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Abstract
Objective Health system leadership plays a critical role in sustaining healthcare delivery during emergencies. Thus, we aimed to assess the contribution of health system leadership in sustaining healthcare delivery under emergency conditions based on adaptive leadership theoretical framework.
Design We employed a concurrent mixed-methods study approach to assess health system leadership roles during emergency. This involved a quantitative survey administered to 150 health facilities managers/service focal persons selected via multistage sampling method from 15 districts, and qualitative interviews with 48 key informants who purposively selected.
Participants We interviewed health facility managers, services focal persons, district health officers and residential district commissioners. We also reviewed weekly emergency situation reports and other relevant documents related to the emergency response. We used structured questionnaire, observation checklist and semistructured questionnaire to collect data. We employed descriptive statistics to analyse quantitative data and thematic analysis for qualitative data.
Main outcome Health system leadership contributions in sustaining healthcare delivery during emergencies.
Results Health system leadership was effective in leading emergency response and ensuring the continuity of health service during emergencies. Community engagement, partners coordination and intersectoral collaboration were effectively used in the emergency response and ensuring continuity of healthcare delivery. Deployment of experienced personnel and essential medical and non-medical supplies played a critical role in the continuity of health service. Availability of incidence management teams across health system significantly contributed to health system leadership. Participation of village health teams in community engagement and information communication helped in the success of health system leadership under emergency.
Conclusion Adaptive health system leadership played a crucial role in managing health services delivery under emergency conditions. Effective partnership coordination and collaboration across sectors, frequent information communication, building local actor capacity and implementing scheduled supportive supervisions emerged as key strategies for sustaining health services during emergencies.
- Health Services Accessibility
- HEALTH SERVICES ADMINISTRATION & MANAGEMENT
- Health policy
- Health Services
Data availability statement
Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information. All data used in this study are presented in the manuscript, however, can be access from the corresponding author on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Health Services Accessibility
- HEALTH SERVICES ADMINISTRATION & MANAGEMENT
- Health policy
- Health Services
STRENGTHS AND LIMITATIONS OF THIS STUDY
Applying the adaptive leadership theoretical framework to understand the role of health system leadership in responding to drought and food insecurity emergencies is the main strength of this study.
Use of a mixed-methods approach, which enables the generation of comprehensive evidence through quantitative and qualitative data collection is also the strength of this study.
The main limitations of this study include the exclusion of the viewpoints of regional and national health officers, as well as implementing partners.
Background
Naturally occurring public health emergencies such as droughts, floods and earthquakes cause widespread social, economic, health and ecological disruptions across the globe.1 2 The Great Horn of Africa (GHoA) region faces a devastating crisis as prolonged drought triggers extreme hunger, outbreak of communicable diseases, which threaten the lives of millions of people and livestock.3 An estimated 46.3 million people in GHoA region faced food insecurity while 13.5 million were internally displaced in 2022.3
Northeast Uganda is ranked among the areas most severely affected by the drought and food insecurity emergency plaguing the GHoA region.4 In Karamoja region alone, over half a million people grapple with food insecure, with a staggering 77 189 individuals classified under the critical emergency (phase 4) category in 2022.4 While no published empirical evidence exists from the area, unpublished report suggests that the drought and food insecurity emergency has significantly impacted the health service delivery system in northeast Uganda. Since July 2022, the WHO in collaboration with Ministry of Health and other partners has initiated a response to mitigate the public health consequences of drought and food insecurity emergency in the region.3
