Coordination across policy domains and government agencies is considered critical for addressing complex challenges such as inequities, urbanisation and climate change. However, the factors influencing coordination among government entities in low-income and middle-income countries are not well known and theory-based health policy and systems studies are limited. This paper examined the factors influencing coordination among government entities at the central government level in Uganda. Our findings suggest that achieving intragovernmental coordination requires more time and resources to guide the software aspects of institutional change—articulating a shared vision on coordination across government. Shaping incentives to align interests, managing coordination costs and navigating historical-institutional contexts are critical. Countervailing political actions and power dynamics should be judiciously navigated.
Clinical trials as disease control? The political economy of sleeping sickness in the Democratic Republic of the Congo (1996-2016)
Human African Trypanosomiasis (HAT), commonly known as sleeping sickness, is closer than ever to being eliminated as a public health problem. We analyse archives and in-depth interviews to explore the role the national HAT programme played in the Democratic Republic of the Congo (DRC). Our political economy lens highlights how the leadership of the programme managed to carve itself substantial autonomy, forged new international alliances, and used clinical trials and international research to not only improve treatment and diagnosis but enhance its under-resourced disease control system. We discuss the sustainability of both the vertical approach embodied in the DRC’s efficient national HAT programme and its funding model at a time when the number of HAT cases is at an all-time low and better integration within the health system is urgent. Our study provides insights for collaborations between unevenly-resourced international research efforts and national health programmes.
A Situation Assessment of Community Health Workers’ Preparedness in Supporting Health System Response to COVID-19 in Kenya, Senegal, and Uganda
This paper reports a mixed methods study to assess the preparedness of Community Health Workers (CHWs) in supporting health system response in prevention and management of COVID-19 in Kenya, Senegal, and Uganda. Interviews were conducted with policy actors, health care workers, CHWs and community members. Findings underscore the important role CHWs play in supporting HS during crisis like COVID-19 to mitigate disruptions and stabilize the system for effective response. The CHWs can improve resilience of social and HS during unplanned disruptions for optimal functioning and attainment of universal health care. Policy makers should develop structured mechanisms for engaging CHWs while committing resources to address challenges that affect seamless synergy between health and CHWs Systems.
‘Where are the dead flies!’: perceptions of local communities towards the deployment of Tiny Targets to control tsetse in the Democratic Republic of the Congo
The National Programme for the control of human African trypanosomiasis in Democratic Republic of Congo includes a large-scale vector control operation using Tiny Targets. These are small panels of insecticide-impregnated cloth that are deployed in riverine habitat where tsetse flies concentrate. The effectiveness of Tiny Targets depends partly on acceptance by local communities. In 2018, we conducted research to explore the perception and acceptability of Tiny Targets in two different village clusters where Tiny Targets had been deployed by the local community or external teams. Our research underlined how awareness campaigns and communication are essential, but also how working within the scope of community social norms and customs are equally important. Prospects for the successful use of Tiny Targets are greater when communities are involved because the use can be adapted to social norms.
Cash, COVID-19 and aid cuts: a mixed-method impact evaluation among South Sudanese refugees registered in Kiryandongo settlement, Uganda
In this paper, we estimate the impact after 4–8 months of a large one-off unconditional cash transfer delivered to refugees in Kiryandongo settlement, Uganda during a time of dual shocks: the COVID-19 pandemic and cuts to monthly aid. We focus on four key outcomes: (1) health-seeking behaviour; (2) COVID-19 specific preventive health practices; (3) food security and (4) psychological well-being.Taken together, we find significant support for the importance of cash transfers to refugee households mitigating against declines in food security and mental well-being in the face of shocks.
