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.”
Makerere’s School of Public Health (MakSPH) is expanding faster than it can house itself. It now hosts more than 1,000 students, runs programmes across multiple countries, and anchors a large share of the University’s research output. Yet parts of its operation still spill into rented space, costing over $113,000 a year, because the infrastructure has not kept pace with its growth.
That constraint sits uneasily with the School’s economic weight. Health research accounts for more than half of Makerere University’s academic output, making it one of the University’s most productive engines. As Vice Chancellor Barnabas Nawangwe put it, “An educated population is a healthy population, and an educated and healthy population is a prosperous population.”
Beyond the university, health is not just a social outcome but a driver of economic performance. Healthier populations are more productive, more resilient, and less costly to sustain. Investments in public health, whether in prevention, systems, or infrastructure, raise an economy’s productive capacity, not just improve outcomes.
Institutions that generate public health knowledge and train professionals are not peripheral to growth; they are part of its foundation.
It is this logic that is shaping how Makerere’s School of Public Health is positioning itself. At its centre is a new, unfinished complex on the University’s main campus, intended to anchor the School’s next phase as a regional hub for research, training, and policy support. But like much of the system it supports, it is being built gradually, in a “build-as-you-go” approach constrained as much by funding realities as by design.
Construction of Phase II of the MakSPH complex is now at an advanced stage, with progress recorded across all sections of the site. As of March 2026, Phase 2B is nearing completion at 98%, while Phase 2A stands at 89%, and Phase 2C at 69%, each tracking close to or slightly ahead of planned targets. Current works are concentrated on interior finishes—including tiling, terrazzo installation, and external rendering—as well as preparations for lift installation, signaling a transition from structural works to final detailing. The project team is working toward a practical completion date of August 31, 2026, with timelines calibrated to align with broader resource flows and implementation considerations.
Six years ago, in February 2020, construction began on what will be the new home of the School of Public Health. The building, a permanent, purpose-built public health facility on Makerere’s main campus, will accommodate a growing student body, provide space for doctoral and postdoctoral fellows, and strengthen the University’s ability to respond to Africa’s most pressing public health challenges.
Professor David Serwadda, Professor Emeritus at Makerere University and Chair of the MakSPH Infrastructure Fundraising Committee, said the construction journey reflects the School’s “ambition, intent, and courage”—a bold step despite limited resources. He was speaking at a public lecture on health financing held at Makerere University on April 9, 2026.
But the ambition behind the project is not modest. “We are not building for today—we are building for the future,” said Professor David Serwadda, reflecting on a decision that shaped the entire construction effort. “We need to build for the next 100 years.”
That long view helps explain both the scale of the project and the risks taken to start it. When construction began, the School did not have the full funding. “We started with about a third of the required budget,” Serwadda said.
The approach was not without setbacks. A major grant from USAID, worth over a million dollars, was later withdrawn, midway through the construction, due to the closure of USAID. “We received what is called a ‘Dear John letter,’” he recalled. “At that moment, we felt the situation was a major blow, almost terminal for the project.”
But the project did not stop. It adjusted. “We said, let us continue, piecemeal,’” he said. “Finish the auditorium first, use it, and keep building the rest.”
“We have come a long way as the School of Public Health,” said Professor Rhoda Wanyenze, the Dean. “We are proud of that history, but we also recognize that it comes with responsibility.”
She argued that responsibility is no longer confined to Uganda. With ongoing collaborative work in more than 25 African countries currently, the Dean says this is “a responsibility to provide leadership in public health not only in Uganda but across the continent.”
The scale of that growth has been visible from what was once a small training unit in the Faculty of Medicine in the 1950s, which has expanded into 12 academic programmes and more than 1,000 students.
“When I came back for my public health training, we were about 40 students,” she said. “Now, we have more than 1,000.” “Public health is growing and evolving,” Wanyenze said. “And we are doing our best to develop the skills needed for this changing landscape.”
That includes new areas such as health informatics and data science, driven by the digitisation of health systems and the growing role of data in decision-making and AI. The School is already coordinating regional platforms on digital health, linking multiple countries in shared learning and practice.
