Health
Where Garimoi Orach Built the Field, Komakech Studied Its Exit: Advancing Health Systems Resilience Amid Refugee Arrivals & Repatriation
On Friday, December 19, 2025, a doctoral defence at Makerere University School of Public Health (MakSPH) made visible how knowledge transcends across generations. Dr. Henry Komakech, who first trained at the School for his Master’s in Health Services Research (MHSR) between 2008 and 2010 and has served as a Research Associate in the Department of Community Health and Behavioural Sciences (CHBS) since 2014, defended his PhD titled Effects of the Repatriation of Refugees on the Health Services of the Host Populations in the West Nile Districts of Arua, Moyo, and Adjumani. The thesis examined what happens after refugees begin to return home and humanitarian partners withdraw, leaving district health systems to absorb the transition.
Just over two months later, on February 25, 2026, MakSPH took its place in the 76th Congregation of Makerere University at Freedom Square, presenting 231 graduands. The four-day ceremony, held from February 24 to 27, saw the University confer degrees and diplomas on 9,295 graduands across nine colleges and two schools, including 213 PhDs. Of the seven doctoral degrees presented by MakSPH, four came from the Department of Community Health and Behavioural Sciences, where Komakech’s work was supervised and examined. The defence in December had tested the scholarship; the congregation in February formally admitted it into the University’s record.
The scholarship itself engaged a structural public health question shaped by Uganda’s refugee experience. By mid-2025, the United Nations High Commissioner for Refugees (UNHCR) estimated that 117.3 million people were forcibly displaced worldwide due to conflict, persecution, or violence. Of these, 42.5 million were refugees, 67.8 million internally displaced persons, and 8.4 million asylum seekers, with 87 per cent of refugees hosted in low- and middle-income countries, including Uganda.
The country today remains one of the key actors responding to this humanitarian crisis, hosting close to two million refugees and asylum seekers and implementing one of the world’s most progressive refugee policies, which integrates displaced populations into national systems of service delivery under the Refugees Act of 2006 and the Refugees Regulations of 2010.
According to UNHCR, refugee repatriation is the return of refugees to their country of origin, ideally voluntarily, safely, and with dignity when conditions allow. It is one of the most preferred and recognised durable solutions to displacement, alongside local integration in the host country and resettlement to a third country, and is typically organised through tripartite agreements between the country of origin, the host country, and the UN refugee agency.
Yet when repatriation occurs, and sometimes this happens rapidly, numbers in host areas decline, affecting financing, staffing, drug supply, infrastructure, and district planning. In this case, repatriation, as Komakech investigates it, is therefore not simply demographic change due to sudden withdrawal but a health systems transition with governance and fiscal consequences.
“This work emerged from observations I made during earlier studies in Northern Uganda, a region that has hosted large refugee populations for many years,” Komakech observed.
He added, “I noticed that the presence of refugees had varied effects on health services, affecting both refugee and host communities. Yet despite this reality, there was limited research examining how health systems function during periods of transition, particularly as refugee populations move in and out of host districts. This raised an important question: Do districts and aid agencies design health services in ways that can accommodate both incoming and outgoing refugee populations, and what does this mean for service delivery for everyone involved? That question ultimately shaped my study.”
Komakech holds that repatriation matters in humanitarian action and public health emergencies because it offers closure for displaced populations while allowing host countries to reorganise health and social systems as displacement pressures change.
The question that shaped his doctoral research did not emerge in isolation, though. It developed within a field built over decades by Prof. Christopher Garimoi Orach, Professor of Community Health at Makerere University and Komakech’s principal supervisor, an author of more than 100 peer-reviewed publications in high-impact journals whose work has anchored refugee health and public health in complex emergencies within Uganda’s academic and policy landscape while also contributing to global scholarship in the field.
If Komakech examined what happens when humanitarian support withdraws, Orach’s earlier scholarship focused on how health systems respond when displacement arrives. The progression reflects an intellectual continuity grounded in history.
“My work has enabled me to mentor many graduate students in disaster risk reduction and refugee health. About ten PhDs have completed under my supervision in this area,” Prof. Orach said, speaking with the benefit of hindsight after decades of academic mentorship and leadership at MakSPH. “Dr. Komakech’s work is extremely unique. His study examines how repatriation affects health systems in hosting districts, a question rarely studied at this depth, especially at PhD level.”
Uganda’s integrated refugee policy makes the study even more important. Unlike the parallel model, where refugee services operate separately from national systems, Uganda uses an integrated model where refugees and host populations share health services. Therefore, when refugees leave, the health system itself experiences a transition. His findings show the need for preparedness and sustainability planning, since humanitarian funding declines when refugee numbers decrease, Prof. Orach argued.
The field before the student
Orach’s entry into refugee health was not theoretical. After earning his Bachelor of Medicine and Bachelor of Surgery from Makerere University in 1988, he completed his internship at St. Francis Hospital, Nsambya, before being posted to West Nile as a Medical Officer at Maracha Hospital in Arua District in 1989. By 1990, he had become Medical Superintendent of the same hospital, serving in a region shaped by displacement from South Sudan and northern Uganda. Decades later, it would be the same West Nile districts where Komakech conducted his doctoral research.
