Uganda

Abstract

The chapter highlights the cost of the pandemic by showing that the lack of recognition of existing inequalities and the needs of vulnerable and marginalized groups subjected them to a higher risk of infection and undermined the broader response to Covid-19. It is clear that Covid-19 disproportionately affected people who were already vulnerable due to comorbidities that are often a result of pre-existing social inequalities. But Covid-19 mitigation and policy responses have also entrenched them. The chapter shows that some response measures and their inadequacy hampered access to mitigation measures. It is recommended to decentralize resource allocation and proper targeting of the most vulnerable, namely, women, informal sector workers, people living with HIV and other diseases, pregnant women, children, the poor, refugees, and people living with disability.

Introduction

The Covid-19 pandemic in Uganda exposed pre-existing structural inequalities and their impacts on social groups. Its health system and multiple disease burdens contributed to shaping the pandemic responses and their impacts. In terms of its population structure, the country has a large youthful population, with 72% under 24 years old. Only 2% are 65 years and above. Ordinarily, this should be an advantage since the Covid-19 infection rate for youth is lower than that of older people. However, other critical structural factors are important to note. Due to rapid urbanization, 25% of the population lives in densely populated urban areas. Uganda also has a large refugee population¹ which has tripled since 2016 and adds an essential dimension to the demographic dynamics that are critical for an effective Covid-19 response. The country’s social services are under stress because of these demographic dynamics.²

Ranked 159 out of 189 countries in the Human Development Index, Uganda is categorized as a lower-middle-income country by the World Bank due to its high poverty levels and other developmental indicators. Economic vulnerability to external shocks is high, with two out of every three people living around the poverty line or falling back below it. In 2016, 42% of the population lived on less than $1.90 per day.³ Despite the high incidence of poverty, only 3% of the population has access to social protection programmes.⁴ Regarding social services, only 38% of households have access to electricity, and around 40% have access to improved sanitation.

Agriculture employs more than 70% of Ugandans. Also, 29% of children under the age of five are stunted, a measure of chronic malnutrition that highlights the need for attention to food security. In Uganda, even before the pandemic, the health system was overstretched, with relatively low ratios of health professionals to population, little intensive care capacity and shortages of medical equipment, including ventilators.⁵ The health system throughout the country is chronically underfunded and fragmented. The doctor-patient ratio is one to 24,000 and nurse-patient ratio is one to 11,000. Only 55 ICU beds are available in-country, of which 20 lack ventilatory capacity, only one-third are part of the public health system, and all are in major urban hubs.⁶ The disparities in the health infrastructure are stark in rural areas. Though communicable diseases are a considerable burden in Uganda, non-communicable diseases such as hypertension and diabetes, which pose a significant risk to those who contract Covid-19, are rising. Though there is limited data, the available evidence points to rising cases not only in the urban areas but also in the rural areas.⁷ The 2014 NCD survey attributed 33% of annual deaths to NCDs. In addition, hypertension and high blood sugar were reported, with many of those affected not being on medication.⁸

The constraints in the health sector and system raise concerns about the country’s capacity to mount an effective biomedical response to the pandemic alongside the fear that necessary public health measures such as physical distancing, handwashing, and wearing facemasks might also be challenging to implement, particularly among some social groups such as the poor.

The chapter is guided by a social-ecological framework whereby individuals’ experiences are shaped by a range of nested, interrelated factors around them, from seemingly “distant” factors such as laws and policies down to more “proximal” factors such as their immediate living situation. We explored the interplay of these factors, mainly the range of laws, policies, and regulations relevant to Covid-19 and their impact on different social groups.

Methodology

This mixed-methods study includes policy, quantitative and qualitative research, and a joint analysis to combine all these different data types. We reviewed web-based search engines such as Google and Google Scholar for the legal and policy analysis. Searches, carried out in October 2020, were limited by the date range of publication and were restricted to the year 2020. Searches included “Uganda + COVID + policy,” “Uganda + COVID + law,” “international + COVID + policy + tracker,” and “Uganda + COVID + legal + response.” Data were assessed for relevance and systematically extracted based on their direct or indirect implications for vulnerable communities.

