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Researchers Design Community-led Behavioural Change Model to Control Rate of Type 2 Diabetes among Rural Population

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By Joseph Odoi

Globally the proportion of undiagnosed diabetes is high, standing at 46.5%. In high-income regions like Europe, of all persons with Type 2 Diabetes Mellitus (T2DM), 39.3% are undiagnosed. Low-income countries in Africa have the highest prevalence of undiagnosed diabetes, estimated at 66.7%. In Uganda alone, a steady increase in the number of diabetes cases has been observed.

Despite the increasing burden of diabetes in the country, little is known about the socio-cultural norms influencing type 2 diabetes risky behaviors, especially in rural areas to inform action.

In the bid to contribute to data driven interventions, Makerere University researchers with funding from Government of Uganda and Makerere University Research and Innovations Fund (Mak-RIF) carried out a study to understand the patterns of socio-cultural norms in two high incidence districts namely, Busia and Bugiri, in Eastern Uganda.

As part of this study, researchers engaged various health stakeholders who shared their experiences about behaviors factors influencing type two diabetes.

It is upon that background that researchers co-designed a contextual strategy to ensure behavioral change to limit type two diabetes among the rural population under the project titled; “Socio-cultural norms influencing Type 2 Diabetes risks Behaviours – an exploratory to intervention co-design innovative study in two high incidence districts of eastern Uganda”. The strategy was developed by a team of researchers led by Dr. Juliet Kiguli, a Senior Lecturer in the Department of Community Health and Behavioural Sciences  at the School of Public Health, Makerere University.

According to Dr. Kiguli, despite evidence confirming a high rate of T2D in Uganda, there is hardly any innovation that speaks to the deep rooted causes of Type 2 Diabetes hence the justification for their new model.

‘’There is enough evidence in Uganda at the national and local/community level confirming a high rate of T2DM, compared to the measures/innovations that try to address the disease. We can argue with confidence that most of the research around T2DM in Uganda and Africa has been largely academic and hasn’t been translated into action at a comparable pace of disease incidence and prevalence. Additionally, since the T2DM is largely a lifestyle disease that is influenced by external factors, exposure and social constructs, the solution to T2DM needs to be socially constructed, and currently, there is no innovation that speaks to the deep rooted causes of T2DM – this is the reason why we designed an evidence based innovation that is socially constructed to address diabetes with prevention in mind too‘’she explained of the model

The Assistant Commissioner Non Communicable Diseases (NCDs) at Ministry  of Health, Dr. Gerald  Mutungi  who participated in the study’s innovation co-design  had this to say;

“This study is unique, I have learnt many things which I had never looked at from a perspective of social norms and I am glad that we are already designing an innovation together with the community stakeholders and influencers to mitigate and reduce T2DM”.

He also tasked researchers   to give answers on  why people doing their daily activities and living a normal lifestyle still get diabetes.

Approaches behind the model

As part of the behavioral change strategy, the research team came up with the following approaches to their community-led behavior change model.

  1. T2DM organized diffusion messaging and practices

This approach of the model will work through community-level social networks and will be used to conduct myths bursting sessions, building new positive social norms and spreading them using social networks related to the norm. This approach will be complemented by deliberation and reflection methodologies and the intent is to create shared commitments to change negative and/or maladaptive risky behaviors around T2DM.

  1. Community-leader-initiated behavior modeling for T2DM

Because of power, control and therefore influence, this approach will target political leaders, religious leaders, cultural leaders, informal community leaders and all individuals with influence to model, demonstrate and promote the recommended behaviors and practices. This will be the first level of establishing reference groups and this approach will complement other approaches.

  1. T2DM Non-conforming trendsetters and positive deviants.

In the co-design process, evidence shows the existence of trendsetters and positive deviants who are willing and able to be the first movers in initiating positive normative change around T2DM risky behaviors. Their nonconformity to the social norms around T2DM will contribute to the erosion of strong perceptions in favor of the negative gendered social norms that facilitate entrenchment of T2DM risky behaviors. This approach will be complemented by creation of new risky-behavior-specific reference groups that are able to enact alternative social sanctions against T2DM risky behaviors.

