Health
Former Grade III Teacher graduates with a PhD: NCDC approves her Study Intervention for Adolescent Care
Published
2 years agoon

Sixty four-year-old Sarah Bunoti Nantono is a retired teacher and Lecturer of Psychology. She enrolled for a Ph.D. program at Makerere University School of Public Health (MakSPH) in 2013 with the goal of studying early adolescent reproductive health.
Having taught for more than thirty years, Dr. Sarah Bunoti Nantono had moved up the academic ladder from being a primary school teacher to a lecturer at Kyambogo University. She believed that earning a PhD would be her ultimate goal in life. While at Kyambogo University, the second largest of the now 13 public universities in Uganda, Dr. Sarah Bunoti devoted her professional life to training social scientists, teachers and teacher educators.
Eleven years later, Dr. Bunoti Sarah Nantono is one of the 46 females of the 132 PhD graduands in the #Mak74thGrad, which begins on Monday, January 29, 2024.
She successfully earns a Doctor of Philosophy ( PhD) in Public Health from Makerere University following her in-depth research titled; “Pubertal and Child Rights Awareness, Communication, and Child Protection against Sexual Abuse and Exploitation among 10–14-year-olds in Jinja Primary Schools: Opportunities, Challenges, and the Effectiveness of a School-Based Intervention.”
Dr. Sarah Bunoti is a seasoned lecturer with a proven track record in teacher training, social sciences, and psychology. Holding an MSc in Environment from Makerere University Institute of Environment, she also earned a Bachelor of Science in Zoology and Psychology from Makerere University in 1999, a Diploma in Teacher Education from ITEK in 1995, and a Grade III Primary School Teachers’ Certificate from the National Institute of Education. Beginning her career in 1981 as a primary school teacher, and later as a Teacher Trainer in the Ministry of Education in 1995, Sarah transitioned to Kyambogo University in 2000, where she currently serves as a part-time Lecturer, following her retirement. Sarah Bunoti Nantono is not only an educator but also an accomplished author, contributing to the development of the Child Rights Curriculum (CRED-PRO).
Dr. Sarah Bunoti’s PhD research examined how Jinja primary school children, aged 10 to 14, understood puberty and their rights related to sexual and reproductive health (SRH). The study looked at their knowledge sources, difficulties, and prospects for managing pubertal health effectively.
The 10-14 age group comprises 10% of the global population, with Uganda having a higher percentage at 16%. This period marks the onset of significant changes, known as the storm in Psychology, involving body transformations and social shifts.
According to Dr. Sarah Bunoti, timely support during these changes fosters a sense of achievement, but delays can lead to anxiety and unpreparedness. Uganda, aligning with international agreements, including the UN Convention on the Rights of the Child, works to uphold children’s sexual well-being through policies and partnerships.
Dr. Sarah Bunoti further notes in her research that the 10-14 age group in Uganda encounters puberty during primary school without appropriate information, support, protection, or preparation for the changes, leading to psychological challenges, sexual abuse, early marriages, unplanned pregnancies, and a rise in school dropouts.
![Dr. Sarah Bunoti's PhD Defense Panel [Professor Stella Neema, Associate Professor Joseph Ssenyonga, Dr. Siu E. Godfrey, Dr. Beyeza-Kashesya Jolly and supervisors Associate Professor Lynn Atuyambe, Prof. Nazarius Mbona Tumwesigye alongside the session chairperson Prof. Garimoi Orach] determining the verdict before she was declared to have passed her defense. Davies Lecture Theatre, College of Health Sciences, Makerere University, Kampala Uganda, East Africa.](https://news.mak.ac.ug/wp-content/uploads/2024/01/Makerere-CHS-SPH-74th-Graduation-Dr-Sarah-Bunoti-Jan2024-PhD-Defense-Panel-1024x683.jpg)
Busoga region, where the study was conducted faces particularly high rates of teenage pregnancies (7%) and school dropouts (91%). Children hold misconceptions driven by myths about puberty, emphasizing the lack of systematic guidance. Current Adolescent Sexual Reproductive Health programs focus on older children in secondary schools, neglecting the needs of those under 15.
Traditional sources, like family discussions, have diminished, placing the responsibility on schools, which often lack the necessary resources and teacher training. As a result, many 10-14-year olds are ill-prepared for changes and lack protection against sexual abuse, highlighting the necessity for evidence-based school interventions to address this information gap.
“Previously in our African traditional setting, the Aunties, Uncles and grandparents talked about puberty and prepared children for adulthood however with the breakdown of African traditional settings, schools are expected to do the role of talking to children about puberty.
