Authors:
Sophie Mylan
Corporate Author:
Social Science in Humanitarian Action Platform
Published:
2024

Humanitarian actors in Ugandan refugee settlements face the dual challenge of preparing for and responding to epidemics, while providing essential humanitarian assistance. They must balance their international mandate to protect refugees and uphold human rights with a variety of public health measures to safeguard refugees, humanitarian workers and Ugandan host communities from epidemic threats. This complex task also involves addressing broader regional, national and international public health implications of uncontrolled epidemic spread.

Previous SSHAP briefs have described specific considerations regarding cross-border dynamics between Uganda and neighbouring countries in the context of epidemics.1,2 The brief Key Considerations: Cross-Border Dynamics Between Uganda and South Sudan in the Context of the Outbreak of Ebola, 20221 highlights the complex movement of people across the highly porous – and sometimes contested – South Sudan-Uganda border, which cuts through multiple ethnic groups. It describes mobility as related to networks of kin, livelihoods, trade, education, healthcare, and the search for safety and security. The brief suggests that Ebola preparedness and response activities need to be locally appropriate, paying specific attention to the livelihoods of people in this region. Another brief3 specifically highlights the need to consider the context specific vulnerabilities of refugees in Uganda in relation to epidemics.

This brief builds on these insights and presents considerations for five areas of epidemic preparedness and response in Ugandan refugee settlements, drawing on the experience of COVID-19 and its implications for humanitarian protection. It focuses on refugee settlements in north Uganda, drawing on ethnographic data collected during COVID-19 in Palabek refugee settlement, Lamwo district. This is combined with insights from published research, grey literature, and discussions with government employees and humanitarian actors engaged in the Ugandan refugee response.

Key considerations

  • Enabling cross-sectoral strategies amongst humanitarian sectors is essential for effective epidemic preparedness and response efforts. Epidemic preparedness and response must include livelihoods, food security, protection, environment and education in addition to health, and water, sanitation and hygiene (WASH).
  • Facilitating flexible funding is critical to meet refugees’ needs. Epidemic preparedness and response policies need to be flexible so that activities can be tailored to the unique needs and priorities of refugees, informed by refugees’ lived experiences. This requires flexibility in funding streams.
  • Acknowledging that refugees’ priorities during epidemics vary greatly and are shaped by economic, political and social influences is a prerequisite to engaging refugees. Successfully engaging refugees in epidemic preparedness and response requires consideration of these wider influences. For example, experiences of fraud in food distrubution4 or inadequate basic provisions, directly impact the success of public health measures.
  • Addressing the context-specific priorities of refugees is critical to the effectiveness of epidemic response and humanitarian protection activities. Epidemic response activities are shaped by international and national priorities that frequently overlook the lived realities of refugees. This has the potential to render epidemic response and humanitarian protection activities ineffective, as refugees circumvent official policies to ensure their ongoing survival in contexts of high precarity.
  • Considering refugees’ mobility in relation to livelihood needs during epidemics is essential. Surveillance and isolation activities need to consider refugees’ mobility in relation to essential livelihood activities, especially in the context of significant food insecurity. Movement of refugees in and out of refugee settlements may not cease during epidemics despite formal restrictions, including at international borders.
  • Focusing epidemic preparedness plans on reception centres as key entry points for early detection of outbreaks helps minimise the spread of disease. Reception centres are sites of intensive protection activities but are also highly prone to infectious disease outbreaks due to congestion and inadequate facilities. However, they are not separate from the wider settlement, as new arrivals mix with other refugees, host communities and humanitarian personnel.
  • Acknowledging that public health policies are shaped by political narratives as well as public health rationale helps humanitarian actors navigate policies effectively. Registration and infectious disease screening of refugees is shaped by district, national and international political discourse. Humanitarian actors must navigate political narratives regarding refugees – including the perception of new arrivals as a health security threat – whilst providing basic humanitarian protection.
  • Collecting context-specific data helps understand how a vaccine is perceived by refugees and how it compares to other priorities, supporting effective campaigns. Uptake of vaccines during epidemics is shaped by previous vaccination campaigns and wider geopolitical dynamics. These include the relationship of refugees to government and humanitarian actors, and inequalities related to displacement.
  • Specific attention should be paid to ensuring practitioners have regular contact with their personal support network. Balancing humanitarian protection and epidemic activities places a strain on humanitarian practitioners. If this is overlooked, it can compromise the effectiveness of activities, as practitioners face ‘burn out’.