But this growth has outpaced the physical systems needed to sustain it. For the University leadership, the implications extend beyond infrastructure.
“One of the most effective ways to invest in health in Uganda is to invest properly in Makerere University,” said Vice Chancellor Barnabas Nawangwe. “We must recognize Makerere as a research-led university with a special national role—not fund it like any other institution or department. Makerere is one of the government’s greatest assets. Invest in her, and the returns will exceed expectations.”
Professor Nawangwe hailed Dr. Ramathan Ggoobi, the Permanent Secretary to the Treasury, who delivered a keynote on investing in health for Uganda’s future in view of Vision 2040. “I wish to thank Dr. Ramathan Ggoobi and his team for their personal intervention in allocating resources in next year’s budget to complete the new School of Public Health building. That support is deeply appreciated,” he said.
Uganda’s progress in health outcomes is evident, but uneven. Life expectancy has risen significantly from about 50 years in 2000 to roughly 68.8 years in 2024, according to the Permanent Secretary to the Treasury, Ramathan Ggoobi. Yet the gains sit alongside persistent financial strain on households. About 4% of Ugandans still spend more than a quarter of their consumption on healthcare, pushing many into poverty as a result of illness.
For Ggoobi, this points to a structural gap that recurrent government spending alone cannot close. “We must mobilise long-term domestic capital without adding fiscal risk,” he argued, pointing to the need for more sustainable financing mechanisms. Central to this is the gradual design and rollout of a national health insurance scheme. Evidence from countries such as Rwanda, Kenya, and Ghana suggests that well-structured contributory models can expand coverage while reducing catastrophic out-of-pocket spending.
“My Ministry and the School of Public Health must be partners. … Evidence framed in fiscal terms drives policy,” said Ggoobi, stressing the need for locally grounded solutions. “What works in Ghana might not work here. We need a model that fits Uganda.”
Uganda’s current macroeconomic conditions, relatively low inflation, currency stability, and expanding private credit may provide a window to move in that direction.
Uganda’s health system is entering a new phase—one where the biggest challenge is no longer building it, but sustaining it. External funding is tightening. Domestic resources are under pressure. Demand for care is rising faster than both.
In this new reality, health is no longer just a social priority but a financing problem and a test of economic strategy.
For years, the system expanded on government investment, backed by strong external support. Infrastructure grew. Services followed. But that model is now under strain. Expectations are rising. Citizens want better care, closer to where they live, and without the financial shock that so often comes with illness.
Uganda is already investing in health. The real question is whether that investment is sustainable and whether it is delivering value.
It was against this backdrop that policymakers, academics, and practitioners gathered at Makerere University on April 9 for a public lecture and high-level dialogue on health financing. At the centre of the discussion was a keynote by Dr. Ramathan Ggoobi, the Permanent Secretary to the Treasury under the theme “Investing in Health for Uganda’s Future: Delivering Vision 2040 through Smart and Sustainable Health Financing.”
The event was organised by Makerere University School of Public Health (MakSPH) in collaboration with the Ministry of Health and the Ministry of Finance, Planning, and Economic Development.
Dr. Ggoobi does not think about health the way most people in government do. He is not persuaded by the language of welfare. When he speaks about health, he reaches for the language of growth, productivity, and national wealth. In his view, the sector is not a cost centre. It is an economic engine.
“Health is not merely a social sector issue. It is an economic transformation issue, a productivity issue, and a national competitiveness issue,” he said, arguing that no country has achieved sustained growth without investing in human capital. Globally, human capital accounts for nearly 70% of national wealth. The World Health Organization (2021) estimates that every dollar invested in health can return four to nine dollars in productivity gains.
“Investment in health is not charity. It is growth finance. So, my first message is to treat health spending as an investment, not as consumption. Every shilling must buy measurable economic and social returns,” he emphases.
His views reveal a shift in how Uganda’s Treasury thinks about health financing. Spending must justify itself. Investments must deliver returns. And inefficiency is no longer just a technical issue but a fiscal problem.
Ggoobi’s worldview is shaped by the idea that Uganda’s long-term growth ambitions under Vision 2040, which is 13 years away, to achieve what he describes as a tenfold expansion to a $500 billion economy, will be decided not just by infrastructure or industry but by the quality of its human capital.
