Validating Uganda's Subnational Health Systems Functionality Index for Universal Health Coverage Outcomes and Revealing Capacity Gaps in Access, Quality, Demand, and Resilience

Introduction: Achieving Universal Health Coverage (UHC) and health security in resource-limited settings like Uganda depends on prioritizing functionality index capacities—access, demand, quality, and resilience—over performance metrics. WHO AFRO validated these capacities using country-level data as key outputs for UHC outcomes towards Sustainable Development Goal SDG 3. This study uses subnational data to validate capacities and guide health system strengthening. Methodology: A prospective longitudinal study began in January 2024, with Sub-National Units SNUs (districts and cities) self-assessing functionality and outcomes using WHO AFRO Likert tools, guided by district coordinators. Re-assessments followed perceived changes. Scores ≥75%, 55-74%, and ≤54% indicated sustainability, scale-up, and reinvention needs, respectively. Data analysis involved Excel and ArcGIS mapping Results : By July 2024, 79% (86/109) of SNUs supported by WHO had completed at least an assessment. Like the country-level data, the functionality index showed a moderate correlation with UHC outcomes at 64% (r = 0.6386, p=0.006). Access to healthcare was singly the UHC’s strongest predictor (82-95%), while total resilience was the weakest (39%), with its exclusion from the index improving UHC correlation to 75% (r = 0.7532, p = 0.0001). However, the nuanced inherent resilience vital sign and its diversity sub-capacity, substituting total resilience in the functionality index, improved UHC correlation to 68% and 69%, respectively. This highlighted a significant intervention gap, as only 47% of SNUs reported no emergency stockouts, such as oxygen and personal protective equipment, in the past year. Access, scoring 63%, showed the largest gaps, with 42% (36/86) of SNUs needing new physical interventions compared to demand (1%), quality (6%), and resilience (7%). The functionality index scored 72%, with UHC outcomes at 55%; 64% (55/86) of SNUs required scaling up, 5% (4/86) needed new measures, and 31% (27/86) maintained sustaining levels. Conclusions: Maximizing functionality predictability of UHC outcomes hinges on addressing both physical access and inherent resilience gaps. Context-specific interventions may better capture resilience's nuanced role in achieving UHC outcomes. Future research should explore dynamic, cross-sectoral synergies, including evidence-based functionality interventions while policymakers ought to prioritise targeted strategies for sustainable health security and UHC progress in Uganda and comparable contexts.