Humanitarian protection and epidemics

The provision of humanitarian aid to refugees revolves around the term ‘protection’. The UN Refugee Agency (UNHCR) has a mandate to protect refugees and coordinate humanitarian responses.5 This encompasses a wide range of interventions to protect forcefully displaced and separated persons from violence and conflict in line with international refugee law, but also to ensure refugees receive access to basic human rights.6 The Refugee Coordination Model outlines the roles and responsibilities of those providing assistance to refugees.5 This includes a specific Refugee Protection Group encompassing working groups for child protection and sexual and gender-based violence. In addition, however, the seven sectors constituting the Multi-Sector Group (refugee emergency telecommunication; food security; health and nutrition; shelter; WASH; education; and livelihoods/ self-reliance) are also key elements of humanitarian protection.

Infectious disease outbreaks and epidemics in refugee settings add an additional dimension to conceptualisations of protection that need to be considered by humanitarian practitioners. The regulated and unregulated movement of refugees is understood to be a health security threat, as refugees may carry the disease in question across international borders.7,8 During COVID-19 in Uganda, the government considered certain groups to be the focus of disease transmission, and therefore the greatest threat to health security. These groups included truck drivers9 and new arrivals of refugees.10 This posed challenges to maintaining the health and safety of refugees residing in settlements and nationals living in the areas hosting refugees, whilst also providing essential services to new arrivals of refugees.

Refugees are also considered a vulnerable group when it comes to infectious disease outbreaks and epidemics and are in need of health protection. Refugee settlements are at risk of disease outbreaks due to overcrowding, inadequate WASH facilities, and high fatality rates driven by pre-existing malnutrition and limited healthcare access.11 Ugandan refugee settlements also receive refugees from areas particularly susceptible to zoonotic epidemics, such as the Congo Basin.12 Furthermore, COVID-19 has demonstrated that consideration needs to be given to the effects of global pandemics within refugee settings,13 with refugees experiencing disproportionally negative socio-economic consequences.14

Uganda’s refugee response

Uganda is Africa’s largest refugee-hosting nation, accommodating approximately 1.7 million refugees.15 Refugees are primarily located in settlements in northern, western and south-western districts16 – some of the poorest areas in the country.17 The largest refugee population in Uganda comes from South Sudan, and they are granted refugee status on a prima facie basis. However, refugees also come from a variety of other countries including the Democratic Republic of the Congo, Rwanda and Burundi.15 The Ugandan Office of the Prime Minister (OPM) oversees all settlements, supported by UNHCR and partnering non-governmental organisations (NGOs) delivering services across the sectors of humanitarian response. A Refugee Welfare Committee comprises elected refugee leaders and mirrors the local council structure of Uganda. Each refugee settlement is divided into zones and blocks, and Refugee Welfare Committee leaders come from the settlement, zone and block levels.

Uganda’s approach to refugees has received international attention, and in 2017 the Comprehensive Refuge Response Framework (CRRF) was launched.18 This confirmed Uganda’s ‘open door policy’ to refugees who live side by side with Ugandan nationals in settlements that enable free movement. The CRRF builds on Uganda’s longstanding refugee policy, which has a ‘development approach’, with the long-term goal of reducing reliance on humanitarian assistance. This development approach includes the 1999 Self-Reliance Strategy;19 the Development Assistance to Refugee-Hosting Area Program (2004); and more recently, in 2015, the Settlement Transformative Agenda.20 The latter advocated for refugee settlements rather than encampments and included refugees in Uganda’s broader development plans.21

There are, however, significant shortfalls in international funding for Uganda’s refugee response. UNHCR’s 2024 South Sudan Regional Refugee Response Plan states:

