_{By Joseph Odoi}

In the remote villages of Eastern and Northern Uganda, a small medical device is doing far more than preventing unintended pregnancies, it appears to be quietly shifting the balance of power in women’s lives.

A new study titled “Is choosing self-injectable contraception associated with enhanced contraceptive agency? Findings from a 12-month cohort study in Uganda” has revealed that self-injection gives women more than just a health service, it can boost their confidence, control, and agency over their reproductive health.

The research was conducted by Makerere University namely; Professor Peter Waiswa, Catherine Birabwa, Ronald Wasswa, Dinah Amongin and Sharon Alum in collaboration with colleagues from the University of California, San Francisco

Why this Study matters for Uganda

For decades, family planning in Uganda has followed a provider-client model. Women travel long distances to clinics, wait in queues, and rely on health workers to administer contraception. This system creates barriers transport costs, clinic stock-outs, long waiting times, and limited privacy.

Self-injectable contraception, known as DMPA-SC, disrupts this model by shifting care from the clinic to the individual woman.

DMPA-SC is a discreet, easy-to-use injectable that women can administer themselves after receiving basic training and counselling.

What the Data Tells Us

To see if self-care technology actually shifts the needle on women’s power, researchers tracked 1,828 women across Eastern (Iganga and Mayuge Districts) and Northern Uganda (Kole, Lira, and Oyam Districts) for a full year. They compared women who chose to self-inject their birth control (216 women) against a control group, most of whom chose methods requiring dependency on clinics (1,612 women).   

The Six-Month “Agency Spike”

The study used a Contraceptive Agency scale (scored from 0 to 3) to measure a woman’s internal confidence and her ability to act on her health choices.

The Self-Injectors

For the Self Injectors, their agency scores rose significantly, from 2.65 to 2.74 by the six-month mark.

The Clinic-Dependent Group

Scores for the group using mostly provider-led methods (like clinic shots or implants) remained nearly flat, moving from 2.61 to only 2.63.

Within just six months, women who took control of their own injections noted that they felt a measurable boost in their Consciousness of reproductive Rights (0.08 points) since they transitioned from being passive recipients of care to active decision-makers.

Using the Agency in Contraceptive Decisions Scale (scored 0–3), the study found a clear empowerment advantage for women who chose self-injection.

The findings come at a time when Uganda has reaffirmed its commitments under FP2030, aiming to expand access to voluntary, rights-based family planning. The study also aligns with the National Family Planning Costed Implementation Plan, which prioritises method choice, equity, and continuation, as well as national gender and youth empowerment strategies.

Can Uganda Sustain and Scale DMPA-SC?

Self-injectable contraception does not require continuous high-cost investment. Training and rollout costs are largely one-time, and the main recurring expense is the contraceptive commodity itself. Compared with the cumulative costs of repeated clinic visits for both the health system and women self-injection is more cost-effective over time.

Advancing primary health care with DMPA-SC

Beyond cost savings, self-injection eases pressure on health facilities and allows health workers to focus on more complex care. It also extends health services into communities, supporting continuity of care in areas where facilities are few and far between. In this way, family planning is no longer confined to the clinic.

While donor support has helped introduce the method, it can be sustained locally without relying on external funding. “With predictable national financing and reliable commodity supply chains, DMPA-SC can reach more women and be fully integrated into Uganda’s health system, strengthening both access and community-level service delivery’’ according to the researchers.

Implications for Policy and Practice

As Uganda continues to reform its primary health care system, the findings add evidence to ongoing discussions about how family planning services are delivered, financed, and prioritised.

The research also positions self-injectable contraception not as a temporary innovation, but as a scalable method with the potential to be embedded within national systems provided that commodity availability and financing are safeguarded.

To ensure these gains are lasting, researchers recommend moving beyond the technology and addressing the structural and social barriers that can limit women’s agency.

Key recommendations from the researchers include the following

1. Reliable Supply Chains

Empowerment collapses when products are unavailable. DMPA-SC must be consistently stocked at the community level.

