Institutional Governance, Capacity and Coordination: Shaping Infectious Disease Surveillance at West Nile Uganda–DRC Land Border Crossings

Introduction

Infectious disease surveillance is a fundamental component of public health systems because it enables the systematic collection, analysis, interpretation, and dissemination of health information for the timely detection, reporting, and response to disease threats (MacIntyre et al., 2022; World Health Organization, 2021). Effective surveillance systems are particularly important at international borders where high levels of population mobility increase the risk of cross-border transmission of infectious diseases. The effectiveness of surveillance systems depends not only on technological infrastructure and reporting mechanisms but also on the institutional environment within which surveillance activities are implemented. Governance arrangements, institutional capacity, and coordination mechanisms influence the ability of surveillance systems to identify, communicate, and respond to public health threats in a timely and effective manner (Reich et al., 2023; Suthar et al., 2024).

The importance of institutional factors in disease surveillance has gained increasing attention following the adoption of the World Health Organization, (2005), which require countries to establish core capacities for disease detection, notification, verification, and response to public health emergencies of international concern (World Health Organization, 2021). Countries with strong governance structures, adequate human resources, reliable surveillance infrastructure, and effective coordination mechanisms have demonstrated superior surveillance performance characterized by timely reporting, improved outbreak detection, and rapid response to disease threats (Bian et al., 2024; Kraemer et al., 2023). In contrast, weak institutional arrangements continue to constrain surveillance effectiveness in many low- and middle-income countries, particularly in settings characterized by high population mobility and limited public health resources.

In Africa, infectious disease surveillance remains challenging in border and high-mobility settings where porous borders, informal migration routes, inadequate surveillance infrastructure, and weak institutional collaboration compromise disease detection and response efforts. More than sixty percent of disease outbreaks on the continent occur in border areas where surveillance systems face operational and institutional constraints that limit their effectiveness (Tambo et al., 2023). Existing studies have identified inadequate staffing, limited workforce training, fragmented information-sharing systems, insufficient resource allocation, and weak inter-agency coordination as major barriers to effective surveillance in many African countries (Mwai et al., 2023; Nkengasong & Tessema, 2024). These weaknesses contribute to delayed outbreak detection, incomplete reporting, and ineffective response mechanisms that increase the likelihood of disease spread across national boundaries.

Uganda has made substantial investments in strengthening disease surveillance through the Integrated Disease Surveillance and Response (IDSR) strategy and the electronic Integrated Disease Surveillance and Response (eIDSR) system. These initiatives have improved disease notification and reporting capacities across many parts of the country (King et al., 2024; Mugasha et al., 2025). Nevertheless, surveillance performance at land border points of entry continues to present significant challenges. Reporting completeness at several border locations remains below national targets, while reporting delays frequently exceed the standards required under the International Health Regulations. Evidence further indicates persistent weaknesses in information sharing, institutional collaboration, workforce capacity, and resource availability within border surveillance systems (Nanyondo et al., 2025). These shortcomings have been associated with delayed detection and response to outbreaks of Ebola Virus Disease, plague, cholera, Mpox, and measles linked to cross-border movement between Uganda and the Democratic Republic of Congo.

The West Nile region represents one of Uganda's most active transboundary migration corridors and experiences extensive cross-border movement associated with trade, social interaction, livelihood activities, and population displacement (Acikalin, 2020). The region contains several formal points of entry while also accommodating substantial movement through numerous ungazetted routes that are difficult to monitor effectively (Sami & Chun, 2024; Tagliacozzo et al., 2024). The region has experienced repeated public health threats associated with cross-border transmission of Ebola Virus Disease, cholera, plague, measles, and Mpox, highlighting the importance of effective surveillance systems within border settings (Nanyondo et al., 2025; World Health Organization, 2023). Despite investments aimed at strengthening disease surveillance and border health security in Uganda, evidence continues to indicate challenges related to reporting timeliness, information sharing, institutional coordination, workforce capacity, and surveillance coverage at points of entry (King et al., 2024; Mugasha et al., 2025).