‘Funding for the Uganda Country Refugee Response Plan (UCRRP) has dwindled in the past years, and the capacity of Refugee Response Plan (RRP) partners to provide life-saving support and protection services to new arrivals and basic assistance to refugees has diminished. This has manifested as significant reductions in food rations, with over 80 per cent of the population receiving USD 3 per person per month, which is barely enough to survive’.15

Furthermore, there is evidence that policies promoting self-reliance and resilience fail to provide adequate assistance to refugees.22–25

Health services to refugees

In line with the CRRF, the OPM and the Ugandan Ministry of Health (MOH) produced the Health Sector Integrated Refugee Response Plan in 2022. The plan outlines a vision for integrated and coordinated health services for both refugees and Ugandan host communities, operating as an addendum to the Health Sector Development Plan 2015-2020.26 This document describes the Ugandan Minimum Health Package to refugees, which includes specific attention to the needs of new arrivals, as well as emergency and epidemic preparedness and response, facility based and community health services, and quality assurance.

The Government of Uganda write clearly that refugees are associated with challenges concerning Water, Sanitation and Hygiene (WASH), disease outbreaks, and the re-emergence of eliminated diseases. Although new or re-emerging outbreaks cause minimal burden in comparison to other more commonly found medical concerns, outbreaks of cholera, measles, polio and Ebola have led to significant resource implications.26 Rather than being delivered through the national Ugandan health delivery system, health services to refugees are usually provided by NGOs through UNHCR funding. These NGOs are also required to provide care to Ugandans living in the vicinity of refugee settlements. The government of Uganda, however, has advocated for a paradigm shift towards more integrated services.26

Epidemic preparedness and response involves the coordination of refugee agencies such as UNHCR; NGOs providing refugee services; and the Ugandan government, including state command, OPM, district government and MOH. Support from additional international agencies such as the World Health Organization (WHO), UNICEF and Médecins Sans Frontières is obtained when epidemics reach pre-determined disease-specific thresholds.

Five areas of epidemic preparedness and response

The following sections outline five areas of epidemic preparedness and response in Ugandan refugee settlements, drawing on the experience of COVID-19 and its implications for humanitarian protection. These areas are: learning from COVID-19 lockdowns; quarantine and isolation; disease surveillance; vaccination; and integration and coordination.

Learning from COVID-19 lockdowns

In March 2020, Uganda instigated a national lockdown in response to COVID-19. Scholars have described how ‘Uganda’s response, though quick and decisive, by restricting movement and social interactions, has negatively impacted the social protection for refugees.’20 Over the following two years, various measures were taken to ‘loosen’ and ‘tighten’ COVID-19 containment measures, commonly known as lockdowns.27 These periods of containment had significant implications for travel and business within the country; schools were essentially closed for two years and the economic consequences for Ugandan citizens and refugees were severe.28

Food and mobility

Prior to the COVID-19 pandemic, refugees in Ugandan settlements experienced significant food insecurity.4,25,29 Most recently this was compounded by insufficient donor funding which led to a reduction in food rations from the World Food Programme22 (the implementation of which coincided with the pandemic). Research has also described corruption within food distribution.4 Prior to the pandemic, refugees relied on other sources of income to generate funds for additional food and other essential items. This included working as casual labour in nearby farms, villages and towns; selling produce at markets; running small shops; or becoming motorcycle taxi drivers. Circular movement to borderlands and neighbouring countries provided access to farmland.30

Many refugees attributed the increase in food insecurity to COVID-19. This aligned with a reduction in overseas funding from countries in the Global North, whose attention turned inwards towards their national COVID-19 policies.31 In the context of reduced food rations and the loss of additional sources of income during lockdowns, refugees continued to travel back to borderlands to farm or search for other economic opportunities,32 crossing officially closed yet porous borders.10

This circular movement of refugees across international borders, e.g., the Uganda-South Sudan border, has been well documented as essential to survival – both prior to and during the COVID-19 pandemic.1,4,30,33 During COVID-19, this unregulated movement of refugees through porous borders challenged humanitarian services in refugee settlements in terms of disease surveillance and isolation, as discussed in the sections below. However, efforts to restrict such movement risks undermining a critical aspect of refugee self-protection,10 in the absence of adequate humanitarian funding to protect against the wider detrimental effects of lockdowns.