Globally, he notes, human capital accounts for the bulk of national wealth. Health, therefore, is not peripheral to development. It is central to it.
If health is an investment, then it must generate returns. If it does not, then something in the system is not working. “Every shilling must buy measurable economic and social returns,” he said.
This is where the optimism gives way to unease. Countries that have achieved and sustained middle-income status did so through deliberate, sustained, evidence-driven investments in human capital.
Uganda is working within tight fiscal limits. The national budget for 2025/26 stands at Shs 72.38 trillion, with about Shs 5.87 trillion going to health.
Government spending on health has increased over time, rising from about Shs 2.8 trillion a few years ago to Shs 4.4 trillion today. But even with this growth, spending per person is still low, around $50 a year, less than half of what is often needed to provide basic health services.
Not all the money is used efficiently. Global estimates suggest that weak systems, poor coordination, and procurement challenges can cause up to a third of health spending to be lost.
According to Dr. Ggoobi, Uganda has made notable progress in strengthening its health system, driven by sustained public investment. Life expectancy has risen from about 50 years in 2000 to approximately 68.8 years in 2024, an increase of over 18 years. Access to services has also improved significantly, with about 91 percent of Ugandans now living within five kilometres of a health facility, while income poverty has declined from 24.5 percent in 2010 to 16 percent.
On the service delivery side, the government has introduced the malaria vaccine for children under five and rolled out electronic medical records across national and regional referral hospitals. Strategic investments have also been made, including 16 high-capacity oxygen plants, three regional blood banks, CT scan equipment in 14 of 16 regional referral hospitals, and 20 digital X-ray machines in general hospitals, with remaining gaps expected to be closed in the next budget. Together, he noted, these efforts demonstrate that sustained investment in health is yielding tangible results.
Beneath that progress, Dr. Ggoobi sees a health financing structure that is fundamentally unstable, noting that external partners still finance as much as 40–45 percent of health expenditure. Government contributes about 22 percent, household’s 31 percent, and insurance remains marginal at less than five percent. This balance, Ggoobi argues, is dangerous. It leaves the system exposed to shocks from outside while pushing risk onto those least able to bear it.
But the issue that troubles him most is government inefficiency. His priorities are to increase and protect domestic health financing, mobilise long-term capital, and improve efficiency.
“We are wasteful even with the little we have. Procurement is a major problem—many fights in government are not about mandate but about procurement. That is why we are moving all entities onto an electronic procurement system to improve transparency, reduce leakage, and ensure accountability,” said Dr. Ggoobi.
The government has enrolled 38 entities on the electronic procurement system. Full adoption is expected by mid-2026.
If you have good audits and we implement their recommendations, then we can expect positive outcomes. Number two is e-government, reducing human contact where it is not necessary. Unless you’re a doctor, you have to examine someone. Why do you have to sit in a hotel to discuss procurement? Humans must get out of discussing procurement. That’s why we are building the eGP and reviewing the procurement law. We are going back to the cabinet; we are going to remove human beings who are not necessary in the chain of procurement,” said Ggoobi.
Across the discussion, one issue drew near-unanimous agreement that prevention remains underfunded.
The Ministry of Health’s position, delivered through John Kauta, the Commissioner in charge of Health Information, Statistics, Monitoring, and Evaluation, is unequivocal that “the cheapest disease to treat is the one we prevent.”
Yet Uganda still spends more on treating illness than preventing it. Freddie Ssengooba, a Professor of Health Economics and Health Systems Management, MakSPH, highlighted malaria as a case study, both costly and preventable, while others pointed to rising non-communicable diseases driven by lifestyle factors.
This imbalance has fiscal consequences. Preventable diseases generate recurrent costs, crowding out other investments and reinforcing the cycle of inefficiency.
Mak Chancellor Hon. Dr. Crispus Kiyonga pushed the debate toward geography and access, citing that while Uganda’s health system was originally designed to follow administrative structures, the ambition to reach every village was never fully realised.