In that environment, displacement was not a policy concept but a clinical reality. Hospital registers reflected migration patterns. Drug shortages, referral pressures, and fluctuating patient volumes were part of daily management. Refugee health was not yet an academic specialisation, Orach recalls. It was a lived service delivery, observed through overcrowded wards, strained supply chains, and district health systems adjusting in real time to population movements.
Those experiences gradually shifted his attention toward population health. Orach returned to Makerere University for postgraduate training in public health, completing the Diploma in Public Health in 1994, with the programme culminating in the Master of Medicine in Public Health in 1996. His master’s research examined maternal mortality in Gulu District using the Sisterhood methodology, a community-based study that earned him the Community Health Research Award from the World Health Organisation (WHO) Regional Office for Africa in 1997.
The recognition marked an early indication of the policy relevance of Prof. Garimoi Orach’s work. During this period, he also undertook specialised training in refugee studies at Oxford University in 1996 and later in large-scale emergency health response through the International Committee of the Red Cross (ICRC)–WHO Health Emergencies in Large Populations programme in 1997. The academic trajectory was beginning to align with what he had already encountered in practice in West Nile.
In 1999, after completing his master’s training, he intended to return to district service from where it all began. A senior academic intervened. “Professor Gilbert Bukenya asked me where I intended to work,” Orach recalls. “I told him I wanted to return to the district. He said, ‘Chris, you are not going anywhere. You will stay here at the university.’” That decision redirected his career toward academic public health. Between 1996 and 2002, he served as a Research Fellow at MakSPH, at the time called the Institute of Public Health (IPH), combining teaching, research, and field engagement.
International collaboration soon expanded the scope of Orach’s work. Through a European Union–supported partnership linking Makerere University, Oxford University, the Institute of Tropical Medicine in Antwerp, and Moi University in Kenya, he deepened research into refugee welfare policy and emergency public health systems. The collaboration also opened further academic pathways. He pursued additional training at the Institute of Tropical Medicine in Antwerp, completing a second Master of Public Health in 2000, before later earning a PhD in Public Health from Vrije Universiteit Brussel in 2006.
His doctoral research examined reproductive health services for refugee and host populations in Uganda and the policy implications of integrating those services within national health systems. The work, published in The Lancet, which is one of the world’s oldest and most prestigious peer-reviewed general medical journals, informed policy reforms on refugee health at a time when Uganda was strengthening its legal and institutional framework for refugee protection, culminating in the Refugees Act of 2006 and the Refugees Regulations of 2010. Decades later, Komakech would revisit the same policy landscape from another angle, examining what happens to those integrated health systems when refugee populations begin to leave host districts, and humanitarian support recedes.
Orach’s academic career at Makerere subsequently progressed through successive ranks from being appointed Assistant Lecturer in 2003, Lecturer in 2006, Senior Lecturer in 2009, Associate Professor in 2012, and a full Professor of Public Health in 2015. Alongside teaching and research, he also served diligently as Head of the Department of Community Health and Behavioural Sciences from 2010 to 2019 and as Deputy Dean of the School of Public Health from 2012 to 2020. Over these years, he supervised postgraduate scholars and helped consolidate refugee health and public health in complex emergencies into an institutionalised field of teaching and research.
Emergency response gradually became a curriculum. What began as field-informed training, including a short course in Public Health in Complex Emergencies (PHCE) that started in 1999, evolved into formal postgraduate programmes.
In 2014, the School established the Master of Public Health in Disaster Management, drawing on earlier emergency health initiatives and international collaborations. Refugee health systems, disaster preparedness, and post-disaster recovery had entered formal academic training within the institution. By the time Komakech embarked on his doctoral study three years later in 2017, the intellectual infrastructure for the questions he was asking had already been built, with the strong contribution to the field by front-runners like Orach. The scholar who would later examine the system at its point of transition had also grown within that very environment.
“Dr. Komakech’s journey mirrors mine. During my PhD, my supervisor’s illness delayed my completion. In his case, he suffered a severe road traffic accident that required multiple surgeries and interrupted his doctoral studies for several years,” Prof. Orach said, reflecting on the life-threatening accident that forced his student to withdraw from the programme before returning to defend his thesis in December 2025. “Despite this, he continued publishing and remained academically active. When he submitted his thesis draft, its quality surprised us greatly. His perseverance demonstrates true resilience, an essential quality in doctoral training.”
The student within the field
Komakech’s formation shows a long relationship with Makerere University and with the public health questions that would later shape his doctoral work. He first trained at Makerere’s Faculty of Social Sciences, earning a Bachelor of Arts in Social Sciences in 2005 before entering development and humanitarian work. Between 2006 and 2008, he worked with CARE International and the Charity for Peace Foundation, supporting communities affected by displacement and gender-based violence.