The movement of adults described above left children unaccompanied within settlements, creating significant child protection concerns. This was noted by many NGOs in Palabek, including those in the health facilities who noted an increasing number of unaccompanied children attending the outpatient departments.

Settlement COVID-19 taskforce

A specific success reported by refugees and humanitarian actors in Palabek was the formation of a settlement-level COVID-19 taskforce during the first lockdown. This success was attributed to a strong commitment from formal authorities to ensure a coordinated response through Refugee Welfare Committee leaders and Village Health Teams in the settlement, ensuring clear and consistent messaging.

However, this success was not replicated during the second lockdown, as Refugee Welfare Committee leaders noted a significant decline in communication quality from OPM and other agencies in the settlement.

Suicide and violence

Lockdowns coincided with a notable increase in suicide and sexual and gender-based violence across many refugee settlements. In June 2021, UNHCR published a press release documenting a worrying rise in attempted and completed suicides amongst refugees in Uganda, with a 129% increase in 2020 compared to 2019. UNHCR states that ‘most cases concern young women affected by gender-based violence’.14

In 2021, the International Rescue Committee, with support from UNHCR and the European Union Civil Protection and Humanitarian Aid, conducted focus group discussions in Palabek refugee settlement to investigate the concerning increase in suicidal behaviours. The report collated community perspectives on why people attempt or commit suicide.

These were summarised as: having no means to support oneself; gender-based or domestic violence; chronic diseases and the associated stigma; alcoholism and drug abuse; bereavement; unemployment; and loss of property.34 ‘No means to support oneself’ is likely to reflect the inseparable nature of food insecurity and mental health that has been documented amongst refugees in Ugandan settlements prior to COVID-19.35 

In contrast, the violent enforcement of national COVID-19 policies reported in other areas of Uganda by police, soldiers, and local defence units36 was considered to be less severe in settlements, at least in part attributed to settlements as a site of international humanitarian protection.

Humanitarian activities

Following national Ugandan COVID-19 policies, NGOs providing direct services across multiple sectors in refugee settlements had to significantly adjust their operations to comply with restrictions on gatherings and social distancing. In response to the unknown risks of a new pathogen, many NGOs withdrew their staff from in-person work in the settlements. This made the delivery of many services to refugees impossible.

However, some activities managed to utilise alternative methods of communication. For example, ‘road drives’ became a common practice for disseminating information to refugees without the need for gatherings. This involved a large speaker being placed on a vehicle with messages conveyed loudly as the vehicle drove around the different areas of the settlement.

Nevertheless, the significant reduction in humanitarian presence in the settlements was experienced by refugees as a failure to provide adequate protection during a time of increased precarity.

Healthcare services

Access to basic healthcare was significantly disrupted by COVID-19 lockdowns. Restrictions on transportation, such as motorcycle taxis, hindered access to health facilities, especially for those with physical disabilities.

Additionally, fear of contracting COVID-19 directly from healthcare workers made refugees hesitant to visit health centres. Community outreach activities in the health sector were also halted during lockdown. This had an impact on the management of other diseases. For instance, in Palabek refugee settlement, weekly ‘community outreach’ sessions targeting high malaria zones stopped with lockdowns, as gatherings and community activities by implementing partners could not take place due to government restrictions. Even when allowed, healthcare staff were hesitant to engage directly with refugees for fear of contracting COVID-19.

These insights from COVID-19 lockdowns are highly relevant to preparedness plans for future epidemics. They demonstrate that the socio-economic consequences of epidemics, such as reduced livelihood opportunities, food insecurity and restricted access to healthcare services directly impact the engagement of refugees with – and thus the success of – containment policies. There is a higher likelihood of success for preparedness plans that can incorporate these considerations and actively involve refugees through inclusive taskforces.

