Key challenges
With the COVID-19 pandemic ongoing around the world, Uganda faced multiple pressing public health concerns with limited resources for sustaining pandemic prevention and response interventions. In addition to the unintended consequences detailed here, challenges associated with the country’s COVID-19 response included:
The impact of movement restrictions and physical distancing on the delivery of key essential health services
Among Ugandan households whose members needed medical care in the first six months of the pandemic, more than half delayed or skipped it. The most frequently cited reasons for skipping health care visits were lockdowns and mobility restrictions.
Indicator data appears to show that the movement restrictions Uganda implemented in April 2020 limited access to essential health services (EHS) such as diphtheria, tetanus, and pertussis immunization and visits to outpatient health facilities for treatment for noncommunicable diseases such as diabetes mellitus and hypertension (see figure below). After those early restrictions were lifted in May 2020, some barriers to health access persisted. However, they were likely due to other issues, such as patient fear of contracting COVID-19 at health care facilities.
Shortfall in service delivery compared to prepandemic trends
Global Financing Facility, https://data.gffportal.org/country/uganda#1189
Unintended consequences of control measures on vulnerable populations
The COVID-19 pandemic and the interventions Uganda implemented to control it were associated with significant economic challenges that have disproportionately affected women, children, and refugees (see text box below).
Unemployment increased, especially in the agricultural sector, and reduced household incomes led to food insecurity. Along with gender-based poverty, gender-based violence also increased. Researchers attribute this increase in part to the COVID-19 lockdowns, but also to losses of income and employment and rising poverty among men. Some interventions, such as the provision of cash and food to vulnerable people, were applied inequitably, not always reaching everyone who needed them.
Case Study: Unintended consequences of COVID-19 public health and social measures in Uganda
Economic growth slowed.
Acute economic challenges predated the COVID-19 pandemic in Uganda. For example, a 2020 invasion of desert locusts destroyed crops and grazing land, undermining food security and destabilizing agricultural households. These challenges had already limited the country’s economic growth—according to the World Bank, real GDP growth in 2020 was 2.9%, compared to 6.8% in 2019 —and paved the way for rising poverty in 2020 and 2021.
According to Ugandan officials, the country’s poverty rate in the first half of 2021 was 28%—10 percentage points higher than in the previous year., Like the pandemic’s effects on education, these negative economic consequences were felt unequally across the country. For example, in 2021, the World Bank estimated that after the first lockdown, more than half of Uganda’s refugees were living in poverty (compared to about 44% prior to the pandemic). Employment rates among refugees fell to 32% by March 2021, compared to around 90% among Ugandans.
From the start of the pandemic in Uganda, reduced domestic revenues and increased health care costs further undermined public finances. Between January 2020 and April 2020, exports declined by 29.6%, imports by 27.4%, workers remittances by 41.5%, tourism receipts by 85.4%, and foreign direct investment by 5.6%. Central government debt as a percentage of GDP grew from 35% in 2018 to nearly 45% in 2020. Customs and import duties and tax revenue fell. Pressures on the Uganda shilling in the domestic foreign exchange market also increased the cost of imported goods in the domestic market.
READ MORE: Economic impact of Uganda's second lockdown
Movement restrictions led to business closures and rising unemployment.
Pandemic lockdowns led more than three-quarters of businesses in Uganda to lay off workers. Lockdown measures halved business activity across the country.,
Before the COVID-19 pandemic began, 87% of Ugandans were employed. In June 2020, that number fell to 71%. It rose again to 92% in March and April 2021, then fell again to 81% in October and November of that year. Researchers believe this decline was likely due in part to reimposed lockdowns in June 2021.
In the formal sector, approximately 100,000 Ugandan workers lost their jobs after officials imposed PHSMs to control the spread of COVID-19. In the informal sector, which employs about 85% of Ugandan workers, some 4.4 million people lost their jobs.
Street vendors, shop owners, and restaurant workers were particularly affected by curfews and lockdowns. So were formal and informal workers in the tourist industry (some 8% of GDP in 2018–2019), which was gutted by the closure of international borders, the suspension of airline travel, and the imposition of quarantine on travelers early in 2020. Tourism officials had expected more than 1,660,000 foreign tourist visitors in 2020, up from 1,400,000 in 2018, but a July 2020 report from the Ministry of Tourism, Wildlife, and Antiquities estimated the country would have 1 million fewer visitors and lose $1.06 billion in foreign exchange that year alone. In 2021, just 521,000 people visited Uganda. In the tourist industry, 70% of workers lost their jobs, and 92% of tourist businesses downsized their staff.
Lockdowns, mobility restrictions, and associated job losses and business closures reduced household incomes.
A 2020 online survey of some 450 people in in Kenya and Uganda showed that more than two-thirds of respondents had experienced income shocks during the initial months of the COVID-19 pandemic.
The agricultural sector suffered especially from these early-pandemic economic downturns. Transportation restrictions and the closure of land borders and local markets limited the number of buyers that farmers could find for their food crops, which in turn reduced the prices they could demand. Nearly three-quarters of coffee-farming households in Uganda reported lost income since the pandemic began.
These income reductions affected young people in particular. About 30.3% of young men experienced a reduction in income, 16% reported loss of a job, and 14.8% reported that their businesses closed as a result of the COVID-19 lockdowns. Lockdowns and other PHSMs in Uganda had left low-income households—especially those with young people in them—without the means to afford necessities like sugar; the same study projected that students would not return to school to complete their studies because of a lack of income. And 41% of children faced increased economic hardships in their families and communities.
Gender-based poverty increased.
