Health
Dr. Achola’s PhD Study Uncovers Family Planning Barriers in Adjumani refugee hosting district
At precisely 10:53 AM, on 14th January 2025, the air in Freedom Square buzzed with anticipation as Dr. Crispus Kiyonga, Chancellor of Makerere University, delivered the life-changing words: “By virtue of the authority entrusted to me, I confer upon you a degree of Doctor of Philosophy of Makerere University.” In that moment, Miss Achola became Dr. Achola, a title that resonated deeply with her sister and father, Ms. Evelyn Nyafwono and Mr. Owino Vincent Olele, who stood nearby joyfully with open arms to receive her.
As Achola bagged her doctoral award, she walked majestically toward her excited lecturers and mentors, who eagerly queued to congratulate her. Her sister, Evelyne Nyafwono, and father, Mzee Owino, could hardly contain their excitement. The rhythmic beats of the cultural ensemble filled the air with celebration, while the vibrant melodies of ethnic music and dance, expertly crafted by Dr. Milton Wabyona and his talented team, wove around her. Each step she took was a heartfelt tribute to her journey, a celebration of hard work and achievement that enveloped her in warmth and joy.
Yet, as Dr. Achola reveled in her triumph, a bittersweet shadow hung over her heart. Her beloved mother, Veronica Abbo Owino (RIP), who had always been her greatest supporter, was not there to share in the joy, having passed away midway through her PhD journey.
In the beginning…
Back in time, 2015 was the year. Ms. Roselline Achola, while working with the United Nations Populations Fund as a Technical Specialist for Maternal Health and Reproductive Health Commodity Security/family planning, was charged with the responsibility of ensuring that there is increased access to voluntary information and services to both men and women who need family planning in Uganda and beyond. She was in charge of the Global Program for RHCS.
At the time, as a team leader, she was supervising an assignment that the UN had contracted an expert – Dr. Christopher Garimoi Orach, a Professor of Community Health, to undertake in developing the first family planning costed Implementation Plan for Uganda.
Achola found her motivation for pursuing a PhD, particularly in family planning, due to its cost-effectiveness in improving maternal and child health in resource-limited countries like Uganda.
“We began with the ambitious idea of evaluating the entire family planning program in Uganda, but that proved impossible at the time. I then went silent for two years, not mentioning anything. One day, Prof [Garimoi Orach] called to ask why I was quiet. I explained that I was overwhelmed with UN work and may not manage to juggle with academics. He fell silent too but continued to check on me and offered encouragement,” Achola recalls.
“Why family planning? It was my mandate to ensure the effective implementation of the family planning program in Uganda by supporting the Ministry of Health and implementing partners. I always felt a deep sadness reading about women dying in childbirth while having their 12th or 13th child, knowing that contraception could help them regulate their births and reduce the risk of dying from pregnancy-related complications associated with too many pregnancies,” recalls Achola.
In 2019, she officially enrolled in the PhD program at Makerere University hosted by the Department of Community Health and Behavioural Sciences at the School of Public Health (MakSPH). This was after submitting a concept that was quickly approved, granting her provisional admission. “It wasn’t an easy path though; I remember going nearly a year without progress until my lead supervisor encouraged me to continue working on my proposal. I had almost lost hope due to the demands of my job at the United Nations and had set aside my academic aspirations. This burden weighed heavily on me until I resumed my efforts, ultimately leading to the acceptance of my proposal.”
Inspired by the challenging conditions in Adjumani district in the West Nile region with several refugee settlements—where low family planning uptake and domestic violence related to its use were prevalent—Achola chose to study decision-making around the issue especially in Nyumanzi, Pagirinya and Mirieyi settlements including the surrounding host communities. Her goal was to develop recommendations to address the barriers faced by women and girls in these refugee-affected areas.
Uganda is a leading Africa’s largest refugee-hosting country with more than 1.6 million refugees residing in various settlements established in 12 districts within its borders, as per the latest National Population and Housing Census data from 2024. Adjumani is home to over 250,000 refugees, with more than half of them being female. Here, 1,310 respondents comprising both men and women were involved in the quantitative study.