Quarantine and isolation

When Uganda closed its borders in March 2020 it also halted asylum processes, shutting down transit points and reception centres. Although these measures were temporarily lifted for a large influx of refugees from the DRC in July 2020, borders largely remained closed.20 Despite this national policy, refugees continued to arrive using unofficial porous borders,10 directly entering settlements. Humanitarian actors were required to provide humanitarian protection to these individuals in line with international refugee law, with additional COVID-19 measures.

New arrivals

During COVID-19, the Government of Uganda mandated quarantine for all new refugees entering settlements until they tested negative for COVID-19. This policy acknowledged that despite the official closure of international borders, refugees continued to arrive. This required a significant allocation of resources and was not always feasible due to the closure of processing sites at border points.

Refugees arriving directly into settlements mixed with established refugees, host community and humanitarian staff prior to COVID-19 testing. This mixing was influenced by pre-existing relationships with family and friends within settlements who often offered support to new arrivals. Those arriving also frequented shops in the settlement trading centres. Additionally, the suspension of new refugee registrations required humanitarian practitioners to seek specific permission from government authorities, delaying registration processes and allowing further mixing within settlements.

In contrast, during an Ebola outbreak in 2022, with an epicentre in Mubende district (Western Uganda) the closest refugee settlements in neighbouring districts temporarily diverted new arrivals to alternative settlements to be registered. These decisions, however, are usually based on settlement capacity rather than disease outbreaks.

Quarantine and isolation facilities

During the initial wave of COVID-19, refugees already residing in settlements were required to visit health centres for testing if they had any symptoms or signs of COVID-19, or if returning from another location. If they tested positive, they were isolated in specific facilities. In Palabek, this created a socially monitored border to the settlement, with anyone entering the settlement escorted to a health centre for quarantine and testing, regardless of symptoms. These policies were generally supported by those in refugee leadership positions, and generally had great adherence from refugees.10

Similar engagement was reported in other settlements such as Rhino. However, the additional quarantine and isolation requirements posed significant challenges for refugee services, including the need for extra funding for food and WASH facilities. Refugees reported inadequate food provision in quarantine and isolation units, whilst humanitarian professionals struggled to secure additional funding for these services. In Palabek, challenges were partially overcome by repurposing closed reception centres for COVID-19 facilities.

Home-based care

At the start of the second wave of COVID-19, Uganda shifted its policy to focus on home-based care for mild and moderate cases,37 including in refugee settlements, though this posed unique challenges. Isolating infected individuals from other family members was often unfeasible due to limited space, and maintaining isolation was difficult given the economic pressures refugees faced to secure income. Officially, home-based isolation ended when individuals tested negative, but delays in result processing meant isolation periods could extend for weeks or months. The likelihood of refugees maintaining isolation during these extended periods diminished as time went on.

Coordinated response

Whether isolated remotely or at home, these measures affected refugees’ engagement with livelihood activities, increasing pressure on humanitarian services to provide additional support. To put it simply: expecting refugees to stay at home when they had no source of food, or engage with infection prevention strategies such as hand washing without soap, was impossible. In this way, epidemic response efforts directly overlapped with livelihood opportunities and WASH services, requiring humanitarian practitioners to work across different sectors. Healthcare professionals had to seek support from alternative sectors to address concurrent social and economic issues, to ensure the success of public health interventions.

Disease surveillance

Disease surveillance in Ugandan refugee settlements incorporates both community-based disease surveillance and facility-based surveillance. Community-based disease surveillance  utilises the Village Health Teams (VHTs) in refugee settlements, which receive training in epidemic preparedness and response (see SHHAP Brief, Key Considerations: Community Based Surveillance in Public Health).38

Surveillance includes passive and active components. Passive surveillance involves the monitoring of weekly and monthly surveillance reports that are submitted via Uganda’s Health Management Information System26 directly to the Ugandan MOH. Diseases are categorised39 variously as diseases targeted for elimination (e.g., bacterial meningitis, lymphatic filariasis); epidemic-prone diseases (e.g., cholera, measles); diseases of public health importance (e.g., viral hepatitis, trachoma); and diseases or events of international concern (e.g., acute viral haemorrhagic fever, SARS). See Uganda MOH’s National Technical Guidelines for Integrated Disease Surveillance and Response for the full list.40

Active surveillance consists of targeted activities in response to specific concerns, such as alerts from VHTs or member of the refugee leadership, about unusual cases.

