Impact of Hospital Closure on Patients with Communicable and Non-Communicable Diseases During the COVID-19 Pandemic in Uganda: A Cross-Sectional and Mixed-Methods Study

Makiko Komasawa,1,2 Myo Nyein Aung,2 Christopher Nsereko,3 Robert Ssekitoleko,4 Mitsuo Isono,5 Kiyoko Saito,1 Jesca Nantume,4 Yoshihisa Shirayama,2 Shrestha Chandani,1 Motoyuki Yuasa2 1Ogata Sadako Research Institute for Peace and Development, Japan International Cooperation Agency, Tokyo, Japan; 2Department of Global Health Research, Graduate School of Medicine, Juntendo University, Tokyo, Japan; 3Department of Internal Medicine, Entebbe Regional Referral Hospital, Entebbe, Uganda; 4College of Health Sciences, Makerere University, Kampala, Uganda; 5Department of Human Development, Japan International Cooperation Agency, Tokyo, JapanCorrespondence: Makiko Komasawa, Ogata Sadako Research Institute for Peace and Development, Japan International Cooperation Agency, 10-5, Ichigaya Honmura-cho, Shinjuku-ku, Tokyo, 162-8433, Japan, Tel +81-3-3269-2911, Fax +81-3-3269-2054, Email mkomasa@juntendo.ac.jpBackground: The COVID-19 pandemic and its measures have had a profound impact on universal access to health services. We investigated the impact of the closure of the Entebbe Regional Referral Hospital (ERRH) for two years on the accessibility to necessary healthcare among non-COVID-19 patients.Methods: This mixed-methods study focused on ERRH patients with tuberculosis (TB), human immunodeficiency virus (HIV), diabetes/hypertension, and mental illness. A quantitative study used a structured-questionnaire with a primary outcome measure to assess the discontinuation of healthcare accessibility. A qualitative study with a focus group discussion (FGD) was conducted on eight patients.Results: Of the 202 quantitative survey participants, 17.8% discontinued necessary healthcare due to the ERRH closure, and the discontinuation rates differed by disease: 48.1% of TB patients, 16.0% of HIV patients, 7.8% of diabetes/hypertension patients, and 4.0% of mental health patients (P < 0.001). Almost 90% of the patients reported a worsened health condition, regardless of the disease. Multivariable logistic regression analysis showed that patients with diabetes/hypertension (adjusted odds ratio [AOR], 12.69; 95% confidence interval [CI], 2.57– 62.52) and HIV (AOR, 7.52; 95% CI, 1.37– 41.27) were more likely to discontinue healthcare than those with mental illness. The factors associated with discontinued healthcare included age ≥ 50 years vs ≤ 30 years (AOR, 4.88; 95% CI, 1.07– 22.34), and high transportation cost vs low cost (AOR, 3.15; 95% CI, 1.13– 8.75). The FGD also identified difficulties in obtaining medication, especially for TB, even though ERRH provided the outreach services.Conclusion: Our study revealed that the ERRH closure and lockdowns had an overall profound negative impact on access to healthcare and health conditions. Younger patients and those with TB were the most affected patients. This study provides practical suggestions from the field for policy makers to strengthen universal health access during health crises in Uganda and other sub-Saharan countries.Plain Language Summary: This study investigated the impact of service disruption in a tertiary hospital (ERRH) that was converted to a COVID-19-dedicated hospital for two years in Uganda. This mixed-methods study focused on the ERRH patients with tuberculosis (TB), human immunodeficiency virus (HIV), diabetes, hypertension, and mental illness. A quantitative study used a structured questionnaire with the primary outcome measure being the discontinuation of healthcare provision. A qualitative study with a focus group discussion (FGD) was conducted on eight patients. Of the 202 quantitative survey participants, 17.8% discontinued necessary healthcare due to ERRH closure, and the discontinuation rates differed by disease: 48.1% of tuberculosis patients, 16.0% of HIV patients, 7.8% of diabetes/hypertension patients, and 4.0% of mental health patients (P < 0.001). Almost 90% of the patients reported worsening health conditions. The factors associated with discontinued healthcare included age ≥ 50 years vs ≤ 30 years (AOR, 4.88; 95% CI, 1.07-22.34), and high transportation costs vs low cost (AOR, 3.15; 95% CI, 1.13-8.75). The FGD also identified difficulties in obtaining medication, especially for TB, even though the ERRH provided outreach services. Our study revealed that ERRH closures and lockdowns had profound negative impacts on access to health care and health conditions. Younger patients and those with TB were the most affected patients. This study provides suggestions from the field for policy makers to strengthen universal health access during health crises in Uganda and other sub-Saharan countries.Keywords: lockdown, public health and social measures, health service disruption, tuberculosis, HIV, mental illness