2. Creating a Supportive Social Environment

Privacy concerns, stigma, and partner resistance must be tackled through community engagement and sensitisation.

3. Prioritizing Informed Choice

Self-injection should be offered as a top-tier option in every facility, framed as a fundamental right to autonomy rather than just a medical convenience.

4. Integrated Counseling

Providers must be trained to support women not only in the “how to inject” but also in navigating the social challenges of self-care.

On the next step, the researchers call for a clear integration of DMPA-SC into national health financing, protection of family planning commodity budgets, and deliberate scaling of self-injectable contraception within Primary Health Care reforms. These actions will ensure sustainability, reliable access, and greater control for women over their reproductive choices according to the researchers.

Read the full study here: https://www.contraceptionjournal.org/article/S0010-7824(26)00003-X/fulltext

On a weekday morning in Kampala, the city snarls without any signs of awakening. Cars grind bumper to bumper along crumbling asphalt, their horns locked in a long, impatient argument. Rusting taxis and private vehicles shudder under the rising sun. Boda bodas slice through impossibly narrow gaps, mount pavements, edge past crossings, and assert dominance wherever there is room to move. The road belongs to whoever is bold enough to seize it.

And on the margins of this contest, there are children.

At 6 a.m., long before office doors open, primary school pupils begin their walk. Backpacks bounce against narrow shoulders as they navigate broken sidewalks and dusty road edges. When they reach a main road, their rhythm changes. Some stop and scan, small hands grip the straps. Others hesitate, then dart, misjudging speed, trusting that a driver will slow down.

But traffic rarely slows.

In Kampala, pedestrians do not command the road; they negotiate with it. Every crossing is a calculation. Every pause carries risk. Children learn early that movement requires courage. They watch for gaps, read the body language of drivers, and step forward in faith.

It is in that fragile second, between hesitation and impact, that the question begins to form.

For Jimmy Osuret, this is not an abstract problem of urban mobility but a daily reality, etched into memory long before it became research.

In 1996, as a Primary Four pupil at Shimoni Demonstration School, then located along the busy Nile Avenue corridor in Uganda’s capital, Kampala, he watched a classmate attempt to cross the road on an ordinary school day. A truck did not slow down. The child did not make it to the other side.

“It stayed with me,” Osuret recalls. “At the time, I didn’t have the language for it. But that moment shaped how I came to understand injuries—not as accidents, but as something patterned, preventable, and deeply unfair.”

Nearly three decades later, the school has moved, and the road has changed, but Kampala’s traffic has only grown more unforgiving. Children still gather at pavements across the city, backpacks bouncing, eyes fixed on gaps in traffic that may or may not come. And Osuret would return to these streets, not as a schoolboy navigating danger, but as a public health scientist determined to change what danger looks like for Uganda’s children.

From Personal Loss to Public Health Purpose

Osuret’s journey into injury research unfolded through lived experience, service, and grief, each layer sharpening his understanding of why pedestrian safety matters.

After completing his Bachelor’s degree in Environmental Health at Makerere University, he volunteered with the Uganda Red Cross Society in Bushenyi District between 2009 and 2011. There, he was exposed to emergency response, first aid, and trauma care. Road crashes were no longer statistics but bleeding bodies, panicked families, and systems struggling to respond in time.

“That experience changed how I saw injuries,” he reflects. “They weren’t isolated events. They were predictable outcomes of unsafe systems.”

His MSc in Public Health at Oxford Brookes University deepened that lens. Focusing his dissertation on alcohol-related road traffic injuries, Osuret built strong skills in epidemiology and behavioural research, tools he would later bring back home.

But it was personal loss that cemented his resolve. A cousin was killed in a hit-and-run crash. Another reminder that vulnerability on Uganda’s roads often carries the highest cost.

Together, these experiences shaped the research question that would define his PhD: Why are Kampala’s roads so unsafe for children, and what actually works to protect them?