Mobility

Uganda’s refugee response allows freedom of movement, and this poses challenges for disease surveillance. When refugees are highly mobile, surveillance becomes more challenging, as following up on cases of concern becomes difficult. This was evident during a measles outbreak in 2022 in Palabek.

The outbreak originated among refugees who had recently travelled from South Sudan. The disease spread across Palabek settlement to Kiryandongo settlement. It was first detected in Palabek through routine (passive) surveillance. Three positive cases from the same sub-county were found in laboratory testing, reaching the threshold for the declaration of an outbreak at the district level. Healthcare practitioners followed up the individuals who had tested positive but were not able to locate them. Successful contact tracing by healthcare workers across the settlements helped to mitigate this challenge.

Village Health Teams

Individuals make up Village Health Teams (VHTs), which represent specific regions of the settlement, in line with the Ugandan VHT Strategy.41 VHTs are a central element of epidemic preparedness and response and provide an essential bridge of communication between humanitarian practitioners and refugees. They are responsible for ‘health promotion, health education, identification and referral of sick/malnourished individuals and follow-up in the community’.26 Members of VHTs provide weekly reports that are analysed by healthcare professionals, who are looking out for signs of potential outbreaks. Concerning trends are monitored closely.

Despite the challenges of funding VHTs, their work remains an essential dimension of disease surveillance. COVID-19 posed additional challenges, with increased pressures placed on VHTs in the delivery of healthcare and disease surveillance. In some settlements, VHTs felt they were not being adequately recognised for the personal risk involved in providing face-to-face care – especially whilst other NGO services withdrew. In Rhino settlement, partner organisations such as the Youth Social Advocacy Team responded to this challenge by working to secure additional funding for VHTs.

Funding challenges

The funding of VHTs has been challenged by the shortfalls in UNHCR’s budget.42 Members of VHTs previously had no stipends but were paid on an activity basis. This fragmented approach was harmonized by introducing a stipend of 50,000 Ugandan Shillings (approx. GBP 10) per month for each VHT member. With reduced funding, the role of Hygiene Promoter was further combined with the VHT role.

Healthcare facilities

Surveillance at healthcare facilities relies on the healthcare-seeking behaviour of refugees and Ugandan nationals. This is essential not only for providing health services but also for collecting routine disease surveillance data. During COVID-19, health facilities became a focus of concern regarding disease transmission. This not only prohibited individuals from receiving medical assistance, but also challenged the collection of accurate surveillance data.

This presented a constant challenge for healthcare workers in settlements, who had to reduce their contact with refugees in line with national policy, whilst also encouraging refugees to seek medical care if symptomatic. Preventive measures to reduce COVID-19 transmission were introduced at health facilities. This included screening at entrances, social distancing for patients attending the outpatient department, and providing longer courses of medical prescriptions for those receiving chronic care management. For example, those with diabetes, hypertension, and those receiving antiretroviral therapy.

New arrivals

In line with the health service package for new arrivals of refugees, initial activities are meant to include screening for epidemic-prone diseases and malnutrition, completed in the ‘acute phase of refugee influx’.26 Timely screening for epidemic-prone diseases, including COVID-19, is not always feasible due to wider political constraints. For example, during COVID-19, humanitarian practitioners had to wait for permission to be granted to authorise the movement of new arrivals of refugees by the Resident District Commissioner (representative of the president and central government) in consultation with OPM. Additionally, there was not always a supply of COVID-19 test kits, so screening was not performed regularly, further compromising efforts to interrupt disease transmission.

