What Ebola taught us about building stronger district health systems

As the BIS Project came to a close, new research by UNIPH epidemiologist Denis Okethwangu showed what helps districts hold firm during an outbreak, and what still holds them back.

When Uganda declared an Ebola outbreak in Mubende on 20 September 2022, the virus had probably been spreading quietly for three weeks or more. In those early weeks, the people standing between the virus and the rest of the country were village health teams (VHTs), staff in local health facilities, and the district health teams of Mubende and Kassanda. Before the outbreak was over, 142 people had been confirmed infected, 55 had died, and 19 health workers had caught the disease.

Their experience is at the heart of research presented on 23 October 2026, at a workshop marking the close of the Building Stronger Public Health Institutions and Systems (BIS) Project.

BIS is a NORAD-funded programme of the Norwegian Institute of Public Health (NIPH), built on the idea that public health institutions grow stronger when they learn from each other. In Uganda, the project brought together the Uganda National Institute of Public Health (UNIPH), NIPH and Makerere University School of Public Health (MakSPH).

The work had two strands. The first focused on digital health and civil registration, with PhD studies by Evelyn Patra Asio on birth registration and Sandra Nabatanzi on maternal and perinatal death registration. The second asked what allows a health system to withstand an outbreak. That became the PhD thesis of Denis Okethwangu, an epidemiologist at UNIPH and a PhD scholar at MakSPH.

Tools such as the Joint External Evaluation looked at a country as a whole. They cannot show a district health officer where their own system is weakest.

Okethwangu began by asking what resilience means in Uganda. He reviewed 83 studies from 48 African countries and interviewed 15 national experts. They described a resilient system as one that prepares for shocks, keeps essential services running when they hit, adapts, recovers, and learns enough to be stronger next time.

He then built ReMeasure, a 61-item scale tested with more than 500 people in 13 districts, that measures resilience at district, health facility and community level.

In Mubende and Kassanda, Okethwangu surveyed 166 district officials, health workers, VHTs and local leaders, and held interviews and seven focus group discussions.

The good news is that the districts held. Community involvement scored highly, coordination structures worked, and VHTs mobilised quickly. Health workers described pulling together as one team, and political attention brought in resources.

The harder finding is that much of this strength arrived with the outbreak and left with it. Simulation exercises were rare, and lessons from after-action reviews were not written down. Some facilities started the response without protective equipment, after going several quarters without medicines. Districts had no preparedness budget of their own. As one biostatistician in Mubende put it, “The district was not fully in charge. It was partially.”

VHTs carried much of the load, yet many worked without gumboots, raincoats, torches or identification, and some faced stigma in their own communities. Once the emergency funds and partners leave, the everyday problems remain: too few staff, empty shelves and tight budgets. So each new outbreak lands on a system a little weaker than before.

The thesis asks the Ministry of Health to make budgeted after-action reviews standard practice, give districts their own preparedness budget lines, and adopt a fair policy for paying and equipping VHTs.

Districts are encouraged to keep emergency plans up to date, run regular simulation exercises, map their risks and keep better records, and to tackle misinformation and stigma with communities before the next outbreak. For partners, the message is to fund preparedness that districts own, not only during a crisis.

Researchers, Ministry of Health officials, partners and district health teams from Arua, Kassanda and Mubende took part. Reflections came from Dr. Herbert Brian Kazoora of AFENET and from Dr. Aloysous Ssenyonjo, Dr. Victoria Nankabirwa and Professor Suzanne Kiwanuka of MakSPH. The Ministry of Health was represented by Dr. Alfred Driwale, Dr. George Upenytho and Dr. Alex Riolexus Ario.

Much of the discussion came back to decentralisation. On paper, districts run their own health services. In an outbreak, the decisions and the money often sit elsewhere. Participants also talked about involving communities and funding preparedness that does not depend on the next emergency.

Uganda’s districts have shown they can respond when an outbreak strikes. The work ahead is to keep them strong in the months and years in between.

UNIPH thanks NIPH, NORAD, MakSPH, the Ministry of Health, and the district teams and communities who made this work possible.