Searches were conducted on Pubmed, Google Scholar, and Scopus using the search terms “Uganda” AND “covid”. Pubmed searches were inclusive of the abstract and article, while Google Scholar and Scopus searches were only inclusive of the title. The Pubmed search yielded 90 results, with 30 articles deemed relevant after a title and abstract review and 15 articles included in the final review. The Google Scholar search yielded 67 results, of which 46 were unique to Google Scholar and deemed relevant after a title and abstract review. Twenty-one articles were included in the final review. The Scopus search did not yield any impressive results. Thus, a total of 36 articles were included for a full review.

We also conducted media analysis of major local and international media channels. Reports from influential organizations actively engaged in the Covid-19 response in Uganda were identified from the media analysis, including UN organizations such as the WHO, UNDP, UNICEF, WFP, FAO, UN Women, as well as civil society organizations including Amref Health Africa, the Red Cross, World Vision, Save the Children, Akina Mama Wa Afrika, and the White Ribbon Alliance. Their latest reports on areas of interest were reviewed, and data relevant to answering the study’s research questions were systematically extracted.

Nine key informant interviews were conducted with various participants across different sectors at the national level and in the Lango region in northern Uganda. Participants at the national level included heads of departments, programme managers, and principal medical officers at the Ministry of Health. At the regional/district level, these included medical superintendents, hospital administrators, Residence District Commissioners (RDCs), Chief Administrative Officers (CAO) of districts, and District Health Officers (DHO). Interviews were recorded and transcribed verbatim for analysis. Ethical approvals were secured through the MILDMAY Uganda Ethics Review Committee and the USC Institutional Review Board.

Overview of the Timeline of the Legal and Policy Response

In the first year of the pandemic, Uganda was widely lauded by the World Health Organization and the Africa Centres for Disease Control and Prevention (Africa CDC) for its strong response to Covid-19. The government put in place a range of legal and policy measures, each covering different aspects of their response. The pre-existing Public Health Act provided the overall legal framework for designing and implementing the Covid-19 response. The Minister of Health invoked powers under this Act to issue rules and orders aimed at combating Covid-19. In the Public Health (Notification of Covid-19) Order, 2020, Covid-19 was declared a notifiable disease to which the provisions on prevention and suppression of infectious diseases under the Public Health Act (Cap. 281) apply. This includes the Minister of Health’s power to make rules for control of the spread of the disease, order the quarantine of infected persons or those suspected to be infected, inspect premises of persons believed to be infected with the disease, and disinfect premises and buildings which have been covered under these rules and orders. Local government authorities are empowered to enforce such regulations and may make their own.

The national Covid-19 Preparedness and Response Plan was developed based on model guidance for countries published by the WHO. The Ugandan plan includes eight pillars: Leadership, Stewardship, Coordination, and Oversight; Surveillance and Laboratory; Case Management; Strategic Information, Research, and Innovation; Risk Communication and Social Mobilization; Community Engagement and Social Protection; Logistics and Operations; and Continuity of Essential Services. This plan was designed to guide the overall national response. It is supplemented by the additional legal and policy measures that have been instituted throughout the pandemic period.

The Ministry of Gender, Labour and Social Development issued Covid-19 guidelines in which it called on employers to retain employees who are paid monthly (regardless of whether they are essential or non-essential staff) and to agree with workers on who may stay home. Casual employees paid hourly or daily were most affected under these arrangements. The guidelines do not, however, have the force of law.

Figure 12.1 provides an overview of the national response until November 2020. A critical characteristic of the government response is the phased re-opening: rather than immediate removal of all restrictions. The government gradually loosened restrictions, continuously tracking their impact on the epidemic.

Fig. 12.1

(Source https://thinkwell.global/wp-content/uploads/2020/05/COVID-19-Uganda_August-2020-Updates-final.pdf)

Uganda’s Covid-19 response timelineFootnote

The Uganda SP4PHC Team (n.d.).