Unfortunately, schools often look at puberty as an issue that is concerned with the family and expect the family to do that but also one possible problem is that the teachers themselves don’t know what to do when they are preparing these children for that,” observes Dr. Sarah Bunoti.
Unfortunately, some stakeholders use threatening language, warnings, and punishments, contributing to risk behaviors, including sexual abuse, mood swings, and trauma among children.
“We wanted to find out what these children know about puberty, challenges they face and the support they get. We also wanted to find out from key duty bearers, these are parents and teachers, what kind of support do they give to the children and to what extent do they fulfill their obligations to protect the children against sexual abuse,” said Dr. Sarah Bunoti.
The study covered 16 primary schools purposefully selected for their diverse characteristics, including boarding status, religious affiliations, gender specifications, and geographical locations. The investigators also engaged with government officials to understand their stance on current sexual and reproductive health issues among young adolescents.
The study exposed deficiencies in children’s understanding of puberty and child rights, along with teachers’ inadequate knowledge and skills in teaching puberty.
Findings for instance revealed that kids—particularly boys—don’t often get the chance to talk candidly about puberty with adults. In all focus group conversations, the study gave boys and girls a forum to openly address their experiences, difficulties, and rights related to sexual and reproductive health. This emphasizes how important it is for all people to become widely sensitive to the issues that face kids. Stepmothers were found not to communicate about puberty because of generalization and others.

“Surprisingly, discussions on pubertal challenges elicited more extensive responses from both boys and girls compared to other topics. Boys, although engaging in perceived anti-social behavior, demonstrated a level of conscience. It became evident that children, despite being sexually and biologically mature, require guidance on navigating the impact of hormones on their sexual feelings. The blame for communication gaps often falls on parents, who may be absent due to work, divorce, or being orphaned,” says Dr. Bunoti.
Subsequently, she developed, applied, and assessed two intervention books; A children’s Resource book and a Teachers’ guide. The Randomized Control Trial demonstrated improved pubertal knowledge among children and enhanced teaching capabilities in teachers, affirming the intervention’s effectiveness. These intervention books were approved by the National Curriculum Development Centre (NCDC) and approved for teaching pubertal health and safety in primary schools nationwide.
Dr. Bunoti has recommended empowering and involving young communicators to convey Sexual and Reproductive Health and Rights (SRHR) information to 10-14-year-olds, working collaboratively with parents and teachers, a strategy she believes will narrow the generation gap and enhance effective communication. Additionally, she calls for increased awareness and participation of male parents and teachers in SRH communication and child protection.
“Parents and adults should supplement school-based SRHR education by instilling age-appropriate individual, family, and community values and skills rooted in social, cultural, and religious contexts. Provide specialized training for Senior Women Teachers and Male Teachers, and reduce their teaching load to ensure dedicated attention to this critical aspect of education,” Dr. Bunoti expertly says.
Her study, funded by Sida and supervised by Dr. Lynn Atuyambe and Prof. Nazarius Mbona Tumwesigye, successfully attained this recognition.
During her PhD defense, Associate Professor Lynn Atuyambe remarked, “It was a very enjoyable defense. You truly and successfully defended your PhD—now, you own your PhD.”
“I want to thank most especially your family, they’ve been part of this journey I am not guessing, I know they’ve been and am excited to see them and I like the support they have offered to mum. The highest level of education in the world is a PhD, you can do no more than that. You have reached at the saddle of your life in academia, congratulations and I wish you good luck,” said Dr. Lynn Atuyambe.

How her PhD Journey started
About a decade ago, SIDA had been consistently supporting Makerere University. However, they decided to extend their support to other public universities. When the opportunity arose, she seized it.
“I have a habit of greeting, and my children often question why I greet so much. Sometimes, it turns out to be quite beneficial. One day, I walked into my Dean Dr. J Katigo – Kaheeru’s office and greeted, asking how he was. He said, ‘Sarah, I am glad you’ve come, read this but I said Doctor I am not ready for this, but he said, ‘Sarah, you can’t give any more excuses, this is a God given opportunity, they want a concept for the SIDA Scholarships, go ahead and write a concept.’ I later met Professor Mary N Okwakol, my undergraduate Lecturer of Zoology, and Professor Albert Lutalo Bbosa, the former Vice Chancellor of Kyambogo University, who too reassured me of my potential to attain a PhD. Out of 26 submissions from Kyambogo University, only three concepts were selected, and fortunately, mine was one of them,” Dr. Sarah Bunoti recalls.