This study was informed by General Systems Theory and Border Theory. General Systems Theory, developed by von Bertalanffy, (1968), views organizations and institutions as interconnected systems whose effectiveness depends on the interaction of multiple components operating through inputs, processes, outputs, and feedback mechanisms. In the context of infectious disease surveillance, the theory suggests that surveillance effectiveness depends on the functioning and interaction of governance structures, human resources, infrastructure, information systems, coordination mechanisms, and reporting processes. Weaknesses in any component of the surveillance system can affect the performance of the entire system. Border Theory, advanced by Gloria Anzaldúa, (1987), conceptualizes borders as dynamic social spaces shaped by movement, interaction, economic activity, and institutional practices rather than fixed administrative boundaries. The theory is particularly relevant to the West Nile Uganda–DRC border context because surveillance activities operate within environments characterized by continuous cross-border mobility, informal movement routes, and interactions among multiple institutional actors. Together, these theories provide a useful framework for understanding how governance arrangements, institutional capacity, and coordination mechanisms influence the effectiveness of infectious disease surveillance within transboundary settings.

Despite these persistent challenges, existing studies have largely focused on migration patterns, disease transmission risks, surveillance performance indicators, and border control mechanisms, while limited empirical attention has been directed toward understanding how institutional governance, capacity, and coordination shape surveillance effectiveness at border points of entry. Consequently, evidence remains insufficient regarding the institutional conditions that facilitate or constrain infectious disease surveillance in high-risk transboundary settings. This study therefore examined the influence of institutional governance, capacity, and coordination on infectious disease surveillance at West Nile Uganda–DRC land border crossings by addressing the question: How do institutional governance, capacity, and coordination influence infectious disease surveillance at West Nile Uganda–DRC land border crossings?

Methods

This study employed a qualitative exploratory design to examine how institutional governance, capacity, and coordination shape infectious disease surveillance at selected Uganda–Democratic Republic of Congo land border crossings in the West Nile region of Uganda. A qualitative approach was considered appropriate because the study sought to generate an in-depth understanding of institutional processes, governance arrangements, organizational capacities, and coordination mechanisms influencing infectious disease surveillance from the perspectives of actors directly involved in surveillance implementation and border management (Creswell & Plano Clark, 2018; Denzin & Lincoln, 2018). The study was conducted at selected gazetted and ungazetted border points of entry located in Koboko, Arua, Maracha, Zombo, Nebbi, and Pakwach districts, which constitute the major Uganda–DRC border corridor and experience substantial cross-border mobility, informal trade, refugee movements, and recurrent public health threats.

Participants were purposively selected based on their knowledge, experience, and involvement in infectious disease surveillance and border management activities. The study included thirteen key informants drawn from immigration, customs, port health, police, and other security agencies operating at border points of entry. Four executive interviews were conducted with national and district-level officials responsible for migration governance and disease surveillance, while three focus group discussions were conducted with community leaders, health workers, local government officials, civil society representatives, and members of the business community residing within border communities. In addition, two narrative interviews were conducted with long-term border residents possessing extensive experience and knowledge of cross-border movement and disease surveillance practices. Participant recruitment continued until information saturation was achieved and no substantial new themes emerged from subsequent interviews and discussions.

Data was collected through key informant interviews, executive interviews, focus group discussions, narrative interviews, direct observations, and document review. Semi-structured interview guides were used to explore issues relating to governance structures, leadership support, accountability mechanisms, resource allocation, workforce capacity, staffing, training, information-sharing systems, policy implementation, community engagement, and inter-agency coordination in infectious disease surveillance. Observation was undertaken at selected border points of entry and health facilities serving border communities to examine surveillance infrastructure, operational procedures, screening practices, reporting processes, and institutional interactions among agencies involved in surveillance activities. Additional data was obtained through the review of surveillance policies, operational reports, guidelines, treaties, regulations, and institutional documents relevant to border health surveillance. The use of multiple data collection methods enabled triangulation and strengthened the comprehensiveness of the findings (Patton, 2015).

Data was analyzed thematically following the procedures proposed by (Braun & Clarke, 2022). Audio recordings from interviews and focus group discussions were transcribed verbatim and integrated with field notes generated during observations. The researcher repeatedly reviewed the transcripts to achieve familiarity with the data before generating initial codes. Similar codes were subsequently grouped into categories and refined into broader themes reflecting institutional governance, organizational capacity, coordination mechanisms, and their influence on infectious disease surveillance. NVivo software supported coding, data organization, retrieval, and interpretation. The iterative analytical process facilitated identification of patterns, relationships, and explanations relevant to understanding how institutional factors shape surveillance effectiveness at border points of entry (Braun & Clarke, 2022; Saldaña, 2016).