The work exposed him to the social and institutional pressures that accompany conflict and forced migration. Seeking stronger analytical tools to understand how health and social systems respond to those pressures, he later enrolled at Makerere University School of Public Health, completing a Master of Health Services Research in 2010.
It was during this period that Komakech first met Prof. Garimoi Orach, beginning an academic relationship that would later shape his doctoral journey. Over more than a decade at the School now, he has served as a Research Associate, contributing to teaching, supervision, and the design and implementation of health systems research.
His work has spanned disaster resilience, refugee integration into national health systems, and the governance of health services in fragile settings, combining field research, project coordination, policy engagement, and academic publication. The doctoral study he defended in 2025 built directly on this sustained engagement with displacement, humanitarian response, and the capacity of public systems to adapt to changing pressures.
The question that emerges when people leave
Komakech’s doctoral study examined the large-scale repatriation of South Sudanese refugees between 2006 and 2009 in the West Nile districts of Arua, Moyo, and Adjumani. Conducted between 2017 and 2019, the research used a mixed-methods design to analyse how district health systems adjust when refugee populations begin to decline.
The study investigated three related questions of how the repatriation process unfolded in the districts, how health services were reorganised once refugees left, and whether those services remained sustainable after humanitarian actors scaled down operations. Evidence was drawn from policy and programme documents alongside 81 key informant interviews with government officials, district health managers, humanitarian agencies, and community stakeholders.
The results from the study confirm that the repatriation process itself within the areas was highly structured and collaborative. In this process, national and district governments worked with UN agencies, humanitarian organisations, and refugee communities to organise voluntary return. Information campaigns, confidence-building visits to areas of origin, health screening, and reintegration support helped prepare refugees for departure and reduce uncertainty about conditions back home. Through this coordinated system, nearly 95,000 South Sudanese refugees were repatriated from settlements across the West Nile districts between 2005 and 2009.
The departure of refugees, however, was found to reshape local health systems within host communities. Dr. Komakech’s thesis reports that during periods of influx, humanitarian agencies expanded district capacity by providing essential medicines, health workers, infrastructure, and logistical support. Once repatriation began and aid organisations withdrew, district health teams assumed responsibility for facilities and services previously supported by humanitarian partners.
Although Uganda’s integrated refugee policy enables these services to be absorbed into the national health system, the study reports, districts often face persistent shortages of medicines, personnel, and operational funding. Many facilities established for emergency response were found to remain in place but lacked sustainable financing for routine service delivery.
In earnest, the study characterises repatriation as a health systems shock, affecting governance, financing, and service sustainability. Its author cogently states that humanitarian resources tend to decline rapidly when refugee numbers fall, while government allocations adjust more slowly through national budget cycles. Consequently, he notes, district health systems in the areas inherit expanded responsibilities without equivalent continuity of resources;
“Districts do not experience relief when NGOs leave,” Komakech explained. “They transition from supported service delivery to unfunded responsibility.” The research also reveals variation across districts. In Arua, earlier integration of partner-supported services into district structures helped cushion the transition, suggesting that governance choices and early planning indeed influence how systems absorb the shift from humanitarian response to routine service delivery.
The evidence in his study points to the need to treat repatriation as a planned health systems transition rather than a simple population movement. Dr. Komakech, in his recommendations, calls for humanitarian agencies to align exit strategies with district health planning, urges the government to integrate refugee-supported services into national systems early, and highlights the need for sustained investment by both government and development partners to ensure that district health services remain functional as humanitarian support declines.
For his mentor and principal supervisor, Prof. Orach, the study confirms Komakech’s growing authority in the field, following his graduation with a PhD in Public Health from Makerere University on February 25, 2026.
“I now consider Dr. Komakech a health systems expert in refugee health. Having worked in this field for nearly a decade now, he is well-positioned to advance research on health systems in emergency settings. His work demonstrates how governments, NGOs, and communities can collaborate to sustain healthcare during repatriation. He is an important asset to the university and will likely be sought after by humanitarian organisations. I hope he remains in academia to continue advancing this developing field.”
Mentorship and the reproduction of scholarship
Mentorship was at the heart of the bond between Prof. Orach and Dr. Komakech, built on trust, mutual respect, and a shared commitment to advancing public health scholarship and research at Makerere University School of Public Health. For Orach, supervising a PhD was never only about research guidance; it meant nurturing a scholar, shaping independent thinking, and opening paths for leadership in the field.
“My mentorship philosophy is simple,” Orach explained. “I see students as future scholars who should surpass me. I guide them toward unexplored areas where they can lead. Knowledge must be shared openly, and students should always have direct access to their mentors. Silence concerns me. Active engagement is essential.”
The philosophy prioritises intellectual independence. Rather than directing students toward his own research agenda, Prof. Orach encourages them to pursue critical questions that expand the boundaries of public health scholarship. Dr. Henry Komakech’s own doctoral work exemplified this approach. “Prof. Orach played a critical role throughout my PhD journey, offering guidance beyond academics, shaping study design, methodological rigour, theoretical grounding, and policy relevance. His mentorship helped me navigate difficult phases of fieldwork, analysis, and writing while encouraging independence and critical thinking,” Komakech reflected.