Once her concept was ready, Dr. Bunoti came to Makerere University, but her research topic was broad. Unfortunately, her background did not align with the faculties that typically received sponsorship from SIDA. Zoology, Psychology, Education, and Environmental Studies were her strengths, but none fell within the supported areas.
Feeling disconsolate, she sought guidance from the then Director of Research and Graduate Studies at Makerere University, Professor Elly Katunguka. “He said, ‘why should you really struggle looking for a home, go and try School of Public Health. With your background, you’ll find a home,” she recalls.
Acting on his advice, Dr. Sarah Bunoti visited the School of Public Health one morning. However, the Dean, Prof. William Bazeyo, then, was away on leave; “I spoke with Assoc. Prof. Fred Wabwire-Mangen, the Acting Dean at the time. I explained my situation, highlighting my expertise in teaching, psychology, and environmental studies. He encouraged me to submit my concept, assuring me that these areas were valued in public health. This led to provisional admission, and I began refining my proposal with their guidance.”
As she exited Dr. Mangeni’s office, he promptly contacted Professor Anne Katahoire, who was by then the Director of Makerere University Child Health and Development Centre and Prof. Atuyambe, who was in Nairobi for a conference and told them; “We have a prospective student here, are you willing to take her up and without hesitation, Prof. Anne said yes and Prof. Lynn said, ‘I am in Nairobi but when I come back, I want to see that student,” Sarah recollects.
Subsequently, Prof. Mangeni reached out to Prof. Nazarius Mbona Tumwesigye upon recognizing the importance of the statistics component, he promptly invited her to discuss further details at the school. “In a short span, I found myself with a dedicated team of supervisors, a supportive Doctoral Committee chaired by Prof. Christopher Garimoi Orach with Prof Joseph Oonyu (RIP) and Dr. Christine K. Nalwadda, and a scholarly home in the Department of Community and Behavioral Sciences at the Makerere University School of Public Health,” Sarah Bunoti says.
Dr. Sarah Bunoti expresses gratitude to the MakSPH PhD Forum, the MakSPH family, the funder and her mother institution -Kyambogo University for the immeasurable support.

Dr. Sarah Bunoti expresses gratitude to the MakSPH PhD Forum, the MakSPH family, the funder and her mother institution -Kyambogo University for the inestimable support. She is also grateful to head teachers, teachers, children, and parents from her 16 project schools; Jinja City and District Education, Health and Community Development officers as well as the Family and Child Protection Unit of the Uganda Police Force and others for the information and support rendered to her.
“I can’t quantify the support I received from MakSPH, from PhD forum, from my supervisors you all did a good job to support me in this. In addition, SIDA did a good job because with our teaching salary, paying for my PhD would have been a problem but they paid all my tuition even when the scholarship was ending they said Sarah, we are paying for two years at ago and paid for the field’s activities,” she recalls.
She is equally grateful to everyone who provided her and her research team with useful information; Kyambogo University for assigning a teaching assistant to help her focus and her husband, Dr. Bunoti, who has promised to support her dream.
“I want to thank my family, my sister Mrs. Rebecca Lucy and her husband Eng. Dr James Muwuluke, my children. They have been there for me, my husband, Dr. Bunoti met me when I was a primary school teacher and he was a Doctor teach and told me, Sarah, I will support you until you are tired of reading and has kept his word, there are few empowered men who will want a woman to come up and get the title they hold,” she said.

“Given what I have gone through, am so excited about this achievement. My family is so excited about this. My husband is extremely excited. They have written short paragraphs about me about my resilience. I had decided not to hold any celebration but my sister and her husband says this could not pass since it is no mean achievement,” she says.
Dr. Godfrey Siu Etyang, her Ph.D. overseer, has invited her to collaborate on a parenting project at the Child Health and Development Center, College of Health Sciences, Makerere University. Over the past month, she has been actively contributing to the development of a comprehensive parenting curriculum for the unit.
Dr. Bunoti anticipates scaling up the approved intervention, particularly to additional primary schools in the Busoga region and beyond and has already began talks with Ministry of Education and Sports to support children’s understanding of puberty, a sine qua non for education and parenting.
Unexpected difficulties affected Dr. Sarah Bunoti Nantono’s journey to earning her Ph.D., resulting in longer than the expected four to six years. Midway through her studies, she developed insomnia, which was an unexpected health problem. In 2020 when it appeared that she would soon graduate, the Doctoral Committee insisted that she must publish her work, and was reluctant to accept a monograph, one of the options for one to graduate with a PhD at Makerere University. Further delays were due to lengthy processes to have her manuscripts published and clearances through the Institutional Review Board (IRB). Other than these challenges, Dr. Nantono also had to repeat the entire data collection process and deal with the untimely death of Assoc. Prof. Joseph Oonyu, a key member of her doctorate committee, in October 2020. Despite these challenges, Dr. Nantono feels proud to have completed her doctorate, demonstrating her incredible endurance in the face of adversity.