On timing of this model, Mr. Ramadhan Kirunda who was key in innovating the model  noted that evidence from the social-norms study revealed a disconnect between the health system and the social system constructs at community and family level, yet T2DM risky behaviors are gendered and influenced by power, control and sanction around submission.

‘’Social norms are responsible for the harmful constructions of dominant masculinity engineered by power and control over women, hence the social-cultural acceptance of inferiority on the part of women. Therefore, even on matters of diet, women have to submit and follow what men prefer, and can become violent in asserting their dominance if women don’t comply. It is important to note that while gender-injustice related consequences affect mostly women, gendered social norms undermine the health and wellbeing of all people, regardless of age, sex, gender, or income setting. Therefore, our proposed model is informed by this reality, it is inclusive by design since it was co-designed together with all community stakeholders/duty bearers and targets risky behaviors that accelerate T2DM, but also other health outcomes.

KEY FINDINGS FROM THE SOCIAL NORMS STUDY

The main behavioral factors influencing type 2 diabetes were a) consuming processed and added sugar products, b) consuming high cholesterol fatty foods, c) excessive alcoholism, d) smoking (traditional and contemporary), e) mental/psychosocial stress and f) lack of exercise. The analysis shows that dietary factors contribute the greatest threat to the fight against type 2 diabetes in Busia and Bugiri according to the researchers.

In terms of social norm strength around dietary factors, the two strongest norms were “people who don’t prepare fried food are poor people”, “taking tea without adding sugar is mistreatment to your husband” and “Bwita/kalo is our staple food, we eat it daily”. Some of the less strong norms included; “eating greens is mistreatment to your man/husband”, “fat people especially men are respected in the community”, and “A true Samia meal must contain meat or fish daily” said one of the study participants

The strongest social norms around alcoholism.The strongest social norms around alcoholism were “alcohol takes away negative thoughts and stress”, “when you take alcohol with your friends, they can’t abandon you”, “Waragi reduces diabetes because it is sour”, “religion does not allow us to take alcohol” explained one of the key informants.

The social norms around smoking included; “if you want to feel good, you have to smoke”, “most old people and our grandparents lived long and were smokers” and “traditional religion demands and allows smoking of pipes, it’s part of our culture”. Affirmed another study participant

The main social norm around physical exercise was that “men are expected to rest/lie down and wait to be served by women”. They have to sit and wait for food’’ added a participant

On drivers that support norm entrenchment, the researchers outlined easy access to alcohol, gender based violence, cultural set up, poverty, wrong peers, poor parenting, one sided food systems as areas that need serious attention.

MORE ABOUT THE STUDY

The study used Social Norms Exploration Tools (SNET). It was conducted in Eastern region in the districts of Bugiri and Busia in December, 2020. This study covered a total of 4 health facility catchment areas: Bugiri Hospital, Nakoma H/C IV, Masafu Hospital and Lumino H/C III.

A number of data collection methods were used including Focus Group Discussions. Key Informant Interviews, In-depth Interviews, Observation and Photography.

This study builds on previous studies funded by Swedish Embassy and conducted in Iganga and Mayuge by the School of Public Health’s Prof. Guwatudde David, Dr. Barbara Kirunda, Dr. Elizabeth Ekirapa, Dr. Roy Mayega and Prof. Buyinza Mukadasi (Research and Graduate Training, Makerere University)

The research team consisted  of the following researchers:  Dr. Juliet Kiguli (Principal Investigator), Dr. Roy William Mayega, Dr. Francis Xavier Kasujja,  Mr. Ramadhan Kirunda, Ms. Gloria Naggayi, Ms. Joyce Nabaliisa, Ms. Rita Kituyi, Sr. Nabwire Mary, and Sr. Nampewo Evarine Wabwire. The social norms study was made possible with funding by Mak-RIF (led by Prof. Bazeyo William) and Government of Uganda.

Mark Wamai

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The Road from Climate Promises to Care in Uganda

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Dr. John Bosco Isunju (second right) and Dr. Didacus Namanya (right) with partners during the COP31 side event on Uganda’s H-NAP implementation at the Uganda Pavilion, Antalya, Türkiye, 10 November 2026. Makerere University School of Public Health, Kampala, Uganda, East Africa joins world leaders, negotiators and researchers are gathered in Antalya, Türkiye, for COP31, the United Nations climate conference, discusses School’s technical support to the Ministry of Health for Uganda’s 2023 Climate Change Health Vulnerability and Adaptation Assessment (VAA) and the subsequent development of the Health National Adaptation Plan (H-NAP) 2025–2030.