Kampala’s Roads, Through a Child’s Eyes

Every day, millions of Ugandans walk to school, to work, to markets, to taxi stages. At some point in the day, everyone becomes a pedestrian. For children, walking is not a choice; it is the only option. Yet Kampala’s roads tell children they do not belong.

Rapid urbanisation and motorisation have transformed the city, but road design continues to privilege vehicles over people. Sidewalks are missing or obstructed. Safe crossings are rare. Speed control is weak. Children are forced to negotiate fast-moving traffic despite their limited ability to judge speed and distance.

Osuret’s research confirms what many parents already fear. Pedestrians account for more than a third of road casualties in Uganda, with children bearing a disproportionate share of that burden. Unsafe crossing behaviours, running, failing to stop at the pavement, and weaving between vehicles are not acts of carelessness. They are survival strategies in hostile environments.

“Children are expected to behave safely in systems that are fundamentally unsafe,” he explains. “That is not reasonable, and it is not ethical.”

Watching the Road Tell Its Story

Rather than relying on self-reports or simulations, Osuret turned to the road itself. Using discreetly mounted video cameras at school crossings across Kampala, his team observed thousands of real interactions between children, vehicles, and the built environment. The footage captured moments of hesitation, confusion, urgency, and occasionally, near misses that left the researchers gasping for air.

His findings were sobering. One in five children failed to wait at the pavement. More than a quarter crossed outside marked crosswalks. Many ran. Some crossed between vehicles, often when drivers failed to yield.

“These behaviours are not random,” Osuret notes. “They respond directly to what drivers do and what the road allows.”

Crucially, the data revealed something else: where trained school traffic wardens were present, children behaved differently, and drivers did too.

The Power of a Raised Hand

Osuret’s PhD went beyond observation. It tested a solution.

In a cluster-randomized trial across 34 public primary schools, his team introduced a school traffic warden behavioural promotion programme, a low-cost intervention placing trained adult wardens at school crossings during peak hours. The wardens wore reflective gear, used stop paddles, made eye contact with drivers, and guided children through safe crossing routines: stop, look, wait, walk.

Strikingly, drivers were more than seven times more likely to yield to child pedestrians where a traffic warden was present. Children were 70% more likely to cross safely, stopping at the pavement, walking instead of running, and avoiding dangerous gaps between vehicles.

“What surprised me most,” Osuret recalls, “was how quickly children adapted. When the system supported them, safer behaviour became the norm.”

The intervention faced some resistance. Some drivers ignored wardens. Others were openly hostile. These moments revealed a deeper truth that behaviour change cannot rely on goodwill alone. It requires enforcement, legitimacy, and policy backing.

Behaviour Is Not the Problem—Systems Are

A central insight of Osuret’s work is that road safety debates often focus on the wrong actor.

“Children are told to be careful,” he says. “But children are not the ones designing roads, setting speed limits, or enforcing laws.”

His research shows that driver behaviour, especially yielding and speed, has a direct protective effect on children. Higher driver-yielding rates are consistently associated with fewer pedestrian collisions. Behaviour change among drivers is therefore not optional but foundational.

This perspective aligns with the Safe Systems Approach, which recognises human error as inevitable and places responsibility on systems to prevent fatal outcomes. In Kampala, where infrastructure and enforcement gaps are stark, behavioural interventions like traffic wardens offer an immediate, scalable bridge, especially in school zones.

Scholarship Grounded in Community

Osuret’s academic home at Makerere University School of Public Health shaped how his research evolved. Mentorship from senior injury researchers at Makerere University grounded his work in rigorous methods and local relevance.

“I worked closely with Dr. Olive Kobusingye at the Trauma, Injury, and Disability Unit and became involved in research on pedestrian road safety through international collaborations. Makerere taught me to ask questions that matter here,” he says. “Not just what is publishable, but what is usable.”

That grounding helped him navigate the most challenging phase of his PhD, especially balancing full-time academic work, research, and personal responsibilities. Like many African scholars, he conducted much of his doctoral research while teaching, mentoring, and engaging communities.