Congratulations Sarah!
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Health
What works, what doesn’t work? Researchers uncover the effect of supporting districts to operationalise digital payments for vaccination campaign workers
Published
2 weeks agoon
September 22, 2025By
Mak Editor
By Joseph Odoi
A motivated and satisfied health workforce is critical for the success of mass vaccination campaigns against diseases like polio. High-quality vaccination campaigns can interrupt disease transmission, especially during and after periods of disrupted health services, such as those caused by the COVID-19 pandemic.
In sub-Saharan Africa, most vaccination campaign healthcare workers (VCHWs) have historically been paid in cash. Cash payments are often plagued by delays in funds disbursement, leakages, theft risks, and limited financial transparency. These challenges can negatively affect vaccination coverage and worker satisfaction.
To address these challenges, many countries are transitioning to digital payment systems, which are perceived as faster, more convenient, traceable, reliable, and easy to implement. Digital financial systems are already being rolled out in countries including Côte d’Ivoire, Ghana, Mali, Congo, and the Democratic Republic of the Congo. Uganda, with a projected population of nearly 41.6 million, had over 30 million registered mobile money customers using e-cash in 2019.
While early rollouts of digital payments have been largely successful, their full impact on vaccination campaign workers had not been systematically evaluated.
From 2021 to 2024, Makerere University (Uganda) and the University of Dakar (Senegal), with support from the Gates Foundation and technical partners including the Solina Group, WHO AFRO, and the Ministries of Health and Finance in both embarked on an important journey of research under the Digital Health Payment Initiatives and Research (DHPI-R) Project in 28 countries in Sub Saharan Africa
To explore the experiences and lessons of polio vaccination campaign healthcare workers (VCHWs), both male and female, during the 2022 oral poliovirus vaccination campaign in Uganda, researchers led by Prof. Peter Waiswa (principal investigator), together with Margaret McConnell, Juliet Aweko, Daniel Donald Mukuye, Charles Opio, Maggie Ssekitto Ashaba, Andrew Bakainaga, and Elizabeth Ekirapa-Kiracho, with support from the Gates Foundation, conducted a study titled “The Effect of Supporting Districts to Operationalise Digital Payments for Vaccination Campaign Workers: A Cluster Randomised Controlled Trial During the 2022 Polio Vaccination Campaign in Uganda.”
This study examined whether supporting districts to implement electronic cash (e-cash) payments, instead of cash, increased e-cash usage and improved vaccine campaign healthcare workers’ (VCHWs) motivation and satisfaction during an oral poliovirus vaccination campaign in 2022 in Uganda.
The mixed method study now published in BMJ Global Health, September 2025 was conducted in 54 districts in Uganda that had set up the government e-cash payment platform by May 2022. It involved healthcare workers supporting the polio vaccination campaign, regardless of direct vaccine contact. This included nurses, clinicians (vaccinators), mobilisers, community health workers (village health team members), recorders, local council representatives, and supervisors. The unit of randomisation was the district, while the unit of enrolment and data collection was the individual worker.
Method and Setting
As part of this study , In November 2022, a total of 54 districts and 2,665 vaccination campaign healthcare workers (VCHWs) were enrolled in the study and randomly assigned to two groups. Intervention districts received training on using the government e-cash platform, including managing user roles, uploading beneficiary data, and generating payment reports.
The control districts received the standard support given to districts during mass vaccination campaigns from the MoH, MoFPED, WHO and other development partners. This support included group training on implementation of payments, provision of vaccination materials and financial aid.
The study collected data on how VCHWs were paid, their motivation, and their satisfaction with the payment method. Overall, 765 VCHWs in intervention districts and 589 in control districts received e-cash payments.
Findings
Mode of payment for the vaccination campaign healthcare workers
Overall, approximately half of the campaign workers, 50.8% (1354/2665) were paid digitally (e- cash), either using mobile money or via the bank (online supple mental table 2). Payment by e- cash was higher among females, 53.9% (656/1215) compared with males, 48.1% (698/1450) and was lowest among campaign workers aged 30–39 years, 48.7% (368/765). E- cash payment was higher in the intervention arm at 57.5% (765/1,330) in comparison to the control arm at 44.1% (589/1,335).