Vaccination

Routine vaccinations are administered to new arrivals of refugees (e.g., measles and polio). Schedules for routine childhood immunisations are also followed.26 Epidemics may require additional vaccination campaigns. For example, outbreaks of measles, cholera and Ebola would require specifically designed vaccination strategies for those considered to be at increased risk. During the COVID-19 pandemic, all refugees were invited to get vaccinated. However, vaccination campaigns during epidemics can have particular challenges, such as those described below.

Supply

During COVID-19, inconsistent supply and changes in the type of vaccine available created logistical difficulties in delivering a continuous vaccination campaign. Furthermore, the wider dimensions of vaccine availability reflected geopolitical dynamics and failures of COVAX (a global initiative focused on equitable access to COVID-19 vaccines).43 This directly shaped refugees’ perspectives on the vaccine in Palabek refugee settlement, where social, economic, political and spiritual dimensions combined to shape vaccine uptake.31

Competing priorities

COVID-19 vaccination occurred in a context in which COVID-19 related illness and death was perceived by refugees to be minimal in comparison to other more pressing health concerns, as well as the wider challenges of food insecurity outlined above. Refugees therefore questioned why such emphasis was being placed on COVID-19, as opposed to other more pressing concerns. When competing priorities were not addressed, the vaccination campaign lost legitimacy among refugees.31 This is challenging for humanitarian actors, whose activities are dictated by international funding flows that do not necessarily reflect the priorities of the beneficiaries of international aid.

Vaccine legacies

Healthcare professionals working with refugees in Uganda have described COVID-19 vaccination among refugees as remaining fairly low, but believe this has not had significant consequences given the minimal COVID-19 morbidity and mortality amongst refugees in comparison to other health threats such as malaria and other respiratory infections (Uganda’s Health Management Information System data reporting these trends are not freely available to reference). However, each vaccination campaign has consequences for the next.

In the event of a new epidemic posing a threat to refugee health, vaccination could become increasingly critical. In this instance, a vaccination campaign will need to overcome the histories of problematic vaccination for COVID-19. For example, if a vaccination campaign was to be required for mpox in Ugandan refugee settlements, detailed qualitative investigation would need to examine what refugees understand about the disease and its perceived threats in relation to wider socio-economic challenges, such as food insecurity. It would also be important to explore if any aspect of vaccination raises specific suspicions amongst refugees, and why.

Integration and coordination

The ability to provide humanitarian protection to refugees depends on the effective coordination of multiple actors. Epidemic preparedness and response within Ugandan refugee settlements also requires attending to the needs of Ugandan nationals and humanitarian staff as well as refugees.

Integration of health services

The Health Sector Integrated Refugee Response Plan emphasises the goal of integrating services for refugees and Ugandan nationals, including during outbreaks.26 There have been significant steps taken to integrate services. Since 1 July 2024, health facilities in Palabek have officially been run by the Ugandan MOH. This follows on from refugee settlements in the West Nile and south-western regions of Uganda, which have already made the transition to integrated health services.

It was anticipated that there would be full integration and transition of all refugee health and nutrition services by the time of writing, but this has not yet been achieved. The government of Uganda remains committed to integration but requires further support to actualise full transition. The move towards an integrated system responds to challenges associated with parallel systems, including concerns that large and unpredictable numbers of refugees can overwhelm Ugandan healthcare systems.44 This would have significant ramifications for epidemic response capacity.

Furthermore, humanitarian agencies providing refugee-specific services in settlements need to balance the needs of Ugandan host communities living in the vicinity of the settlement with the needs of refugees. This can be a delicate balance, with both Ugandan nationals and refugees reporting inadequate attention to their respective needs.

Areas of integration that have been considered particularly successful include vaccination campaigns coordinated by humanitarian and national health services. These campaigns simultaneously targeted refugee and host communities, as was the case for a measles outbreak in Palabek in 2022. Additionally, health campaigns and monitoring exercises are frequently planned jointly by humanitarian agencies and government services.