The major highlight of her research was the low uptake of family planning methods in Adjumani, where only about one-third of the population utilizes modern contraceptives. She explored decision-making processes at individual, family, community, and institutional levels, identifying key factors influencing family planning use.
Her findings show that fear of harassment from family members and concerns about side effects deter many from using contraceptives, while motivations include limiting family size and financial constraints. To enhance family planning uptake, Dr. Achola recommends community outreach strategies to raise awareness about its benefits and promote couple counseling.
“I want to take this opportunity to once again thank SET SRHR for the scholarship that saw progress this far, the Tuition and initial research was supported by SET SRHR. The Mak-RIF support was equally timely because it supported the intervention and evaluation components of my PhD study. Both funds played a big role in enabling me to complete this study and have the achievement today,” says Achola.
While decision-making is a key part of everyday life, Dr. Achola found that it involves complex processes with four dynamic pathways: starting ideas, thinking them through, consulting others, and finally making a decision. Gender dynamics too play a definitive role in contraceptive use, as women often have less power and men typically dominate health decisions.
“I am so excited that my work has resulted in the development of a model for decision-making pathways. These include the idea inception, cognitive process, consultation, and making a decision I sincerely hope that this contribution will enhance the improvement of maternal and child health in humanitarian settings across Uganda and Sub-Saharan Africa, ultimately reducing pregnancy-related deaths associated with the non-use of family planning among both refugee and host populations,” says Achola.
At first, the language barrier stood in her way during her investigation with interpreters often sharing only what refugees wanted to hear instead of her intended messages. “Cultural norms favoring large families made it hard to communicate contraception information. Limited funding also slowed our progress in Adjumani. Although delays in getting my papers published affected my PhD requirements, I’m relieved that it’s finally complete and here we are,” she says.
How her PhD will impact family planning programs in Uganda
Dr. Achola’s research uncovered several key factors influencing contraception use, highlighting a pressing need for targeted solutions. To make a meaningful impact on family planning programs in Uganda, she advocates for community-based strategies that connect people with essential information and services to help them make informed decisions. She views community dialogues and outreach events as vital tools to spark conversations about the benefits of family planning and encourage couples to seek counseling together. “This approach will be instrumental in creating a supportive environment where families can make informed decisions about their health and future.”
With her background as a public health specialist and technical advisor to the Ministry of Health on family planning, she is eager to integrate the four decision-making pathways into all family planning efforts. She recognizes how influential significant others can be in shaping contraceptive choices, whether through encouragement or hesitation. By involving them in the planning process, she aims to develop more effective strategies and hopes her recommendations will be included in the Ministry of Health’s plans, thereby strengthening support for family planning initiatives at every level.
Achola firmly believes that family planning is a cost-effective way for the government of Uganda to reduce maternal and child mortality rates. And that by choosing to space births, mothers bond with their babies and allow themselves time to heal before the next pregnancy, thus allowing their bodies to heal and rejuvenate for the next pregnancy.
“When mothers space their childbirth for at least two years, their health improves, which reduces the risks of pregnancy-related challenges. Babies born with at least a two-year gap have a higher chance of survival than those born less than two years apart,” she stresses.
The next steps…
Achola resonates with the sentiment that “Research never ends.” She recognizes there’s still much to explore in her field and believes her work paves the way for others to examine how culture influences family planning perceptions and practices. This broader perspective can lead to more comprehensive results, with an emphasis on the role of family in decision-making. Achola also imagines future research that will dig deeper into these processes through longitudinal studies with key stakeholders. She also sees the importance of exploring decision-making pathways before applying her findings to larger populations, especially since her study focused on a refugee community in Adjumani, which may differ from other groups in Uganda. For her, the possibilities for further exploration are enormous and stresses that the journey of research is a shared and ongoing adventure. She is, therefore, set to continue with research in this area as a post-doctoral undertaking.
Upon achieving her PhD, Achola feels a renewed sense of determination and purpose in her field. “I will not look back,” she declares with conviction. “I will continue my work in sexual and reproductive health and rights (SRHR) and family planning, where I have developed passion, skills and expertise, positioning me as a leader in this area.”