Mentorship remains a cornerstone of MakSPH’s scholarly culture, reflected in the Department of Community Health and Behavioural Sciences, chaired by Assoc. Prof. Christine Nalwadda, since March 2020 Dr. Nalwadda praised Komakech’s contribution to advancing the School’s mission, noting: “As a School, we are proud of the work of our scholars and the impact it has on the University and the communities we serve. Dr. Komakech’s research addresses a matter of national and regional importance. Uganda hosts nearly two million refugees, the largest refugee population in Africa, and understanding how health systems adjust when populations move is critical. His work provides vital evidence to guide planning and ensure health services remain responsive during these transitions.”
She said her department now has 12 faculty members, 11 holding doctoral degrees, with the remaining colleague progressing through their doctoral training. This concentration of expertise reflects a culture where mentorship and scholarly development are central. Within this environment, the mentor-student relationship between Orach and Komakech represents more than individual achievement. Orach’s scholarship established refugee health and public health in complex emergencies as an institutionalised area of study at the School, and Komakech’s research extends this trajectory, examining how health systems endure once humanitarian intensity declines.
Looking ahead, Dr. Henry Komakech wants to consolidate this emerging field, mentor younger scholars, and ensure research evidence informs policy and practice for refugee and displaced populations. For Prof. Christopher Garimoi Orach, this progression represents the deeper purpose of doctoral training. “Public health must lead in fragile and humanitarian settings,” he asserts. “We must train highly skilled professionals like Komakech in disaster and humanitarian response who can operate within strong governance and funding structures. My greatest satisfaction is producing more PhDs equipped to lead in these contexts. I am confident our efforts are bearing fruit, though much work remains.”
Fifteen years after a sustained investment of over $100 million, Makerere University has transitioned Uganda’s digital health systems and assets to the Ministry of Health, marking a fundamental shift from externally supported interventions to full national ownership.
On 31 March 2026, a handover ceremony at Uganda’s Ministry of Health marked the closing of one chapter in Uganda’s digital health journey and the beginning of another, one in which systems built over 15 years through the Makerere University School of Public Health Monitoring and Evaluation Technical Support (MakSPH-METS) Program now sit firmly within government hands.
The national handover event brought together a cross-section of Uganda’s health leadership, academia, and development partners, led by the U.S. Ambassador to Uganda, H.E. William W. Popp; the Permanent Secretary, Dr. Diana Atwine; and the Director General of Health Services, Dr. Charles Olaro. They were joined by the CDC Country Director, Dr. Mary A. Boyd, senior government officials, implementing and development partners, technical teams, and the media. At the center of that moment was Makerere University School of Public Health, an institution that, over more than 70 years, has built its reputation as one of the region’s most enduring public health research and training hubs, working hand in hand with ministries of health, districts, referral hospitals, and partners to turn evidence into public systems that last.
Back in time, Uganda had made important gains in HIV control, but behind those gains were structural weaknesses that could not be ignored: fragmented data monitoring and evaluation systems, parallel reporting channels, weak digital integration, limited surveillance responsiveness, constrained oversight in decentralized structures, and uneven quality assurance across the HIV continuum of care. The problem was not simply that data existed in too many places but it was that the health system could not always use that data quickly enough, coherently enough, or at sufficient scale to guide action.
The MakSPH-METS program was designed as a response to that reality, build the backbone of a data-driven health system, supported through three successive grants totaling US$103.8 million by the United States Government through Centers for Disease Control and Prevention (CDC) and the President’s Emergency Plan for AIDS Relief (PEPFAR).
The program, rather than working around government systems, worked inside them with a deliberate and system-wide focus to strengthen health information systems, expand surveillance, improve governance and accountability, institutionalize quality improvement, and build the workforce needed to run all of it.
That choice to work within the Ministry of Health structures and across decentralized systems made all the difference. It meant the investment was not in parallel projects, but in national architecture, and over time, that architecture began to take shape.
Reporting through DHIS2 (District Health Information System 2), the world’s largest open-source health management information system platform improved from 58 percent in 2020 to 98 percent in 2025. DHIS2 is a flexible, web-based tool used to collect, manage, and analyze both aggregate and individual-level data.
Also, tracked through the MakSPH-METS program, electronic medical record coverage rose to a high of 86 percent in 2024 from 50 percent in 2020, and reached 100 percent in high-volume sites. Additionally, a functional National Data Warehouse came into place. Across the country, 1,300 health facilities implemented HIV case-based surveillance, 1,084 facilities implemented HIV recency surveillance, and 300 sites established all-cause mortality surveillance. Six regional referral hospitals were implementing integrated surveillance for severe acute respiratory infections, influenza-like illness, acute febrile illness, and SARS, popular for Severe Acute Respiratory Syndrome, which is a viral respiratory illness caused by the SARS-associated coronavirus. At the governance level, 10 regional referral hospitals and 65 CDC-supported districts were trained and supported in planning and oversight, while regional referral hospital capacity scores improved from 58 percent in 2021 to 79 percent in 2024.
