Health
Uganda has until 2030 to end Open Defecation as Ntaro’s PhD Examines Kabale’s Progress
Silhouettes slip along narrow paths, farmers heading to their gardens, women balancing yellow jerrycans on their hips, children in oversized sweaters hurrying to school, and herders steering cattle toward open pasture, each movement part of a choreography older than memory. This is a quiet ritual in Kabale’s terraced hills, moments before the sun lifts.
The quiet procession to ahakashaka, or omukishaka, often sees figures moving quickly along familiar footpaths in the half-light, as children and adults walk with the urgency of habit. It is not a stroll but often a small, hurried run before daylight exposes what should be private.
It is February 2026, and the century-old Makerere University is celebrating its 76th Graduation Ceremony. The world paces and races toward artificial intelligence and digital revolutions. But some families still begin their day by rushing to the bushes for relief and concealment, while others engaged in economic activities such as gardening and grazing have no sanitation option other than using their surroundings to respond to the nature call!
The deadline to end open defecation is 2030. The science is settled, and the commitments are written into Sustainable Development Goal 6. Yet in parts of Kabale, only a small fraction of households is truly open defecation free.
In his PhD research, Dr. Moses Ntaro did not start with global targets or conference declarations. He began where the morning run ends, at the edge of the compounds, behind banana stems, along worn paths leading to Omukishaka. He asked whether students, equipped not with bricks but with conversation, follow-up, and persistence, could help communities replace that dash with something quieter: a door that closes.
What he found is both hopeful and unsettling. Change is possible. But dignity, like sunrise, should not require a run. And with 2030 approaching, time is no longer generous.
The Question That Would Not Let Him Go
Ntaro did not encounter open defecation as a statistic. While on foot and serving as Assistant Coordinator of Community-Based Education at Mbarara University of Science and Technology (MUST), he learned while supervising students placed in rural communities across southwestern Uganda. They walked villages together, conducted transect walks… and they observed.
“In my role as academic coordinator,” he explains, “students always took me on transect walks within the villages to show me how high open defecation practice was. The effect was evident in the high prevalence of intestinal infections we saw in health facility records.”
The link between sanitation and disease was not theoretical but visible in clinic registers. Diarrhea, intestinal worms, recurring infections among children, and more were all visible in the clinic registers.
Nineteen years ago, in 2007, Uganda adopted Community-Led Total Sanitation (CLTS), a strategy designed to trigger collective behavior change and eliminate open defecation. Progress, however, remained uneven. That same year, Ntaro was working as an Environmental Health Officer with the Water and Sanitation Development Facility under the Ministry of Water and Environment. He was three years away from completing his Environmental Health degree at Makerere University School of Public Health.
And so, the question emerged, to Ntaro, that, ‘If students are already embedded in these communities through COBERS placements, why are we not intentionally harnessing them to accelerate sanitation change?’
That question became his PhD.
This is a Crisis That Should No Longer Exist
Globally, more than 350 million people still practice open defecation. Sub-Saharan Africa carries a disproportionate share. SDG 6, specifically Target 6.2, commits the world to ending open defecation and ensuring universal access to safe sanitation and hygiene by 2030. It prioritizes women, girls, and vulnerable populations. It speaks of dignity, of safely managed services, and of disease prevention.
We are four years away from that deadline. And in rural Kabale District, somewhere in southwestern Uganda, Ntaro’s research found that only 3 percent of households were truly open defecation-free.
Yes, three percent. His 2025 BMC Public Health study examined 492 residents. The average age was 49. Nearly 30 percent had no formal education. Most were women, the custodians of household hygiene and child health.
The determinants of Open Defecation Free (ODF) status were deeply behavioral.
Male-headed households had higher odds of being ODF. Households with clean compounds, clean latrine holes, and consistent handwashing practices were significantly more likely to sustain sanitation improvements.
Sanitation, Ntaro realized, is not only infrastructure but also power, memory, habit, and social expectation.