She is committed to advising government bodies and engaging with the international community and development partners to advance this important field. Additionally, Achola plans to continue teaching in Public Health, nurturing the next generation of specialists and mentoring aspiring doctoral candidates. With her steadfast commitment, she is ready to make a lasting impact, inspiring others to embark on this important journey alongside her.
Nearly half of Uganda’s prison population has latent tuberculosis (TB), according to the latest Uganda National Prevalence Survey on Tuberculosis, HIV, and COVID-19. The survey, released on May 15, 2025, found that active TB cases in prisons stand at 1,900 per 100,000—eight times higher than in the general population.
The survey was conducted by Makerere University School of Public Health (MakSPH) in conjunction with the Uganda Prisons Services (UPS) and the Ministry of Health—with funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and technical support from the U.S. Centers for Disease Control and prevention (CDC)—and purposed to have a more profound understanding of TB to help inform public health programs for this high-risk population.
Dr. Simon Kasasa, a Senior Lecturer at MakSPH and Principal Investigator of this study, stressed that “staying for a longer duration, three years and above, posed a greater risk to TB infection in prison.” He also noted TB infection was much higher among male prisoners (48%) compared to female prisoners (38%) and among those of older age, 65 years and above. Meanwhile, the report noted concerns about excessive numbers in prisons as a key risk factor for TB transmission.
UPS consists of 257 prisons spread over 16 administrative regions with an average prisoner population of 56,400 (95% male), accommodation capacity of 16,612 (340%), and 9,904 staff (29% female).
HIV prevalence among prisoners was also alarmingly high at 11%, twice that of the general population. Notably, female persons in prison (PIP) had the highest HIV rates at 21%, compared to 11% for male PIP and just 2% among prison staff. However, the data also showed a significant drop in overall HIV prevalence within prisons, falling from 15% in 2013 to 11% in 2023, with the most dramatic decline among staff, from 12% to 2%.
Dr. George Tumusinze, a Program Manager and Research Associate, pointed out that although 92% of people with HIV in prisons know their status and 99% are receiving antiretroviral therapy (ART), only 70% have successfully reduced the virus in their bodies, highlighting important issues with how well the treatment is working.
Mr. Samuel Akena, the Deputy Commissioner General of Prisons, echoed these concerns by stating that the survey represents a significant milestone for the Prisons, not only in terms of data collection but also in Uganda’s journey towards achieving equity, justice, and the right to health for all. “This survey is historic. It represents one of the most comprehensive efforts to understand the health status of people in prisons in Uganda.” He emphasized the necessity of a collective and bold response, urging that “the time for piecemeal responses is over.”
Dr. Charles Olaro, Director General of Health Services at the Ministry of Health, emphasized the urgency of the situation, stating, “As we gather today to reflect on the findings of this important survey, we must recognize the urgent need for action in our fight against tuberculosis (TB) in Uganda. Despite our efforts, we are still grappling with the burden of this disease, and our progress toward eliminating it by 2030 has not been as swift as we had hoped.” He pointed out that the survey serves as a critical baseline that will shape future responses and guide resource allocation.
HIV prevalence among prison staff members was the lowest, at just 2%, reflecting a significant achievement in workplace health. Dr. Daniel Byamukama, Head of HIV Prevention at the Uganda AIDS Commission, praised prison authorities for their efforts, noting the remarkable progress over the past decade. In the first survey in 2013, only 34% of HIV-positive staff on treatment had achieved viral load suppression. Today, that figure has reached an impressive 100%, underscoring the impact of sustained prevention and care efforts.
While the prison HIV program has shown effectiveness—evidenced by a drop in prevalence from 15% to 11% among the prisoners over the past decade—Mr. Akena stressed the importance of prioritizing gender-responsive strategies in health interventions.
“Diseases do not recognize bars or borders. They thrive in environments where conditions are poor and resources are scarce. Women in prison face disproportionately higher risks, yet often remain invisible in program planning. This is not acceptable. If we are serious about health equity, we must prioritize gender-responsive strategies — within prison health systems and beyond,” Mr. Akena.