Covid-19 Response Measures

Further information on these measures is provided below, organized by the different sectors they are designed to impact. The section ends with an analysis of how these measures may have influenced the spread of Covid-19 throughout 2020. The actual impact of the measures will be explored in the subsequent sections. For example, in November (after the period covered in the timeline above), it was reported that a new national strategy had been launched in which community health workers (CHWs) were to be paid a monthly allowance to fight Covid-19 at the community level.¹⁰

President Museveni imposed various restrictions on different types of mobility. For example, on March 25, airports and land borders were closed. This included banning new refugee arrivals, a significant change from the usual “open door” policy for refugees.¹¹ A fourteen-day lockdown was imposed on March 30, 2020 and reviewed. In addition, a 7 p.m. to 6:30 a.m. curfew was effected. Apart from transporting food and essential goods, private transportation was also restricted. Some measures were eased sequentially with locational variations.

The government of Uganda decided to open its borders to Ugandan nationals who had been stranded abroad in neighbouring East African Community (EAC) countries. On September 20, land borders and airports were opened, and tourists and citizens who were stranded abroad were allowed to enter the country. As of October 1, Uganda’s borders opened, and international flights resumed. Passengers arriving in the country required a negative PCR test certificate within 72 hours of arrival in Uganda.

On April 1, President Museveni ordered the closure of all non-food shops. However, shops that sold food, agricultural products, veterinary products, detergents, and pharmaceuticals were allowed to remain open. Closure of schools and public places was also enforced. These measures were accompanied by hygiene and sanitation protocols such as handwashing, face-mask-wearing, and social distancing mandates.

Mitigation Measures

To mitigate the impact of school closures, the government developed a response plan focusing on continuity of learning during the closure of schools. According to UNHCR, nearly 500,000 children accessed distance learning programmes across Uganda while schools were closed, and 1,127 children with disabilities received support. However, there was some apprehension about e-learning because access was impossible for some social groups.¹²

Regarding fiscal measures, Uganda secured US$491.5 million in emergency financing from the IMF under the Rapid Credit Facility programme, which was intended to boost international reserves and improve health spending on vulnerable populations. In June 2020, Finance Minister Matia Kasaija announced that the Uganda budget for the fiscal year 2020/21 would focus on improving the well-being of Ugandans, boosting economic transformation, and improving peace, security, and good governance.

Tax cuts were announced in June 2020 as part of the stimulus package. In addition, the budget included an economic stimulus and growth strategy, including introducing tax relief to businesses, expanding social protection for the vulnerable, improving household incomes through work programmes and credit facilities, and reduction of mobile transaction costs to prevent the spread of the pandemic.¹³ On June 29, the Uganda Covid-19 Economic Crisis and Recovery Development Policy Financing received $300 million in budget support from the World Bank to support reforms to provide immediate relief to businesses and individuals hit hardest by the pandemic.

Non-state Actors’ Inclusion in the National COVID Response

Within the government, there was cross-sectoral involvement in designing the Covid-19 response. However, evidence suggests that the government acted unilaterally in designing the response, restricting consultation and contributions to decision-making. While the chosen strategies were quickly deemed successful, with few reported Covid-19 cases, this came at a cost. Nevertheless, some key informants felt this approach was justified given the need for the quick action and reported that even community engagement came in much later.¹⁴ It has fuelled growing demands from civil society and the private sector for greater involvement and accountability. There were calls for community involvement in Covid-19 management, including strengthening community structures such as political, religious, and cultural leaders to mobilize their constituencies to improve response measures.¹⁵ Key informants suggested that civil society involvement in the national response increased over time. However, their primary function was often described as support to the government in terms of providing financing and supplies and sensitizing communities rather than playing an active role in designing the Covid-19 response.¹⁶ A national-level official justified this by explaining that “the government response framework is science-based, so there is no need to involve [civil society].”¹⁷ Another key informant, however, thought that civil society could be more effectively involved in policy-making, implementation and monitoring.¹⁸ Some inclusion of religious and cultural leaders was reported to ensure acceptability of and compliance with restrictions on mass gatherings rather than as a matter of inclusive participation of Covid-19 management.