Effective health system leadership is crucial for overcoming the health, socioeconomic and environmental consequences of naturally occurring public health emergencies because they require strong collaboration and coordination of efforts of diverse stakeholders.5 6 Effective public health emergency response also demands leadership capable of developing and overseeing high-quality strategic policies which ensures a clear direction and framework for action; fostering collaboration and coordination that necessitates effective communication and partnership building among diverse stakeholders; and establishing regulations and accountability measures which ensures adherence to standards and promotes responsible action during the crisis.5 6 Moreover, effective health system leadership during emergencies hinges on strong coordination and collaboration between local and national governments, alongside international partners. This collaborative approach is critical to mitigate the consequences of public health emergencies.1 Furthermore, research has identified several key qualities and capabilities essential for effective health emergency leadership.7 8 A unique and effective health emergency leaders possess, include public health science expertise; decisive yet adaptable leadership; situational awareness and assessment; cross-disciplinary coordination; compelling communication skills; and ability to inspire trust.7
In emergency response, a theoretical framework-based leadership approach is crucial because emergency management systems are complex adaptive systems8 Applying a leadership theoretical framework to assess emergency response and health service sustainability during emergencies is essential to guide the assessment process.9 10
Adaptive leadership is a prominent theoretical framework frequently applied to health system leadership assessment across diverse settings.10–14 It has gained widespread application in public health emergency and crisis response.6 8–10 13 15 For instance, adaptive leadership principles were applied in the global response to COVID-19 pandemic.10 13 15 In addition, it has been applied in Ebola outbreak response in west African countries.6 While adaptive leadership enjoys widespread application in public health emergency responses across various context, its specific application in drought and food insecurity emergencies remains less explored. Moreover, limited research exists regarding the application of the adaptive leadership principles in assessing health system leadership during drought and food insecurity emergencies. Uganda is a context where research on the application of leadership theoretical framework within the specific context of drought and food insecurity emergency response is scarce. Therefore, we employed the four principles of the adaptive leadership theoretical framework: contextual factors, self-correction and reflection, creating win-win solution and compassionate leadership16 to assess the health system leadership roles in the context of the drought and food insecurity emergency in northeast Uganda (figure 1).
Conceptual application of adaptive leadership framework for health system leadership (adapted from Mulder16).
Methods
Study design and area
We employed a concurrent mixed-methods approach to assess health system leadership during the drought and food insecurity emergency conditions in Karamoja region and its neighbouring districts in northeast Uganda through applying an adaptive leadership theoretical framework principle. This concurrent mixed-methods approach incorporates a descriptive cross-sectional quantitative study alongside qualitative semistructured key informant interview. The quantitative component of our mixed-methods approach serves a crucial role in numerically characterising the problem under study.17 This allows us to generate generalisable evidence relevant to the sampled population.17 However, quantitative studies often encounter limitations in capturing the intricacies and lived experiences related to the problem under study, especially regarding behavioural topics. Therefore, to achieve a holistic and comprehensive understanding of the problem, we employed a concurrent mixed-methods approach in this study, combining the strengths of quantitative and qualitative data collection.18 We triangulated concurrently collected data during analysis and results interpretation. This data triangulation technique, combine insight from both quantitative and qualitative data sources, allowed for a more comprehensive understanding of the problem under study.
This study was conducted in northeast Uganda, specifically in the Karamoja region and its neighbouring districts. Nine districts within Karamoja region and 10 in surrounding areas face a significant drought and food insecurity emergency, classified as level 2 or above on the Insecurity Food Security Phase Classification (IPC) scale. A total of 19 districts in the region are grappling with a drought and food insecurity emergency. All districts in the Karamoja region face severe health, social and economic consequences, classified under IPC phase 3 (crisis) or above indicating critical food security situation.4 Therefore, we conducted this study in 150 health facilities across 15 districts: 9 from the Karamoja region and 6 neighbouring districts in Acholi, Teso and Lango regions.
Interviewees
We interviewed key personnel including district health officers (DHOs), residential district commissioner (RDCs), health facility managers and health services focal person. In addition, we conducted direct observations of service delivery in 150 health facilities using a standardised health facility assessment checklist. We also reviewed weekly emergency situation reports and other relevant documents related to emergency response.