CDC Uganda Director Dr. Adetinuke (Mary) Boyd reinforced the significance of the survey in addressing public health risks. “In Uganda, CDC partners are helping to ensure inmates stay healthy during custody. This work facilitates safe reintegration into their communities, mitigates disease transmission to the general population, and reduces public health risks like untreated TB,” she stated. Dr. Boyd highlighted the role of PEPFAR in tackling critical global health threats, asserting that the survey offers helpful data for enhancing health collaboration within this vulnerable population.
The U.S. CDC has been supporting Uganda Prisons Services to provide comprehensive HIV/AIDS, STI, and TB prevention, care, and treatment services for the last 15 years (2010–2025), totaling over $18,046,263 in investment—including $550,000 to this study alone, through the Makerere University School of Public Health. The program supports capacity building, scale-up, and health system strengthening efforts in HIV/TB testing, care, and support for prisoners and prison staff, plus surrounding communities.
With 80% of prison wards overcrowded and 95% lacking adequate natural ventilation, the conditions in which these individuals live exacerbate the spread of infectious diseases, public health specialists have warned. This survey underlines the urgent need for systemic changes within the prison health system, as well as a commitment to uphold the rights and health of all individuals, regardless of their circumstances.
As Uganda grapples with these alarming statistics, the call to action is clear. Stakeholders must come together to implement effective health interventions, improve screening and treatment protocols, and ensure that the rights of incarcerated individuals are respected. The health of the general population is inextricably linked to the health of those within prison walls, and addressing these challenges is not just a moral imperative but a public health necessity.
Professor Rhoda Wanyenze, one of the investigators and Dean of the School of Public Health, asserts that the Survey findings are a wake-up call for stakeholders to prioritize health equity and justice for society’s most vulnerable members.
Prof. Wanyenze advocated for improved TB screening methods and institutionalization of regular mass TB screening using the WHO-recommended advanced diagnostic tools like digital chest X-rays with Computer-Aided Detection (CAD), as well as molecular diagnostics like GeneXpert and TB LAM, noting that traditional symptom-based screening missed nearly half of TB cases. “The use of molecular diagnostics like GeneXpert significantly improved case detection in our study,” she added, emphasizing the importance of timely diagnosis and treatment.
Uganda Prisons Service, in partnership with the Ministry of Health, has so far installed 14 GeneXpert machines in medium- to high-volume prison health facilities.
While some, including Members of Parliament, have raised concerns about the potential infringement on individual rights through mandatory TB testing in prisons, Dr. James Kisambu, the Commissioner for Prison Health Services, noted that it is now apparent, with these findings, for everyone to appreciate that in such confined settings, the risk of transmission is extraordinarily high. TB testing in these settings is not just a medical practice but also a crucial public health precaution that protects both prisoners and the wider community.
“Prisons are high-risk, high-transmission environments where one undetected case can rapidly escalate into an outbreak. In such settings, the right to refuse testing must be weighed against the right of others to be protected from infection. Mandatory TB screening, when done with dignity and linked to prompt treatment, is not a violation of rights — it is an essential public health measure to protect both people in prison and the communities they return to,” said Dr. James Kisambu.
The researchers from MakSPH were; Dr. Simon Kasasa, Associate Professor Esther Buregyeya, Dr. George Tumusinze, Dr. Simon Walusimbi, Dr. Dick Kasozi, Dr. Ronald Senyonga, John Baptist Bwanika, Prossy Nabaterega and Professor Rhoda Wanyenze.
Additionally, the study team from the Uganda Prisons Service comprised of Dr. Leonard Marungu, Charles Butagasa, Dr. James Kisambu and Dr. Johnson Byabashaiza, the Commissioner General of Prisons.
Finally, Dr. Deus Lukoye, Dr. Julius Ssempiira, Charles Kavuma, Rise Nakityo, Samuel Sendagala, Grace Nantege, Lisa Mills, Dr. Lisa Nelson, Kenneth Mwambi from U.S. CDC Uganda/Atlanta and PEPFAR USG agencies, and George William Kasule, Didas Tugumisirize, Dr. Simon Muchuro, Professor Moses Joloba, Dr. Turyahabwe Stavia from the Uganda Ministry of Health National TB and Leprosy Program (NTLP) completed the team.
