Essential Health Services: Uganda

Around the world, public health emergencies such as the COVID-19 pandemic can profoundly disrupt the delivery of routine or . 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 (). 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:

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. 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. 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. (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. 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). 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.

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.,  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 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.

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. 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.

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

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. 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.

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. The subsequent decline in data reporting rates led to difficulties in monitoring the delivery and maintenance of essential health services.

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.

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.
• 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.
• 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.

With the support of local and international partners, Uganda has implemented several interventions to overcome these supply- and demand-side barriers to  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 .

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. 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.

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. 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. 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.

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.

Outpatient visits

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

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.

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.