Sample size and sampling method
We employed a proportionate multistage sampling technique to select both districts and health facilities within those districts. The proportionate multistage sampling method involved three stages. The first stage was drought-affected regions (Karamoja, Acholi, Teso and Lango regions), while the second districts within each region, and the third health facilities within the selected districts. At the first stage, we included four regions that experiencing drought and food insecurity emergencies. In the second stage, we employed simple random sampling to select 60% of the total districts (6/10) from Acholi, Lango and Teso regions which were all affected by drought and food insecurity emergencies. However, we purposefully included all nine districts from the Karamoja region due to the severity of the drought and food insecurity emergency impacting the entire region. Accordingly, our study encompasses 15 districts (78.9%) from the 19 districts affected by the drought and food insecurity emergencies in the region. In the third stage, we selected 150 health facilities (53.4% of the total 281 facilities) found in the 15 selected districts. We employed simple random sampling method to select 50% of levels II and III health centres (HCs) out of the HCs in the region with. However, we included a total of nine level IV HCs and all (seven) hospitals in the selected districts by purposive sampling method, because the majority of the selected districts have few HCs level IV and hospitals.
We interviewed 14 DHOs and 14 RDCs from all 15 randomly selected districts using a semistructured interview questionnaire. However, due to scheduling conflicts during the 1-week data collection period, we were unable to interview representatives from the DHO and RDC in one of the selected districts We included health facility managers and services focal person by purposive sampling method until information saturation reached. To achieve a representative sample within purposive sampling, we initially employed simple random sampling method. After interviewing 5–7 health facility managers or service focal persons, we assessed the variability in key respondent characteristics including sex, work experience, profession and health facility level. If the variability was achieved within the first few interviews, we continued random sampling until information saturation reached. However, if respondent characteristics variability remains insufficient, we continued purposive sampling to include additional participants until reaching information saturation. Information saturation was reached at 20 health facilities managers and services focal persons interviewed.
Data collection and management
We used structured questionnaires and observation checklists to collect quantitative data on health system leadership roles under emergency response. We entered all quantitative data into open data kit (ODK) during data collection in the field. All data collectors were trained for 2 days on data collection procedure, data quality assurance and data entry into ODK database.
We used in-depth interview method to collect qualitative data using semistructured questions. The semistructured questions helped in guiding the interviewer process and allows for probing to identify relevant information on the topics under study. We recorded all qualitative interviews in audio tape record after obtaining permission from the key informants. We also took field note thoroughly during interview with the interview assistant. The interview of one participant was taken on average 35 min. We also extracted both qualitative and quantitative data from weekly emergency situation reports and other relevant documents related to emergency response. Face-to-face interview was administered by trained healthcare workers and researchers (MD, MPH, nurse) who have experience on qualitative interview. The interview was conducted in preprepared suitable room in the selected health facilities, and office of DHOs and RDCs. Data from the emergency report and other documents were extracted by epidemiologist (PhD). We recorded the qualitative interview data in tape recorder and field note. The interviewers were neutral about the topics under study and free from bias.
Data analysis
We used descriptive statistics to summarise quantitative data. We used statistical package for social scientists (SPSS) V.22 to analyse the quantitative data. We transcribed the qualitative interviews that recorded in tape recorder and merged with field note and data that extracted from the documents before the main analysis. We employed thematic qualitative data analysis approach to analyse qualitative data. Thematic analysis and framework analysis are both valuable methods to qualitative data analysis. The difference between them is very miner, and deciding in selecting between them is not easy. However, we selected thematic analysis in this study to examine the perspectives of study participants, highlight similarities and differences, and generate unanticipated insights on the problem under study. It allows us to identify, analyse, organise, describe and report themes as found within a data set.19
Thematic analysis is an important analysis method to understand new and unknown aspects of the problem under the study.19 20 It is flexible and inductive nature which allows to identify themes directly from the data without imposing a pre-existing framework.19 20 However, framework analysis, sometimes is used for theory building, more focused on confirming pre-existing research questions and to test pre-existing theoretical framework.21 Thematic analysis is also considered as more flexible and easier to learn and implement, requires less complex organisation and can be applied to various types of data.20 22 It also offers fresh insights on the problem under study.20 22 Moreover, thematic analysis is more efficient to analyse small data and yield sufficient insight results with small data.19 20 22 However, framework analysis could be difficult with small data due to its complex matrices and comparisons.22 23 Thus, in the current study, we selected thematic analysis to explore the experience of health system leaders in assuring the sustainability of essential health services under the emergency condition with small data, rather than testing the pre-existing theoretical framework. In addition, framework analysis approach is more useful when the aim of the study is comparison of cases or groups. However, in this study, our aim was not comparison between case or groups rather than exploring the experience of health system leaders.