Inclusivity of Mitigation Measures and Policy Responses

Some key informants, especially government representatives at the national level, emphasized that laws and policies apply equally to everyone in the country, which, in their view, meant that it was unnecessary to accord additional attention to any sub-population.¹⁹ While others stated that vulnerable populations were targeted in mitigation measures, there was an acknowledgement that when the government first designed the response, it was based on biomedical criteria without due attention to social factors, such as poverty, that might put some people at greater risk.²⁰ Finally, some noted that attention was given to vulnerable groups at the intervention level rather than within laws and policies. Food relief, for example, was targeted the urban poor and provisions were made to allow special permission for pregnant women to travel outside curfew to reach health facilities.²¹ But, the government’s mitigation measures and policy responses have disproportionately affected specific populations, including women, the urban poor, children, people with disabilities, and people living with HIV and other chronic health conditions. For example, the impact on women is reflected by an increase in reported domestic violence, a loss of jobs across sectors dominated by women, a rise in abortion cases, and the limitation of travel for essential health services.^22,23,24

Overall, it seems that there was little consideration for vulnerable populations. For example, people with disabilities such as people with hearing, speech, or sight impairments were left out, yet they needed communication.²⁵ Even when vulnerabilities were considered, more health-related challenges were at the fore, leaving the socioeconomically disadvantaged inadequately covered. Policy responses mainly focused on combating the spread of the infection and protecting those at high risk of Covid-19 but did not consider the effects on the poor.²⁶

Immediate Impacts of the Response on Covid-19-Related Outcomes

Overall, many interview respondents argued that the legal and policy measures implemented intended to affect Covid-19-related outcomes, including keeping mortality low, shielding the elderly from infection, and improving health infrastructure. While some government officials reported that the response had its intended impact on Covid-19 outcomes, many challenges remained. In the first six months of the pandemic, Uganda was internationally lauded for a successful response, but that changed with fast community transmission. In addition, the level of risk of exposure to the coronavirus was not equally distributed among population groups. Figure 12.2 shows the distribution of risk among different populations based on household exposure to seven risk factors:

Fig. 12.2

(Note Red indicates higher risk, yellow indicates moderate risk, and green indicates lower risk)

Number of risk factors to which people are exposed

• i. levels of overcrowding

• ii. population living with an older person (aged 60+)

• iii. population with no access to water in their dwelling or on their premises (yard/plot)

• iv. population who reports having to collect their water

• v. population sharing sanitation facilities with others or who lack any toilet facilities

• vi. population who reports not having handwashing facilities near their toilets

• vii. population who must collect fuel for cooking.²⁷

At the national level, almost 67% of the population has a high risk of exposure to more than four risk factors, while rural areas have a higher risk exposure than urban areas (73% and 46%, respectively). People living in poverty are also at higher risk than the non-poor, and specific sub-regions such as Karamoja, Acholi, Bukedi, and West Nile are particularly affected.

The socioeconomic features of the country show that the lockdown was unfeasible for the poor. Reliance on a daily wage to meet basic needs is incompatible with lockdown measures. Half of the residents in the Greater Kampala Metropolitan Area live in informal settlements, comprising only 16% of total land, presenting challenges to compliance with measures such as physical distancing and self-isolation.²⁸ Lockdowns also limited job opportunities for sex workers, which led them to engage in riskier behaviours that could contribute to community transmission.²⁹

The costs of food, medicine, and transportation increased, making life unbearable for the poor. Health workers were also affected by mobility challenges. Rural people could no longer travel to access health care in urban areas.

Implications of Measures for the Health Sector

By November 10, 2020, at least 1,070 health workers in Uganda were confirmed to have contracted Covid-19.³⁰ At least 17 frontline health workers had lost their lives to the pandemic.³¹ Although some district hospitals and lower-level facilities received personal protective equipment (PPE) and infection prevention and control commodities that had been centrally procured, there were widespread reports of shortages and deficiencies in PPE supply, with some reports indicating that some health workers did not have access to basic PPE such as face masks and gloves.^32,33 Our media analysis showed that health workers were exposed to unsafe working conditions, low pay, long working hours, and violence.³⁴ Healthcare workers reported being anxious and panicked and had avoided patients with COVID-like symptoms due to concerns of being infected.^35,36,37 One study found that workers in non-Covid-19 designated hospital departments were more at risk because infection prevention and control measures were inadequate.³⁸ In some places, UNICEF supplied health facilities with PPE, detergents, handwashing stations, and soap for infection prevention and control.³⁹ Healthcare workers, particularly midwives, reported increased workloads, frequent schedule changes, and exhaustion⁴⁰ which had implications for their mental and physical health.