“It made me deeply aware of the structural barriers young researchers face,” he reflects. “And it strengthened my commitment to mentorship.”

From Evidence to Action

On January 10, 2025, Osuret publicly defended his PhD in a hybrid session at the Makerere University School of Public Health Auditorium. The defense was both a scholarly milestone and a personal reckoning, a moment when decades of memory, loss, and inquiry converged.

But for Osuret, the PhD was never an endpoint.

Today, he serves on the National Road Safety Committee, contributing evidence to Uganda’s National Road Safety Action Plan. He mentors students, collaborates with policymakers, and continues to argue, persistently, that injuries deserve the same public health urgency as infectious diseases.

“The gap is not knowledge,” he says. “We know what works. The gap is translating evidence into action.”

If policymakers took just one lesson from his research, “design roads around children, not vehicles,” he says. Osuret believes that speed management, safe crossings, and visible enforcement around schools are essential obligations, not luxuries.

Walking Toward Safer Futures

As the country prepares for the 76th Makerere University Graduation Ceremony this February 2026, where Osuret and 184 others will receive their PhDs, we are reminded of what scholarship can do when it remains rooted in lived reality.

Every day, children still gather on the road pavements outside schools like Shimoni. Traffic still hums, and risk has not disappeared. But in some places, a raised hand, a reflective vest, and a trained presence have shifted the balance, if only slightly, toward safety.

When asked what responsibility he now carries, Osuret does not hesitate.

“To ensure that evidence informs decisions,” he says. “Because at some point in the day, we are all pedestrians. And no one should have to gamble with their life just to cross the road.”

—A publication of the Makerere University School of Public Health Communications Office, Graduation Profiles Series, 76th Graduation Ceremony

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In March 2020, Uganda slowed to a near standstill. Roads emptied. Clinics fell quiet. Fear moved faster than information. Many perceived COVID-19 as a virus to avoid. Others saw it as a barrier that stood between a mother and antenatal care, a child and routine immunization, and a patient and life-saving HIV medication. What followed was not only a public health emergency but also a test of whether health systems could keep doing the ordinary work of care while responding to the extraordinary.

In early December 2025, a question first asked with urgency during a global crisis resurfaced in a quieter, more reflective moment. On December 2, a single bound copy of Steven Kabwama’s doctoral thesis was fastened to a wooden board dubbed ‘The Wall of Fame‘ at Karolinska Institutet. The ritual, known as spikning, is modest in appearance but weighty in meaning: a thesis is made public, opened to scrutiny, and years of private intellectual labour are released into the world. For Kabwama, it marked the moment when research forged in the pressure of a global emergency became part of the public record, no longer his alone but open to collective examination.

The tradition stretches back centuries, often traced to Martin Luther’s public posting of his theses in the 15th century. But in Stockholm, on a winter afternoon, history gave way to something more immediate. Kabwama stood briefly by the wooden board with a hammer and fixed his work in place. The moment was less about ceremony than readiness. The research was complete. The questions were now open.

Three days later, on Friday, December 5, 2025, Kabwama publicly defended the thesis in a hybrid ceremony at Wretlindsalen in Solna, joined, both in person and online, by colleagues from Uganda, Sweden, and beyond. By then, the work, which examines how health systems sustain essential services during crises, had already begun to circulate, quietly shaping conversations about preparedness, continuity, and care.

What that bound document contained, however, had been forged years earlier, inside outbreaks, lockdowns, data sets, and long nights spent asking how health systems hold together when everything else is falling apart.

Steven Ndugwa Kabwama remembers the beginning not as a single crisis, but as a series of decisions, some made urgently, others too late. As an epidemiologist by training, Kabwama, who had spent years responding to outbreaks through Uganda’s Field Epidemiology Fellowship Program, clearly understood that outbreaks had patterns; they arrived, demanded attention, and eventually receded.

COVID-19 was different.

