This blog is a part of #COVID19Africa Series

Uganda typically experiences recurring disease outbreaks throughout the year is in a state of continuous alerts (1). The country has invested in the Integrated Disease Surveillance and Response (IDSR) system which has helped to mitigate numerous outbreaks. Despite our fairly advanced surveillance system, the threat of an outbreak of the scale of COVID-19 poses a challenge. COVID-19 has a higher rate of spread when compared to previous outbreaks (2). The disease is difficult to identify as its symptoms are like many endemic diseases – common flu, malaria, and pneumonia being a few examples. Testing and treating the disease is expensive and are overwhelming even well-resourced health system.

Uganda’s response to COVID-19 

In the face of COVID-19, Uganda took a precautionary approach. Control measures were instituted three weeks before the first case was diagnosed.  In the last week of February, the Ministry of Health started screening travellers from affected countries at border points set-aside two hospitals to receive patients, intensified mass communication, and  set-up an emergency helpline. A timeline of other measures to prevent its spread are :

• 7th March- all international conferences and mass gatherings were stopped, and travellers from affected countries were advised to suspend their travel.
• 18th March-all schools and institutions of higher learning were closed.
• 22nd March- the first case was confirmed with 33 more cases being confirmed within a  week
• 30^th March onwards- series of lockdowns and a night curfew were instituted permitting only essential workers to move.
• April 28^th– a total of 79 cases had been reported with 0 deaths. The lockdown still endures till 3rd May 2020 if all remains as planned.

Our reflection is on three main aspects; first, how service delivery has been affected; second, missed opportunities due to a lack of robust information systems, and, third we review what we term as an “ill”-prepared ambulance system.

Health Service delivery 

A resilient health system is one that continues to provide core services even amidst a crisis (3). Unfortunately, in the face of COVID-19, indications are that our system is not so resilient. Data from the two biggest maternity centres in East-central Uganda where we have field sites show a rise in maternal deaths, a rise in malaria deaths, and a drop in small and sick babies returning for review and immunization. In addition, the failure of health workers to get to work was widespread owing to a lack of transportation during the lockdown.

Although our focus is on the health system, it is imperative to recognize that this is only the smaller picture. The effects of these restrictions have had far-reaching effects on the rest of society. To mention just a few examples, the closure of businesses has affected employees who are now unable to earn an income, and the perils of street children with no homes during curfew hours are unknown. Our Police also reported a rise in domestic violence during this period (6).

Health information systems 

The lack of a robust health information system has been an obstacle to a better response. Our health information systems still suffer from poor completeness and data quality issues (11). Robust information systems would have provided information for predicting consequences of control measures and thus informing mitigation. For instance, having integrated information on patients with chronic illnesses would have informed the strategies like how to deliver their medicines in the face of travel bans.

Ambulance system

The absence of an ambulance system was most felt following a ban on private and public transport. To mitigate,  government vehicles at the district level were draftws as ambulance. However, there has been widespread frustration as the population is unable to access these vehicles. A local daily reported a nurse who pushed a patient in a wheelchair for over 2 km to get her to a referral center (7). There have been various incidences of laboring mothers who failed to get transport to hospitals and gave birth on the way (4,5). All these originate from the lack of know-how in handling an ambulance system and when combined with a crisis the negative consequences are inevitable.

Conclusion

Uganda had drawn on experiences from previous diseases outbreaks and responded well to COVID-19. However, the response has been at the cost of continuity of routine services. Better preparedness to ensure the resilience of our health system is a point of reflection . We need to take this into consideration and act as we move forward.

 References

1. Mbonye AK, Sekamatte M. Disease outbreaks and reporting in Uganda. Lancet [Internet]. 2018 Dec 1;392(10162):2347–8. Available from: https://doi.org/10.1016/S0140-6736(18)32414-0
2. Zhao S, Lin Q, Ran J, Musa SS, Yang G, Wang W, et al. Preliminary estimation of the basic reproduction number of novel coronavirus (2019-nCoV) in China, from 2019 to 2020: A data-driven analysis in the early phase of the outbreak. Int J Infect Dis [Internet]. 2020 Mar 1;92:214–7. Available from: https://doi.org/10.1016/j.ijid.2020.01.050
3. Kruk ME, Myers M, Varpilah ST, Dahn BT. What is a resilient health system? Lessons from Ebola. Lancet [Internet]. 2015 May 9;385(9980):1910–2. Available from: https://doi.org/10.1016/S0140-6736(15)60755-3
4. The Independent. Woman gives birth to twins on roadside. 2020 Apr 1; Available from: https://www.independent.co.ug/woman-gives-birth-to-twins-on-roadside/
5. Biryabarema E. In Uganda, mothers in labour die amidst coronavirus lockdown. 2020 Apr; Available from: https://www.reuters.com/article/us-health-coronavirus-uganda/in-uganda-mothers-in-labour-die-amidst-coronavirus-lockdown-idUSKCN21R2FA
6. Matovu M. 328 cases of domestic violence reported during Covid-19 lockdown so far. Nile post [Internet]. 2020; Available from: https://nilepost.co.ug/2020/04/17/328-cases-of-domestic-violence-reported-during-covid-19-lockdown-so-far/
7. URN. Nurse summoned for wheeling patient to hospital. 2020; Available from: https://observer.ug/news/headlines/64254-nurse-summoned-for-wheeling-patient-to-hospital

Authors:

Phillip Wanduru^1*, Moses Tetui^1,2, Peter Waiswa^1,3

¹Makerere University School of Public Health, Kampala, Uganda,

²Departement of Epidemiology and Global Health, Umeå University, 901 87 Umeå, Sweden

³Department of Global Health Karolinska Institutet, Sweden,

Competing interests:

We have read and understood the BMJ Group policy on declaration of interests and I declare that there are no competing interests.