COVID-19 disruptions to essential health services in Uganda : access, interventions and lessons for emergency

<p dir="ltr">Background</p><p dir="ltr">Public health emergencies like disease outbreaks cause disruption to delivery of, and access to essential health services. Prior to the COVID-19 pandemic, existing frameworks for preparedness and response to public health emergencies did not explicitly highlight the maintenance of essential health services as an important strategic operation of an emergency response. Previous researchers have also noted that the morbidity and mortality due to these disruptions can outstrip the disease outbreak specific morbidity and mortality.</p><p dir="ltr">Aims</p><p dir="ltr">The overall aim was to investigate how responses to public health emergencies can minimize disruptions to the delivery of and access to essential health services while strengthening systems for service delivery. Specific aims were:</p><p dir="ltr">1. To describe the interventions and strategies that were implemented for continuity of HIV/AIDS, TB and Malaria service delivery during public health emergencies (Study I).</p><p dir="ltr">2. To investigate the challenges to access and delivery of essential health services during the response to the COVID-19 pandemic in Uganda (Study II).</p><p dir="ltr">3. To describe the interventions and innovations that were implemented to ensure the continuity of health service delivery during the COVID-19 pandemic in Uganda (Study II).</p><p dir="ltr">4. To investigate the effects of the COVID-19 vaccine rollout on the continuity of routine childhood immunization services in Uganda (Study III).</p><p dir="ltr">5. To describe the innovations and adaptations for continuity of services that were adopted for delivery of routine maternal and child health services in Uganda (Study IV).</p><p dir="ltr">Materials and Methods</p><p dir="ltr">In this thesis, I used both quantitative and qualitative research methods.</p><p dir="ltr">Quantitative Methods Analysis of Routine Data: Interrupted times series analysis was conducted using monthly data at national (Study II) and district (Study III) level to estimate the magnitude of change in service use before and during the COVID-19 pandemic. Qualitative Research Methods Systematic Review (Study I): Articles describing interventions to maintain the delivery of or demand for HIV/AIDS, TB and/ or malaria services in low- and middle-income countries were searched in Medline, Web of Science, Embase, Cochrane and Global Index Medicus and thematically analyzed.</p><p dir="ltr">Document Review (Study II): Uganda Ministry of Health documents and reports were reviewed to synthesize the challenges to service delivery and interventions for continuity of services during the COVID-19 response.</p><p dir="ltr">Key Informant Interviews (Study II, Study III, Study IV): Study II participants were purposively selected from all levels of the health system. Study III and Study IV included health workers at public and private health facilities in Wakiso District. Focus Group Discussions (FGD) (Study III and Study IV): Three FGDs were conducted with mothers if they had at least 2 children below the age of 3 years to understand the effect of the COVID-19 vaccine rollout on routine immunization services and experiences regarding use of maternal and child health services. Qualitative data were thematically analysed using inductive (Study I), deductive (Study II and Study IV) and abductive (Study III) approaches.</p><p dir="ltr">Results</p><p dir="ltr">Interventions to maintain HIV/AIDS, TB and Malaria services included leveraging existing service delivery platforms for service delivery, modifying existing logistics operations systems, combining operational workflows and scaling up self-care. New interventions included population-based interventions (e.g. mass administration of antimalarials) and policy level interventions (e.g. removing user fees).