Satisfaction with payment received during the campaign
Only 36.5% (705/1930) of the VCHWs were satisfied with the payment received during the campaign, with satisfaction being slightly higher in the intervention arm, 37.9% (353/931) compared with the control arm 35.2% (352/999) and among females 37.9% (351/925) compared with males 35.2% (354/1005). Satisfaction was lowest among the married workers, 35.7% (575/1611) compared with the other categories.
Timing and completeness of payments
Nearly, all VCHWs were paid after the campaign, 97.6% (1884/1930), with no significant difference between the intervention (98.1%, 913/931) and the control (97.2%, 971/999) arms
Delayed/non- payment was highest among those with no formal education, 34% (17/50) and among community mobilisers, 30.7% (392/1071). The majority (70.6%, 1362/1930) of the VCHWs stated that the payment received met or even exceeded their payment expectation.
Participants also stated that e-cash was convenient, transparent, time-saving, and cost-saving, as it reduced travel and waiting times and minimized informal deductions.
Despite these benefits and support to districts to operationalize digital payments , there was no significant difference in workers’ motivation or satisfaction between the intervention and control groups. The researchers attributed this partly due to challenges associated with both cash and digital payment modes.
Challenges experienced in effecting payments at the district level
Also a number of challenges were uncovered in this study . Challenges with e-cash payments included unanticipated withdrawal charges, unreliable internet networks, and lengthy processes for validating mobile telephone numbers. For example, payments were delayed or not processed when VCHWs’ names did not match the registration details held by telecommunication companies, or when workers did not have phones registered in their names.
One key informant had this to say on challenges around e-cash payments
‘’ There was a general complaint of charges. Remember when they are dispersing funds, they stick to the budget exactly. They are not looking at the charges. And when you are also paying you have to allocate minus the charges. You get the point. So the people would be expecting let’s take an example of 150 000/= and then they get 149 something. So, they would ask, ‘Why are we getting less money?’ So we labored to explain to them that the bank is charging a certain fee to facilitate the e- cash. (KII_West_EPI FP) There were also challenges associated with an unreliable internet network that was necessary to facilitate log ins for approval of payments
On Challenges experienced in effecting payments at the district level ,Key informant interviews with district leaders involved in the payment process identified several bottlenecks during the payment process of the campaign healthcare workers. One of the major e- cash payment challenges was a lengthy process of validating mobile telephone numbers. ensuring that the VCHW’s names matched the registered mobile account names attached to the telephone number provided by the VCHW for receipt of funds.
‘’Unsuccessful validation occurred when the VCHW’s names did not match the registration details held by the telecommunication companies. Payments for such individuals were delayed or not effected at all. Because some of them do not even have the phones, but they are very good at doing the work…Or if they have, then the phone is not registered in their names. We were supposed to bring that database of the community as well and feed them into the system. That became a problem’’. (KII_North_ADHO)
Suggestions to improve use of e-cash payment system
To increase the use of e- cash, the majority of key informants identified continued training of key staff as a critical intervention with subsequent follow- up to ensure payments are well implemented.
‘’We are not yet ready; our capacity hasn’t been built. We have a big knowledge gap regarding the e- cash system here in this district. (KII East CFO) We request for more training to be conversant [with the system], and to discuss the challenges together during that training, as we share the experiences. Where we have challenges, we sit together and see how they can be addressed’’. (KII_Central_CFO)
The participants also expressed the need for feedback mechanisms to allow them to dialogue with the payers in case there was a delay in payment. Additionally, the participants also acknowledged that there was a need to gradually expand adoption of digital payments considering contextual barriers. A hybrid approach would be an alternative, especially in the remote and hard-to-reach districts.
Other suggested solutions include early preparation of campaign health worker databases to allow for the lengthy telephone validation processes, improvement of the internet infrastructure, consistent use of e- cash payments across programmes and inclusion of withdrawal charges when making payments.
Moving forward policy, the researchers recommend the need to support e- payment systems, in order to minimize challenges in the pay ment processes.