The rigor of the study was enhanced through triangulation of multiple data sources, including interviews, focus group discussions, observations, and document review. Consistent interview procedures, detailed field documentation, maintenance of an audit trail, and the inclusion of participants drawn from different institutional and community settings strengthened the credibility, dependability, confirmability, and transferability of the findings (Lincoln & Guba, 1985).

Ethical approval was obtained from the Research Ethics Committee of Mbarara University of Science and Technology, while research clearance was granted by the Uganda National Council for Science and Technology. Administrative permission was obtained from relevant national, regional, and district authorities responsible for border management and public health surveillance. Participation was voluntary, informed consent was obtained from all participants before data collection, confidentiality was maintained through anonymization of participant identities, and all research materials were securely stored throughout the study period.

Results

The analysis explored how institutional governance, capacity, and coordination shape infectious disease surveillance at Uganda–Democratic Republic of Congo border crossings in the West Nile region. Analysis of interviews, focus group discussions, observations, and documentary evidence generated three interrelated themes: institutional coordination, governance and leadership support, and institutional capacity. These themes collectively explain the institutional conditions that facilitate or constrain surveillance effectiveness within border settings. Across all participant categories, respondents emphasized that surveillance effectiveness depended not only on technical surveillance systems but also on the strength of organizational relationships, leadership structures, and resource availability supporting surveillance implementation.

Institutional Coordination Remains Reactive Rather Than Institutionalized

Institutional coordination emerged as a dominant theme across interviews and focus group discussions. Participants consistently described surveillance as a multi-agency function requiring collaboration among health workers, immigration officials, customs officers, police personnel, military officers, local government authorities, and community actors. Despite recognition of the importance of collaboration, participants reported that coordination remained largely reactive and event-driven rather than embedded within routine surveillance systems. Three sub-themes emerged under institutional coordination: outbreak-driven collaboration, informal communication systems, and weak cross-border information sharing.

Outbreak-Driven Collaboration

Participants consistently reported that collaboration among institutions increased substantially during disease outbreaks and public health emergencies. During periods of heightened disease risk, agencies conducted joint meetings, coordinated screening activities, exchanged information, and implemented collective response measures. However, respondents noted that such collaborative arrangements weakened considerably once outbreaks subsided.

Participants explained that coordination mechanisms frequently depended on perceived disease threats rather than established institutional systems. Consequently, surveillance activities were often implemented independently during routine periods, limiting opportunities for joint planning, learning, and preparedness.

One participant explained:

“When there is an outbreak, everyone becomes serious, and coordination improves immediately. Meetings are called, information is shared, and roles are clearer. But when there is no outbreak, health, immigration, and security work separately, and disease surveillance is no longer a shared priority” (FGD Participant 3, Vurra Town Council, Arua District, February 2025).

Similar concerns were expressed by another participant who observed:

“Most of the collaboration happens because there is fear of an outbreak. Once the emergency ends, meetings become fewer and agencies go back to their normal mandates” (FGD Participant 5, Goli Border Point, Nebbi District, February 2025).

These findings suggest that collaboration was primarily emergency-oriented and lacked institutional arrangements capable of sustaining routine coordination across surveillance actors.

Reliance on Informal Communication Systems

The second sub-theme concerned communication and information exchange among agencies. Participants described surveillance communication systems as largely informal and dependent on personal relationships between frontline personnel. Mobile telephone calls, WhatsApp messages, and interpersonal networks were reported as the most common channels for sharing surveillance information.

Although respondents acknowledged that informal communication facilitated rapid information exchange, they expressed concerns regarding accountability, documentation, and continuity. Information sharing frequently depended on individual initiative rather than organizational procedures.

A participant noted:

“Most of the time we use phone calls or WhatsApp to communicate. It helps when something urgent happens, but there is no formal system to capture that information or track what was agreed” (FGD Participant 7, Goli Customs Border, Nebbi District, February 2025).

Another respondent explained:

“If the officer you normally communicate with is transferred, information flow becomes difficult because there is no established system that automatically connects agencies” (Key Informant, Vurra Border Point, Arua District, March 2025).

Observation findings supported these views by revealing inconsistent documentation of communication processes and limited integration of information systems across agencies.