This week, world leaders, negotiators and researchers are gathered in Antalya, Türkiye, for COP31, the United Nations climate conference, seeking to turn years of climate commitments into action countries can finance and implement. Among them is Dr. John Bosco Isunju, a climate and health researcher at Makerere University School of Public Health, named among TIME’s 100 most influential climate leaders in 2024.

Dr. Isunju led the School’s technical support to the Ministry of Health for Uganda’s 2023 Climate Change Health Vulnerability and Adaptation Assessment (VAA) and the subsequent development of the Health National Adaptation Plan (H-NAP) 2025–2030. The assessment covered 716 health facilities across 43 districts, documenting vulnerabilities that helped shape the country’s priorities for protecting healthcare from climate hazards.

Flood damage at Kilembe Mines Hospital in Kasese District. Damaged wards can disrupt treatment and limit access to care. Photo: H-NAP Team. Makerere University School of Public Health, Kampala, Uganda, East Africa joins world leaders, negotiators and researchers are gathered in Antalya, Türkiye, for COP31, the United Nations climate conference, discusses School’s technical support to the Ministry of Health for Uganda’s 2023 Climate Change Health Vulnerability and Adaptation Assessment (VAA) and the subsequent development of the Health National Adaptation Plan (H-NAP) 2025–2030.
Flood damage at Kilembe Mines Hospital in Kasese District. Damaged wards can disrupt treatment and limit access to care. Photo: H-NAP Team.

That experience speaks directly to the task before the 9–20 November summit. With “Dynamic and Resilient Health Systems” among the COP31 Presidency’s Action Agenda priorities, the conference is seeking practical solutions and financing to keep services functioning through climate shocks. Adaptation, the practical changes needed to cope with a changing climate, must ultimately reach the facilities where people seek care.

Protecting facilities from floods and drought also safeguards the public investment behind them, giving Uganda’s adaptation effort an economic significance alongside its importance to patients. In a 27 October 2026 statement ahead of COP31, UN Climate Change Executive Secretary Simon Stiell placed climate action within that wider calculation of public benefit.

“More governments are taking climate action right across their economies, to bank the vast benefits of clean energy and climate resilience,” he said. “Almost every major economy, and many medium-sized and smaller economies, now see climate action as a central driver of economic growth, jobs, and affordable and secure energy.”

UN climate chief Simon Stiell delivers opening remarks at COP31 in Antalya, Türkiye. Photo: UN Climate Change/Kiara Worth. Makerere University School of Public Health, Kampala, Uganda, East Africa joins world leaders, negotiators and researchers are gathered in Antalya, Türkiye, for COP31, the United Nations climate conference, discusses School’s technical support to the Ministry of Health for Uganda’s 2023 Climate Change Health Vulnerability and Adaptation Assessment (VAA) and the subsequent development of the Health National Adaptation Plan (H-NAP) 2025–2030.
UN climate chief Simon Stiell delivers opening remarks at COP31 in Antalya, Türkiye. Photo: UN Climate Change/Kiara Worth.

On 21 October, nearly three weeks before the Antalya talks, the H-NAP was before Ugandan parliamentarians in Kampala. Convened by the Ministry of Health and Parliamentary Forum on Climate Change Uganda, with support from Regenerate Africa and the Clinton Health Access Initiative, the engagement examined the plan and Parliament’s role in securing funding, scrutinising implementation and ensuring accountability.

Presenting the VAA, Dr. Isunju explained that the team examined the hazards facing each area, the extent of exposure and the weaknesses that made services vulnerable. They also considered the communities the facilities served. A flood could turn an already difficult journey to treatment into one that patients and staff could no longer make, as seen in many parts of Uganda, including Kasese.

“Either health workers will not work, or communities will not be able to access care, or outreaches will not be possible because roads are cut off,” he told legislators.

