Cost, Distance and Limited Services Leave Uganda’s Stroke Survivors Without Rehabilitation

A stroke survivor's recovery does not end when they leave the hospital. Regaining movement, independence, and the ability to manage everyday life can depend heavily on rehabilitation; yet new research from Uganda shows that many patients struggle to obtain rehabilitation care once they return home.

The study, 'Access to stroke rehabilitation services for patients discharged from the Mulago National Referral Hospital Neurology unit, Kampala—Uganda: a mixed-methods study,' was published in Frontiers in Stroke by Ronald Bwambale and colleagues. The researchers found that only 7.5% of assessed participants achieved a high overall level of access to stroke rehabilitation, exposing a large gap between the need for rehabilitation and patients' ability to obtain it.

The study notes that around 70% of strokes and 87% of stroke-related disabilities worldwide occur in low- and middle-income countries, where unmet rehabilitation needs remain substantial. Stroke is reported as Uganda's sixth leading cause of death, while more than 5,000 people are estimated to require rehabilitation each year.

Only a Small Share of Patients Had High Access to Rehabilitation

Researchers examined adults who were discharged from the Neurology Unit at Mulago National Referral Hospital in Kampala and had been advised to continue rehabilitation. The mixed-methods study combined quantitative information from 120 participants with in-depth interviews involving six participants, allowing the researchers to measure access while also hearing directly about the practical difficulties patients experienced. Of 203 stroke patients discharged alive between February and May 2025, 126 were alive and reachable when researchers conducted the study, and 120 agreed to participate.

Access was assessed through five areas: accessibility, availability, accommodation, affordability and acceptability. A score of at least 80% was classified as high access. Thirteen participants who reported no knowledge of rehabilitation services could not complete the access assessment, leaving 107 people in the main access analysis. Among them, only eight, or 7.5%, reached the threshold for high overall access.

The differences between the five dimensions were striking. Acceptability performed best, with 66.4% reaching the high-access threshold, followed by accessibility at 24.3%, availability at 20.6%, accommodation at 15.9%, and affordability at just 3.7%. The result makes the imbalance particularly clear, showing affordability far below every other component of access.

The relatively high acceptability result does not necessarily mean patients had plenty of choice. The researchers suggest that stroke survivors may have little autonomy in selecting rehabilitation providers and may accept whichever care is available because their need for treatment is so strong.

Cost, Distance and Hospital Systems Can Interrupt Recovery

Affordability emerged as the most serious obstacle, as patients described paying for physiotherapy while also meeting continuing medication expenses, creating costs that could become impossible for households to sustain. One interview described physiotherapy costing 80,000 Ugandan shillings, around US$22, per session, while medication cost another 85,000 shillings, around US$24, each week. Faced with combined expenses like these, some patients stopped rehabilitation.

Family support often became the financial and practical safety net: Relatives and friends paid treatment expenses, arranged transport and accompanied patients to facilities. Recovery outside the hospital could therefore depend heavily on whether someone had family members with the money, time or transport needed to help.

Getting to rehabilitation created another layer of difficulty: Patients reported long distances, unsuitable transport options and expensive journeys. Some attended only a few sessions before distance became too difficult. Even living near a facility did not guarantee easy access because stroke-related disabilities or other health problems could make common transport options unsuitable.

The organization of services also shaped whether patients could continue treatment. Some rehabilitation units operated mainly in the morning, meaning patients arriving later could miss care even after making the journey to the hospital. Long waits, unclear directions and movement between several hospital departments added further strain.

Private rehabilitation sometimes offered a different experience, with scheduled appointments and occasional home visits providing more predictable care. Patients who could not regularly reach rehabilitation facilities often turned to exercises at home, sometimes receiving guidance from relatives, medically knowledgeable friends or online videos.

Availability was another concern as some participants struggled to identify any rehabilitation provider in their community. The researchers point out that much of Uganda's stroke rehabilitation is concentrated in national and regional referral hospitals rather than extending into communities, which leaves patients living farther from major facilities at a disadvantage.

Bringing Rehabilitation Closer to Patients Could Change Recovery

The findings point toward a rehabilitation system that needs to become more affordable, local and flexible rather than expecting stroke survivors to repeatedly overcome financial and physical barriers to reach centralised services.

The researchers recommend subsidized community-based rehabilitation to reduce out-of-pocket spending, longer operating hours so patients are not restricted to morning sessions, structured caregiver training before discharge and during follow-up, and decentralised rehabilitation points supported with trained staff and essential equipment.

Home and community rehabilitation could be especially valuable. Trained caregivers and community health workers could provide standardized exercises under periodic professional supervision, reducing repeated trips to hospitals while making care easier to continue. Tele-rehabilitation and mobile-health services could extend professional support to rural communities, while public-private partnerships may help expand affordable services into underserved areas.

The study also calls for stronger referral systems, discharge planning and follow-up after hospitalization, alongside greater investment in training and distributing rehabilitation professionals beyond national referral hospitals. Task-sharing could allow trained mid-level providers and community health workers to deliver basic rehabilitation under supervision.

The researchers acknowledge several limitations. Consecutive sampling, a relatively small sample, self-reported access, and the exclusion of patients who had died or could not be reached may limit how widely the results can be applied. Recall, survival and selection bias are also possible. Larger multi-site studies would provide a stronger picture of rehabilitation access across Uganda.

Only 7.5% of assessed stroke survivors had high overall access to rehabilitation after leaving hospital. For many patients, recovery was shaped not simply by their medical condition but by whether they could afford another therapy session, find suitable transport, reach a provider during limited operating hours or locate rehabilitation services near home. Making rehabilitation cheaper and closer to communities could turn post-stroke care from a difficult journey into a realistic part of recovery.