and COVID-19 commodities. To ensure and maintain the availability of family planning methods, the division also reviewed family planning procurement plans and asked the National Medical Stores to supply facilities accordingly.
  • Patient transportation: The MOH guidelines for maintaining essential health services recommended that district health officers provide transportation for people seeking urgent health care unrelated to COVID-19.
  • Construction of medical oxygen production plant: Beginning in June 2021, a new medical oxygen plant at Mulago National Referral Hospital increased Uganda’s oxygen production capacity by 35 times (from 2000 to 70,000 liters per minute).

INTERVENTIONS AT THE NATIONAL LEVEL

  • Designation of facilities for COVID-19 treatment: Uganda’s health system includes national referral hospitals, regional referral hospitals, district hospitals, health centers, and community health workers. The regional referral hospitals became COVID-19 treatment units so that health service delivery at other levels of the health system could continue. Officials also designated special clinics for essential health services delivery, such as young child clinics for maternal and child health.
  • Guidance on outreach and other community-based services: In April 2020, Uganda’s MOH recommended the continuation of community-based health service delivery and access to medications and supplies for chronic conditions through multi-month dispensing and community distribution. For example, medicines for chronic conditions such as HIV were dispensed for three or more months to decongest health facilities, minimizing transmission of COVID-19 and protecting people with underlying conditions. The MOH also recommended targeted and integrated antenatal care and immunization outreach and modified indoor residual spraying and mosquito net distribution campaigns in compliance with COVID-19 prevention protocol.11
  • Communication about health services maintenance: To raise awareness about maintaining essential health services during the pandemic, Uganda’s MOH developed a COVID-19 awareness website with a specific page for the pillar on continuity of essential health services18 and conducted online campaigns to increase access to sexual and reproductive health services among young people.17

INTERVENTIONS AT THE SUBNATIONAL AND COMMUNITY LEVELS

  • Using multiple communications platforms: The MOH used traditional platforms, such as newspapers, along with social media to communicate with the public about adjustments to critical service delivery and provision of specific services at designated health facilities, and to encourage HIV self-testing. These platforms also enabled facilities to place emergency orders for essential commodities and communicate with clients outside the clinic setting.
  • Integration of services and screening for gender-based violence: To address the increasing frequency of gender-based violence associated with financial strain and curfews, the MOH integrated gender-based violence screening into immunization programs, antenatal care visits, and community health outreach efforts. At these service delivery points, health care workers asked mothers about gender-based violence and linked survivors with necessary support.17 The Ministry of Education and Sports likewise developed an early-child violence detection tool that was used to identify victims and people at risk of gender-based violence, particularly in high-risk areas.17
  • Using patient networks for supply distribution: For diseases and conditions such as HIV that have established patient networks, where patients know one another from support and treatment groups, service providers gave medicines to selected patients who then distributed them to others within their community.

INTERVENTIONS AT THE NATIONAL LEVEL

  • Addressing reporting gaps: To close gaps in data reporting, Uganda’s Division of Health Information provided reporting tools to health facilities and engaged district health officers and district biostatisticians to improve reporting.11 Reporting personnel received transportation assistance from district health officers while others received movement permits from the resident district commissioner through the district health office.19

How Did Uganda Perform Across Essential Health Service Indicators During the COVID-19 Pandemic?

The COVID-19 pandemic and the response to it substantially disrupted indicators related to essential health services at the national level—especially immediately after the lockdowns in March and April 2020. Over the course of the following year, however, most indicators recovered.

Indicators can reveal different patterns of disruption to essential health services. In general, it appears that the movement restrictions in April 2020 limited access to essential health services such as diphtheria, tetanus, and pertussis immunization and visits to outpatient departments for diabetes mellitus and hypertension—especially in urban areas in the central region of Kampala and Wakiso. After those restrictions were lifted in May 2020, barriers to health access were likely due to other issues, such as patient fear of contracting COVID-19 at health care facilities.

  • DTP immunization: This indicator refers to the monthly number of doses of DTP (diphtheria, tetanus, and pertussis) vaccine given to children younger than one year old.20 In April 2020, there was a significant decline in the number of children who received DPT3 immunization, compared with 2018 and 2019. This drop coincided with Uganda’s strictest movement lockdown. The figure below shows the ratio of DTP vaccine doses delivered in 2020 compared with the same month in 2019; a value of 1 represents no change and values less than 1 indicate delivery disruption.