Mental health has also been affected for some peer support workers due to their inability to meet in person because of the restrictions. Peer support workers in mental health are not salaried employees and therefore have to resort to meal and transport allowances and other small income-generating activities to survive. In addition, while some peer support workers were able to participate in weekly conference calls, mobile phones and cellular data were not affordable for others, meaning that they could not keep in touch with co-workers, leaving them socially isolated.⁴¹

Although guidance for non-severe Covid-19 was home-based care, there was no provision of PPE for caregivers, which, while understandable in the context of nationwide shortages, presents challenges, particularly in crowded households where true self-isolation might not be possible.

Impacts of Measures on Social Groups

The first issue to note is that managing the Covid-19 crisis created additional problems for the health of non-COVID patients. Due to the ban on public transportation, some pregnant women died because they had to walk long distances to get to hospitals.⁴² Regarding livelihoods, many people working in the industries most affected by shutdowns, including tourism, hospitality, horticulture, infant educators, petty trade, markets, and cleaning, are dominated by women.^43,44

Many women who are over-represented in the informal sector, sex workers, market vendors, hawkers, and caterers, among others, most of whom live hand to mouth and are the only breadwinners of their families, lost their only sources of income because they were forced to stop working indefinitely.⁴⁵ Forty-six per cent of workers employed in the informal sector are reported to have been pushed below the poverty line in the first months of the pandemic, with similar trends seen in the hospitality industry (43%) and trading and services (41%), all of which disproportionately affected women.⁴⁶ The number of households with no income earner rose by 41% in the first three weeks of the lockdown, with female-headed households, people living with disabilities and older adults most affected.⁴⁷ The closure of Kalerwe market resulted in lost livelihood for 10,000 vendors, 80% of whom were women and the vast majority of whom had no access to social safety nets.⁴⁸

The government stated that food markets could only remain operational if workers socially distanced themselves and slept in the markets. Female vendors have an extra burden due to childcare responsibilities and some resorted to either sleeping with their children in the market or leaving them home for days.⁴⁹ Some poor women were unable to afford to pay fees to sell in the market and had to resort to hawking and roadside trading.⁵⁰ With school closures and isolation in homes, many women who already bore the brunt of unpaid domestic care work had attend to it as a full-time job.⁵¹ Some of these chores also fell to girls as they were not attending school, limiting their opportunities to study. Female refugees were also particularly affected by the additional burden of domestic responsibilities.⁵² Many interview participants recognized the impact of movement restrictions on pregnant women’s access to health services, but no one mentioned any of these gender-related factors exacerbating the pandemic’s impact on women. One participant noted that women might have been left out of livelihood support programmes.⁵³

According to the Bureau of Labour Statistics, in Greater Kampala, over 87% of total employment is informal sector workers who experienced a high risk of loss of income and livelihood and Covid-19 infection due to trading with close person-to-person contact.⁵⁴ In addition, a survey in April found that approximately 84% of the small- and medium-scale businesses in Kampala had reduced their workforce by more than half since the start of the pandemic.⁵⁵ Additional layoffs, pay cuts, and terminations occurred because of cash flow shortages stemming from the lockdown.⁵⁶ The layoffs were due to the ban on internal travel, which mainly affected small and medium-sized businesses.

Health: Biomedical and Public Health Response

Covid-19 also increased gender-based violence (GBV). Between March 30 and April 28, 2020, alone, 3,280 cases of gender-based violence cases were reported to the police. In addition, anger and frustration due to loss of income increased strain on relationships and aggravated emotional and physical violence.^57,58 Due to the isolation regulations being enforced and widespread loss of employment, people spent more time at home, and some women, particularly those who lacked financial independence, may have been unable to escape abusive partners, leaving them at risk of being severely harmed.^59,60,61 Certain districts, including Wakiso, were more impacted than others.⁶²