Health system resilience during COVID-19 understanding SRH service adaptation in North Kivu
There is often collateral damage to health systems during epidemics, affecting women and girls the most, with reduced access to non-outbreak related services, particularly in humanitarian settings. This rapid case study examines sexual and reproductive health (SRH) services in the Democratic Republic of the Congo when COVID-19 hit, towards the end of an Ebola Virus Disease (EVD) outbreak, and in a context of protracted insecurity. It found that the EVD outbreak was an opportunity for health system strengthening that was not sustained during COVID-19. This had consequences for access to SRH services, with limited-resources available and deprioritization of SRH.
Managing community engagement in research in Uganda: insights from practices in HIV/AIDS research
Community engagement (CE) in research is valuable for instrumental and intrinsic reasons. Despite existing guidance on how to ensure meaningful CE, much of what it takes to achieve this goal differs across settings. Considering the emerging trend towards mandating CE in many research studies, this qualitative study involving respondents experienced in HIV/AIDS biomedical research involving CE (data collected between August 2019 and August 2020), aimed at documenting how CE is conceptualized and implemented. It also provides context-specific guidance on how researchers and research regulators in Uganda could think about and manage CE in research. Ultimately, the study suggests that existing guidance on how to conduct robust CE in research is no substitute for creativity, flexibility, and reflexivity on the part of both researchers and research regulators.
Operational challenges and considerations for COVID-19 research in humanitarian settings: A qualitative study of a project in Eastern Democratic Republic of the Congo and South Sudan
We conducted a qualitative study to explore the barriers and enablers of a COVID-19 cohort study conducted in South Sudan and Eastern Democratic Republic of the Congo, to inform future research on COVID-19 and infectious diseases in humanitarian settings. We used a case study design embedded within the original prospective cohort study. Findings suggest most of the challenges affecting the cohort study were not specific to COVID-19 research but have been a feature of previous infectious disease research carried out in complex emergencies. However, the pandemic has exacerbated certain problems. Facilitating factors were also identified. The global impact of COVID-19, its high public profile, and specific pandemic policies pose further operational challenges for research in already complex humanitarian settings. Future studies could plan mitigation measures that include flexibility in staffing and budgets, strategies to expand testing, and early partnerships with local organizations and health authorities.
Effect of COVID-19 on older adults 50 years and above living with HIV in a less-developed country
In Uganda, as soon as the first case of COVID-19 was identified, strict lockdown measures were enforced, including a ban on all public and private transport, night curfew, closure of schools, and suspension of religious and social gatherings and closure of non-essential shops and markets. This qualitative study explored how COVID-19 affected the health and social life of older people living with HIV (PLHIV) through interviews in two hospitals. Overall, the findings indicated that the COVID-19 lockdown negatively affected the health and social well-being of older PLHIV. This calls for strategies to improve HIV care and treatment access during the lockdown to sustain the HIV program gains in this vulnerable population.
Perceptions of ebola virus disease among the bambuti hunter group: a mixed-methods study
The second largest Ebola virus disease (EVD) epidemic occurred in the DRC from 2018–20. The Bambuti, a hunter population in the Ituri Forest of the DRC, may be vulnerable to the zoonotic spread of EVD due to their frequent handling of forest animals. We conducted a study to discern how the Bambuti perceived and responded to EVD. Thematic analysis of focus group discussions revealed three major themes: (1) deprivation and discrimination; (2) mistrust; and (3) epistemic dissonance with public health messages emphasizing risks posed by forest animals. Surveys pointed to widespread multidimensional poverty, lack of formal education, dependency on wild meat and opposition to bushmeat bans, limited trust in government overall knowledge of EVD. Compliance with public health measures was associated with higher levels of education and trust in government. Our findings point to a particular vulnerability of the Bambuti to the effects of EVD.
Private sector engagement in the COVID-19 response: experiences and lessons from the Democratic Republic of Congo, Nigeria, Senegal and Uganda
Private entities play a major role in health globally. However, their contribution has not been fully optimized to strengthen delivery of public health services. The COVID-19 pandemic has overwhelmed health systems and precipitated coalitions between public and private sectors to address critical gaps in the response. We conducted a multi-country cross-sectional study in the Democratic Republic of Congo, Nigeria, Senegal and Uganda between November 2020 and March 2021 to document the public and private sector partnerships and engagements to inform current and future responses to public health emergencies. Findings indicate the private sector contributed to the COVID-19 response through engagement in COVID-19 surveillance and testing, management of COVID-19 cases, and health promotion to maintain health access. There is a need to develop regulatory frameworks for sustainable public–private engagements including regulation of pricing, quality assurance and alignment with national plans and priorities during response to epidemics.