Disruption in DTP vaccine doses

IHME
Maternal deaths

Uganda’s national surveillance system defines maternal death as the death of a woman from a pregnancy-related causes, including abortion, malaria in pregnancy, obstructed labor, antepartum or postpartum hemorrhage, hypertension in pregnancy or labor, or death in the first six weeks after delivery.20 Between March and July 2020, there was a significant increase in maternal deaths in Uganda compared with that same period in the previous two years. These findings are consistent with findings from an assessment of the socioeconomic impact of COVID-19 in Uganda conducted by Development Initiatives, a civil society organization that reported a reduction in access to primary health care, an increase in preventable deaths during childbirth, and a reduction in access to family planning and other health programs.21 However, a subnational analysis of the distribution of maternal deaths from 2018 to 2020 suggested that the spike in maternal deaths may have preceded the pandemic—especially in Kampala, where the national referral hospital is located and where maternal death rates are higher because health care workers from all over the country send women with high-risk pregnancies to Kampala for delivery.

Interrupted time series of maternal deaths

Routine Health Systems Data from Makerere University School of Public Health
Health facility births

This indicator refers to the total number of women who gave birth in a health facility in a given year.20 Early in the beginning, facility births dropped but quickly recovered to pre-pandemic levels. In fact, between May and November 2020, the number of women who gave birth in health facilities was actually higher than in the preceding years. This could be the result of the close attention paid to maintaining maternal and child health services by the MOH and its partners WHO and UNICEF.

Interrupted time series of in-facility births

Routine Health Systems Data from Makerere University School of Public Health
Outpatient visits

Outpatient visits of all types decreased at the start of the pandemic by about 18 percent nationwide, with substantial variation by region.

Interrupted time series of outpatient health visits

Routine Health Systems Data from Makerere University School of Public Health
Other indicators

Outpatient visits experienced statistically significant disruptions in the months following the start of the pandemic—28 percent reduction for diabetes, 8 percent for hypertension, and 36 percent for malaria. Hypertension visits returned to pre-pandemic levels later in 2020 but visits for diabetes and for malaria remained much lower than in 2018 and 2019.

What Are the Key Lessons From Uganda’s Efforts to Maintain Essential Health Services During the COVID-19 Pandemic?

Non-pharmaceutical interventions such as movement restrictions, physical distancing in public places, and strategies to support mask-wearing effectively slowed the spread of COVID-19 in Uganda, but they also interfered with the supply of—and demand for—essential health services there. It is difficult to tease out the impact of specific solutions to this problem since so many were implemented simultaneously. However, several have shown particular promise, for Uganda and elsewhere:

Lessons learned from Uganda’s COVID-19 experience

  • Effective communication with the public about how to stay safe and healthy can prevent disruptions to essential health service delivery caused by fear of contracting COVID-19.
  • Improving health workforce surge capacity at all levels can boost the health system’s ability to handle shocks such as the COVID-19 pandemic.