“Factors associated with ODF status were not just economic,” he notes. “They were behavioral and contextual.”
Why It Feels So Wrong to Still Discuss This
Talking about open defecation in 2026 feels unsettling for three reasons. First, it feels like a failure of basic dignity.
Think of an era of global connectivity and rapid technological advancement, and hundreds of millions still lack privacy. For women and girls, this exposes them to harassment, exploitation, and fear. Sanitation is not just about disease but safety.
Second, it feels like an avoidable health crisis. One gram of feces can contain millions of viruses, bacteria, and parasites. Open defecation directly fuels cholera, typhoid, diarrhea, and environmental enteropathy, a silent contributor to child malnutrition and stunting. The science is settled, and yet the practice persists.
Third, it feels like a poverty trap. Illness leads to lost productivity; lost productivity deepens poverty, and poverty limits investment in sanitation. The cycle continues.
“Open defecation is not simply a sanitation issue,” Ntaro says. “It is linked to poverty, nutrition, and broader development.”
Testing a Different Approach
Ntaro’s doctoral thesis, “Effect of Student Community Engagement on Open Defecation-Free Status,” tested whether health profession students could effectively facilitate Community-Led Total Sanitation.
In some villages, traditional Health Extension Workers led the sanitation process. In others, trained students facilitated it under the COBERS (Community-Based Education, Research, and Service) model, which places medical trainees in community health facilities to learn through real-world practice, bridging classroom theory with primary care and public health work in rural settings.
Through this model, students led triggering, follow-ups, and community engagement. Open defecation declined. More households achieved Open Defecation Free status. And the cost per household was lower than in traditional approaches.
“Students were more effective,” Ntaro explains. “More households became open defecation-free compared to the traditional approach. And they were a cheaper human resource.”
But cost was not the real breakthrough. Presence was. Students stayed for weeks. They returned to check on latrines. They built trust. They kept coming back. Because sustainability, Ntaro argues, is not built in a single visit. It is built in repetition.
“There is a need for continued follow-ups and continued student engagement if long-term impact is to be realized.”
Change cannot be declared once and forgotten.
Behavior… and Not Just Bricks
Using the RANAS framework, Ntaro found that households that remembered to wash hands and kept latrines clean were far more likely to sustain Open Defecation Free status. In sanitation, behavior leaves evidence.
“Behavioral change interventions that empower communities,” he recommends, “such as CLTSH, should be strengthened to increase households with ODF status.”
In other words, building latrines is not enough, but communities must believe in them.
The Defense and the Countdown
On December 11, 2025, Ntaro defended his PhD. Examiners pressed him on scale and sustainability. Could student engagement be institutionalized? Could universities be embedded in district sanitation planning?
His answer was pragmatic: “Yes, but community-based education must be included in planning and budgeting.”
Four years remain to meet SDG 6.2. Four years to end open defecation and turn dignity from promise into practice. In 2026, this conversation should feel outdated. Instead, it remains urgent.
The Slow Work of Restoration
In Kabale, progress does not look dramatic. It looks like a latrine door closing firmly behind someone, a handwashing station with water and soap, a compound swept clean. It looks like a child who does not fall ill this month. Public health victories are often quiet.
As Makerere University approaches its 76th Graduation Ceremony, Dr. Ntaro Moses stands among its PhD graduands not with theory alone, but with evidence that change can be accelerated by reimagining who leads it. Students, he shows, are not only learners. They are the workforce, facilitators, and bridges between policy and path.
The hills of Kabale still wake under mist. But in more compounds now, privacy exists where bushes once stood open. Dignity is not restored in headlines, but one household at a time.
And with 2030 approaching, Ntaro’s work leaves a final, unavoidable question: if we already know how to end open defecation, if we already have the tools, the evidence, and the people, what, exactly, are we waiting for?