‘There Were Moments We Wished She Could Just Die’: The Highly Gendered Burden of Nodding Syndrome in Northern Uganda
Nodding Syndrome (NS) occurs within a wide spectrum of epilepsies seen in onchocerciasis endemic areas of sub-Saharan Africa. It has debilitating consequences on affected individuals and increases the socio-economic, physical and psychological burden on care-givers and their households, diminishing their standing within the community. Social science research on the disproportionate burden of the disease on females is limited. Based on ethnographic research over 3 years in northern Uganda, we explored the burden of being ill and care-giving for persons with NS from a gendered perspective. We found that NS-affected females were at greater risk of physical and psychological abuse, sexual violence, unwanted pregnancies, sexually transmitted infections and stigma, in a context of deteriorating socio-economic conditions. Primary care-givers of the NS-affected, mostly women, struggled to make ends meet and were subjected to stigma and abandonment. Targeted interventions, including legal protection for affected females,
Whose voices matter? Using participatory, feminist and anthropological approaches to centre power and positionality in research on gender-based violence in emergencies
This article examines how applying participatory, feminist and anthropological methods in gender-based violence research can hold researchers accountable to both acknowledging and explicitly addressing power disparities.
The social dimensions of community delivery of intermittent preventive treatment of malaria in pregnancy in Madagascar, Mozambique, Nigeria and the Democratic Republic of the Congo
Intermittent preventive treatment in pregnancy with is a key malaria prevention strategy. We conducted an anthropological study to understand the social context of a community based approach to delivering sulphadoxine pyrimethamine (C-IPTp) through community health workers (CHWs) in four countries (the DRC, Madagascar, Mozambique and Nigeria) to identify key factors influencing the intervention’s acceptability. In-depth interviews, focus group discussions and direct observations were undertaken between 2018 and 2021. The findings provide evidence on the reported acceptability of C-IPTp among a wide range of actors, as well as the barriers and facilitators for delivery and uptake of the intervention. Overall, C-IPTp was accepted by the targeted communities, supporting the public health value of community-based interventions, although the barriers identified should be examined if large-scale implementation of the intervention is considered.
Not for us, without us: examining horizontal coordination between the Ministry of Health and other sectors to advance health goals in Uganda
Little is known about the coordination relationship between Ministries of Health and other sectors to advance health and development goals in low- and middle-income countries (LMICs). Our study examined the coordination relationship between MoH and other government ministries, departments and agencies (MDAs) at the national level in Uganda. Document review and key informant interviews with government officials and non-state actors indicated the coordination relationship was characterized by interdependencies generally framed in terms of health sector goals and not vice versa. Actor opportunism and asymmetrical interests interacted with structural–institutional factors contributing to variable influence on internal and external coordination within and beyond MOH. The study suggests critical actions needed to improve coordination.
Human African trypanosomiasis (HAT) in the Republic of Congo: why the Congolese population is reluctant to screening?
Human African trypanosomiasis (HAT) is a neglected tropical infection, and surveillance of the disease relies on community participation in screening. This study aimed to identify the main factors associated with low community uptake of HAT screening in endemic districts in the Republic of Congo. A cross-sectional survey carried out during a HAT sensitisation campaign in the districts of Mpouya, Ngabé and Loudima, which are endemic for the disease, indicated a range of local perceptions about HAT including that it is a rural disease, and is associated with witchcraft. Participants identified sleep disorder, prolonged fever and madness as key symptoms. The main reasons for non-adherence to HAT screening was the fear of lumbar puncture and stigmatisation. These findings suggest that more effort should be put into raising awareness of HAT and the benefits of screening amongst the Congolese population, in order to strengthen the national disease control program.