These are strong statistics. But the deeper story is that Uganda moved from fragmented systems to a more integrated, data-driven public health response. What had once been separate reporting streams, paper-heavy workflows, and delayed visibility became a system able to provide more timely access to data, better accuracy, stronger dashboards, and more confident decision-making. Health workers could access patient information faster. Today, district leaders are able to review performance data more accurately, national programmes can respond more strategically and data is no longer just collected, but used.
The transition also touched the practical side of care, including laboratory systems, patient records, commodity tracking, quality improvement, and outbreak intelligence.
Dr. Alice Namale, Executive Director of MakSPH-METS Program, was careful during the handover not to let the digital systems overshadow the broader institutional gains. MakSPH-METS, she noted, had “improved regional referral capacity and the district health team capacity to manage programs,” and those systems were now being leveraged by disease programs beyond HIV. She also captured the spirit of the team behind the work, saying the staff had adapted through a changing landscape. “For us, it was never business as usual. We had to continuously adapt as the landscape kept changing, and the team delivered with grace and professionalism,” Dr. Namale said.
Adding that; “We have strengthened systems and built capacity across the health sector, and these gains are now supporting not just HIV programs, but broader health services.”
That wider view matters that the systems handed over were not only about HIV reporting but they included platforms for electronic medical records, HIV case-based surveillance, stock monitoring, quality improvement, early infant diagnosis, viral load reporting, PEPFAR reporting, DREAMS tracking tool for tracking adolescents and young people data, outbreak and respiratory illness surveillance, ICT asset tracking, and e-learning platforms. In plain terms, these are the tools that allow clinicians to see results faster, managers to monitor performance more clearly, districts to respond to outbreaks sooner, and national leaders to plan with greater confidence.
The Ministry of Health now boasts of 16 such systems that have been fully developed and handed over, including UgandaEMR repositories, DREAMS Tracker, PREV Tracker, the HIV CBS dashboard, the Weekly Stock Status System, OpenHIM for health information exchange, EMR metrics, eIDSR, a platform for documenting patient level data on acute illnesses like pandemics, the QI database for visualising facility data on continuous improvement, EID and viral load dashboards, TB eCBSS, PIRS that supports PEPFAR indicator reporting beyond the DHIS2, and the SURGE Dashboard, a power BI based reporting platform.
This handover included 725 servers, more than 4,700 computing devices, solar systems for nearly 800 facilities, connectivity equipment for more than 1,300 sites, video conferencing systems, and network upgrades for regional referral hospitals. Those investments, valued at about US$9.3 million in ICT infrastructure alone, helped kick-start Uganda’s digitalization journey in practical terms: power, devices, connectivity, storage, and the ability to sustain real-time data exchange across facilities.
For the Ministry of Health, the significance of this transition is both strategic and immediate. Dr. Charles Olaro, Director General of Health Services, put it plainly that “Data is the lifeblood of decision-making,” and it provides “the raw materials for accountability.” In a sector where financing, human resources, commodities, and performance all depend on credible information, that was not a ceremonial line, but was a statement of what national ownership now requires.
“As a Ministry, we are focused on how this can support sustainable national ownership that is built to last, while strengthening resilient health systems. We look forward to leveraging these gains as part of our national digitalization roadmap, ensuring they continue to support and improve our systems moving forward,” said Dr. Olaro.
Dr. Diana Atwine, Permanent Secretary at the country’s Ministry of Health, spoke with equal clarity about what comes next. She described the handover as both a celebration of “tangible milestones of growth” and a call to responsibility. Uganda, she said, is not going back to paper-heavy systems. “We are not going to start again. We are just moving ahead.” At the same time, she was firm that ownership must come with inventory, verification, deployment, maintenance, and continued investment in people.
Calling the digital systems and assets “this treasure,” she urged districts and hospitals to take care of it, and made a broader plea that Uganda government should not lose the skilled workforce developed through the partnership, especially the technical teams that established these systems under the program. “This is the cream of the cream,” she said, arguing that the country should find ways to retain this talent as digital systems expand.
On his part, the U.S. Ambassador to Uganda, William W. Popp, framed the handover in similar terms, as a move from project implementation to self-reliance. He described it as “a new phase in national ownership and sustained self-reliance,” and linked it to the December 2025 U.S.-Uganda health memorandum of understanding, which set out a broader vision of government-led delivery, accountability, and stronger national systems. He stressed that foreign assistance, when delivered with discipline and accountability, should build lasting national capacity. In his words, the handover symbolizes a stronger Ugandan health system that benefits Uganda, the region, and the wider world.
For Makerere University School of Public Health, the moment was deeply consistent with its long institutional identity. The School began in the 1950s as preventive medicine, grew into one of sub-Saharan Africa’s earliest public health institutions, and has remained closely linked to the Ministry of Health through teaching, service, research, and workforce development.