— Makerere University School of Public Health Communications Office, Graduation Profiles Series, 76th Graduation Ceremony
Kampala wakes early, but for some girls, the day begins already heavy. In Uganda, nearly three-quarters of the population is under 30, growing up happens fast, and often without protection. One in four Ugandan girls aged 15–19 has already begun childbearing, giving Uganda the highest teenage pregnancy rate in East Africa.
Layered onto this is displacement. The country hosts about 1.7 million refugees, many living in cities like Kampala, where survival depends on navigating systems not designed with them in mind. Also, nationally, 1.4 million people live with HIV, and 70 per cent of new infections among young people occur in adolescent girls, a reminder that vulnerability is rarely singular. When COVID-19 shut the country down, the consequences were immediate, with pregnancies among girls aged 15–19 rising by 25.5 per cent, while pregnancies among girls aged 10–14 surged by 366 per cent.
The numbers tell a story of youth, risk, and quiet urgency. But they do not tell it all. For years, Olivia Nakisita, a public health researcher,has followed how adolescent girls, many of them refugees, navigate pregnancy in Kampala: how far they must travel for care, how early they arrive or delay, and how often services that exist fail to meet them where they are. Her work lives at the uneasy intersection of policy and lived reality, where access does not always translate into care.
February 25th 2026, is the day that her work on whether urban health systems are truly ready for the youngest mothers they now serve will bring her to Freedom Square at Makerere University, where she will graduate with a PhD in Public Health.
Her doctoral journey, focused on maternal health services for adolescent refugees in urban Uganda, has unfolded at the intersection of scholarship, community service, and the daily realities of young girls navigating pregnancy far from home.
The Work That Came Before the Question
Long before she began writing a PhD proposal, Olivia Nakisita was already immersed in adolescent health. As a Research Associate in the Department of Community Health and Behavioral Sciences at Makerere University’s School of Public Health, she taught graduate and undergraduate students, supervised Master’s research, and worked closely with communities. Beyond the university, she led New Life Adolescent and Youth Organization (NAYO), a women-led organisation she founded in 2021 to strengthen access to sexual and reproductive health and rights (SRHR) information and services for adolescents and young people.
It was through this community work that a troubling pattern began to surface.
“During our community service,” she explains, “we noted increasing teenage pregnancies, and we also noted challenges with access to maternal health services by teenage pregnant girls.”
Among those girls were adolescents living as urban refugees in Kampala, young, displaced, often poor, and navigating pregnancy in a city not designed with them in mind.
For Nakisita, the concern deepened through her academic training in Public Health Disaster Management, one such programme that prepares multidisciplinary professionals with the technical expertise and leadership competencies required to plan for, mitigate, respond to, and recover from complex disasters through a public health lens. This programme sharpened Nakisita’s interest in how displaced populations survive within complex urban systems. Uganda’s integrated health model, where refugees and host communities are expected to use the same facilities, appears equitable on paper. In practice, it can be unforgiving.
“I got interested in understanding how these refugees who get pregnant manage to navigate the complexities of integration in host societies like Kampala,” she says. “This was driven by the desire to address their needs and to inform and evaluate existing refugee health policies.”
That desire became the foundation of her PhD.
Asking Hard Questions in a Crowded City
Her doctoral research, “Maternal Health Services for Adolescent Refugees in Urban Settings in Uganda: Access, Utilisation, and Health Facility Readiness,” was conducted in Kampala between November 2023 and August 2024. It combined quantitative surveys with qualitative interviews, engaging 637 adolescent refugees aged 10–19 years, alongside health workers and facility assessments.
Her findings showed high perceived access to maternal health services. Clinics existed. Services were available. Yet utilisation, particularly of antenatal care (ANC), lagged. “About three-quarters of the girls attended at least one antenatal visit,” she explains, “but only about four in ten attended in the first trimester.”
And that gap matters. Public health research shows that early and regular antenatal care allows health workers to detect high-risk pregnancies, initiate supplements such as iron and folic acid, monitor fetal development, and provide psychosocial support. Without it, risks compound silently.