Weak Cross-Border Information Sharing

Participants further identified weaknesses in surveillance information sharing between Ugandan authorities and their counterparts in the Democratic Republic of Congo. Although participants acknowledged occasional collaboration during outbreaks, routine exchange of surveillance information was described as limited and inconsistent.

Respondents indicated that disease events were often detected independently on each side of the border because formal mechanisms for continuous information sharing were weak.

One participant explained:

“Information from the other side usually comes when there is already an outbreak or strong suspicion. Routine sharing of surveillance data does not happen, so we often detect issues on our side without prior warning” (FGD Participant 8, Vurra Town Council, Arua District, February 2025).

Similarly, another participant noted:

“We know diseases do not stop at the border, but information still stops at the border most of the time” (Key Informant, Goli Border Point, Nebbi District, February 2025).

Taken together, these findings demonstrate that institutional coordination was constrained by temporary collaboration arrangements, informal communication structures, and weak cross-border information-sharing systems. As a result, surveillance activities frequently depended on individual relationships and emergency-driven responses rather than sustainable institutional mechanisms.

Governance Structures Provide Limited Strategic Direction for Border Surveillance

Governance structures emerged as a critical factor shaping the effectiveness of infectious disease surveillance at border points of entry. Participants consistently emphasized that surveillance systems require clear leadership, effective accountability mechanisms, supportive policy implementation structures, and timely decision-making processes. Although governance frameworks for surveillance existed at national, district, and border levels, respondents indicated that their operational effectiveness was constrained by limited leadership engagement, centralized decision-making processes, weak accountability systems, and implementation gaps. These governance weaknesses reduced the ability of surveillance actors to coordinate actions, mobilize resources, and respond promptly to emerging public health threats.

Three sub-themes emerged under governance and leadership support: limited leadership engagement, centralized decision-making structures, and weak accountability and policy implementation mechanisms.

Limited Leadership Engagement in Routine Surveillance

Participants consistently reported that leadership attention towards surveillance activities increased during outbreaks but remained limited during routine surveillance periods. Respondents described a pattern whereby senior officials became actively involved when disease threats attracted national attention but were less visible during normal surveillance operations.

Participants explained that routine supervision, monitoring visits, and strategic guidance were often inadequate, resulting in reduced oversight of surveillance activities at border points of entry. This situation was perceived to weaken motivation among frontline surveillance personnel and reduce opportunities for addressing operational challenges before they escalated.

One participant explained:

“District leaders are responsible for surveillance, but they are not here every day. They come when there is an alert or an outbreak. On ordinary days, border health work continues without much supervision from leadership” (FGD Participant 5, Goli Town Council, Nebbi District, February 2025).

Another respondent observed:

“When Ebola is reported somewhere, everyone comes and wants updates. When there is no outbreak, surveillance becomes something that is left to a few officers at the border” (Key Informant, Arua District, March 2025).

Participants further indicated that irregular leadership engagement contributed to delays in addressing staffing shortages, infrastructure deficiencies, and logistical constraints affecting surveillance operations. Observation findings similarly revealed infrequent supervisory visits and limited evidence of routine performance review mechanisms at some border points of entry.

Centralized Decision-Making and Delayed Response

The second sub-theme concerned the concentration of decision-making authority within higher administrative structures. Participants reported that many operational decisions relating to surveillance required approval from district, regional, or national authorities before action could be taken.

Respondents explained that although such arrangements were intended to ensure consistency and accountability, they often delayed responses to emerging surveillance concerns. Frontline personnel frequently lacked sufficient authority to implement immediate interventions even when potential disease threats had been identified.

A key informant explained:

“At the border, there is no leader with full authority to make decisions immediately. We report upwards, and sometimes by the time guidance comes, the situation has already changed” (Key Informant, Vurra Border Point, Arua District, March 2025).

Similarly, another participant stated:

“Many decisions have to move through several offices before approval is obtained. This affects how quickly surveillance teams can respond when unusual situations are detected” (Key Informant, Koboko District, February 2025).

Participants argued that surveillance effectiveness would improve if greater operational authority were delegated to personnel directly responsible for surveillance implementation at border points of entry. Such decentralization was viewed as essential for improving timeliness in decision-making and response.

Weak Accountability and Policy Implementation Mechanisms

Participants also highlighted weaknesses in accountability systems supporting surveillance implementation. Although surveillance policies, guidelines, and reporting procedures were widely available, respondents indicated that mechanisms for monitoring compliance and holding responsible actors accountable remained weak.

