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Background: The negative impact of COVID-19 on population health outcomes raises critical questions on health system preparedness and resilience, especially in resource-limited settings. This study examined healthworker preparedness for COVID-19 management and implementation experiences in Uganda’s refugee-hosting districts. Methods: A cross sectional, mixed-method descriptive study in 17 health facilities in 7 districts from 4 major regions. Total sample size was 485 including > 370 health care workers (HCWs). HCW knowledge, attitude and practices (KAP) was assessed by using a pre-validated questionnaire. The quantitative data was processed and analysed using SPSS 26, and statistical significance assumed at p < 0.05 for all statistical tests. Bloom's cutoff of 80% was used to determine threshold for sufficient knowledge level and practices with scores classified as high (80.0–100.0%), average (60.0–79.0%) and low (≤ 59.0%). HCW implementation experiences and key stakeholder opinions were further explored qualitatively using interviews which were audio-recorded, coded and thematically analysed. Results: On average 71% of HCWs were knowledgeable on the various aspects of COVID-19, although there is a wide variation in knowledge. Awareness of symptoms ranked highest among 95% (p value < 0.0001) of HCWs while awareness of the criteria for intubation for COVID-19 patients ranked lowest with only 35% (p value < 0.0001). Variations were noted on falsehoods about COVID-19 causes, prevention and treatment across Central (p value < 0.0356) and West Nile (p value < 0.0161) regions. Protective practices include adequate ventilation, virtual meetings and HCW training. Deficient practices were around psychosocial and lifestyle support, remote working and contingency plans for HCW safety. The work environment has immensely changed with increased demands on the amount of work, skills and variation in nature of work. HCWs reported moderate control over their work environment but with a high level of support from supervisors (88%) and colleagues (93%). Conclusions: HCWs preparedness is inadequate in some aspects. Implementation of healthcare interventions is constrained by the complexity of Uganda’s health system design, top-down approach of the national response to COVID-19 and longstanding health system bottlenecks. We recommend continuous information sharing on COVID-19, a design review with capacity strengthening at all health facility levels and investing in community-facing strategies.
Uganda’s health system comprises of both the private and public sector in terms of infrastructure, ownership and delivery of health services [39, 40]. The health system is decentralized and hierarchical with seven levels starting from the household/village level and culminating at national referral institutions and the Ministry of Health [41]. In order of hierarchy there are the Village Health Teams (VHTs) or community health workers (CHWs) who are the first point of contact with health service users and resident within the village. Next is the Health Centre (HC) IIs, HCIIIs, HCIVs, District Hospitals, Regional Referral Hospitals (RRH) and National Referral Hospitals (NRH). In principle, each level of the health system is equipped to handle progressively complex cases while also referring to the next level upwards [9]. Referrals are therefore an integral part and key operational area of the success of the entire health system. The WHO lists the six key pillars or building blocks critical to any system’s functionality as service delivery, the health workforce, health information systems, access to essential medicines or vaccines, financing, and leadership or governance [42]. Having a hierarchical system also means that, across each one of the building blocks, lower-level units in Uganda can only handle less-complex cases which also determines the considerably less resources and inputs available for their use. Majority of the health facilities are public and therefore government/donor funded where, ideally, services should be provided free of charge. However, the latest figures report private expenditure as a percentage of Current Health Expenditure (CHE) to be 41% and out-of-pocket expenditure at 38% [43]. Health financing remains a key national challenge and the recommended Abuja target 15% of the GDP apportioned to health [40, 44, 45] has never been achieved, with average health sector allocations ranging from 6 to 9% [45, 46]. In particular, the low funding for Uganda’s healthcare system continues to create an ongoing challenge of insufficient health workforce numbers [47] which has sometimes been mitigated by task shifting since 1918 [48] and which the evidence shows to have improved quality of care in the treatment of HIV/AIDS, tuberculosis, maternal, newborn and child health (MNCH) programs as well as malaria [49–51]. However, task shifting has the potential to significantly undo its intended benefits in the absence of adequate training or supervision from skilled health workers, inappropriate compensation and work overloads as is the case for Uganda [52]. Older and more recent assessments show that Uganda continues to experience serious shortfalls and challenges across all six of the building blocks in its health system [53, 54].
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