“It became clear very early on,” he recalls, “that the urgency of the response was going to affect everything else: malaria, immunization, maternal health, HIV. And yet, very little had been written about how systems are supposed to hold both at the same time.”

That realization would shape the next chapter of his life and, eventually, his PhD.

From Outbreak Response to System Questions

Kabwama’s academic journey did not begin in epidemiology. In 2006, he enrolled for a Bachelor’s degree in Food Science and Technology at Makerere University, a programme traditionally geared toward food processing, quality assurance, and industrial production. It is a discipline that prepares graduates for careers in manufacturing plants, laboratories, and supply chains, work that often unfolds far from clinics, outbreaks, and emergency response rooms.

Yet even then, his interests leaned beyond production lines and quality controls. He was drawn to how systems affect people’s health long before illness appears and how nutrition, safety, access, and policy intersect. That early grounding in systems thinking would later resurface in unexpected ways.

He went on to earn a Master of Science in Public Health from the University of Southern Denmark in 2013, supported by a Danish State Scholarship. It was there that population-level analysis sharpened his interest in data, surveillance, and health equity. But it was the Advanced Field Epidemiology Fellowship, jointly run by Makerere University School of Public Health (MakSPH), Uganda’s Ministry of Health, and the U.S. Centers for Disease Control and Prevention, that placed him directly inside emergencies, where evidence, decisions, and lives converge.

As a Fellow, his work stood out. He later received the Outstanding Fellow Award from the Uganda Public Health Fellowship Program (Field Epidemiology Track, Cohort 2015), recognition of his contributions to outbreak response, national non-communicable disease analyses, and policy work, including Uganda’s Alcohol Control Policy. “You respond, you stabilize, you move on,” he says. “But I kept asking myself—what happens to everything else while we’re responding?”

The arrival of COVID-19 made it impossible to delay these questions.

A Crisis Within the Crisis

As countries rushed to contain the virus, restrictions came swiftly: lockdowns, curfews, and travel bans. From a disease-control perspective, the logic was familiar and defensible. In outbreak management, 21 days is a standard epidemiological window, often used to break chains of transmission in infectious diseases. But during COVID-19 in Uganda, the phrase “therefore…another 21 days of lockdown” took on a different meaning altogether: The repeated phrase in presidential addresses stretched from a technical containment tool into a lived reality that reshaped access to care, livelihoods, and movement. From a health-system perspective, the consequences were profound.

Kabwama joined a multi-country research effort spanning Uganda, Nigeria, the Democratic Republic of Congo, Senegal, and Ghana, examining how countries attempted to maintain essential health services while responding to COVID-19. This work was spearheaded by Dr. Rhoda Wanyenze, a Professor of Disease Control, Researcher, Public Health Expert, and Dean of the School of Public Health at Makerere University. She was then a member of the COVID-19 Scientific Advisory Committee to the Ministry of Health.

Kabwama volunteered to lead the objective of documenting these experiences, an area he quickly realized was underexplored.

“Criticism is always easier in hindsight,” he reflects. “But generally, the considerations about how restrictions would affect access to essential health services were made after the fact.”

His doctoral research, later defended at Karolinska Institutet, set out to answer a deceptively simple question: How can health systems minimize disruptions to essential services during public health emergencies while emerging stronger afterward?

What the Data Revealed

Kabwama examined how health service use changed before and during the pandemic by using a mix of interrupted time-series analysis, document reviews, key informant interviews, and focus group discussions.

The findings were sobering.

Facility deliveries and outpatient visits dropped sharply during lockdown periods. Routine childhood immunizations declined, and DPT3 doses fell by more than 4 percent, with similar reductions across polio vaccines. Movement restrictions, fear of infection, and overwhelmed facilities combined to keep patients away.

But the story did not end there.

Where systems were adapted by integrating services, leveraging community health workers, removing user fees, modifying logistics, and establishing coordination mechanisms for continuity of care, the declines softened. In some cases, the adaptations strengthened systems beyond their pre-pandemic state.