Emphasizing the Ministry’s continued reliance on national expertise and long-standing institutional partnerships, the Permanent Secretary underscored the critical role of the Makerere University School of Public Health in sustaining and advancing Uganda’s health systems:
“We are still going to work with you… because you are our important resource in the country. You have the skill, you have the experience—and above all, you are Ugandans,” Dr. Diana Atwine said emphatically.
Her remarks stresses not only MakSPH’s technical capacity, but also the trust it has built over years of collaboration with government positioning the School of Public Health as the Ministry of Health’s strategic partner in driving nationally owned, sustainable health system improvements.
MakSPH has worked across more than 25 countries in Africa in recent years, trained thousands of public health professionals, and sustained long-term partnerships with organizations including CDC, NIH, the Global Fund, Johns Hopkins, WHO, the UN agencies and others. Its own strategic direction emphasizes community engagement, policy influence, partnership, and translating research into practical public good.
That is why Prof. Rhoda Wanyenze, Dean of MakSPH and Principal Investigator of METS, described the handover not as an ending, but as a transition. “As an academic institution, we are always exploring—looking for innovative, creative ways of doing things. We test them, and then work with key actors to take them over, scale them up, and sustain them,” she said. Later, she added, “This is not the end. This is the beginning of a new phase.”
For Wanyenze, that philosophy has always been intentional. “This is not our data, this is not our house, this is Ministry of Health,” she emphasized, an approach that places national ownership at the center from the very beginning. The School’s role, then, is not to hold systems, but to build them, prove them, and let them go when they are ready to stand.
And when that happens, she argues, it is not a loss but success. “When what we have contributed to is taken over, sustained, and continues to grow—that is success.”
For years, much of Uganda’s health system operated with limited visibility, records stacked in paper files, data delayed, and decisions often made without a clear picture of what was happening on the ground. That is what makes this moment different.
After more than 15 years of investment and collaboration, Uganda is now taking over a digital health infrastructure built not just to collect data, but to actually use it, making information more timely, accessible, and practical for decision-making. The handover of the Monitoring and Evaluation Technical Support (MakSPH-METS) programme assets and systems marks more than a transfer of equipment or platforms; it reflects a shift toward a system that can better generate and use its own data.
In the end, the legacy of MakSPH-METS is not only the hardware, but something less visible and more important: a stronger ability to make informed decisions, knowing where the burden lies, where gaps remain, where stockouts occur, where patients are lost, and where progress is being made.
In Uganda, children arrive at health facilities every day with fever, cough, injuries or routine illnesses. What health workers rarely recognise is that some of these children are already living with alcohol or other substance use disorders, conditions that complicate diagnosis, delay treatment, and quietly undermine children’s health, development, and long-term wellbeing.
This hidden reality was uncovered by Dr. Harriet Aber Odonga during her doctoral research at Makerere University School of Public Health (MakSPH). Her PhD study, titled “Substance Use among Children in Mbale, Uganda: Health System Landscape and Support Structures,” examined how Uganda’s health system detects and responds to substance use among children aged six to 17 years.
The findings revealed a problem far more widespread than many health workers and caregivers assumed. Nearly one in four children attending health facilities showed signs of alcohol or other substance use problems, with alcohol the most common substance. In the study, a child was classified as having a “probable” substance use disorder when responses to a standard screening questionnaire indicated harmful or dependent patterns of use requiring further clinical assessment.
The discovery adds urgency to an already serious public health challenge. Globally, alcohol and other substance use is responsible for one in five deaths and contributes to more than 200 disease and injury conditions, according to WHO. Across Africa, alcohol alone accounts for 6.4 per cent of all deaths and 4.7 per cent of disability-adjusted life years. In Uganda, alcohol use disorder affects roughly 7.1 per cent of the population and contributes to about 7% of all deaths, while research among young people shows that alcohol exposure often begins early in life.
Despite these risks, most policy and research attention has historically focused on adults and older adolescents. Much less is known about children who begin experimenting with alcohol and other substances earlier in their childhood, a gap Aber set out to examine by studying how Uganda’s health system identifies and responds to substance use among children.
A research question begins
Aber’s interest in the subject began unexpectedly. “I remember seeing a notice calling for PhD students to research child alcohol use,” Dr. Aber recounted. “The phrase struck me immediately. I could not believe that children were drinking alcohol. That moment sparked my curiosity, so I began reviewing the literature on the subject in Uganda. During that search, I came across a study documenting alcohol use among children as young as five years old. That finding was deeply unsettling and raised many questions for me.”
With a longstanding interest in child health, Aber saw the research as an opportunity to investigate a problem that had received little systematic attention. What began as disbelief developed into a doctoral investigation examining how Uganda’s health system identifies and responds to substance use among children. She began her doctoral studies in 2021 at MakSPH under the supervision of Dr. Juliet N. Babirye, Prof. Fred Nuwaha, and Prof. Ingunn Marie S. Engebretsen from the University of Bergen, Norway. She defended her thesis on October 25, 2025, before graduating during Makerere University’s 76th graduation ceremony on February 25, 2026.