However, integrated health services for refugees and host populations in the West Nile region are reported to have inadequate infrastructure and persistent shortfalls in medicines, essential supplies and healthcare workers.45 This has significant impacts for epidemic preparedness and response activities, since the provision of essential health components of humanitarian protection are not being met.

Speed of response

Epidemics can spread rapidly, and the effectiveness of response efforts is directly influenced by the speed of action. However, response activities often involve sign-off from multiple different organisations and individuals, across district and national political landscapes, in addition to international humanitarian actors. This can significantly impede the speed of response, as response actors await the allocation of funding.

Protection of humanitarian actors

Caring for the physical and mental health of humanitarian practitioners is required in order for these individuals to work effectively within epidemic and refugee response efforts.

Those delivering services within settlements are at risk of contracting infectious diseases, due to the proximity of contact while providing a variety of services to protect refugees. For example, humanitarian practitioners have developed symptoms during outbreaks of cholera, Ebola, dysentery and COVID-19 in Ugandan refugee settlements. This could be partially mitigated through adequate provision of personal protective equipment (PPE), in conjunction with infection prevention and control training. However, the adequate stockpiling of PPE has been mixed. On occasion, inadequate stores were available. In other contexts, such as during COVID-19, staff reported that adequate supplies were available, with a surplus of PPE that had been acquired in preparation for previous outbreaks of Ebola.

There are also wider psychological effects on humanitarian practitioners that need to be considered. During COVID-19, humanitarian practitioners spent prolonged time away from their families, working under highly pressurised conditions, with reports of significant ‘mental strain and fatigue’. High levels of stress, with reduced ability to spend time with family and friends, risked ‘burn out’ amongst humanitarian practitioners.

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Authors: This brief was written by Sophie Mylan (London School of Hygiene and Tropical Medicine – LSHTM), whose ethnographic fieldwork in Palabek refugee settlement was conducted for her PhD. Ethical clearance was obtained from LSHTM, Gulu University and UNCST (Uganda). Doctoral funding was provided by the ESRC (ES/P000592/1), plus fieldwork support from the Parkes Foundation, and LSE through the AHRC Safety of Strangers grant (AH/T007524/1).

Acknowledgements: Oversight for this brief was provided by Melissa Parker (LSHTM). Contributions and reviews were made by Emmanuel Kerukadho (UNHCR), Byasali Kabi Yoab (Office of the Prime Minister, Uganda), Afema Erick (International Rescue Committee), John Jal Dak (Youth Social Advocacy Team), Leben Nelson Moro (University of Juba). Editorial support provided by Georgina Roche. This brief is the responsibility of SSHAP.

Suggested citation: Mylan, S. (2024). Key considerations: Balancing epidemic preparedness and response with humanitarian protection in Ugandan refugee settlements. Social Science in Humanitarian Action (SSHAP). www.doi.org/10.19088/SSHAP.2024.042

Published by the Institute of Development Studies: September 2024.

Copyright: © Institute of Development Studies 2024. This is an Open Access paper distributed under the terms of the Creative Commons Attribution 4.0 International licence (CC BY 4.0). Except where otherwise stated, this permits unrestricted use, distribution, and reproduction in any medium, provided the original authors and source are credited and any modifications or adaptations are indicated.

Contact: If you have a direct request concerning the brief, tools, additional technical expertise or remote analysis, or should you like to be considered for the network of advisers, please contact the Social Science in Humanitarian Action Platform by emailing Annie Lowden ([email protected]) or Juliet Bedford ([email protected]).

About SSHAP: The Social Science in Humanitarian Action (SSHAP) is a partnership between the Institute of Development Studies, Anthrologica , CRCF Senegal, Gulu University, Le Groupe d’Etudes sur les Conflits et la Sécurité Humaine (GEC-SH), the London School of Hygiene and Tropical Medicine, the Sierra Leone Urban Research Centre, University of Ibadan, and the University of Juba. This work was supported by the UK Foreign, Commonwealth & Development Office (FCDO) and Wellcome 225449/Z/22/Z. The views expressed are those of the authors and do not necessarily reflect those of the funders, or the views or policies of the project partners.

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