In thematic analysis, first we transcribed audio recoded data and harmonised with data obtained from field note and extracted from emergency situation report. After familiarisation of the data through reading of the interview reports and transcripts, two researchers applied both deductive and inductive coding. The deductive coding was guided by themes as presented in the interview topic list and inductive coding allowed for unanticipated themes to arise from the data. After the coding of the first few interviews, the two researchers were discussed and triangulated their coding schemes and developed a coding framework to guide the coding of the rest of the interviews. The researchers searched, reviewed and defined the themes based on the principles of adaptive theoretical framework after coding the interviews. Finally, the results of the analysis were described under the principles of adaptive leadership theoretical framework. We used ATLAS.ti V.7.5.18 software to analyse qualitative data.
Minimising risk of bias and trustworthiness
By triangulating findings from both quantitative and qualitative data sources, we enhanced the credibility and transferability of the evidence generated in this study. The use of random sampling techniques at each stage of the recruitment process helped in minimising the risk of selection bias, and ensure a more representative sample of the target population. We minimised respondents bias by creating neutral interview environment, and by minimising interview length to 25–30 min. We have adopted a transparent approach by clearly outlining the research procedures, including the chosen data analysis method, and by providing rich and detailed descriptions of the collected data to ensure the trustworthiness of our study results.
Patient and public involvement
Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Results
Characteristics of the key informants
Among the 150 health facilities managers and services focal persons interviewed, nurses comprised the largest proportion (82, 54.7%), followed by midwives (35, 23.3%), clinical officers (26, 17.3%) medical officers (4, 2.7%) and laboratory personnel (3, 2.0%). Of the total 48 key informants included in semistructured interview: 20 were health facility managers and services focal person, while 28 were either DHOs or DRCs who recruited from 14 districts. However, one district DHOs and DRCs were not interviewed due to activity overlap during study period. Among the 48 key informants, 21 were females, and the median age of the key informants was 34 years with IQR of 23–45 years.
Health system leadership under emergency
We presented the results on the roles of health system leadership under the four principles of adaptive leadership theoretical framework. These principles include (1) contextual factors of the region, (2) self-correction and reflection, (3) compassionate leadership and (4) creating win-win solution.
Contextual factors in the emergency regions
The Karamoja region and its neighbouring districts are characterised by a semiarid climate, primarily inhabited by agropastoralist and pastoralist communities whose livelihood depends heavily on livestock rearing. Agricultural and urban livelihoods also play a role in subsistence in the region to some extent as a source of income. A combined community level and fixed health service delivery methods were used to effectively reach the mobile pastoralist community. Health system leadership actively promoted and supported the delivery of health services at the community level; and the provision of essential medical and non-medical supplies was ensured at each health facility level. Lack of food, limited access to food, high negative coping mechanisms and exhaustion of food stocks including seed stockout in the community were also the challenges of emergency response process. However, the public health consequences of the emergency were reduced and saved the life of thousands through partner coordination and intersectoral collaboration in food supply distribution at each districts and health facilities across emergency-affected districts.
Internal displacement due to conflict between warriors and armed actors and livestock raids were also the obstacles of livelihood of the resident in emergency-affected area to some extent. However, the effectiveness of emergency response leadership might have been limited by lack of implementation of conflict management scheme.
Self-correction and reflection
Under self-correction and reflection principle, we presented several activities such as health service quality improvement (QI), data management and utilisation in decision-making, supportive supervision and capacity building of local actors and availability of health services.
Health service QI
Among the 150 health facilities assessed to understand the current quality of health services, 91 (60.7%) had QI committee. While 64 of these facilities with a QI committee (70.3%) held regular meetings to discuss service quality issues, a concerning finding was that 66 (72.5%) lacked documented minutes from previous meetings (table 1). Nearly half (47.3%) of health facilities lacked an external quality assessment (EQA) project, and 59.3% (89 facilities) did not conduct QA in quarter before the study (table 1). Moreover, 113 (75.3%) of assessed health facilities lacked documented information on EQA from previous assessments (table 1).