“These were not perfect solutions,” Kabwama notes. “But they showed us what flexibility, leadership, and trust can do under pressure.”

The Human Cost—and the Human Shield

Behind every data point were health workers navigating impossible conditions. Many worked without adequate protective gear. Others faced delayed allowances, long hours, and constant risk.

Kabwama asserts that health workers risk their lives in their work. “If we expect services to continue, then protecting their physical and mental well-being is not optional.”

His research consistently returned to one conclusion: that service continuity depends on people. Policies can guide. Infrastructure can support. But without motivated, protected health workers and trusted community intermediaries, systems falter.

Uganda’s community health workers, he observed, became a backbone of resilience. They traced contacts, delivered information, encouraged women to attend antenatal care, and helped sustain immunization demand when facilities felt distant or dangerous.

“In our context,” he says, “they were critical. That’s a lesson worth holding onto.”

Learning Across Borders

Conducting his PhD through a collaborative programme between Karolinska Institutet and Makerere University School of Public Health exposed Kabwama to how different systems responded under pressure.

At Karolinska’s Department of Global Public Health, students from around the world shared experiences shaped by culture, trust, and governance. One story stayed with him: Sri Lanka’s military, highly trusted by the public, played a key role in vaccine rollout.

“It taught me that resilience looks different everywhere,” he says. “What matters is understanding what each system already has and how trust operates within it.”

His supervision team, spanning Sweden and Uganda, including Prof. Tobias Alfvén, Prof. Rhoda K. Wanyenze, Dr. John Ssenkusu, Prof. Helena Lindgren, and Dr. Neda Razaz, reflected that same cross-system thinking.

Wanyenze describes Kabwama as “focused, committed, and remarkably productive.” She notes that he led two major workstreams across the five participating countries, helping generate critical evidence on health systems resilience and trust during infectious disease emergencies. “He made an enormous contribution to the research,” she says, “and he continues to do excellent work in this area.”

The Quiet Challenge of Doing Research in a Pandemic

Methodologically, the pandemic forced adaptation. Interviews moved to phones and Zoom. Access was negotiated carefully. Yet Kabwama sees the technology not as a limitation but as a strength.

“We captured experiences while they were still fresh,” he explains. “Before details were forgotten, before narratives were smoothed over.”

That immediacy gave his work an unusual clarity, documenting decisions as they unfolded, not as they were later remembered.

But beyond COVID-19, Kabwama’s thesis does not treat it as an anomaly. Rather, it presents COVID-19 as a stress test, exposing pre-existing weaknesses and potential strengths.

His central argument is that the ability to maintain essential health services during emergencies depends on baseline capacity.

“Now is the time,” he says, “to invest in health workers, in infrastructure, in guidelines for service continuity. This should be done now, not when the next crisis arises.

That conviction extends to learning itself. After-Action Reviews are conducted, lessons are noted, but too often, they fade.

“We need to be deliberate about learning,” he insists. “About documenting what worked and making sure those gains are not lost once the emergency ends.”

Work That Continues

Today, Kabwama is a Research Associate at Makerere University School of Public Health, a Monitoring, Evaluation and Learning Specialist with the Uganda Public Health Fellowship Program, and a member of WHO initiatives on trust and pandemic preparedness. He leads mortality surveillance in Uganda’s island districts, supports national NCD analyses, and continues to advise on emergency preparedness across Africa.

He remains, by his description, an optimist.

“There are people who think we are worse off now than before COVID-19,” he says. “In some ways, that’s true. But there are also many ways in which we are better prepared.”

Vaccines, data systems, community engagement, and global awareness have all shifted. The challenge is ensuring that momentum does not fade.

Dr. Steven Ndugwa Kabwama joins fellows in the MakSPH PhD forum who concluded their doctoral journeys in 2025. And the work of his research and scholarship does not promise certainty but offers something more useful: evidence that systems can bend without breaking—if they are prepared to learn, invest, and protect the people who hold them together.

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