Several participants reported that surveillance failures were rarely linked to specific institutional responsibilities. Consequently, it was often difficult to determine who should be held accountable when reporting delays, coordination failures, or surveillance gaps occurred.

One participant noted:

“There is no clear way to measure leadership performance on disease surveillance at the border. If gaps happen, no one is directly held responsible” (Key Informant, Goli Border Point of Entry, Nebbi District, February 2025).

Another respondent explained:

“Everyone knows the policies and guidelines, but implementation depends on whether resources are available and whether officers are motivated to follow them” (FGD Participant 2, Paidha Town Council, Zombo District, February 2025).

Participants further observed that policy implementation was complicated by the operational realities of porous borders and numerous informal crossing points. Although surveillance guidelines prescribed comprehensive screening and monitoring procedures, respondents indicated that resource limitations often prevented full implementation of these requirements.

One participant explained:

“The policies are good on paper, but implementing them is difficult when you do not have enough staff, transport, equipment, or control over the many unofficial crossing routes” (Key Informant, Paidha Border Area, Zombo District, February 2025).

Document review findings supported these observations and revealed recurring references to staffing constraints, funding limitations, and infrastructure deficiencies affecting implementation of surveillance policies across border districts.

Institutional Capacity Constraints Undermine Surveillance Effectiveness

Institutional capacity emerged as the most prominent theme influencing infectious disease surveillance at the West Nile Uganda–DRC border crossings. Participants consistently described capacity limitations as a major impediment to surveillance effectiveness, affecting disease detection, reporting, information management, and response activities. While surveillance structures and procedures existed across the border districts, their implementation was frequently constrained by shortages in human resources, inadequate infrastructure, insufficient training, fragmented information systems, and weak integration of community-based surveillance mechanisms. Participants emphasized that surveillance effectiveness depended not only on the availability of policies and coordination structures but also on the institutional capacity required to operationalize them.

Four interrelated sub-themes emerged under institutional capacity: human resource constraints, inadequate infrastructure and logistical resources, workforce development challenges, and fragmented surveillance information systems and community integration.

Human Resource Constraints and Staffing Shortages

Participants consistently identified inadequate staffing as one of the most significant barriers to effective surveillance implementation. Respondents reported that many border points of entry operated with limited numbers of health personnel despite increasing volumes of cross-border movement and expanding surveillance responsibilities.

Participants explained that health workers were often required to perform multiple functions simultaneously, including traveller screening, disease surveillance, health education, reporting, referral coordination, and administrative duties. This workload reduced the ability of personnel to conduct comprehensive surveillance activities and compromised surveillance quality.

One participant explained:

“At this border point, you may find only one health worker present for the whole day. That same person is expected to screen travellers, take temperatures, record details, communicate alerts, and sometimes even assist with referrals” (FGD Participant 4, Paidha Town Council, Zombo District, February 2025).

Similarly, another participant observed:

“The number of people crossing the border has increased, but staffing levels have not increased at the same rate. One officer is expected to do the work of several people” (Key Informant, Koboko Border Point, March 2025).

Participants further reported that staffing shortages frequently resulted in fatigue, delayed reporting, inadequate follow-up of suspected cases, and reduced surveillance coverage, particularly at busy crossing points and during periods of increased population movement.

Observation findings supported these concerns and revealed situations where surveillance functions were temporarily interrupted because designated personnel were simultaneously engaged in other operational duties.

Inadequate Infrastructure and Logistical Resources

The second sub-theme concerned limitations in surveillance infrastructure, equipment, and logistical support. Participants reported that several border points of entry lacked appropriate facilities for conducting surveillance activities, including screening areas, isolation units, office space, communication equipment, and transportation resources.

Respondents indicated that surveillance infrastructure established during previous outbreaks had deteriorated over time due to inadequate maintenance and replacement. In some locations, temporary structures initially intended for emergency response had become permanent surveillance facilities despite being unsuitable for long-term use.

One participant explained:

“Most of the screening we do happens in tents or very small rooms that were never designed for health work. There is no proper space for isolation, no privacy for assessment, and no secure storage for equipment” (FGD Participant 6, Vurra Town Council, Arua District, February 2025).

Another respondent stated:

“Some of the equipment we received during Ebola preparedness is no longer functioning properly, but there are limited resources available for replacement or maintenance” (Key Informant, Arua District, March 2025).