By contrast, her study found that facility-based deliveries were remarkably high, with nearly all adolescent refugees (98.3%) giving birth in health facilities, suggesting that the system was reachable, but uneven.
Where the System Falls Short
Her research went beyond utilisation to examine whether health facilities were actually ready to serve adolescent refugees.
Findings show that lower-level health centres in Kampala were moderately prepared to offer adolescent-friendly maternal health services. Some staff were trained. Some spaces existed. Despite this, critical gaps remained. For instance, facilities lacked essential equipment and supplies. Non-provider staff were often untrained. Separate, private spaces for adolescents were limited. Language barriers complicated care. Overcrowding strained already stretched health workers.
In her qualitative interviews, health workers expressed empathy and willingness to help. Many relied on peer educators and community health workers to reach adolescent refugees. But good intentions were not enough.
“They recommended training of healthcare workers, translators for refugees, and improvement in the availability of essential drugs, supplies, and equipment,” Nakisita notes.
She notes that readiness is not just about infrastructure but about the people, preparation, and priorities.
Research with an Emotional Cost
For Nakisita, working with adolescent refugees required care, not only methodologically, but emotionally.
Finding participants in Kampala was itself a challenge. Unlike settlement settings, urban refugees are dispersed, often invisible. Ethical considerations were constant. Adolescents who had given birth were legally considered emancipated minors, but their vulnerability remained.
Though the thesis focused on systems rather than personal narratives, Nakisita’s earlier work with adolescents informed every decision she made. It shaped how she framed questions, interpreted data, and weighed policy implications. This was not detached research, but careful, deliberate, and grounded.
The Scholar Formed by Continuity
Nakisita’s PhD sits atop more than 18 years of experience in training, research, and community service. She is an alumna of Makerere College School (UCE), 1996 and Greenhill Academy Secondary School (UACE), 1998, a long journey through Uganda’s education system before her Diploma in Project Planning and Management at Makerere University completed in early 2000s.
She would later return eight years later to Makerere University for her Bachelor’s degree in Social Sciences and a Master’s in Public Health Disaster Management, and now a PhD in Public Health.
Her academic rigor is reflected in extensive training across SRHR, impact evaluation, research methods, ethics, disaster resilience, and humanitarian health. She has presented at regional and international conferences and published in peer-reviewed journals on adolescent health, refugee maternal care, gender-based violence, and health systems readiness.
As a PhD student, she supervised three Master’s students to completion, with another currently progressing, quietly extending her influence through mentorship.
When Evidence Demands Action
If policymakers were to act on one lesson from her research, Nakisita says; “Emphasis should be given to maternal health services for adolescents.” “They are high-risk mothers,” she adds.
Her findings call for targeted community-based interventions, outreaches, home visits, and financial support for adolescents who cannot afford prescribed drugs, delivery requirements, or critical tests like ultrasound scans.
They also call for health systems to move beyond one-size-fits-all models, recognising that age, displacement, and poverty intersect to shape how care is accessed and experienced.
Now that her PhD is complete, Nakisita plans to translate research into action. Several papers from her study have already been published. A policy brief is planned to influence decision-making in urban and humanitarian health settings.
When asked what she would say directly to adolescent refugee girls navigating pregnancy in unfamiliar cities, her response is simple and direct.
“If it happens,” she says, “as soon as you find out, go to the nearest health facility and seek care. Always return for the visits as asked by the health worker. Ensure that you deliver in a health facility with a skilled health worker.”
Arrival, Without Illusion
When Dr. Olivia Nakisita steps onto the graduation stage at Freedom Square, applause will follow. But the true significance of that moment lies in health facilities still struggling to adapt; in adolescent refugees whose pregnancies unfold quietly in rented rooms and crowded neighborhoods; in policies waiting to be sharpened by evidence.
Her scholarship does not promise quick fixes but offers clarity.
