Barriers to health service delivery in Uganda: analysis of performance reviews at the sub- national level in the Mbale Region

<title>Abstract</title> <p>Background Low- and middle-income countries, including Uganda, continue to face many constraints to health care and service delivery. Uganda and other African nations are operating at approximately half of their achievable levels in health access, quality, community demand, and resilience. Challenges to health service delivery in developing nations are often captured in large-scale datasets, and often overlook operational barriers at the subnational level. Performance reviews provide unique insight into the health care challenges at the subnational level. We aimed to use 2024–2025 performance review data for districts in the Mbale Region of Uganda to describe sub-national health system gaps in Uganda and better guide investment and development. Methods We analyzed district performance review findings presented for 11 of 17 districts at the 2024–2025 Mbale Regional Performance Review meeting. The findings were extracted, coded, and grouped into thematic categories under 8 domains, and summarized using descriptive characteristics. Results Across all eight domains, the most commonly observed performance gaps in the 11 districts were staffing shortages (90.9%), excessive staff absenteeism (72.7%), lack of access to EMR (72.7%), and difficulties in operationalizing Health Unit Management Committee meetings (63.6%). Other notable deficiencies included a lack of patient feedback (54.5%), inadequate supplies (45.5%), inadequate workspace (45.5%), lack of training in health delivery (45.5%), and inconsistent data review (36.4%). Conclusions At the sub-national level in Uganda, challenges to providing adequate healthcare service delivery were identified in the healthcare workforce, governance, digitization, infrastructure, and data systems. These findings support targeted district-level investment to improve the delivery of health services at the sub-regional level.</p>