A Qualitative Evaluation of COVID-19 Preventative Response Activities in South Kivu, Democratic Republic of the Congo
In this evaluation of COVID-19 preventative response programs in South Kivu, Democratic Republic of the Congo (DRC), we aimed to explore community understandings of COVID-19, assess operational successes and challenges of COVID response activities, and identify barriers to practicing COVID-19 preventative behaviors. We interviewed a total of thirty-one community members (n = 16) and programmatic stakeholders (n = 15) (healthcare providers, government officials, and developmental and NGO staff engaged in COVID-19 response) between April and September 2021. Findings suggest that community-informed approaches are needed for effective COVID-19 preventative response programs in South Kivu, DRC. Our study identified successes and challenges in COVID-19 response activities. Future research should assess the effectiveness of integrating preventive programs with COVID-19 vaccination efforts.
Engaging faith communities in public health messaging in response to COVID-19: Lessons learnt from the pandemic in Ituri, Democratic Republic of Congo
This qualitative participatory research (using a workshop methodology) sought to understand challenges faced by faith leaders in the Democratic Republic of Congo (DRC) (Ituri and Nord-Kivu) in engaging with current public health strategies for the COVID-19 pandemic; to explain why long-standing collaborations between government, faith-based health services and leaders of faith communities had little impact; and to identify novel approaches to develop effective messaging that resonates with local communities. Findings indicate that public trust in faith leaders is crucial in health emergencies. The initial request by government authorities for faith leaders to deliver set health messages rather than co-develop and design messages appropriate for their congregations resulted in faith communities not understanding health messages. Delivering public health messages using language familiar to faith communities could help to ensure more effective public health communication and counter misinformation.
Evaluation of public health surveillance systems in refugee settlements in Uganda, 2016-2019: lessons learned
Civil wars in the Great Lakes region resulted in massive displacement of people to neighboring countries including Uganda. With associated disease epidemics related to this conflict, a disease surveillance system was established aiming for timely detection of diseases and rapid response to outbreaks. We describe the evaluation of and lessons learned from the public health surveillance system set up in refugee settlements in Uganda (Bidibidi, Adjumani, Kiryandongo and Rhino Camp). We found that it was functional with many performing attributes but with many remaining gaps. There is need for improvement to align surveillance systems in refugee settlements with the mainstream surveillance system in the country.
The enduring consequences of conflict-related sexual violence: a qualitative study of women survivors in northern Uganda
One in three women in northern Uganda report having suffered from conflict-related sexual violence (CRSV), including forced marriage and rape. Understanding women’s perceptions of and experiences with CRSV, especially related to the persistent health and social challenges they continue to face, is critical for developing effective and targeted interventions. We worked with a local, survivor-led organization to recruit interview participants from three post-conflict districts in northern Uganda: Gulu, Lira, and Pader, conducting them between October 2016 and March 2017. Results indicate that women survivors continue to face multifaceted health and social problems in the post-conflict period. Most health-related programs that were set up at the end of the war in northern Uganda are no longer available. Increasing access to care, particularly services tailored to treating chronic reproductive health issues and mental health, is paramount for women survivors in northern Uganda and other conflict-affected regions.
Access to HIV/AIDS or TB care among refugees in Kampala, Uganda: exploring the enablers and barriers during the COVID-19 pandemic
The rapid spread of COVID-19 overwhelmed existing health care systems, finding it challenging to provide essential health services besides the COVID-19 response interventions. Refugees are disproportionately affected by the COVID-19 pandemic because of the barriers they face to access health care. However, there is limited research investigating how access to HIV/AIDS or TB care services by urban refugees is affected during pandemics such as the COVID-19. This study adopted a cross-sectional survey among urban refugees living in Kampala, Uganda. Results offer major insights into the effect of COVID-19 control measures on disruption of access to services particularly in relation to being able to access service points. The findings suggest recognizing structural barriers to uninterrupted or continued access to HIV/AIDS or TB services during pandemics such as COVID-19 can help stakeholders to design measures that make it possible for more urban refugees to access HIV/AIDS or TB services.