Other dimensions of GBV were the risks posed by curfew, the ban on public transport and its attendant walking to work necessities.⁶³ Furthermore, sex workers experienced increased violence and were forced to engage in more risky behaviours because of the pandemic.⁶⁴ Informal trade closures have led to female refugees engaging in transactional sex to support their families.⁶⁵ This same trend has been reported generally among younger people.⁶⁶

In the five months of lockdown, Uganda registered more than 21,000 cases of child abuse.⁶⁷ A recent survey found that 60% of people have observed an increase in sexual violence against children since the lockdown began, and 80% reported that parents used violence against children.⁶⁸ Increased child poverty and hunger, child marriage and labour were reported as some of the additional dimensions of violence.⁶⁹ Girls from families of low socioeconomic status—pushed further into poverty during lockdown—resorted to trading sex for money, food, and even sanitary towels.⁷⁰ Child marriage and teenage pregnancy also increased⁷¹ which led to high school dropout rates. A study indicated that half of street children surveyed had been exposed to violence. In addition, the challenges associated with being on the streets during the pandemic forced some street children to return to their abusive families.⁷²

The measures also affected mental health. The inability to attend social gatherings caused fear, uncertainty, and stress, particularly for salaried workers.⁷³ The suicide rate among men, including a disproportionate number of male teachers, increased during the pandemic, likely due to school closures leading to monthly payment suspension.⁷⁴ The lack of social interaction disproportionately affected girls, who were less likely than boys to maintain social contact because of boys’ greater access to mobile phones and the ability to meet in person at community gatherings.⁷⁵

People with disabilities were heavily impacted by barriers to health access and were often met with violence by authorities.⁷⁶ They faced challenges accessing health centres and markets to seek medical attention and essential items for their families. Without support from the government or others, people with disabilities were left behind at a time when they needed access to services and support more than ever.⁷⁷ The inclusion of representatives from the National Union for Disabled Persons Uganda in district-level meetings in Lira is a good example of inclusivity within the pandemic response.⁷⁸

The high food insecurity experienced by many was due to the many restrictions and measures. In addition, the lockdown amplified the food crisis.⁷⁹ It affected the food supply chain at all stages, and income shocks further amplified food insecurity with increased prices, food shortages, and the inability of supply chains to adapt.⁸⁰ These changes disproportionately impacted socioeconomically vulnerable households, particularly those not growing their food.⁸¹

One survey found that compared to a “normal period,” there were significant increases in the number of respondents who reduced the amount of food eaten (30 percentage points), were unable to eat healthy and nutritious food (35 percentage points), consumed less diverse diets (45 percentage points), or worried about not having enough food (50 percentage points).⁸² Another survey found that 17% of Ugandans living in Kampala faced acute food insecurity, with six in ten families selling productive assets such as land and livestock and begging or turning to illegal activities to find food and two in ten urban households not having enough food to eat.⁸³ Some young people borrowed money, going into debt, to buy food and other essentials.⁸⁴ A decrease in the amount and variety of food consumed in urban slums was also documented.⁸⁵ Millions of children were no longer receiving school meals due to the schools’ closure.^86,87

Ugandans were worried about insufficient food, were unable to eat healthy food, were eating reduced portions, and consumed limited food varieties.⁸⁸ Groups noted to have experienced increased food insecurity include street children, indigenous communities, people with disabilities, the elderly, sex workers, and people with pre-existing chronic health conditions such as HIV or diabetes.^89,90,91,92 The government provided targeted food donations for sex workers in one district, but these efforts were limited in impact and did not entirely address their challenges.⁹³ Diabetes associations provided food and other support to families that have a child with Type 1 Diabetes in some areas.⁹⁴

In March 2020, the government recognized the severe negative impacts of the lockdown on household earnings, especially the urban poor, and requested US$15 million to provide food for two million poor people living in urban centres.⁹⁵ Interview participants widely cited this intervention as a pro-poor and essential response to the unforeseen impact on food security caused by Covid-19-related restrictions.⁹⁶ The Uganda Coronavirus Response Team directed food distribution to the urban poor but only targeted major urban groups living in and near Kampala.^97,98,99 This move benefited women, lactating mothers, the elderly, the sick, and small business owners.¹⁰⁰ However, urban refugees were left out because food distribution programmes required individuals to present national identification cards that refugees do not possess.^101,102 Due to movement restrictions, rural populations were also excluded from food distribution programmes and could no longer access their gardens.¹⁰³