Investigating the health system response
Aber’s study examined four key questions. It measured how common substance use disorders are among children visiting health facilities. It assessed whether health facilities are equipped to screen and manage these cases. It evaluated whether screening tools are acceptable to children, caregivers, and health workers. It also examined how families seek help when children begin using substances.
To answer these questions, the research used a mixed-methods design combining quantitative surveys and qualitative interviews. Aber collected data from 834 children attending health facilities in Mbale District, assessed 54 health facilities in the district to determine their readiness to screen and manage substance use disorders, and interviewed health workers, caregivers, and children to understand experiences of care and barriers to seeking help. Additional surveys involving 602 children and 355 caregivers examined help-seeking patterns and support structures.
Quantitative data were analysed to estimate prevalence and identify associated risk factors, while qualitative interviews provided insight into how families, communities and health workers respond when children begin using substances.
What the research found
Data collected between 2023 and 2024 across health facilities in Mbale District in Eastern Uganda showed that substance use among children was far more common than many health workers and caregivers assumed. Alcohol use disorder emerged as the most prevalent form of substance use disorder among children in the study. The analysis also showed that children were significantly more likely to use substances if they were exposed to peer or sibling use, lived in lower-income households, or experienced strained relationships with caregivers.
The research also revealed major health system gaps. Only 19 of the 54 health facilities assessed, representing 35 per cent, met the minimum readiness criteria required to screen, diagnose or manage substance use disorders. Many facilities lacked trained staff, standardised screening guidelines, and clear referral pathways for specialised care.
Aber explained that substance use often goes undetected because it is rarely the primary reason children visit health facilities. “Substance use is hidden,” she asserted, reflecting on evidence from her doctoral study. “While health workers are treating other illnesses, some children coming to these facilities are already struggling with alcohol or other substances.”
She added that early substance use can have lasting consequences for children’s development. “Risk was higher among children exposed to peer or sibling substance use, lower household income, lower caregiver education, and strained child-caregiver relationships. The public should be concerned because early substance use affects brain development, mental health, education completion, and long-term well-being.”
Families often navigate the problem alone
Her research also examined how families and communities respond when children begin using substances. She found formal help-seeking to be rare. Many caregivers relied on informal networks, including relatives, teachers, religious leaders, and local authorities. Health services were seldom the first point of support.
Meanwhile, punitive responses such as discipline or punishment were sometimes used by caregivers attempting to stop the behaviour of substance use among children, but these responses rarely addressed the broader social and family pressures influencing the vice.
One encouraging finding emerged from her study’s assessment of early detection tools. Aber evaluated the use of the CRAFFT screening tool, a short set of structured questions used by health workers to identify whether a child may be using alcohol or other substances. Children, caregivers, and health workers generally found the questions from the tool easy to understand and acceptable to use. In the study, over 85 per cent of children reported the questions were easy to answer, and nearly nine in ten caregivers were comfortable with the screening process.
These findings, however, suggest that routine early detection could be integrated into primary healthcare within the communities. “If policymakers were to act on one finding from my research, I would prioritise integrating routine, age-appropriate substance use screening into primary healthcare,” Aber argued. “With proper training and referral systems, health workers can identify early risk and support children before the problem escalates.”
Training across nutrition, public health and health systems
Aber’s approach to the problem reflects a research journey shaped by training across multiple areas of child and public health. She first studied Food Science and Technology at Kyambogo University, graduating in 2011, before specialising in Nutrition during her Master of Public Health at Makerere University, graduating in 2015, before embarking on her doctoral training in Public Health at the School, completing in 2025 to graduate at Makerere University 76th Congregation.
Before beginning her PhD, she worked on nutrition research and later coordinated studies examining climate risks, anticipatory humanitarian action and community health systems. This background shaped how she approached substance use among children, not as an isolated behavioural problem but as an issue influenced by broader health and social conditions.
“I do not see child substance use as a problem with a single cause,” she noted. “It is influenced by biological, psychological, social, and system-level factors. My nutrition training helped me appreciate how substance use intersects with broader child health concerns such as mental health, family stress, and even food insecurity.” These pressures are visible in her research site in Mbale, where environmental shocks, economic hardship, and family instability persistently shape daily life. Recurrent landslides and livelihood disruptions place strain on households, and adolescents facing stress or instability may turn to substances as a coping mechanism, she holds.
From evidence to solutions
Completing her PhD has now shifted Aber’s perspective from documenting problems to identifying solutions for social impact. “Completing my PhD shifted my perspective from simply generating evidence to actively providing solutions,” she observed. “Child health challenges such as substance use, nutrition, and climate-related risks are interconnected. As a researcher, I have become more systems-focused, and as an advocate, I feel a stronger responsibility to ensure evidence informs policies that improve children’s wellbeing.”