MPs at the orientation on implementing Uganda’s Health National Adaptation Plan, led by Makerere University School of Public Health, the Ministry of Health and partners in Kampala, 21 October 2026. Makerere University School of Public Health, Kampala, Uganda, East Africa joins world leaders, negotiators and researchers are gathered in Antalya, Türkiye, for COP31, the United Nations climate conference, discusses School’s technical support to the Ministry of Health for Uganda’s 2023 Climate Change Health Vulnerability and Adaptation Assessment (VAA) and the subsequent development of the Health National Adaptation Plan (H-NAP) 2025–2030.
MPs at the orientation on implementing Uganda’s Health National Adaptation Plan, led by Makerere University School of Public Health, the Ministry of Health and partners in Kampala, 21 October 2026.

Uganda’s H-NAP grew out of commitments made at COP26 in Glasgow in 2021 to assess health vulnerabilities and develop an adaptation response. The Ministry of Health commissioned the School to undertake the VAA in 2023, with Rockefeller Foundation funding supporting both the assessment and the plan’s development. Developed through stakeholder consultation, with WHO technical support and contributions from other partners, the plan was launched on 22 August 2024.

What the assessment found

The VAA found that drought and floods were disrupting the conditions needed to deliver care. Nearly half of the assessed facilities reported drought exposure, while about two in five reported floods. Among the 284 facilities reporting flood exposure, 141 (about half) said health professionals had been unable to arrive at or leave their workplaces, and 198 (about seven in ten) reported shortages of safe water. Because districts were selected for their history of hazards, these findings describe the assessed facilities and cannot be treated as national estimates.

Findings from Uganda’s 2023 health vulnerability assessment helped shape its Health National Adaptation Plan 2025–2030. Makerere University School of Public Health, Kampala, Uganda, East Africa joins world leaders, negotiators and researchers are gathered in Antalya, Türkiye, for COP31, the United Nations climate conference, discusses School’s technical support to the Ministry of Health for Uganda’s 2023 Climate Change Health Vulnerability and Adaptation Assessment (VAA) and the subsequent development of the Health National Adaptation Plan (H-NAP) 2025–2030.
Findings from Uganda’s 2023 health vulnerability assessment helped shape its Health National Adaptation Plan 2025–2030.

The H-NAP responds across ten components of the health system, including leadership, workforce training, risk monitoring and sustainable financing. Its proposed actions include revising infrastructure standards and using weather and disease information to warn of health risks earlier. Protecting care requires investment in buildings alongside the people and systems that make them function.

“A significant proportion of healthcare facilities lack water management and safety plans to address contamination risks,” the H-NAP states. “They lack water safety plans and contingency plans for monitoring and reducing contaminants as well as on-site water purification equipment.” Such gaps can leave facilities unable to maintain hygiene, clean equipment and provide treatment safely when water supplies fail or become contaminated.

The H-NAP already includes a budget, giving implementation a basis for resource mobilisation. The UN climate secretariat’s 2026 report on national adaptation plans across sectors identifies the difficulty of turning priorities into fundable projects. It recommends costing specific interventions and securing delivery partners, steps that can help advance Uganda’s health adaptation priorities.

At household level, climate pressures on livelihoods can leave families less able to get care or keep children in school, as community consultations showed.

“Their problems are interconnected. If climate, for example, affects their livelihoods, it directly impacts their health, because that means when they fall sick they can’t get care, and they can’t take their children to school, so things are all interconnected,” Dr. Isunju said.

Dr. John Bosco Isunju briefs MPs on climate risks to Uganda’s health services in Kampala, 21 October 2026. Makerere University School of Public Health, Kampala, Uganda, East Africa joins world leaders, negotiators and researchers are gathered in Antalya, Türkiye, for COP31, the United Nations climate conference, discusses School’s technical support to the Ministry of Health for Uganda’s 2023 Climate Change Health Vulnerability and Adaptation Assessment (VAA) and the subsequent development of the Health National Adaptation Plan (H-NAP) 2025–2030.
Dr. John Bosco Isunju briefs MPs on climate risks to Uganda’s health services in Kampala, 21 October 2026.

The Ministry’s Focal Point for Climate Change and Health, Dr. Didacus Namanya, told MPs that resilience, the ability to withstand disruption and keep providing care, must inform how services are built and managed.