Dramatic effects of COVID-19 public health measures and mass reverse migration on youth sexual and reproductive health in rural Uganda
Youth (aged 10 to 24 years) comprise nearly one-third of Uganda’s population and often face challenges accessing sexual and reproductive health (SRH) services, with a disproportionately high incidence of negative SRH outcomes. Responding to COVID-19, Uganda implemented strict public health measures including broad public transportation, schooling, and business shut-downs, causing mass reverse-migration of youth from urban schools and workplaces back to rural home villages. Our study aimed to qualitatively describe the perceived unintended impacts of COVID-19 health measures on youth SRH in two rural districts.
How social norms contribute to physical violence among ever-partnered women in Uganda: A qualitative study
This paper contributes to the literature that studies how social norms sustain undesirable behavior. It establishes how norms contribute to intimate partner physical violence against women. First, norms organize physical violence as a domestic and private matter. Second, they organize physical violence as a constituent part of women’s lives, thereby normalizing women’s experience of abuse. Third, norms define appropriate boundaries within which male partners perpetrate violence. The findings draw essential information for social change interventions that target improvement in women’s and girls’ wellbeing. For social and behavioral programmes to change harmful norms, they have to deconstruct physical violence as a private matter, advance the de-normalization of physical violence, and dismantle acceptable boundaries within which violence happens.
Health Care Workers’ Experiences, Challenges of Obstetric Referral Processes and Self-Reported Solutions in South Western Uganda: Mixed Methods Study
This study described the profile of emergency obstetric referrals, challenges faced in implementation of obstetric referral processes and explored self-reported solutions by health workers.
Addressing the Syndemics of HIV, Mental Health, and COVID-19 Using the Health and Human Rights Framework among Youth Living with HIV, in Uganda: an Interpretive Phenomenological Study
Stigma and discrimination negatively impact the prevention, treatment, and care of HIV. The COVID-19 pandemic increased this complexity and created a cluster of synergistic health contexts, wherein the physiological aspects of HIV and the social and environmental conditions increased the vulnerability in health outcomes for youth living with HIV (YPLHIV) in Kampala, Uganda. We used interpretive phenomenological analysis (IPA) and the syndemics framework to understand the lived experiences of YPLHIV.
Help-seeking and challenges faced by transwomen following exposure to gender-based violence; a qualitative study in the Greater Kampala Metropolitan Area, Uganda
The high prevalence of gender-based violence (GBV) among transwomen is a human rights and public health challenge. Nonetheless, there is limited evidence of sources of GBV support services and the challenges faced by transwomen while help-seeking, especially in transphobic settings like Uganda. This study explored the sources of GBV support services and the challenges faced by transwomen in the Greater Kampala Metropolitan Area during help-seeking.
Using Population Mobility Patterns to Adapt COVID-19 Response Strategies in 3 East Africa Countries
The COVID-19 pandemic spread between neighboring countries through land, water, and air travel. Since May 2020, ministries of health for the Democratic Republic of the Congo, Tanzania, and Uganda have sought to clarify population movement patterns to improve their disease surveillance and pandemic response efforts. Ministry of Health–led teams completed focus group discussions with participatory mapping using country-adapted Population Connectivity Across Borders toolkits. They analyzed the qualitative and spatial data to prioritize locations for enhanced COVID-19 surveillance, community outreach, and cross-border collaboration.