Participants also highlighted transport challenges affecting surveillance activities. Limited availability of vehicles and motorcycles constrained supervision, referral of suspected cases, outreach activities, and monitoring of informal crossing routes.

One participant explained:

“We know many people use unofficial routes, but monitoring those areas requires transport. Without transport, surveillance remains concentrated at the main border points while many crossings remain uncovered” (FGD Participant 7, Koboko District, February 2025).

Observation findings confirmed variability in infrastructure quality across border points and revealed shortages of essential equipment in several surveillance locations.

Workforce Development, Training, and Supervision Challenges

Participants further emphasized that workforce development remained a major challenge affecting surveillance effectiveness. Although training programmes had been implemented during periods of heightened disease risk, respondents indicated that training opportunities were often irregular and concentrated around specific outbreaks.

Many participants reported receiving surveillance-related training during Ebola Virus Disease preparedness activities and the COVID-19 pandemic. However, refresher training opportunities became less frequent after emergency periods ended.

One participant explained:

“Most of the training we received came during COVID and Ebola preparedness. After that period, there have been no refresher trainings. New staff come and learn on the job, but there is no structured system to make sure everyone understands surveillance procedures properly” (FGD Participant 3, Goli Customs Border, Nebbi District, February 2025).

Participants further indicated that surveillance training often focused primarily on health workers, while immigration officers, customs personnel, security personnel, and other frontline actors received limited capacity-building support despite their critical role in identifying and reporting suspected cases.

A respondent noted:

“Immigration officers are usually the first people to interact with travellers, but many have never received comprehensive surveillance training. They depend on experience and informal guidance from health workers” (Key Informant, Nebbi District, February 2025).

Participants also described supervision systems as inconsistent. Supervisory visits were reported to occur more frequently during outbreaks but less frequently during routine surveillance periods.

One participant explained:

“Supervision increases when there is a disease threat, but routine supervision is not consistent. Many challenges remain unresolved because follow-up visits are irregular” (FGD Participant 2, Arua District, February 2025).

Frequent staff transfers further compounded these challenges by disrupting institutional memory and creating knowledge gaps among newly deployed personnel.

Fragmented Information Systems and Weak Community Surveillance Integration

The final sub-theme related to information management systems and community engagement structures supporting surveillance. Participants consistently reported that surveillance information remained fragmented across institutions, limiting coordinated decision-making and timely response.

Respondents explained that health, immigration, customs, and security agencies maintained separate information systems with limited interoperability. Consequently, information exchange often depended on personal communication rather than integrated surveillance platforms.

One participant observed:

“If immigration notices someone who looks sick, they usually just call the health worker they know. There is no formal system where immigration records are linked to health data” (FGD Participant 1, Paidha Town Council, Zombo District, February 2025).

Another respondent explained:

“Each institution collects information for its own purposes. Sharing happens, but there is no single system where everyone can access the same surveillance information” (Key Informant, Arua District, March 2025).

Participants also reported limited feedback after submission of surveillance reports. The absence of regular feedback reduced opportunities for learning, performance improvement, and motivation among frontline surveillance personnel.

Beyond formal institutional systems, participants highlighted the importance of community structures in supporting surveillance activities. Village Health Teams, local council leaders, religious leaders, community volunteers, and informal social networks frequently served as early sources of information regarding unusual illnesses and suspected disease events.

One participant explained:

“Most of the time, it is the community that first notices when someone is very sick. People talk, rumours move fast, and that information reaches the village health team or local leader before it reaches any official health system” (FGD Participant 8, Vurra Town Council, Arua District, February 2025).

Despite their importance, respondents indicated that community-based surveillance structures received limited training, supervision, and logistical support.

Another participant stated:

“Village Health Teams help us identify health problems, but they receive very little support. Many are working voluntarily and have limited resources to carry out surveillance activities effectively” (FGD Participant 6, Koboko District, February 2025).

Document review findings similarly highlighted recurring concerns regarding inadequate support for community surveillance structures and limited integration between community-based surveillance and formal surveillance systems.

The findings demonstrate that institutional capacity significantly shaped infectious disease surveillance effectiveness at West Nile Uganda–DRC border crossings. Human resource shortages, inadequate infrastructure, limited workforce development opportunities, fragmented information systems, and weak integration of community surveillance structures collectively constrained surveillance performance. Participants consistently emphasized that improvements in governance and coordination alone would be insufficient unless accompanied by sustained investments in staffing, infrastructure, training, information management systems, and community-based surveillance capacities. These capacity limitations reduced the ability of surveillance systems to achieve timely disease detection, reporting, information sharing, and response across the border region.