Quality improvement status in drought and food insecurity affected districts in Uganda, 2022
Data management and utilisation in decision-making
Of the 150 assessed health facilities, 97 (64.7%) had data focal person (table 2). A considerable proportion of health facilities lacked key registrations: 43.3% had no antiretroviral therapy register, and 30.7% lacked a health unit tuberculosis (TB) register (table 2). The majority of health facilities (96.70%) delivered weekly surveillance reports (96.7%), and nutrition reports (82.7%) (table 2). About 60% of assessed health facilities used routine data for decision-making (table 2).
Routine data collection and management status in drought and food insecurity affected districts in Uganda, 2022
Supportive supervision
Prior to the current study’s implementation, 84.7% (127 out of 150) of health facilities had undergone integrated supportive supervision. However, a significant concern was identified: 35.8% of facilities lacked documented reports for the most recent supervision round, and 17.3% did not receive feedback on the same supervision. However, frequent and regular supportive supervision was employed in the health system leadership to respond to the emergency and to assure the continuity of health service.
Local actor capacity building
Table 3 depicts trainings that provided for healthcare workers at different health service points to support emergency response and to assure the continuity of health services. Of 150 assessed health facilities, 120 (80%) had at least someone who trained on integrated management of acute malnutrition. 75 (50.0%) of health facilities had at least someone who trained on maternal, infant, young child and adolescent nutrition service, and 79 (52.7%) had someone who trained on Basic Emergency Obstetric Care (BEmOC). Moreover, 88 (58.7%) health facilities had someone who trained on HIV diagnosis and care, and 98 (65.3%) had someone who trained on TB diagnosis and care. Only 43 (28.7%) had someone trained on non-communicable diseases (NCDs) screening and management, and 37 (24.7%) had someone who trained on mental illness screening and management. However, to assure the continuity of health service, several capacity-building trainings were provided for local actors as a part of emergency report.
Trainings distribution on different service points in drought and food insecurity emergency-affected districts in Uganda, 2022
Capacity-building trainings were also provided for district-level leadership. Of the 14 districts, 13 (92.9%) districts health teams (DHTs) were obtained training on integrated disease surveillance and response (IDSR). About 70% of DHTs had at least five staff members who trained on IDSR. All assessed DHOs had trained rapid response teams (RRTs) and 12 (85.7%) of district RRTs were trained on IDSR. All districts had emergency operation plan to effectively lead the emergency at local level.
Compassionate leadership
Leadership and governance were identified as one of the intervention strategic areas of emergency response at the beginning of the response. Incident management teams (IMTs) were established at national and regional level to oversee the response closely. The IMTs were held weekly meeting to assess the response implementation activities and provide correction for each action points. The WHO activated or repurposed three regional hubs in the affected districts to coordinate the response closely at a grass root, and the team was actively engaged in emergency response coordination. Capable and experienced staff were either repurposed or deployed to support the response with sufficient transportation and logistics. Regional hubs and country office staff actively coordinated response the response and provided regular supportive supervision. Health facilities had management team, with 147 (98%) having a core team dedicated to coordinating health services. Most of health facilities had sufficient health professional overall, but there were notable shortages in specific areas (table 4). Only 46.7% had laboratory personnel, and a mere 8.7% had mental health specialist (table 4).
Availability of health professional across the levels of health facilities in drought and food insecurity affected districts in Uganda, 2022 (n=150)
Community engagement and risk communication were coordinated through village health teams (VHTs). Each village had trained VHT actively involved in community mobilisation. Trained risk communication officers were also disseminated essential messages through various channels, including engaging media and partnering with community, to support the emergency response.
Continuity of essential health service
Among the 150 assessed health facilities, 56.7% (84 facilities) offered HIV treatment and follow-up services, while 67.3% (101 facilities) provided TB treatment and follow-up services (table 5). Approximately 60% of health facilities provided both NCDs screening and management services, as well as BEmoC services (table 5). More than 50% of health facilities provided both mental illness screening and management services (table 5). Immunisation service was provided in almost all (98.7%) assessed health facilities, and family planning service was provided in 130 (86.7%) health facilities (table 5). Of the 150 assessed health facilities, 90 (60%) provided laboratory test either by equipment or rapid test (table 5).