For Aber, that responsibility extends to the families whose experiences informed the research. Parents, teachers, and health workers often notice behavioural changes first, even when they feel unprepared to respond. Listening without judgment, recognising warning signs, and linking children to appropriate support can make a significant difference, she noted, especially in a context where formal services remain limited.
Her research ultimately sends a clear message for Uganda’s health system. Children affected by substance use are already present in communities and health facilities. Detecting the problem earlier, strengthening screening systems, and equipping frontline health workers with appropriate tools could significantly improve outcomes for vulnerable children.
Behind the research journey stood a wide network of support, including MakSPH supervisors and doctoral committee, the TREAT consortium, the MakSPH PhD forum, the Health Development Centre secretariat, study participants, research assistants, family and friends, and funding support from the Government of Uganda through the Makerere University Research and Innovations Fund (MAKRIF) and the Norwegian Research Council, all of whom she remains grateful.
Aber’s research ultimately points to a critical gap in Uganda’s health system. Children affected by substance use are already present but remain largely invisible. Without routine screening, trained health workers, and clear referral systems, opportunities for early intervention are often missed. Addressing this gap, as indicated by her study, goes beyond clinical care. It requires strengthening how the health system recognises and responds to emerging risks that affect children’s long-term health and development.
By Carol Kasujja and Zaam Ssali
Medical students at Makerere University have been urged to wear the white coat with humility as they begin their journey in the medical profession.
The call was made during the White Coat Ceremony held on Thursday at the Makerere University College of Health Sciences in Mulago.
The White Coat Ceremony marks the beginning of a new journey in healthcare and symbolises professionalism, compassion and excellence. It represents not only the mastery of medical knowledge but also a promise to always place patients at the centre of care. It is a commitment to listen, advocate, heal, and treat every individual with dignity and respect.
“We would have given you a suit, but the symbol of the white coat reminds you that you are here to work. White signifies purity in service. You are in medical school because you are among the best, and you have some of the best lecturers,” said Bruce Kirenga, the Principal of the College of Health Sciences.
Prof Kirenga lauded the students for their dedication to a path dedicated to preserving lives and urged the students to serve with dedication and protect the image of health workers.
“These days, you can use Artificial Intelligence to generate entire coursework, but when it comes to practice, remember the university has an AI policy and you must use it responsibly. In medicine, you take responsibility for your decisions. AI may make life easier, but you must learn and use your hands. Go where the patients are,” he noted.
Prof Kirenga also reminded the students that a medical career offers different paths, including research, teaching, clinical care, and administration.
“As first-year medical students, support each other. Find peers to share your struggles with, especially those in your year. Get mentors and coaches. It took me 26 years to become a Principal, so find mentors who can guide you,” he advised.
Speaking at the event, Sabrina Kitaka, a senior lecturer at the medical school, urged students to uphold the values expected of someone putting on the white coat by being humble and making sure that they connect with their patients.
“Wearing a white coat is a symbol of your commitment to a profession full of honour. This moment is like a rite of passage, from adolescence into adulthood. Joining this noble profession does not make you more important than other students. Be humble,” Dr Kitaka said.
She also encouraged the students to show kindness and compassion to their patients.
Addressing the students, Dr Idro Richard, the Deputy Principal at the College of Health Sciences, called upon the students to always make sure that they keep patients secrets.
“People will come to you and share secrets they have never shared even with their closest family members, do not share people’s pains. If one of you makes a mistake the public will blame all the fraternity so handle your patients with dignity. Always place yourself in the life of those patients when you are in the ward,” Dr Idro, said.
Dr Idro reminded the students to always think of their safety while on the ward by avoiding open shoes.
“Be smart for your own safety, always wear closed shoes, a needle can fall and hurt your legs when you are wearing open shoes. Maintain the excellence you had when you joined and avoid doing life alone,” Dr Idro said.
He further advised the students to always create time and have fun because it is not all about medicine
“Have an open mind, have some fun and also learn other things like soft skills, write, sell and travel. You are in the best School with the best teachers do not allow mediocrity. Avoid cheating, laziness, drugs and betting,” Dr Idro, noted.
In her speech, Anne Atukunda Ronaldine, the chairperson of the Makerere University Medical Students Association (MUMSA), told the first years that they are privileged to join the College as it celebrates a century of excellence.
“Be your brother’s keeper. You will make it together if you work together as a class. Do not avoid your lectures. Medical school is a lot of work, but it gives back,” Atukunda said.
During the ceremony, the College of Health Sciences safeguarding and inclusion champions encouraged students to speak up and report any form of harassment, abuse, or unsafe situations, noting that safeguarding is everyone’s responsibility.
The champions reminded students that creating a safe learning environment requires respect for one another, responsible behavior, and the courage to raise concerns when something is not right. They also urged the new students to support their peers and make use of the available safeguarding channels whenever they feel unsafe or witness misconduct.
The Champions also called upon their peers to support students with disabilities so that no one is left behind. It was a proud moment for many first-year students to finally see themselves wearing white coats, as it was a dream come true for many. The event concluded with a cake-cutting ceremony and a dinner.
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