‘’Suggestions to improve the e- cash experience include training of personnel in charge of e- cash payments, timely creation of VCHWs databases, expanding e- cash payments across programmes for efficiency and inclusion of withdrawal charges for the digital payments. To ensure the institutionalisation of digital payment interventions across Uganda, several key enablers are essential. These include formal policy integration by the Ministry of Health and Ministry of Finance into operational guide lines and budget frameworks, as well as ongoing capacity strengthening at the district level to enhance digital planning, payroll management and troubleshooting. Reliable infrastructure such as mobile connectivity and access to digital financial services like mobile money must also be prioritised, especially in rural areas. Implementing routine monitoring and feedback systems will be vital for tracking payment timeliness, worker satisfaction and system performance, allowing for continuous improvement. Furthermore, fostering public–private partner ships with telecom providers and payment platforms is critical for cost- effective scaling. With strong political commitment, aligned funding and active community engagement, this model holds the potential for broader national and regional adoption, leading to more efficient and equitable health service delivery’’. The paper concludes on the way forward
To read the paper; click; https://gh.bmj.com/content/10/Suppl_4/e016666
About The DHPI-R project
The DHPI-R project was commissioned by the Bill and Melinda Gates Foundation (BMGF) to generate evidence on digital payments in Africa. Although inception, conceptualization of the proposal, and grant award were conducted earlier in 2021, the DHPIR project officially started implementing activities in November 2021, up to March 2025. DHPIR is hosted at the School of Public Health, College of Health Sciences at Makerere University and is implemented in Anglophone and Francophone hubs (countries) in Africa. The Anglophone hub is hosted at MAKSPH, while the Francophone Hub is hosted by the University of Dakar (UCAD) in Senegal.
DHP-IR was rooted in the End Polio Game Campaign, championed by WHO-Afro and partners in 28 countries in Sub Saharan Africa, where digital payments was a key strategy for timely and complete payments to campaign workers.
Health
Digital Payments Boost Vaccination Campaign Efficiency in Uganda
Published
2 weeks agoon
September 19, 2025
KAMPALA, Uganda —Supporting districts to adopt digital payments can significantly improve the efficiency of mass vaccination campaigns in Uganda, even if the gains do not directly translate into higher worker motivation, a new study by Makerere University School of Public Health (MakSPH) researchers has found.
Published on September 10, 2025, in BMJ Global Health, the study examined how helping districts in Uganda transition from cash-based to electronic payments affected vaccination campaign workers. Conducted in early 2023, some four months after the nationwide oral poliovirus vaccination campaign of November 2022, the research assessed the impact of digitised payments on efficiency, timeliness, and worker satisfaction.
With generous support from the Bill & Melinda Gates Foundation, the study was led by MakSPH researchers Peter Waiswa, Juliet Aweko, Maggie Ssekitto Ashaba, Elizabeth Ekirapa-Kiracho, and Charles Opio, in collaboration with Margaret McConnell of the Harvard T.H. Chan School of Public Health, Daniel Donald Mukuye from Uganda’s Ministry of Health, and Andrew Bakainaga from the World Health Organisation (WHO)–Uganda Country Office.
The study’s Principal Investigator and lead author, Assoc. Prof. Peter Waiswa, a health systems researcher at Makerere University School of Public Health, said while the research was conducted in Uganda, its implications are global. He pointed out that some African countries, such as Côte d’Ivoire, Zambia, Tanzania, and Kenya, are already ahead in adopting digital payment systems, while others still lag behind. The study’s findings, he said, are relevant across these contexts and have already informed the work of global actors such as Gavi, WHO, and the Global Fund, who are now integrating digital payments into their own processes.
“This paper is part of several studies we are conducting, but perhaps the most significant,” said Dr. Waiswa, clearly enthusiastic about the findings. “Another outlines the research agenda for digital payments, emphasising the need for more evidence on whether they improve the quality of immunisation campaigns, ensure timeliness and efficiency, and identify which groups face barriers to their use.”

The study was coordinated by MakSPH in collaboration with a network of partners. In Uganda, these included the Ministry of Finance, the Ministry of Health, the World Health Organisation, several implementing organisations, district authorities, as well as telecommunication companies. Importantly, the involvement of Airtel as a non-traditional actor in the study demonstrated the critical role of private sector engagement, often absent in such collaborations, in generating evidence and advancing digital health solutions, particularly in addressing challenges such as timely payments for health campaign workers.
The November 2022 polio campaign, led by the government of Uganda with support from the U.S. CDC and WHO, targeted 8.7 million children under five with the novel oral polio vaccine (nOPV2). Nearly 72,000 teams, including health workers, Village Health Teams, and Local Council representatives, were mobilised nationwide, administering about 10 million doses despite the temporary exclusion of five districts due to the Ebola outbreak at the time.
