Back pain is negatively affecting Uganda’s productivity in a non-responsive health system.

By Dan Kajungu, Msc. PhD

Let us talk about a woman I will call Nakato. She is 43 years old, lives in a village in Iganga district, and has spent the last two years waking up every morning with a lower back that aches so persistently she has stopped attending her women’s savings group, reduced the land she farms, and sent her eldest daughter to take over the heavier household chores. She has never been to a hospital for her back. She has never been told there is a name for what she has, a clinical reason it is happening, or a treatment that could meaningfully improve her functioning. She has simply accepted it as most people around her have, as an inescapable consequence of age and a life of physical labour.

Nakato is not an anomaly. She is the norm.

This is not from anecdote but from data we have collected from communities like hers through the Iganga-Mayuge Health and Demographic Surveillance Site, Makerere University’s population research platform in Eastern Uganda. Our latest study, published last month in the International Journal of Environmental Research and Public Health, surveyed 8,645 adults across seven sub-counties of rural Eastern Uganda, whose findings I believe every health planner, every Member of Parliament on the health committee, and every official in the Ministry of Health or District Health Team needs to sit with and take seriously.

One in six adults (15.2%) of all respondents had experienced chronic low back pain in the last twelve months. Of those, nearly nine in ten reported pain severe enough to limit their ability to carry out household, work, or recreational activities. We measured what the health system was actually doing about it, not just whether people had attended a service, but whether that service had produced a meaningful improvement in their ability to function. The answer was devastating. Only 7.05% of adults with chronic low back pain and functional limitations had received care of sufficient quality to generate meaningful health gain.

Seven percent. In a condition affecting one in six adults.

My experience in public health is over a decade. I have analysed data from clinical trials, vaccination campaigns, pharmacovigilance studies, and population surveillance across Uganda and across Africa. But these numbers stunned me. Because what they reveal is not a gap at the margins of our health system, they reveal a near-total absence of effective rehabilitation services for one of the most prevalent and productivity-draining conditions in our adult population.

Are we looking at the wrong diseases?

I want to be clear about what I am not saying. I am not saying Uganda’s investments in HIV, malaria, tuberculosis, and maternal health have been wrong. They have been right, they have saved lives, and they must continue. But Uganda’s epidemiological landscape is changing or has already changed, and our health system planning has not kept pace.

The 2019 data tell us that 6.8 million Ugandans were living with conditions amenable to rehabilitation. Six point eight million. That is not a marginal population. That is a substantial fraction of our entire adult workforce. Farmers, traders, drivers, boda-boda riders, teachers, health workers, mothers, fathers living with unaddressed functional limitations that reduce what they can contribute to their families, their communities, and their country’s economy.

Low back pain alone is the single leading cause of years lived with disability globally, surpassing every infectious disease in its contribution to lost productive capacity. It does not kill people, and that is precisely why it has received so little attention in health systems built around the imperative of mortality reduction. But a health system that only counts the dead is not measuring most of the suffering it is failing to address.

What “effective coverage” reveals, and why it matters more than bed counts

Let me explain the concept at the heart of our study, because it reframes how we should evaluate health system performance entirely. Effective coverage asks not merely whether a person accessed a service, whether they attended a clinic, received a consultation, walked through the door of a health facility, but whether the service they received actually improved their health in a meaningful, measurable way. It is the difference between counting inputs and measuring outcomes.

When we applied this standard to rehabilitation for chronic low back pain in this population in Uganda, we found that 46% of people in need had accessed some form of rehabilitation service. Nearly half, meaning over half of the people in need, accessed nothing at all. But of those who did access services, the vast majority received care of insufficient quality to produce a meaningful improvement in their functioning. For effective coverage, people in need who received care that actually worked was just seven percent.

This is not a criticism of individual health workers. The nurse at the health centre who saw a patient with back pain and did what she could with the training and resources available to her was not failing through negligence. She was operating in a system that was never designed, never resourced, and never trained to deliver rehabilitation at the community level. The failure is systemic, and it is a policy failure, not a frontline failure.

What this means for countries like ours

Our study is the first population-level measurement of effective coverage of rehabilitation using chronic low back pain as a tracer condition anywhere in the world. Not in Uganda alone. In the world!

That tells you something about how invisible rehabilitation has been in global health research, and it tells you something about what Uganda, through the IMHDSS platform, is able to contribute to that conversation. But it also means that every health ministry in sub-Saharan Africa, South Asia, and Latin America reading these findings should recognise that they likely have a similar or worse gap in their own countries, and that they now have the validated methodology to measure it. The WHO tracer indicator questions and the WHODAS 2.0 functioning assessment tool we used are standardised, portable, and affordable. Any country serious about Universal Health Coverage can replicate this measurement. I would argue that every country should.

Call to action

At Makerere University, we ensure that the evidence we generate does not remain in academic journals but reaches the decision-makers who can act on it. So let me be direct about what this study demands.

First, rehabilitation must be formally incorporated into Uganda’s essential health services package. It cannot remain a voluntary addition, a donor-funded project, or a referral option available only in urban centres. If one in six adults is living with chronic low back pain and fewer than one in ten is being effectively treated, rehabilitation is not a specialised service! It is a basic health need being systematically unmet.

Second, the training curriculum for health workers at all levels, from community health workers to health assistants to clinical officers, must include the assessment and basic management of chronic musculoskeletal conditions. This is currently almost absent from health worker pre-service and in-service training in Uganda. It needs to change.

Third, the Ministry of Health should institute routine measurement of effective coverage of rehabilitation, using the methodology our study has now validated at the population level. You cannot manage what you do not measure. We have been measuring vaccination coverage, HIV treatment coverage, and malaria case management rates for years. We must now begin measuring rehabilitation coverage with the same rigour.

Fourth and I say this as someone who has dedicated significant professional energy to building and sustaining a population-based surveillance cohort (like IMHDSS). The government of Uganda must formally recognise and resource such population research platforms as national health infrastructure. The findings in this study, like those we have published on COVID-19 excess mortality, climate-driven malaria deaths, NCD burden, and disability, were only possible because Makerere University has maintained a continuously updated, community-based surveillance system for over twenty years. That is not an academic luxury. It is the foundation of evidence-based governance in health.

A message to Nakato and the millions like her

I began with Nakato because her experience is not exceptional. It is representative. She represents the majority of Ugandan adults with chronic back pain who have no access to effective treatment, who do not know that what they are experiencing has a name and a solution, and who are quietly bearing a burden of disability that our health system has yet to acknowledge as its responsibility.

She deserves better. Not charity. A functioning health system that sees her condition, measures it honestly, and organises itself to address it. Our study has taken one step toward making her visible in the data. The next steps belong to those with the power to change the system.

The evidence is on the table. Seven percent effective coverage for one of the most prevalent disabling conditions in our adult population is not a baseline to accept. It is a baseline to transform, urgently, systematically, and with full recognition that the millions of Ugandans living with unaddressed pain and functional limitation are not waiting.

Dan Kajungu PhD is a Public Health Research Scientist and Biostatistician, Executive Director of the Makerere University Centre for Health and Population Research (MUCHAP), and Senior Lecturer in the Division of Biostatistics and Epidemiology, Department of Global Health at Stellenbosch University, South Africa. He is the Principal Investigator of the Iganga-Mayuge Health and Demographic Surveillance Site (IMHDSS). 

The full study is available open access at: https://www.mdpi.com/1660-4601/23/6/693 

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Dan Kajungu

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