Among the PhDs conferred at Makerere University’s 76th graduation, her work reminds us that some research does not begin in libraries and does not end with theses. It lives on in the slow, necessary work of making health systems see those they have long overlooked.
— Makerere University School of Public Health Communications Office, Graduation Profiles Series, 76th Graduation Ceremony
The ward is never quiet during labour. Even at night, there are cries, some sharp with pain, others muted by exhaustion. Monitors beep. Midwives move quickly between beds. In the moments just before birth, everything narrows to breath, pressure, and time.
It was in places like this, years ago, that Phillip Wanduru first learned how fragile that moment can be.
Working as a clinical nurse at Nakaseke Hospital in central Uganda, he watched babies who should have survived struggle for breath. Some were born still. Others cried briefly, then went silent. Many were not premature or unusually small; they were full-term babies whose lives unraveled during labour.
“What troubled me most,” Wanduru recalls, “was that these were complications we have known how to manage for more than a hundred years, prolonged labour, obstructed labour, and hypertension. And yet babies were still dying or surviving with brain injuries.”
Those early encounters never left him. They became the questions that followed him into public health, into research, and eventually into a doctoral thesis that would confront one of Uganda’s most persistent and preventable tragedies.
A Public Defense, Years in the Making
On Friday, June 13, 2025, Wanduru stood before colleagues, mentors, and examiners in a hybrid doctoral defense held at the David Widerström Building in Solna, Sweden, and online from Kampala. The room was formal, but the subject matter was anything but abstract.
His PhD thesis, “Intrapartum-Related Adverse Perinatal Outcomes: Burden, Consequences, and Models of Care from Studies in Eastern Uganda,” was the culmination of years spent listening to mothers, following newborns long after delivery, and documenting what happens when birth goes wrong.
He completed the PhD through a collaborative programme between Makerere University and Karolinska Institutet, under the supervision of Prof. Claudia Hanson, Assoc. Prof. Peter Waiswa, Assoc. Prof. Helle Mölsted Alvesson, and Assoc. Prof. Angelina Kakooza-Mwesige, a team that bridged global expertise and local reality. His doctoral training unfolded as the two institutions marked 25 years of collaboration, a partnership that has shaped generations of public health researchers and strengthened research capacity across Uganda and beyond.
By the time he defended, the findings were already unsettlingly clear.
One in Ten Births
In hospitals in Eastern Uganda, Wanduru’s research found that more than one in ten babies experiences an intrapartum-related adverse outcome. This medical term refers to babies who are born still, die shortly after birth, or survive with brain injury caused by oxygen deprivation during labour.
Among those outcomes, stillbirths accounted for four in ten cases. Five in ten babies survived with brain injury.
“These are not rare events,” Wanduru explains. “They are happening every day, often in facilities where care should be available.”
But survival was only part of the story.
Following infants diagnosed with intrapartum-related neonatal encephalopathy for a year, his research revealed that about seven in ten babies with severe brain injury died before their first birthday. Among survivors, many faced lifelong challenges, difficulty walking, talking, and learning.
“What happens in labour,” he says, “does not end in the delivery room. It follows families for years.”
He describes the findings of his PhD research as appalling, evidence of an urgent failure in how labour and delivery are managed, and a call for immediate action to prevent avoidable complications. “Babies with severe brain injuries,” he notes, “faced the greatest odds. Even when they survived birth, nearly seven in ten died before their first birthday. Of those who lived beyond infancy, about half were left with long-term challenges, including difficulties with walking, talking, or learning.”
Mothers at the Centre—Yet Often Invisible
Wanduru’s work did not stop at numbers. Through in-depth interviews with mothers and health workers, he uncovered a quieter truth that parents, especially mothers, were desperate to help their babies survive, but often felt unsupported themselves.
Mothers followed instructions closely. They learned to feed fragile babies, keep them warm, and monitor breathing. They complied with every rule, driven by fear and hope in equal measure.