Women dominate the informal service industry as well as the service and personal care industries, which were severely affected by lockdowns and other PHSMs. Women workers are also overrepresented in the leisure, travel, and hospitality business. By contrast, male-dominated sectors such as construction and manufacturing were less disrupted over time.
By June 2020, 23% of previously employed women had lost their jobs compared to 16% of men. Female-headed households were most likely to report a total loss of business income. The unpaid care work associated with school closures and other COVID-19 restrictions (and with caring for household members exposed to and sick from COVID-19) fell disproportionately on women.,
Gender-based violence increased.
Uganda’s annual crime report for 2020 reveals a 29% increase in domestic violence from the previous year. The majority of victims (70%) were women. Some researchers attribute this increase to the COVID-19 lockdowns, as well as losses of income and employment and rising poverty among men.
READ MORE: 2020 report on COVID-19 rapid gender assessment in Uganda
Reduced household incomes led to food insecurity.
The 2020 online survey of Kenyans and Ugandans showed that in Uganda, the proportion of food-insecure respondents increased by 44%. As expected, food insecurity affected poor households more than wealthy ones.
Almost half of respondents to a separate online survey reported they were unable to access social services such as food or EHS during Uganda’s first lockdown period in April 2020. About 20% said they experienced extreme poverty and hunger during that time. Other studies indicate that food insecurity was more evident in female-headed households and refugee households.
Some families reported coping with food insecurity by depleting their food reserves, while others—even city dwellers—reported growing their own food. Other coping strategies included reducing the amount of food consumed, reducing the frequency of meals, and accepting provisions from friends and extended families.
Lockdowns and other restrictions had negative impacts on mental health.
The early COVID-19 pandemic and Uganda’s response to it also had unforeseen social consequences.
Butabika Hospital, Uganda’s only national referral facility for mental health care, reported a higher number of patients seeking treatment for anxiety disorders in 2020 compared to 2018 and 2019. Other studies found increased anxiety, depression, and anger: among low-income earners during the COVID-19 lockdown, among university students, and among adult respondents to a telephone survey conducted between December 2020 and April 2021. Despite an acute demand for mental health care, regional psychiatric treatment centers were often converted into isolation units for patients with COVID-19.
Rates of teenage pregnancy increased.
Teenage pregnancy in Uganda is a persistent problem—and as in many other countries around the world, COVID-19 resulted in an increased rate of teenage pregnancy. A World Bank report found an increase in teenage pregnancy of 17% in the six months following the March 2020 lockdown., The Ministry of Education’s count is even higher: according to its data, more than 90,000 girls under 18 became pregnant during the country’s first lockdown, including more than 9,000 underage girls—a 28% increase,, which researchers attribute in part to school closures and to the increased vulnerability of girls living in poverty. The increase was especially acute in poorer and more rural parts of the country, where rates of teenage pregnancy already tended to be higher, young people are more likely to drop out of high school, and there is a strong culture of early marriage.
READ MORE: Finding the balance: PHSM in Uganda
Data limitations and misinformation
Limited funding and personnel made contract tracing as well as mortality and genomic surveillance difficult. As the pandemic progressed and community spread increased, Uganda’s testing and surveillance systems were likewise overwhelmed. This led to gaps in local surveillance capacities, lower rates of case detection, and the underreporting of test results.
These limitations on the quantity and quality of available data for decision making have led to information gaps, among both policymakers and the public. Over time, misinformation about the pandemic and the interventions Ugandan authorities implemented to control it eroded public trust in health officials and curbed compliance with PHSMs.
COVID-19 vaccine uptake challenges
Uganda received its first shipment of COVID-19 vaccines from COVAX in March 2021. As in other countries, the first phase of vaccination targeted health and frontline workers, older people, and those with underlying health conditions. Eligibility did not to include all people over 18 until August 2021—well into the second, more severe pandemic wave fueled by the delta variant. Even then, many communities faced vaccine shortages and high levels of unmet demand.
Other obstacles to vaccination in Uganda include limited cold chain and other infrastructure, vaccine hesitancy among some groups, and difficulty accessing vaccine delivery locations.
By the end of December 2021, just 3% of Ugandans had received a complete dose of the COVID-19 vaccine; 15% were partially vaccinated.
Consequences of school closures
Uganda’s schools were closed for nearly two years, until January 2022. These school closures likely kept many students, teachers, and family members from contracting COVID-19. However, their negative consequences were also substantial: learning loss, widening educational inequalities, high dropout rates, and increased numbers of teenage pregnancies. The full impact of prolonged school closures is still being understood.
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To meet Uganda’s many pandemic challenges, its Ministry of Health (MoH) leaned on best practices and structures it had established during previous epidemics and outbreaks of infectious disease. Strong, coordinated leadership was committed to controlling the spread of COVID-19 and maintaining access to EHS. At all levels of the health system, innovation and adaptation were key to the country’s pandemic response.
Lessons learned from Uganda’s pandemic-response strategies can inform improvements for future pandemic preparedness and response efforts. In fact, they have already done so. In May 2021, Uganda’s MoH worked with the World Health Organization (WHO) to update national EHS guidelines. Research from Makerere University School of Public Health and the Exemplars in Global Health informed these updates. Building on lessons from this research, the team emphasized the need to integrate resilience in preparedness and response; include EHS as a critical pandemic response pillar; and track and mitigate the unintended consequences of interventions.
Although Uganda has experienced challenges with their COVID-19 response, there are lessons that can be learned from how the country innovated and adapted strategies to address these challenges. Documenting the country’s response may also inform improvements for future pandemic preparedness and response efforts.