The impact of the COVID-19 pandemic on healthcare access and utilisation in South Sudan: a cross-sectional mixed methods study
Indirect effects of the COVID-19 pandemic on communities in fragile and conflict-affected settings may be severe due to reduced access and use of healthcare, as happened during the 2015 Ebola Virus Disease outbreak. Achieving a balance between short-term emergency response and addressing long-term health needs is particularly challenging in fragile and conflict-affected settings such as South Sudan, given the already significant barriers to accessing healthcare for the population. This study sought to characterise the effect of COVID-19 on healthcare access and South Sudan’s healthcare response.
Social networks, mobility, and HIV risk among women in the fishing communities of Lake Victoria
A cross-sectional qualitative methods study was conducted to understand mobility patterns among women resident and or working in fishing communities of Lake Victoria in Kenya, Tanzania, and Uganda. The study was conducted in six fishing communities from March 2018 to June 2019.
After all, we are all sick: multi-stakeholder understanding of stigma associated with integrated management of HIV, diabetes and hypertension at selected government clinics in Uganda
Integrated care is increasingly used to manage chronic conditions. In Uganda, the integration of HIV, diabetes and hypertension care has been piloted, to leverage the advantages of well facilitated and established HIV health care provision structures. This qualitative study aimed to explore HIV stigma dynamics whilst investigating multi-stakeholder perceptions and experiences of providing and receiving integrated management of HIV, diabetes and hypertension at selected government clinics in Central Uganda.
Becoming Secondary Survivors: Exploring the Effects of Conflict-Related Sexual Violence on the Health and Well-Being of Families in Northern Uganda
The enduring consequences of conflict-related sexual violence (CRSV) and its catastrophic effects on the health and well-being of survivors has been well documented. However, there is a dearth of evidence on the impact of CRSV on families of survivors who care for them. The aim of this study was to explore the ripple effects of CRSV on families of survivors living in three post-conflict districts in northern Uganda: Gulu, Lira, and Pader.
Data flows during public health emergencies in LMICs: A people-centered mapping of data flows during the 2018 ebola epidemic in Equateur, DRC
In infectious outbreaks, rapid case detection and reporting, coordination, and context-specific strategies are needed for rapid containment. Data sharing between actors, and the speed and content of data flows, is essential for expediting epidemic response. In this study, researchers mapped data flows during the 2018 Ebola Virus Disease (EVD) outbreak in Equateur Province in the Democratic Republic of the Congo using semi-structured interviews, ethnographic research, and focus groups with EVD response actors.
Challenges and commonly used countermeasures in the implementation of lifelong antiretroviral therapy for PMTCT in Central Uganda: Health providers’ perspective
Uganda has implemented lifelong antiretroviral therapy for the prevention of mother-to-child HIV transmission since September 2012. Implementation of this strategy has been met with health provider and client challenges which have persisted up to date. This study explored providers’ perspectives on the challenges and countermeasures of the implementation and scale-up of lifelong ART among pregnant and breastfeeding women.
Understanding malnutrition management through a socioecological lens: Evaluation of a community-based child malnutrition program in rural Uganda
The objective of this evaluation was to understand the factors influencing malnutrition management in a CMAM program in rural Uganda, using the socioecological model to assess the multilevel determinants of outpatient malnutrition management. This evaluation used qualitative methods to identify factors related to caregivers, healthcare providers and societal structures that influence children’s outpatient care.
Reproductive materialism and justice for women with abortion care needs in Uganda.
While reproductive health justice is often assumed to be inherent in reproductive health interventions, the nature of injustices, and the reasons for and mechanisms of concealment, are often unclear. In this article, we draw on an ethnography of priority setting and healthcare practice in eastern Uganda to illuminate these injustices and the mechanisms of concealement. We focus on discursive practices as the mechanisms through which power is activated and navigated, such that health practitioners are able to evade state surveillance and retribution.
Communities’ Perception, Knowledge, and Practices Related to Human African Trypanosomiasis in the Democratic Republic of Congo
Community members see their role more in terms of vector control than participation in screening, referral, or accepting treatment. We propose recommendations for achieving sustainable community engagement, including development of an information and communication strategy and empowerment of communities to take greater ownership of HAT control activities.