Discussion

This study examined how institutional governance, capacity, and coordination shape infectious disease surveillance at West Nile Uganda–Democratic Republic of Congo land border crossings. The findings demonstrate that surveillance effectiveness is determined not only by the existence of surveillance policies and procedures but also by the interaction of institutional actors, organizational resources, and operational realities within a highly mobile border environment. The study revealed that coordination mechanisms remained largely reactive and outbreak-driven, governance structures provided limited strategic direction for routine surveillance activities, and institutional capacity constraints weakened surveillance implementation. These findings suggest that surveillance effectiveness is shaped by the ability of institutions to function as interconnected systems capable of sustaining continuous detection, reporting, information sharing, and response activities under conditions of persistent cross-border mobility.

The finding that coordination remained dependent on informal communication channels and intensified primarily during outbreaks suggests that surveillance activities have not been fully integrated into routine border operations. Although health authorities, immigration officials, customs officers, security personnel, and local government actors were all involved in surveillance activities, collaboration was often activated in response to immediate threats rather than maintained as a continuous operational function. Similar challenges have been reported in African border settings where fragmented institutional arrangements and weak information-sharing systems undermine surveillance effectiveness (Nkengasong & Tessema, 2024; Tambo et al., 2023). These findings are consistent with General Systems Theory, which emphasizes that system performance depends on effective interaction among interconnected components operating through continuous communication, coordination, and feedback processes. Where coordination remains informal and episodic, information flows become fragmented, institutional learning is weakened, and surveillance systems struggle to function as integrated entities. The findings therefore extend existing evidence by demonstrating that surveillance weaknesses at border points of entry are not solely resource-related but are also rooted in the inability of institutional actors to maintain stable and routine collaborative relationships.

The study further revealed that governance structures provided limited strategic direction for surveillance implementation. Leadership engagement was reported to increase during outbreaks but decline during routine periods, while centralized decision-making processes constrained the ability of frontline personnel to respond rapidly to emerging public health threats. Weak accountability mechanisms further reduced institutional ownership of surveillance outcomes. These findings support previous studies showing that governance quality influences surveillance responsiveness, policy implementation, and organizational performance (Kraemer et al., 2023). From a General Systems Theory perspective, governance structures perform critical control and feedback functions that enable systems to adapt to changing conditions and maintain operational effectiveness. When leadership engagement is inconsistent and accountability mechanisms are weak, surveillance systems lose the capacity to coordinate actions, allocate resources efficiently, and respond effectively to emerging threats. The findings therefore suggest that strengthening surveillance requires governance arrangements that support continuous oversight, decentralized operational decision-making, and accountability across all agencies involved in border health surveillance.

Institutional capacity emerged as a critical determinant of surveillance effectiveness. Participants consistently identified shortages of trained personnel, inadequate infrastructure, limited equipment, fragmented information systems, and insufficient support for community-based surveillance as major constraints affecting surveillance performance. These findings corroborate evidence from surveillance systems in resource-constrained settings, where workforce limitations, inadequate infrastructure, and weak information management systems continue to undermine disease detection and response capacities (MacIntyre et al., 2022; Suthar et al., 2024). General Systems Theory suggests that system effectiveness depends on the adequacy of inputs required to support operational processes. In this study, deficiencies in staffing, training, infrastructure, and information systems weakened the capacity of surveillance actors to perform surveillance functions consistently across border locations. The findings therefore reinforce the argument that surveillance effectiveness depends not only on policy frameworks but also on sustained investments in the institutional resources required to operationalize surveillance systems.

The findings also highlight the importance of understanding surveillance within the context of border environments characterized by continuous mobility, informal crossings, and complex social and economic interactions. Border Theory provides an important explanation for why surveillance challenges persist despite the existence of formal surveillance structures. The theory views borders as dynamic social spaces rather than fixed administrative boundaries and recognizes that mobility patterns are shaped by livelihoods, social networks, trade relationships, and community interactions. The study demonstrated that surveillance systems operated within a border environment where movement occurred through both formal and informal routes, requiring institutions to respond to realities that extend beyond conventional points of entry. Consequently, surveillance effectiveness was influenced not only by institutional arrangements but also by the ability of surveillance systems to adapt to the fluid and dynamic nature of border mobility. These findings contribute to the growing body of border health literature by demonstrating that surveillance systems designed primarily around formal points of entry may struggle to achieve effective coverage in contexts where substantial movement occurs through informal channels.