Recommendations for other contexts based on lessons from Uganda

  • Maintain resources by engaging with the private sector for funding, procurement of supplies and commodities, and transportation for health workers and people seeking care.
  • Designate and create separate, specific facilities for COVID-19 treatment and isolation centers across all levels of the health system to maintain continuity of essential health services in other facilities.
  • Create and implement alternate service delivery strategies such as special or mobile clinics, multi-month drug dispensing, and community distribution of medicines to reach people who need services in a safe and accessible way.
  • Redistribute tasks by training non-medical staff to perform non-technical tasks such as symptom or temperature screening so health workers can focus on providing patient care.
AUTHORS
Steven N. Kabwama, Suzanne N. Kiwanuka, Fred Monje, Rawlance Ndejjo, Susan Kizito, Rhoda K. Wanyenze
  1. 1
    National Village Health Teams (VHT) Assessment in Uganda. Uganda Ministry of Health. March 2015. http://154.72.196.19/publications/health-education/national-village-health-teamsvht-assessment-uganda
  2. 2
    National Health Facility Master List 2018. Uganda Ministry of Health, Division of Health Information. 2018. http://library.health.go.ug/sites/default/files/resources/National%20Health%20Facility%20Master%20List%202018_0.pdf
  3. 3
    Atumanya P, Sendagire C, Wabule A, et al. Assessment of the current capacity of intensive care units in Uganda; A descriptive study. J Crit Care. 2020;55:95-99. https://doi.org/10.1016/j.jcrc.2019.10.019
  4. 4
    GBD 2019 Universal Health Coverage Collaborators. Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1250-1284. https://doi.org/10.1016/S0140-6736(20)30750-9 
  5. 5
    World Health Organization. Risk of COVID-19 surge threatens Africa’s health facilities. Published June 3, 2021. Accessed November 12, 2021. https://www.afro.who.int/news/risk-covid-19-surge-threatens-africas-health-facilities
  6. 6
    Our World in Data: https://ourworldindata.org/coronavirus/country/uganda. Accessed November 12, 2021. 
  7. 7
    Kyeyune H. Uganda declares curfew to curb spread of COVID-19. Anadolu Agency. March 31, 2020. https://www.aa.com.tr/en/africa/uganda-declares-curfew-to-curb-spread-of-covid-19/1785775
  8. 8
    Esagala A, Mabala R, Lubowa A, Buule G. Canes, tears in Kampala over coronavirus. Daily Monitor. March 26, 2020.  https://www.monitor.co.ug/News/National/Photos-that-will-compel-you-cancel-your-journey-Kampala/688334-5505362-g3u0ib/index.html
  9. 9
    Public transport ban bites Kampala. The New Vision. March 26, 2020. Accessed November 12, 2021. https://www.newvision.co.ug/new_vision/news/1517117/kampala-feels-pinch-public-transport-ban 
  10. 10
    Kapchorwa hospital partially closed after 50 medics tested positive for COVID-19. The Independent Uganda. September 20, 2021. Accessed November 12, 2021. https://www.independent.co.ug/kapchorwa-hospital-partially-closed-after-50-medics-tested-positive-for-covid-19/
  11. 11
    Ministry of Health (MOH), Republic of Uganda. COVID-19 Response Draft Report, March 2020 – June 2021. Kampala: MOH; 2020. http://library.health.go.ug/publications/disease-survielance-outbreaks/coronavirus-disease-2019-covid-19-preparedness-and 
  12. 12
    Kamulegeya LH, Bwanika JM, Musinguzi D, Bakibinga P. Continuity of health service delivery during the COVID-19 pandemic: the role of digital health technologies in Uganda. Pan Afr Med J. 2020;35(Suppl 2):43. https://doi.org/10.11604/pamj.supp.2020.35.2.23115
  13. 13
    Kakwezi, Collins. COVID-19 Updates: How Does the GeneXpert Test for COVID-19 Work? KIU News. May 14, 2020. https://kiu.ac.ug/news-page.php?i=covid-19-updates-how-does-the-genexpert-test-for-covid-19-work
  14. 14
    Ministry of Health (MOH), Republic of Uganda. Annual Health Sector Performance Report Financial Year 2019/20. Kampala: MOH; 2020. https://www.health.go.ug/cause/annual-health-sector-performance-report-financial-year-2019-20/
  15. 15
    Relief Web International. Easing COVID-19 impact on key health services. Published November 5, 2020. Updated November 6, 2020. Accessed November 12, 2021. https://reliefweb.int/report/uganda/easing-covid-19-impact-key-health-services
  16. 16
    Ministry of Health (MOH), Republic of Uganda. Guidance on Continuity of Essential Health Services during the COVID-19 outbreak. Kampala: MOH; 2020 https://tciurbanhealth.org/wp-content/uploads/2020/05/MOH-GUIDANCE-ON-BUSINESS-CONTINUITY-000.docx3_.pdf 
  17. 17
    World Health Organization (WHO). WHO Monthly Information Exchange Report on Maintenance of Maternal, Newborn, Child, Adolescent and Older People’s Health. Geneva: WHO; 2020. 
  18. 18
    Ministry of Health, Republic of Uganda. COVID-19 Response Information Hub. Accessed November 5, 2021. https://covid19.gou.go.ug/
  19. 19
    Mandu R. How a Ugandan district is copying with a lockdown to deliver MNCH services. Makerere School of Public Health. Published June 1, 2020. Accessed November 12, 2021. https://www.mnh.musph.ac.ug/MNH%20NEWS/how-a-ugandan-district-is-copying-with-a-lockdown-to-deliver-mnch-services/ 
  20. 20
    Ministry of Health (MOH), Republic of Uganda. The Health Management Information System, Health Unit Procedure Manual. Kampala: MOH; 2010. https://www.gou.go.ug/sites/default/files/media-files/THE%20HEALTH%20MANAGEMENT%20INFORMATION%20SYSTEM_0.pdf 
  21. 21
    Owori M. Socioeconomic Impact of Covid-19 in Uganda: How Has the Government Allocated Public Expenditure for FY2020/21? Development Initiatives; 2020. Accessed November 12, 2021. https://www.devinit.org/resources/socioeconomic-impact-of-covid-19-in-uganda/