On April 23, 2025, Makerere University School of Public Health (MakSPH) convened district leaders, health managers, and project partners to disseminate the outcomes of a major leadership and management strengthening initiative in Wakiso District, Central Uganda. The one-year project, part of the Global Health Partnerships programme funded by NHS England, was implemented in collaboration with Nottingham Trent University, Nottingham University Hospitals NHS Trust, Wakiso District Local Government, and Uganda’s Ministry of Health.
Launched in 2024, the project titled Strengthening Leadership and Management Among Local Government Health Managers in Wakiso District, aimed to co-design and pilot a leadership and management training tailored to the realities of Uganda’s decentralised health system. The intervention, led by Makerere University’s Dr. David Musoke and Nottingham Trent University’s Prof. Linda Gibson, through the over 15-year-old NTU-Mak Partnership impacting lives in Wakiso, began with a field visit to over 60 public health facilities in the district, a needs assessment within these facilities to identify key priority gaps, and a baseline survey with the health in-charges to establish the initial status of key indicators.
“We have been very fortunate to work with a supportive local government in Wakiso, from the top leadership down. While many projects struggle to engage district teams, our longstanding relationship with Wakiso made collaboration seamless. Although this was our first initiative specifically focused on leadership and management, we hope it will serve as a stepping stone for even more impactful work in the future,” Dr. David Musoke, a Senior Lecturer at Makerere University and the Uganda Project Lead, said during the dissemination workshop, highlighting the key success factors for the leadership and management project.
Initial results from the needs assessment and baseline on leadership and management competencies conducted among Wakiso District health facility supervisors early last year by the project team and shared during the three-day workshop in June 2024, held in Kampala, which kickstarted the six-month structured fellowship programme for 53 health managers in Wakiso, had found critical capacity gaps. Using a tool evaluating 17 leadership and 33 management competencies, only 40% of the managers met the 80% benchmark for leadership, scoring highest in cognitive skills, while just 33% met the required management standard, performing best in self-management and lowest in quality management.
Then, the health facility managers with postgraduate training, longer service, and strong team dynamics, showed overall better performance. While working relationships with subordinates and the district leadership were largely positive, performance was hampered by systemic challenges such as limited resources, low motivation, and weak teamwork. Overall, the study also pointed to a misalignment of expectations between the District Local Government and the Health Ministry, underscoring the need to strengthen coordination to improve services.
The result of this mismatch was to the effect that, as of this time last year, Wakiso District ranked among the bottom 10 on the national health league table, which is an annual Ministry of Health assessment of district performance across key service delivery and patient satisfaction indicators. This was despite Wakiso being Uganda’s most populous district, with over 3.4 million residents today, as it continued to struggle to deliver essential health services to the public. The 2022/2023 Annual Health Sector Performance Report also flagged persistent challenges, including frequent transfers of facility in-charges, overstretched management structures, and weak internal communication and coordination.
It was this stark reality that informed the leadership and management intervention in Wakiso. Officiating the dissemination of the project outcomes, Dr. Sarah Byakika, Commissioner for Planning, Financing, and Policy at the Ministry of Health and a member of the National Oversight Mechanism for the programme, commended the remarkable progress made in just six months, citing visible improvements across the district as a direct result of the intervention.
“I have been involved with this programme right from its inception, and I’m proud that Uganda became one of its major beneficiaries,” Dr. Byakika said with gratitude, commending the strong collaboration between the Ministry of Health, Makerere University, Nottingham Trent University, Nottingham University Hospitals, Wakiso District and the development partners for supporting the initiative. She emphasised the value of this partnership in strengthening leadership and management competencies among Wakiso District health managers to address critical performance gaps in health service delivery.
“Wakiso is Uganda’s largest and most populous district, yet it has long underperformed on key health indices. Despite its semi-urban nature, it faces enormous health service delivery challenges, partly due to the overwhelming burden on its District Health Officer, who oversees more than 60 public and over 340 private health facilities. Many of these private facilities open and close frequently, complicating service oversight,” Dr. Byakika observed with concern.
Her sentiments were echoed by the District Health Officer, Dr. Emmanuel Mukisa, in a message delivered by Wakiso District Biostatistician, Mr. Frank Kakande. He noted that the project had contributed to a noticeable shift in the district’s health system performance, with visible improvements in leadership, communication, and accountability among facility in-charges beginning to translate into better overall health service delivery outcomes.