Building on the campaign, the researchers conducted an exploratory cluster-randomised trial using a mixed-methods approach across 54 districts in Uganda, where they enrolled 2,665 healthcare workers. Intervention districts were trained to use Uganda’s e-cash platform, a government innovation managed by the Ministry of Finance. Introduced in 2017 and formalised in 2019, the cashless system was designed to digitise urgent government payments, enhance efficiency, and improve transparency. It now complements the Integrated Financial Management System, which, though effective for routine payments, was seen as too slow for time-sensitive transactions, including paying campaign health workers, where timely remuneration is critical for maintaining workforce readiness, sustaining campaign momentum, and promptly addressing public health challenges in the communities served.
Intervention studies usually introduce a treatment or program to a group to observe its effects, and the results are compared with a group that does not receive it. The training during the study addressed the delays, leakages, and administrative bottlenecks common in cash-based systems. Intervention districts received instruction on navigating the government e-cash platform, managing user roles, uploading beneficiary data, and generating payment reports, while control districts maintained standard cash payment procedures, serving as a baseline.
Dr. Juliet Aweko, co-author and Research Associate at MakSPH, said the study was timely, observing that health workers are central to successful vaccination campaigns and delayed payments can demotivate them and compromise campaign effectiveness.
“To make digital payments truly work, campaigns must be planned with the workforce in mind. Government and partners need to ensure funds are disbursed on time, streamline and automate registration and verification, and keep accurate records of health workers and their performance. Making mobile money systems compatible and giving workers real-time updates on their payments would not only build trust but also keep them motivated, ultimately improving turnout and ensuring smoother service delivery,” Dr. Aweko stated.

The study found that electronic cash adoption was significantly higher in intervention districts, where 57.5% of workers were paid digitally compared to 44.1% in control districts. What’s more, digital payments did not delay disbursement, as 97.6% of all workers received payment after campaign completion, regardless of method. Still, workers paid via e-cash consistently described the cashless system as convenient, transparent, and cost-effective, citing reduced travel time, lower personal costs, and fewer security risks.
Today, Uganda’s rapidly expanding digital ecosystem provides ground for scaling up cashless payment systems. The Uganda Communications Commission reports that the country has over 43 million active mobile subscriptions, nearly 88% of the estimated 49 million population. Its latest market report shows 26.1 million active internet users, while mobile money continues to dominate financial transactions with more than 33 million accounts and transaction values growing by over 25% annually, according to reports by the Bank of Uganda as of March 2025. This trend reflects a population increasingly reliant on digital platforms, creating a strong opportunity to embed e-payment systems in health service delivery.

For MakSPH researchers Dr. Waiswa and Dr. Aweko, the study evidence confirms that digital payments are both feasible and practical for strengthening the delivery of mass campaigns in low- and middle-income countries like Uganda. With relatively modest support, districts can adopt e-cash systems, providing a scalable model for the health sector. This approach, they suggest, would streamline compensation, reduce administrative delays, and provide a stronger basis for integrating digital payments into future immunisation drives and other public health interventions in the country, thereby strengthening our health systems.
The researchers further emphasised that digitising campaign payments reduces transaction costs and minimises leakages, enabling more funds to reach frontline workers quickly. E-cash also simplifies logistics, strengthens accountability, and enhances financial tracking in health campaigns. These advantages, they found, directly align with the global effort to advance digital transformation in health systems and ensure reliable, transparent worker compensation. The implications also extend beyond just polio, as Uganda continues to rely on mass campaigns for routine immunisation and other outbreak responses, such as measles and yellow fever, where digital payments could improve the efficiency of scarce health resources.
Still, the study acknowledged barriers that could hinder full adoption of a cashless system. Some districts lacked the technical capacity to operate the government’s e-cash platform, upload beneficiary data, and manage user roles. Connectivity issues, limited digital literacy among staff, and occasional system downtimes further disrupted implementation. Additionally, many campaign workers lacked national identity cards or mobile money accounts, making them ineligible for digital payments. To address these challenges, the researchers, among others, recommend targeted capacity building for district finance and health teams, expanded identity and mobile registration for campaign workers, improved internet connectivity, and integration of e-payment systems into routine health planning.
Health
Ekyaalo Diagnostics; Johns Hopkins University Partners with Makerere and MUST to Advance AI Innovation for Breast Cancer Diagnosis
Published
4 weeks agoon
September 9, 2025By
Mak Editor
By Joseph Odoi
Globally, Breast cancer remains a serious health challenge, with the World Health Organization (2022) reporting over 2.3 million new cases annually and nearly 670,000 deaths. In Uganda, breast cancer is one of the leading cancers among women, yet the majority of patients are diagnosed at late stages due to delays in accessing diagnostic services, most of which are centralized at the Uganda Cancer Institute (UCI) in Kampala. Since 72% of Uganda’s population lives in rural areas, women often face late diagnosis due to long travel distances. Even after accessing care, results can take 1–6 months due to the slow process of transporting samples to central laboratories. This delay directly impacts the timely start of treatment.