“We must plan based on what we can sustainably afford. We cannot import another country’s system. But where shall we save the majority of our people? It is in the villages. That is where children miss school due to illness. Where young girls drop out due to a lack of basic support, like pads. So, we must choose: given limited resources, what system gives the greatest impact? When the Minister of Health asks for a CT scan—something people travel to Nairobi for—that is important. But in the village, a child needs an antimalarial. The choice is between a CT scan and basic treatment. These are tough decisions,” says Dr. Kiyonga.
While the country is “highly indebted” and resources are limited, the level of care that Uganda can realistically provide to its citizens should borrow from China’s early pragmatic reforms of universal access first and quality later, according to the Chancellor.
“You cannot deliver health from a distance,” he said, arguing for a renewed focus on community-level access.
The Chancellor also strongly supported a shift from tertiary care to primary care. From Mulago National Referral and reducing its congestion to the village by investing in lower health facilities.
He urged the government ministries of Finance and Health to strongly collaborate with academic institutions to improve their work. “This dialogue should not be a one-off. It must be continuous. Makerere must engage the government with well-costed, risk-weighted proposals. We should build structured collaboration between universities and government so that research informs policy, and we reduce reliance on expensive foreign consultants. There is valuable research here,” said Dr. Kiyonga.
Taken together, the dialogue revealed a country’s health system in transition, from scarcity to expansion but not yet to performance.
As Ms. Jane Kyarisiima Mwesiga, Deputy Head of Public Service (Service Delivery), Office of the Prime Minister, framed it, the next phase must move “from expansion to performance, from inputs to outcomes, from financing to public value.”
But the path forward remains contested. Should Uganda prioritise insurance or direct public provision? Prevention or specialised care? Infrastructure or functionality?
The answers lie not in choosing but in sequencing, something Uganda has historically struggled to do.
Dr. Ian Clarke, a Physician, philanthropist, entrepreneur, and Chairman of Clarke Group Companies, speaking while representing the Private Sector during the dialogue, spoke emotionally on national health insurance, whose discussion has been ongoing for close to 20 years, but with minimal progress.
“We have had studies and proposals, but many were rightly rejected because they were not practical. You cannot design a National Health Insurance scheme that looks like private insurance. There is simply not enough money in Uganda—or anywhere—to sustain that. We still think in silos: public sector and private sector. Then we ask, how do we support the private sector? There are many ways—but as has been emphasized, we must focus on prevention and equity, especially in rural areas.”
For Ssengooba, while insurance is important and long-term, its implementation needs to be phased. He called for more investments in the health sector as the first line of insurance for citizens. He also called on the government to partner with institutions such as the National Social Security Fund (NSSF), which already have systems, capacity, and reach in place to support health investments. “If we leverage institutions like NSSF—for collection, for pooling resources—we can make progress. During COVID, they demonstrated that they can support national priorities. So, we should think about how to leverage what already exists,” he says.
Stephen Omojong of the National Social Security Fund highlighted an untapped opportunity. The Fund currently manages about Shs 30 trillion in assets, with millions of contributors.
This pool, he argued, could support health financing either through insurance-linked products or long-term investment vehicles. His example of a voluntary savings scheme now has 68,000 participants and Shs. 114 billion mobilised in a year, suggesting that behavioural barriers may be less rigid than often assumed.
Makerere University Vice Chancellor, Professor Barnabas Nawangwe, framed the dialogue as more than an academic exercise, describing it as a call to action. He urged the government to tap into the University’s research capacity to inform strategic investments, noting that “health research constitutes more than 50% of all research at Makerere University,” with institutions like the School of Public Health and the Infectious Diseases Institute playing a central role.
He referred to their national impact—from supporting over 20% of Uganda’s HIV patients to operating in more than 90 districts—and emphasised that Makerere brings in over one trillion shillings annually in research income. “When you fund Makerere University,” he said, “you should understand that we are not a net consumer—we are a net producer for the country.”
Taken together, the dialogue revealed a system in transition from expansion to performance, from spending to results. Uganda is no longer short of ideas, nor entirely short of resources. The real test is execution.
Whether the country can turn health spending into measurable outcomes will determine not just the future of its health system but the credibility of its economic ambitions.
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