“The survival of the baby became the only focus,” Wanduru says. “But the mothers were exhausted, emotionally drained, and often ignored once the baby became the patient.”
Even as mothers remained central to care, their own physical and mental well-being received little attention. For the poorest families, the burden was heavier still: long hospital stays, transport costs, and uncertainty about the future.
These insights shaped one of the thesis’s most powerful conclusions: saving newborn lives requires caring for families, not just treating conditions.
Why Care Fails—Even When Knowledge Exists
One of the most uncomfortable findings in Wanduru’s research was that emergency referrals and caesarean sections did not consistently reduce the risk of brain injury, except in cases of prolonged or obstructed labour.
The problem, he found, was not the intervention, but the delay.
In many facilities, hours passed between identifying a complication and acting on it. Ambulances were unavailable. Referral systems were weak. Operating theatres lacked supplies or staff.
“These are not failures of science,” Wanduru says. “They are failures of systems.”
His work reinforces a sobering reality for policymakers that most intrapartum-related deaths and disabilities are preventable, but only if care is timely, coordinated, and adequately resourced.
From Bedside to Systems Thinking
Wanduru’s path into public health began at the bedside. After earning a Bachelor of Science in Nursing from Mbarara University of Science and Technology in 2011, he trained as a clinician, caring for patients during some of their most vulnerable moments. He later completed a Master of Public Health at Makerere University in 2015, a transition that gradually widened his focus from individual patients to the health systems responsible for their care.
His work gradually drew him deeper into the systems shaping maternal and newborn care. As a field coordinator for the MANeSCALE project, he worked within public and private not-for-profit hospitals, helping to improve clinical outcomes for mothers and babies. Under the Preterm Birth Initiative, he served as an analyst, contributing to efforts to reduce preterm births and improve survival among vulnerable infants through quality-improvement and discovery research across Uganda, Kenya, and Rwanda.
In the Busoga region, he coordinated prospective preterm birth phenotyping, following mothers and babies over time to better understand the causes and consequences of early birth. Since 2016, this work has been anchored at Makerere University School of Public Health, where he serves as a Research Associate in the Department of Health Policy, Planning, and Management.
Across these roles, he found himself returning to the same question: why babies continue to die during a moment medicine has long learned to handle.
Models of Care That Could Change Outcomes
Wanduru’s thesis does more than document failure; it points toward solutions.
He highlights family-centred care models, including Kangaroo Mother Care, which keep babies and parents together and improve recovery, bonding, and brain development. He emphasizes early detection of labour complications, functional referral systems, and rapid access to emergency obstetric care.
“These are not new ideas,” he says. “The challenge is doing them consistently.”
He also calls for recognizing stillbirths, not as inevitable losses, but as preventable events deserving data, policy attention, and bereavement support.
“Stillbirths are often invisible,” he notes. “But they matter to mothers, to families, and to the health system.”
Research That Changes Practice
For Wanduru, the most meaningful part of the PhD journey is that the evidence is already being used. Findings from his work have informed hospital practices, advocacy reports, and quality-improvement discussions.
“Yes, the PhD was demanding,” he admits. “But knowing that the work is already contributing to change makes it worthwhile.”
His mentors see him as part of a broader lineage, researchers committed not only to generating evidence but to ensuring it improves care.
With a PhD in his bag, Wanduru sees his work as a continuation rather than a conclusion.
“The fight to make birth safe for every mother and baby continues,” he says. “I want to contribute to improving care and to building the capacity of others to do the same.”
That means mentoring young researchers, strengthening hospital systems, and keeping the focus on families whose lives are shaped in the delivery room.
Dr. Wanduru joins fellows in the MakSPH PhD forum who concluded their doctoral journeys in 2025, and his work speaks for babies who never cried, for mothers who waited too long for help, and for health workers doing their best within strained systems. It insists that birth, while always risky, does not have to be deadly.
— Makerere University School of Public Health Communications Office, Graduation Profiles Series, 76th Graduation Ceremony
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