“You cannot talk about management without addressing performance: they go hand in hand. As someone who sits at the centre of district health data, I can confidently say that performance has improved. During the most recent national local government performance assessment, where I participated in the evaluation, Wakiso District’s health department ranked 18th out of 146 districts. That health ranking is a major achievement. We have consistently performed poorly in the past, but this time, we made significant progress,” Mr. Kakande told the attentive audience, speaking with an air of relief and satisfaction.
The Wakiso District Biostatistician credited part of this progress within the district, from the poor performance last year, to the leadership training and mentorship delivered through the project, citing visible improvements across key health indicators. He stressed the need to sustain this momentum through continued mentorship, internal capacity strengthening, and consistent application of the skills acquired by health managers, particularly in tackling persistent management challenges such as absenteeism, delegation, and accountability.
“Last week, I held a performance review at Kakiri Health Centre III, and the improvements were clear. These management skills are making a difference. You can see the change across indicators. But what matters now is sustainability. The support provided through supervision and mentorship was essential. But it’s up to us to keep the fire burning. We have learned a lot: communication skills, problem-solving, time management, and decision-making. Managers are now communicating better. Even issues like absenteeism are being addressed through proper reporting and action,” Mr. Kakande said.
Earlier, Dr. Musoke, presenting the overall project overview and success, explained that based on initial findings from the baseline and needs assessment, the team co-designed and delivered a structured six-month capacity-building programme targeting 60 health facility in-charges in Wakiso District. The programme blended in-person and virtual sessions, combining practical training with one-on-one mentorship, and included an exchange component between Uganda and the UK to promote international exposure and peer learning. This allowed the health managers to apply new skills to strengthen health outcomes in Wakiso.
“This project rightly focused on addressing gaps in leadership and management. I advocated for including this component in the programme, because our national health review missions consistently show that poor performance often stems from weak leadership and management,” Dr. Byakika affirmed, adding that: “I am pleased to see that nearly all public facilities in Wakiso participated. While the project had a short implementation window, the evaluation already shows encouraging results. Health managers feel more empowered, motivated, and aware of their roles. That’s a significant step.”
For her part, Dr. Sheba Gitta, Uganda Country Director for Global Health Partnerships, formerly Tropical Health and Education Trust, applauded the leadership and management capacity-building initiative in Wakiso as a timely, locally driven intervention. She underscored the value of two-way learning between Uganda and the UK health systems through the programme, noting that Global Health Partnerships works closely with the Ministry of Health to ensure all funded initiatives align with Uganda’s national development priorities.
“What excites me most is that this was not a pre-packaged programme imported from the UK. The training was co-created by partners, based on local realities and needs. That approach reflects strong collaboration between Makerere University School of Public Health and Nottingham Trent University. I thank Prof. Linda Gibson for her continued commitment and Dr. David Musoke for his proactive leadership in bringing this programme to life. Your consistency and quality of work continue to stand out,” Dr. Gitta shared.
While commending the progress made, she cautioned against “pilotism”, as a tendency for promising projects to end prematurely, calling for the model to be scaled up nationally. To support sustainability, she stressed the importance of documenting the training process, outcomes, and costs to inform ministry-level decision-making and long-term adoption.
Dr. Gitta joined Prof. Linda Gibson, the UK Lead for the Project, to encourage the trained managers to become champions of leadership within their facilities and districts, ensuring that the impact of the programme endures beyond its current cycle. She also thanked NHS England and the UK Government for their trust and investment in Uganda’s health system.
-
General2 weeks agoPre-entry Exam Results for Bachelor of Laws 2025/2026
-
Engineering, Art & Tech1 week agoAdvert: Application for Additional Undergraduate Programmes 2025/26
-
Research6 days agoUganda’s National ID Delivers $1.35 for Every $1 Invested
-
Agriculture & Environment7 days agoClimate Resilience and Sustainability Collaborative: 30 Masters, 6 PhD Scholarships 2025/2026
-
General5 days agoMaster’s Scholarship Opportunities: Call For Applications – Faculty Initiated Ideas