To address this gap, Johns Hopkins University in collaboration with Makerere University and Mbarara University of Science and Technology (MUST), is spearheading innovative solutions that leverage artificial intelligence (AI) and low-cost technologies to improve early diagnosis and treatment.
As part of this collaboration, the Centre for Maternal, Newborn, and Child Health Research at Makerere University School of Public Health led by Associate Professor Peter Waiswa in July hosted a team of graduate biomedical engineers from the Center for Bioengineering Innovation and Design (CBID) at John Hopkins University.
The team is developing a low-cost, AI-powered technology called Ekyaalo Diagnostics, aimed at reducing the turnaround time for breast cancer diagnosis, especially in hard-to-reach areas. As part of their work, they undertook a learning tour at the Ministry of Health, Uganda Cancer Institute, and regional cancer referral centres. The purpose was to map stakeholders in the breast cancer space, gather Ekyaalo diagnostic technology usability feedback, and understand the local innovation ecosystem in breast cancer care.
Ekyaalo Diagnostics and Bringing Pathology Closer to Communities
The flagship innovation, Ekyaalo Diagnostics, is a portable AI-powered whole-slide scanner (WSS) designed to digitize cytology samples at Health Centre IVs and General Hospitals. These digitized images are securely transmitted to pathologists at higher-level facilities for timely review, eliminating the need for physically transporting samples to Kampala.

This technology has the potential to reduce diagnosis delays from several months to just a few days, thereby improving survival outcomes for breast cancer patients.
Building Local Solutions to Global Challenges
In addition to Ekyaalo Diagnostics, Makerere researchers at the Department of Biomedical Engineering are also advancing other innovations such as development of artificial breast prototypes to be used in educating women on breast cancer symptoms while Research at Mbarara University led by Dr. William Waswa, are developing PapsAI, a low-cost automated tool that support whole slide scanning of slides for cervical cancer screening.
These initiatives are aligned with the National Cancer Control Plan (NCCP) of the Ministry of Health, which emphasizes prevention, early detection, timely diagnosis.
Design Challenges and Considerations
Despite the progress being made, challenges persist, according to the team’s findings from the tour,these technologies hold great promise however their success in Uganda will depend on addressing some critical barriers.
One of the biggest challenges is limited staffing. Many lower-level health facilities lack trained laboratory personnel to prepare slides. For this reason, new technologies must be designed to be simple, user-friendly, and capable of being adopted after short training sessions.
Another major barrier is equipment maintenance. Past medical innovations in Uganda have often struggled with frequent breakdowns and software failures. The team emphasized that new diagnostic tools must be affordable, durable, and resistant to common system crashes if they are to serve rural health facilities effectively.
Finally, high operational costs continue to undermine sustainability. Some innovations fail because their maintenance costs are too high or because they are incompatible with existing health systems. Ensuring cost-effectiveness and system integration will therefore be vital for the long-term success of breast cancer diagnostic technologies in Uganda.
MORE ABOUT THE PROJECT
The project is led by the Johns Hopkins Center for Bioengineering Innovation and Design (CBID) in collaboration with Makerere’s Department of Biomedical Engineering and MUST researchers. Field learning tours have already been conducted at Mulago National Referral Hospital, Jinja, Mbarara, and Fort Portal Regional Referral Hospitals, with input from clinicians, technologists, and innovators in Uganda’s health ecosystem.
The Johns Hopkins team has conducted usability interviews with clinicians, laboratory technologists, and surgeons at multiple hospitals including Mulago, Jinja, Mbarara, and Fort Portal. They have also engaged with Uganda’s innovation ecosystem, including makerspaces and industry partners. It has been noted that the Ministry of Health together with Partners working on treatment of cancer has drafted the National Cancer Control Plan (NCCP) that is aimed at reducing incidence, morbidity and mortality through prevention and early treatment and palliative care. The Plan will give guide on health education, early detection, and diagnosis among others Special thanks go to the Center for Bioengineering Innovation and Design (CIBID) Johns Hopkins University for funding this field learning tour, Centre for Maternal Newborn and Child Health Research at School of Public health (Makerere University) for hosting the team, Departments of Bioengineering at Makerere University and Mbarara University of Science and Technology, Mulago pathology department and the Uganda cancer institute, Regional Referral hospitals of Jinja, Mbarara and Fort Portal among other General hospitals and Health center IVs visited for technical input.
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