Availability of essential health services in drought and food insecurity affected districts in Uganda, 2022 (n=149)
Creating win-win solution
Health system leadership employed a win-win solution to facilitate emergency response coordination and ensured the continuity of health services throughout emergency. Both local and international partners were effectively coordinated in the way they contributed to the emergency response. The majority (85.7%) of DHOs received either direct cash or in-kind or technical support from different partners including WHO. The main materials received in-kind: nutrition supplies, anthropometric equipment, mosquito bed nests, health management information system tools, report forms and medical supplies including tracer drugs and ready to use therapeutic food.
The emergency response coordination benefited from multisectoral collaboration, both within and across districts. All districts (100%) which have border with other countries had cross border collaboration activities. The main cross-border activities on which the districts collaborate with neighbour countries were diseases surveillance, outbreak response, infection prevention and control, immunisation, security, mass deworming and cattle vaccination. The cross-border collaboration and local intersectoral collaboration were effectively employed in emergency response and sustainability of health service during drought and food insecurity emergency.
Discussion
The current study identified the critical roles played by the health system leadership in responding to drought and food insecurity emergency in northeast Uganda. The combined use of community-level outreach strategies and fixed health service delivery points, along with efficient management of medical and non-medical supplies, played a significant role in reaching the mobile pastoral community during the emergency response. The distribution of food and nutrition supplies to affected districts and health facilities also significantly contributed to the effective health system leadership. Effective community engagement, partner coordination and intersectoral collaboration were effectively employed in emergency response and continuity of health services. Mobilising resources from international and national sources used effectively in emergency response. The deployment of experienced professionals at grass root served as a key manifestation of adaptive leadership in coordinating emergency response activities. The presence of IMTs at all levels of health system significantly contributed to effectiveness of health system leadership during emergency. In addition, maintaining sufficient staffing at health facilities and investing in capacity building for local healthcare workers, DHOs and VHTs all contributed to the continuity of health services. The active participation of VHTs in community engagement and information communication significantly contributed to mitigating the public health consequences of the emergency.
Health system leaders, in response to the emergency, successfully implemented a combined community level and fixed health service delivery points to reach the pastoralist community. This finding aligns with previous research highlighting the importance of flexible service delivery models such as mixed mobile and temporary fixed options, that cater to the sociocultural context and ensure service acceptability within pastoralist communities.24 Moreover, a study from Ethiopia found that mobile health team played a vital role in delivering health and nutrition services to mobile community.25 These findings consistent with this study, where the combined approach of community-based outreach and fixed health service delivery points effectively extended health service during drought and food insecurity emergency.
Emergency-affected regions experienced disruptions in their supply chain management systems, leading to stockouts of essential tracer medicines and nutrition supplies in health facilities. The health system leadership proactively developed a procurement plan, securing and distributing essential medical and non-medical supplies to health facility to support the emergency response and maintain the health service. These proactively measures by health system leadership helped in addressing the of stockouts of essential medicines and supplies. This finding aligns with previous research highlighting the importance of preplanning and budgeting of supply to prevent stockouts during emergency.26 Moreover, immediate distribution of mask for the community played an important role during COVID-19 pandemic in the reduction of disease incidence.15 Thus, availability of tracer medicines and necessary supplies in the health facilities increased the efficiency of health system leadership in the drought and food insecurity emergency in northeast Uganda.
Despite government efforts to disarm the community and reduce conflict with armed actors, the emergency response lacked a formal conflict management model. This omission has limited the effort of the health system leadership, as documented public health consequences of armed conflict have affected millions globally.27 Armed conflict often triggers internal displacement, a major public health concern. Displaced populations face limited access to food, shelter, sanitation and health services, increasing their vulnerability to illness and disease. These limitations posed significant challenges for health system leadership in implementing an emergency response. Incorporating conflict management strategies into future emergency response plans is crucial for effective health system leadership, ensuring continuity and mitigating the public health consequences of armed conflict during natural emergency response.