“So, our vision in the H-NAP is to have a responsive, adaptive, and resilient health system. Adaptive, we are talking about adaptation. These impacts will not stop; they will continue coming, but we must develop our adaptive capacity. The way we build our health facilities, the way we tackle the disease burden, we must be highly adaptive,” he said.

Dr. Namanya called for district-specific assessments, noting the different conditions in Nakasongola and Bududa, and described an ongoing review of infrastructure design standards. Dr. Isunju reported that guidelines for coordinating climate and health action across institutions were undergoing approval.

A partnership announced in October 2025 by the Rockefeller Foundation and the International Development Research Centre is helping the School and the Clinton Health Access Initiative, working with the Ministry of Health, build an investment case for H-NAP implementation. A separate Ministry of Health and Global Green Growth Institute initiative, begun in June 2026, is advancing climate-resilient water, sanitation and hygiene standards, investment plans for health facilities and the government’s capacity to deliver improvements.

Rt. Hon. Lukia Isanga Nakadama signs a display copy of Uganda’s Health National Adaptation Plan at its launch in Kampala, 22 August 2024. Makerere University School of Public Health, Kampala, Uganda, East Africa joins world leaders, negotiators and researchers are gathered in Antalya, Türkiye, for COP31, the United Nations climate conference, discusses School’s technical support to the Ministry of Health for Uganda’s 2023 Climate Change Health Vulnerability and Adaptation Assessment (VAA) and the subsequent development of the Health National Adaptation Plan (H-NAP) 2025–2030.
Rt. Hon. Lukia Isanga Nakadama signs a display copy of Uganda’s Health National Adaptation Plan at its launch in Kampala, 22 August 2024.

Questions for Antalya

Legislators sought evidence of what implementation had delivered. Terego East MP Hon. Wilfred Babanga Erima asked how much of the plan had been implemented, how many facilities had been audited and refitted for climate resilience, and how funding was divided between domestic and donor sources. Hon. Shafiga Wanyenya, Vice Chairperson of Parliament’s Committee on Climate Change, proposed joint follow-up with the health committee and regular progress reviews.

“Our role is to ask the difficult questions and also identify implementation gaps, to advocate for the vulnerable communities and ensure that the national commitments translate into tangible improvements in the lives of our people,” Hon. Wanyenya said.

Hon. Shafiga Wanyenya, Vice Chairperson of Parliament’s Climate Change Committee, calls for oversight of Uganda’s health adaptation plan in Kampala, 21 October 2026. Makerere University School of Public Health, Kampala, Uganda, East Africa joins world leaders, negotiators and researchers are gathered in Antalya, Türkiye, for COP31, the United Nations climate conference, discusses School’s technical support to the Ministry of Health for Uganda’s 2023 Climate Change Health Vulnerability and Adaptation Assessment (VAA) and the subsequent development of the Health National Adaptation Plan (H-NAP) 2025–2030.
Hon. Shafiga Wanyenya, Vice Chairperson of Parliament’s Climate Change Committee, calls for oversight of Uganda’s health adaptation plan in Kampala, 21 October 2026.

Those questions belong in Antalya too. The Yearbook of Global Climate Action 2026 identifies gaps in global data for assessing whether health systems are becoming more resilient, underlining the importance of tracking what adaptation efforts deliver for health.

The COP31 health programme links implementation of the Belém Health Action Plan with a financing framework intended to help turn health priorities into investable projects. Launched on 9 November, the Antalya Initiative for Health Resilience provides a platform for countries to share practical experience. The COP28 adaptation framework sets targets for climate-resilient health services by 2030 and progressively beyond, alongside national adaptation planning by 2030 and multi-hazard early-warning systems by 2027.

The H-NAP gives Uganda a practical agenda for that next stage. It calls for climate and health priorities to enter government budgets and for proposals capable of attracting finance. It also identifies academic partnerships as a route to research and capacity-building funds. Annual reviews would then assess progress and guide subsequent work.

As negotiations continue in Antalya, the next test is whether decisions there, and action at home, help keep care available, on the road to a health facility, and at the water point on which safe treatment depends.