The findings demonstrate that governance, coordination, and capacity operate as interdependent determinants of infectious disease surveillance effectiveness. Effective surveillance requires institutional systems that are coordinated, adequately resourced, and capable of adapting to the realities of high-mobility border environments. Strengthening surveillance at West Nile Uganda–DRC land border crossings therefore requires moving beyond outbreak-driven approaches toward institutionalized coordination mechanisms, stronger governance and accountability structures, integrated information-sharing systems, sustained workforce and infrastructure investments, and surveillance models that incorporate both formal border controls and community-based approaches. Such reforms would enhance the resilience and responsiveness of surveillance systems and strengthen preparedness for emerging and re-emerging infectious disease threats in transboundary settings.

Conclusion

The study demonstrated that infectious disease surveillance at West Nile Uganda–Democratic Republic of Congo land border crossings is shaped by the interaction of institutional coordination, governance structures, and organizational capacity. Surveillance effectiveness was constrained by reactive and outbreak-driven coordination mechanisms, fragmented information-sharing systems, limited leadership engagement, weak accountability structures, staffing shortages, inadequate infrastructure, and insufficient integration of community-based surveillance mechanisms. These findings indicate that surveillance performance in transboundary settings depends not only on technical surveillance procedures but also on the extent to which governance arrangements, institutional relationships, and organizational resources support routine surveillance implementation. Consistent with Institutional Theory and Capacity Theory, the findings show that surveillance systems function more effectively when coordination mechanisms are formalized, governance structures provide strategic direction and accountability, and institutions possess the human, technological, and financial resources required to sustain surveillance activities.

The findings further suggest the need to institutionalize routine inter-agency coordination, strengthen cross-border information-sharing arrangements, establish clear accountability mechanisms, and improve integration among health, immigration, security, and local government actors involved in border surveillance. Strengthening workforce capacity through continuous training, improving surveillance infrastructure and information systems, and formally incorporating community-based actors such as Village Health Teams, local leaders, and transport operators into disease detection and alert systems would enhance surveillance coverage and responsiveness. Such measures would contribute to more resilient and adaptive surveillance systems capable of supporting public health security in high-mobility transboundary settings.

Limitations

This study was conducted at selected Uganda-side border points of entry within the West Nile Uganda–Democratic Republic of Congo border corridor and therefore did not directly capture surveillance practices operating on the Democratic Republic of Congo side. The cross-sectional qualitative design also limited assessment of how institutional arrangements and surveillance practices evolve over time in response to changing disease threats and mobility patterns. In addition, some findings were based on participant experiences and perceptions, which may have been influenced by recall bias or social desirability. However, these limitations were minimized through triangulation of interviews, focus group discussions, observations, and document review, which enhanced the credibility and robustness of the findings.

Acknowledgements

The authors acknowledge the Faculty of Interdisciplinary Studies, Mbarara University of Science and Technology, for academic and institutional support during the conduct of this study. The authors are grateful to the border management officials, health personnel, community participants, and local authorities who generously shared their experiences and perspectives. Special appreciation is extended to the research assistant for support provided during data collection.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of Interest

The authors declare that they have no competing interests.

Ethical Approval and Consent to Participate

Ethical approval for the study was obtained from the Research Ethics Committee of Mbarara University of Science and Technology (Approval No. MUST-2024-1693). Research clearance was further obtained from the Uganda National Council for Science and Technology. Written informed consent was obtained from all participants prior to their participation in the study. Participation was voluntary, and confidentiality and anonymity were maintained throughout the research process.

Availability of Data and Materials

The datasets generated and analysed during the current study are available from the corresponding author upon reasonable request.

Author Contributions

S.B. conceptualized the study, developed the methodology, conducted data collection, performed data analysis, interpreted the findings, and prepared the original manuscript draft. E.M. contributed to the conceptual development of the study, provided academic supervision, reviewed the methodology and findings, critically revised the manuscript for important intellectual content, and provided overall guidance throughout the research process. Both authors read and approved the final manuscript.