Only 7.5% of Stroke Survivors in Kampala Get the Rehabilitation They Need

When a stroke patient leaves Mulago National Referral Hospital in Kampala, Uganda’s largest public hospital, the hardest part of recovery is often just beginning. Rehabilitation, the primary therapy for stroke survivors, is meant to continue after discharge, ideally during the critical first three months when the brain is most responsive to recovery. Yet a new mixed-methods study published in Frontiers in Stroke has found that only 7.5 percent of patients discharged from Mulago’s Neurology unit achieved high access to stroke rehabilitation services, a figure that exposes a deep gap between what survivors need and what they can actually reach.

The study, led by Ronald Bwambale of Makerere University’s School of Public Health together with colleagues in Uganda and the United States, followed 120 adult stroke patients discharged from the Mulago Neurology unit between February and May 2025. The unit, which records between 40 and 60 newly diagnosed stroke patients each month, recommends that discharged patients continue rehabilitation at nearby facilities. But the researchers found that the journey from hospital bed to sustained therapy is riddled with obstacles, most of them financial.

To measure access rigorously, the team used a 17-item multidimensional tool based on Penchansky and Thomas’s classic framework, which breaks access into five dimensions: availability, accessibility, accommodation, affordability, and acceptability. Each item was scored on a five-point Likert scale, and participants scoring 80 percent or above on the composite measure were classified as having high access. The results were stark. Affordability scored lowest at just 3.7 percent, followed by accommodation at 15.9 percent, availability at 20.6 percent, and accessibility at 24.3 percent. Only acceptability, at 66.4 percent, approached adequate levels.

The affordability finding is the study’s most alarming. In-depth interviews with six purposively selected participants revealed that patients were paying out of pocket for every physiotherapy session on top of ongoing medication costs. One 75-year-old male participant described hiring a private healthcare worker who charged 80,000 Ugandan shillings, roughly 22 US dollars, per two-hour session, while weekly medications cost another 85,000 shillings. The combined burden proved unsustainable, and the family eventually stopped rehabilitation altogether. This pattern of discontinuation due to cost was a recurring theme across interviews.

Transport emerged as the second major barrier. Many patients lived far from the few facilities equipped to provide stroke rehabilitation, which in Uganda are concentrated in national and regional referral hospitals. Long travel distances made consistent attendance difficult, pushing some patients to abandon therapy after just a few sessions. Even those living relatively close faced challenges, as one caregiver explained that she could not expose her vulnerable relative to the wind on a motorcycle taxi, known locally as a boda-boda, without triggering vomiting. For others, the cost of fuel or hired transport fell on already strained family members, with some patients themselves contributing money toward trips they could not afford.

The organization of rehabilitation services also fell short of patient needs. Participants reported that rehabilitation at some facilities was available only during morning hours, leaving afternoon arrivals unattended even when staff were present. Long waiting times and confusing referral pathways within the hospital system led to missed appointments and frustration. One 34-year-old female participant described being sent from one department to another without clear direction, ultimately leaving at 6 p.m. without seeing a doctor. In contrast, patients who accessed private rehabilitation services reported more organized care, with scheduled appointments and even occasional home visits, highlighting a two-tier system that favors those who can pay.

Faced with these barriers, many families improvised. Some patients shifted to self-directed exercises at home, guided by relatives, friends with medical knowledge, or instructional videos found online. While this resourcefulness reflects resilience, the researchers note that unguided home exercise cannot substitute for professional rehabilitation, particularly during the early post-stroke window when structured therapy has the greatest impact on functional recovery. The study also found that higher access was reported among younger participants, urban residents, those of higher socio-economic status, and married individuals, suggesting that the burden of poor access falls disproportionately on older, rural, and less connected patients.

The acceptability dimension’s relatively high score deserves careful interpretation. The authors suggest it may reflect the limited autonomy stroke patients have in choosing providers. Given their urgent need for rehabilitation, patients often accept whatever care is available regardless of provider characteristics, meaning the score may indicate willingness to receive care rather than genuine satisfaction with its quality. This nuance matters for policymakers who might otherwise read the 66.4 percent figure as a sign that the system is working.

The findings land within a broader global context. Stroke is the second leading cause of death worldwide, and roughly 70 percent of strokes and 87 percent of stroke-related disabilities occur in low- and middle-income countries. In Africa, stroke incidence reaches up to 316 per 100,000 annually, with a three-year fatality rate exceeding 80 percent. In Uganda specifically, stroke is the sixth leading cause of death and the third most diagnosed neurological condition, with a 30-day mortality rate of 38.1 percent. Yet at least 63 percent of Africans needing rehabilitation do not receive it, a gap the World Health Organization’s Rehabilitation 2030 initiative has flagged as a systemic failure driven by under-prioritization, inadequate funding, and shortages of trained rehabilitation professionals.

The researchers propose concrete interventions tailored to this context. They recommend subsidizing community-based rehabilitation services to reduce out-of-pocket costs, extending service hours beyond mornings, strengthening caregiver training before discharge so families can support affordable home-based care, and decentralizing rehabilitation points to regional, district, and community levels. They also point to home-based and community-led rehabilitation models, which evidence shows can be effective even in resource-limited settings, as well as tele-rehabilitation and mobile health interventions that could extend services to rural populations. Public-private partnerships, they argue, could expand affordable care in underserved areas. Without such reforms, the study warns, the majority of Uganda’s stroke survivors will continue to face recovery alone, their rehabilitation cut short by the price of a bus fare or a therapy session.

Subject of Research: Access to post-discharge stroke rehabilitation services in Kampala, Uganda

Article Title: Access to stroke rehabilitation services for patients discharged from the Mulago National Referral Hospital Neurology unit, Kampala—Uganda: a mixed-methods study

Article References: Bwambale, R., Ssenyonga, R., Kaddumukasa, M., Sajatovic, M., & Mukose, A. D. (2026). Access to stroke rehabilitation services for patients discharged from the Mulago National Referral Hospital Neurology unit, Kampala—Uganda: a mixed-methods study. Frontiers in Stroke, 5, Article 1913292. https://doi.org/10.3389/fstro.2026.1913292

Image Credits: AI Generated

DOI: 10.3389/fstro.2026.1913292

Keywords: stroke, rehabilitation, Uganda, Mulago National Referral Hospital, health access, affordability, low- and middle-income countries, physiotherapy, mixed-methods research, global health, stroke recovery, health policy