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John Okeya

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Makerere University’s Prof. Peter Waiswa Appointed to WHO Technical Working Group on Essential Child Health Services

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Prof. Peter Waiswa (C) with participants at the World Health Regional Summit on 29 April 2026 in Nairobi Kenya. Photo: MNCH. Makerere University Center of Excellence for Maternal, Newborn and Child Health (MNCH), based at the Makerere University School of Public Health in Kampala Uganda

Makerere University’s Professor Peter Waiswa has been appointed to the World Health Organization (WHO) Technical Working Group of Experts tasked with developing the Essential Child Health Services (ECHS) framework.

The appointment, communicated in an official letter dated October 21, 2026, and signed by Dr. Pascale Allotey, Director of WHO’s Department of Sexual, Reproductive, Maternal, Child, Adolescent and Ageing Health, runs until December 31, 2027.

The technical working group will support WHO in defining a core package of essential health services for newborns, older children and adolescents, alongside practical approaches for delivering these services effectively and equitably to improve their health and well-being.

As a member of the working group, Prof. Waiswa will contribute scientific and technical expertise to the development of the framework. His responsibilities will include participating in technical consultations, reviewing draft documents, providing written feedback and contributing to consensus-building on key technical issues.

The group is expected to hold approximately five online meetings between November 2026 and mid-2027. Members will serve in their individual capacities as independent experts rather than as representatives of their respective governments or institutions.

The appointment builds on Prof. Waiswa’s longstanding service and contributions to WHO. He previously served for seven years on WHO’s Strategic and Technical Advisory Group of Experts (STAGE) on Maternal, Newborn, Child and Adolescent Health and Nutrition, with his tenure concluding in June 2026.

Congratulations Prof. Peter Waiswa.

Mak Editor

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Mak Staff Receive Prestigious International “Future of the Field” Recognition in Global Research Administration Class of 2026.

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Mr. Mordecai Tayebwa (L) and Ms. Bonny Tusiime(R)

Makerere University proudly celebrates the recognition of Mr. Mordecai Tayebwa, Senior Grants Manager, Makerere University Lung Institute and Ms. Bonny Tusiime, Grants and Contracts Officer, Makerere University College of Health of Sciences (MakCHS) as recipients of the prestigious Future of the Field Award of Society of Research Administrators International (SRAI), an international recognition that Honors emerging leaders making outstanding contributions to the advancement of research administration. This year’s ‘Future of the Field’ honorees were formally recognized at SRAI’s Annual Meeting held in Honolulu, Hawaii, USA in October, 2026.

The Future of the Field Award recognizes professionals who demonstrate exceptional leadership, innovation, and commitment to strengthening research management and administration. The award celebrates individuals whose work is shaping the future of the profession by improving research support systems, fostering collaboration, and advancing excellence in research administration.

At Makerere University, Mr. Tayebwa and Ms. Tusiime have played key roles in strengthening grants and contracts management, supporting researchers throughout the grant lifecycle, promoting compliance with sponsor requirements, and contributing to the development of sustainable research management systems. Their efforts have enhanced institutional capacity to attract, manage, and administer competitive research funding while ensuring accountability and excellence. Commenting on the recognition, the award recipients expressed their gratitude for the opportunity to contribute to the growth of research administration. “This recognition reflects not only our individual efforts but also the collaborative environment at  MakCHS and Makerere University. It inspires us to continue strengthening research administration and supporting researchers in generating impactful scientific discoveries that improve lives.” They said.

The achievement highlights the growing international recognition of research administration professionals in Africa and underscores Makerere University and MakCHS’s  general commitment to building strong research support systems that enable world-class research. This also reflects the institution’s investment in professional development and its dedication to advancing research excellence through effective grants management.

Commenting on the award, Dara C. Little, President, (SRAI) said “In a field as dynamic and rapidly evolving as research administration, the need for visionary,adaptable leaders have never been greater,” . “SRAI’s Future of the Field recipients represent the next generation of changemakers – those who will not only navigate complexity but shape the future of our profession. To embrace change, is to lead your innovation, resilience, and leadership are exactly what this moment demands. Rise to the opportunity and you will do great things!”

Makerere University congratulates Mr. Mordecai Tayebwa and Ms. Bonny Tusiime on this significant achievement and wishes them continued success as they contribute to shaping the future of research administration both regionally and globally

Zaam Ssali
Zaam Ssali

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