Community engagement,28 29 partners coordination and intersectoral collaboration1 6 30 are the most important leadership activities in emergency response. These findings are consistent with the current study results in which community engagement implemented by trained VHTs, response activities coordination at each level of health system and intersectoral collaborations played an essential role in emergency response and maintenance of health services. The VHTs played an important role in the awareness creation and information communication across the community which contributed in community engagement.
Public health emergencies, such as pandemics or natural disasters, can disrupt health services by overwhelming healthcare systems, limiting transportation or causing shortages of medical supplies. This can limit access to essential care for existing health conditions, such as chronic diseases, maternal health complications or infectious diseases not directly related to the emergency, and potentially leading to higher mortality rates than those directly caused by the emergency itself.31 To mitigate mortality risk associated with the disrupted health services, emergency response plans must prioritise ensuring the continuity of essential health services. The current drought and food insecurity emergency response plan prioritises ensuring the continuity of health services, recognising its critical role in mitigating the overall impact of the emergency. Prioritising continuity of health services within the emergency response plan played a significant role in mitigating the public health consequences arising from the disruption of health services during the emergency.
To effectively address human resource shortages during emergency, implementing an integrated and comprehensive human resource management plan recommended.32 This study identified the deployment of experienced personnel and the availability of healthcare workers within health facilities as critical contributions to health system leadership during the emergency. The deployed personnel played a multifaceted role, effectively coordinated response activities, engaging community, assuring the continuity of essential health services and facilitating intersectoral collaboration.
The main limitation of health system leadership under the current drought and food insecurity emergency response in northeast Uganda was the absence conflict management strategy. Integrating conflict resolution mechanisms into future emergency response plans can facilitate safe access and the free movement of essential personnel and supplies, ultimately strengthening healthcare delivery during emergencies. In addition, this study has also a limitation in that it did not include key respondents from the regional and national health officials, as well as implementing partners. This limitation may affect the generalisability of the current study findings to all levels of health system. Despite the limitations stated above, we believe that the results of this study were less likely influenced by those limitations.
Conclusion
This study found that health system leadership, guided by the four principles of adaptive theoretical framework, effectively contributed to the emergency response and ensured the continuity of health services during the drought and food insecurity emergency. This study also identified several leadership activities that were implemented to mitigate the impact of contextual factors in the emergency region, facilitate the emergency response and ensure the continuity of health services. Implementing several emergency response activities aligned with the self-correction and reflection principle such as health service QI, data-driven decision-making, supportive supervision and local actors capacity-building, helped ensure the continuity of health service under drought and food insecurity emergency. This study also highlighted the crucial role of leadership and governance as a key strategic area for emergency response. Establishing IMTs at all levels significantly contributed to the effeteness of emergency response and the continuity of health services. Effective leadership of emergency response also relied heavily on coordinating partners and fostering intersectoral collaboration at all levels of health system. This study’s insights into effective health system leadership during emergencies can inform future practice and strengthen preparedness for future crises. Effective emergency response during drought and food insecurity should prioritise coordinated and collaborative activities across the healthcare system, capacity building of local actors, utilisation of routine information to guide decision-making, and regular and effective health service supervisions to ensure health service continuity. Future research could explore the utility of adaptive leadership theoretical framework in assessing the role of health system leadership in ensuring health services continuity during emergency.
Data availability statement
Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information. All data used in this study are presented in the manuscript, however, can be access from the corresponding author on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Makerere University, School of Social Sciences Research and Ethics Committee and the approval number is MAKSSREC 08.2023.696). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors acknowledge the contribution of Ugandan Ministry of Health and WHO for their collaboration and support during the implementation of this study. We also would like to appreciate all study participants and data collectors for their tolerance and cooperation.
Footnotes
X @kwikiriza3
Contributors CN, HT, BNM, KNM, SN and YWT conceived and designed the study; HT, BNM and KNM collected the data; CN, HT and BNM analysed the data and interpreted the results; HT drafted the manuscript. All authors have critically reviewed and approved the manuscript for submission. CN-guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Disclaimer The views expressed in this article are only those of the authors, and do not necessarily reflect the view of Ugandan Ministry of Health and WHO Uganda Country Office.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.