Food aid was insufficient in amount and variety to address the food insecurity crisis.¹⁰⁴ It was reported that about 1.5 million people needed food assistance.¹⁰⁵ Yet, early in the pandemic, the World Food Programme (WFP) cut rations for refugees in the settlements by 30% due to funding shortfalls.¹⁰⁶ The government stated that they would provide food relief to vulnerable workers who were the most impacted by the lockdown, but this was yet to be seen at the time of writing.¹⁰⁷

Farmers’ logistical challenges also contributed to food insecurity. Although the government expressly permitted farm workers to travel, they were often denied access to their farms by security personnel. They also struggled to transport their produce to markets, and many markets closed due to social distancing protocols.^108,109 The risk was that primary rural production, food deliveries, exports, employment, and incomes would be affected. The subsequent agricultural season production would also be affected due to the disruptions. Local businesses and supply chains were more likely to be affected than international ones.¹¹⁰ Disruptions to food supply chains, caused primarily by travel restrictions and social distancing rules that disrupted food flows, were likely to have a sustained impact on the availability of farm inputs and labour, post-harvest losses, and thus farmers’ ability to purchase inputs for the following year.¹¹¹ The poultry, cattle, and fishing industries were similarly affected as well.

Impact on Access to Other Services

Access to health care for non-Covid-19 patients decreased due to the response measures. For example, between February and March 2020, there was a decline in individuals testing for HIV (16%), linkage to HIV care (20%), antenatal care (ANC) visits (14%), and facility-based deliveries (6%), and increases in deliveries by caesarean section (4%), neonatal deaths (7%), perinatal deaths (9%), maternal deaths (43%), and GBV cases (6%).¹¹² Routine health system data confirm that most maternal health indicators (e.g. pregnant women with at least 1 ANC visit, pregnant women with 4 ANC visits, health facility deliveries) worsened in the first two or three months of the pandemic but also show that they had recovered by August 2020 (the most recent data available at the time of writing). In addition, the number of women newly diagnosed with HIV during pregnancy and the number then linked to care were lower than in previous years.¹¹³

Vitamin A supplementation to children under five suffered because biannual campaigns are run in April and October every year, but the April 2020 campaign could not be carried out. Sexual and reproductive health services were initially not listed as essential, impeding access for women of reproductive age seeking services such as contraception or abortion.¹¹⁴ Patients with chronic illnesses such as diabetes, HIV, heart conditions, cancer and prostate issues were advised to wait or consult online.¹¹⁵ In addition, certain conditions (diabetic patients, people living with HIV, sickle cell anaemia patients, and patients with cardiac conditions) were not designated as an emergency, negatively impacting access to services.^116,117 No HPV vaccinations were given to adolescents and women during the lockdown. While the Family Health Days programme had previously increased access to vaccine immunizations, this programme was stopped due to the pandemic.¹¹⁸

In April 2020, a coordination mechanism was established, cognizant of the disruption to routine health services and the heavy disease burden attributed to conditions other than Covid-19. In addition, the Ministry of Health published the Guidelines for Continuity of Essential Services during the Covid-19 Outbreak.^119,120 These guidelines outline which health services could be continued or discontinued depending on three transmission scenarios. While these guidelines were welcome, health resources, including infrastructure, health workers, and financing, continued to be reallocated from regular services to accommodate the COVID response. For example, at the Hoima Referral Hospital, a coronavirus treatment unit displaced a mental health department and its patients.¹²¹

Social Protection Programmes

Before Covid-19, only 3% of the Ugandan population accessed direct income support.¹²² The Social Assistance Grants for Empowerment (SAGE) cash transfer programme for senior citizens pre-dated Covid-19. However, it was expanded, but restrictions on mobility affected access to beneficiaries. This Senior Citizen Grant of UGX 25,000 per month was paid in advance to mitigate the negative impacts of the pandemic on beneficiaries.¹²³ People had to present a national identification document to access these grants, which was challenging for some.¹²⁴

The GirlsEmpoweringGirls Programme, implemented by Kampala City Council Authority (KCCA), has three components: empowering girls through a network of peer mentors; engaging them through education, training, and referrals to support services; and enabling them to pursue better opportunities for their future through a small cash transfer.¹²⁵ While the programme continued through the pandemic, its reach and impact were unclear.