</p><p dir="ltr">Using the interrupted times series analysis, I found that there were significant differences in the pre-COVID-19 trends compared with the post-COVID-19 trends of service use for facility deliveries and new attendances in out-patient departments. During the COVID-19 pandemic in Uganda, challenges to service delivery included movement restrictions and concerns for health worker safety, shortage of resources for continuity efforts, shortage of equipment, commodities and space as well as mobility restrictions affecting service delivery and use. Interventions to address the challenges included establishment of coordination mechanisms for essential health services continuity, provision of infection control commodities and stocking essential health products, provision of financial resources for continuity efforts, strengthening existing health workforce through temporary hires and leveraging the community health workforce and modifying existing service delivery strategies.</p><p dir="ltr">Between March and April 2021, Diptheria, Pertussis and Tetanus (DPT3) vaccine doses administered reduced by 4.3%, Polio 1 vaccine doses reduced by 5.5%, Polio 2 doses reduced by 5.8% and Polio 3 doses reduced by 5.6%. The challenges to continuity of routine childhood vaccination services included increased workload, competition for cold chain and storage capacity and impact on perceptions about vaccination. Interventions to sustain demand included engaging community health workers, community mobilization, health education, and prioritizing routine immunization services. Interventions to maintain delivery included integration of services and increasing health workforce. Interventions to maintain essential health services led to sustained changes like new infrastructure and supplies e.g ambulances, new roles involving infection control, increased role of community health workers and outcomes like better workplace safety and teamwork.</p><p dir="ltr">Conclusions</p><p dir="ltr">In this thesis, I showed that the capacity to maintain essential health services during emergencies is dependent on baseline capacities and therefore its important to invest in the policies and infrastructure for service delivery before emergencies. Multisectoral engagement to balance response strategies with continuity efforts is critical to forestall service disruptions. Also, in low- and middle-income countries, community structures and systems are important for response and maintenance of services. Ultimately, services are provided by health workers and its important to prioritize their safety and wellbeing during emergency response. Finally, there should be deliberate efforts to document lessons to inform sustained system improvements that result from the innovation, flexibility and dynamism required to maintain service delivery during an emergency.</p><h3>List of scientific papers</h3><p dir="ltr">I. Interventions to Maintain HIV/AIDS, TB and Malaria Service Delivery During Public Health Emergencies in Low- and Middle-Income Countries: A Systematic Review. <b>Steven N Kabwama</b>, Rawlance Ndejjo, Tobias Alfvén, Neda Razaz, John M Ssenkusu, Helena Lindgren, Rhoda K Wanyenze. [Submitted]</p><p dir="ltr">II. Interventions for Maintenance of Essential Health Service Delivery during the COVID-19 Response in Uganda, between March 2020 and April 2021. <b>Steven N Kabwama</b>, Rhoda K Wanyenze, Suzanne N Kiwanuka, Alice Namale, Rawlance Ndejjo, Fred Monje, William Wang, Siobhan Lazenby, Susan Kizito, Christopher Troeger, Anne Liu, Helena Lindgren, Neda Razaz, John Ssenkusu, William Sambisa, Rebecca Bartlein, Tobias Alfvén. International Journal of Environmental Research and Public Health. 2022, 19, 12522. <a href="https://doi.org/10.3390/ijerph191912522" rel="noreferrer" target="_blank">https://doi.org/10.3390/ijerph191912522</a></p><p dir="ltr">III. Maintenance of Service Delivery During Medical Countermeasures Deployment: The Association between the COVID-19 Vaccine Rollout and Continuity of Routine Childhood Immunization Services in Uganda. <b>Steven N Kabwama</b>, Neda Razaz, John M Ssenkusu, Helena Lindgren Rhoda K Wanyenze, Tobias Alfvén. PLOS Global Public Health. 2025, 5(6): e0004731. <a href="https://doi.org/10.1371/journal.pgph.0004731" rel="noreferrer" target="_blank">https://doi.org/10.1371/journal.pgph.0004731</a></p><p dir="ltr">IV. How interventions to maintain services during the COVID-19 pandemic strengthened systems for delivery of maternal and child health services: a case-study of Wakiso District, Uganda. <b>Steven N Kabwama</b>, Rhoda K Wanyenze, Neda Razaz, John M Ssenkusu, Tobias Alfvén, Helena Lindgren. Global Health Action. 2024 Dec 31;17(1):2314345. <a href="https://doi.org/10.1080/16549716.2024.2314345" rel="noreferrer" target="_blank">https://doi.org/10.1080/16549716.2024.2314345</a></p>