During the lockdown, the government began distributing food to vulnerable people affected by the pandemic in the Kampala, Wakiso, and Mukono districts. Within the first 37 days of the lockdown, the government distributed food to 1,385,000 people in 372,397 households. The programme was, however, discontinued.¹²⁶ Questions have been raised about the decision to provide food relief rather than cash transfers to the urban poor, which many global agencies and countries have promoted as the most effective mechanism to expand access to health and other social services.¹²⁷ In another effort to support food security, the government reported that farmers would be supported to access high-quality agricultural inputs, seeds, and fertilizers using e-vouchers. However, its implementation was unclear.

Another scheme that pre-dates the pandemic is the Ministry of Gender Labour and Social Development’s National Special Grant for Persons with Disabilities. Although the amounts disbursed were unclear, the Ministry decided to make payments during the pandemic. That said, one study found that social protection programmes were not accessible for people with disabilities because they fall into a category that requires special emotional, financial, and social assistance, and they depend on a third person to access benefits, which may have impeded access during this time.¹²⁸

Conclusion and Recommendations

The pre-existing epidemic response structures were an essential foundation for the national response to Covid-19. They allowed the government to act quickly and decisively, which undoubtedly helped slow the spread of the disease. Initially, health funding focused on case management in high-level facilities. However, more significant investment in community structures and primary health care is also paramount. This includes not only investments in infrastructure but also expansion of the health workforce, strengthening of supply chains, and upgrading of health management information systems to efficiently capture and link data at all levels from the community to the national. This will help improve access to a wide range of other services which will better meet community needs and assist the country to reach its universal health coverage targets.

The fact that most resources were invested in Covid-19 management exacerbated the health conditions of other non-COVID patients. Efficient decentralization and allocation of resources in the health sector is needed to prevent the reoccurrence of the fallouts of the Covid-19 management problems. In the longer-term, alternative guidelines for budget and staff allocation during infectious disease outbreaks might be developed to provide a framework within which this could be done.

It is important to note that given the economy’s structure, lockdown measures were not viable given the reliance on daily wages for meeting basic needs unless a cash transfer programme could be instituted to reach all those who needed assistance very quickly. It will be essential to consider what policy options might exist in the context of a future pandemic that might be viable across all the different contexts of Uganda and to put in place structures to facilitate this as soon as possible. Instituting targeted social protection programmes could help mitigate the impact of the pandemic on livelihoods. These were very effective in other locations and could be equally valuable in this context. For example, payments to households whose income is derived solely from everyday work would allow greater compliance with any future movement restrictions or lockdown measures allowing families to survive with dignity. However, this will require a complete social protection plan to support vulnerable and marginalized populations.

Early engagement with communities and the private sector is critical to effective disease response. Even in an emergency where time pressure is immense, involving these partners from the outset will help promote trust in government and cohesive response to which all stakeholders can commit. The importance of public trust in the government during an infectious disease outbreak cannot be overestimated: it is critical to comply with government directives and willingness to collaborate in the disease response. Establishing protocols and mechanisms for how this should be done and where responsibility lies might help facilitate this for future disease outbreaks. In addition, civil society has demonstrated that its advocacy can influence the government response. Capacity building of civil society organizations will expand their ability to engage in and advocate for appropriate responses to future pandemics. They can also play a beneficial watchdog role, helping to hold duty bearers to account.

The need for investment in the food supply chain has also been highlighted. Investment in infrastructure to create resilience in domestic food production, storage, and distribution can help mitigate food insecurity and ensure a timely government response if food distribution is needed.¹²⁹ In addition, creating a strategic food reserve could facilitate a rapid government response to sudden shocks to food and nutrition security among vulnerable and marginalized households. During future disease outbreaks, if schools are closed again, alternative mechanisms would be helpful to sustain school feeding programmes in place.