By Dr. Peter Waiswa (MD, MPH, PhD)
In Uganda today, one of the greatest paradoxes in our health system is that while more babies are being born in health facilities, too many still don’t make it past their first month of life. The Uganda Demographic and Health Survey (UDHS) 2022 paints a sobering picture. 22 newborns die for every 1,000 live births. Each number represents a real family, a real loss and a system that is failing its most vulnerable citizens.
Globally, the numbers are even more staggering. According to the World Health Organization, nearly 2.4 million newborns die each year globally, with the majority of these deaths occurring in low- and middle-income countries. In sub-Saharan Africa alone, the average neonatal mortality rate (NMR) is around 27 per 1,000 live births, almost ten times higher than in high-income countries, where it’s just 2 to 3 per 1,000.
Uganda, while making commendable strides in reducing under-five mortality, still records an NMR of 22 deaths per 1,000 live births (UDHS 2022). This is well above the Sustainable Development Goal (SDG) target of 12 per 1,000 a benchmark set to be achieved by 2030.
Amidst this challenge, something extraordinary is quietly taking shape, a systems-based response that is actually working, and it deserves attention.
One of the impressive health systems interventions observed recently is the Uganda Newborn Programme (UNP) an initiative co-led by Uganda’s Ministry of Health and Makerere University School of Public Health with support from partners like Adara Development, Baylor Uganda, Nsambya hospital and funded by the ELMA Philanthropies.
The Uganda Newborn Programme is a national health system strengthening initiative focused on improving care for 120,000 small and sick newborns over the next three years. It aims to reduce newborn deaths by 40% at selected hospitals across 22 districts by scaling up and replicating some of the most effective newborn care interventions in Western, Kampala, and North-Central Uganda.
The programme builds on work Makerere University has been doing for over one and a half decades and draws heavily on evidence we generated with support from ELMA Philanthropies in Eastern Uganda. In that work, we found out that one of the most effective and sustainable ways to scale up quality maternal and newborn care is through a regional approach. In the Regional approach, you map out all facilities that are within a network and you don’t improve in only one facility but you do improvement across different facilities in the Region. The idea is that if every facility is improved then referral becomes easier but also but also management of mothers and newborn within the network of care
Turning the Tide on Neonatal Mortality
Through this approach, the programme’s impact is already measurable and improving care for small and sick newborns . In some regions, institutional neonatal mortality has dropped impressively. In Tooro, for example, mortality fell from 11.9/1000 to 2/1000 live births, a reduction of over 85%. Similarly, in Bunyoro, the rate decreased by 16.7%. These outcomes challenge the often-accepted narrative that progress in neonatal care in low-resource settings must be slow or marginal. Of course this being health facility data could have limitations, but the extent of the reduction shows that positive health system changes are taking place.
Moreover, asphyxia case fatality rates have reduced from 8.9% to 5%, signaling improved clinical response in resuscitation of babies and better-equipped/skilled health workers. Much of this progress stems from targeted training and mentorship of over 800 health workers in essential practices such as neonatal resuscitation, Kangaroo Mother Care (KMC), and Continuous Positive Airway Pressure (CPAP) therapy.
A Fresh Perspective Under Hospital-to-Home Care Model
One of the most forward-thinking aspects of the programme is its Hospital-to-Home (H2H) follow-up model currently implemented in North Central region of Uganda. Unlike traditional facility-based programmes, H2H recognizes that health outcomes don’t end at discharge from the hospital but continue at home as well.
The H2H Model trains and supports Village Health Teams (VHTs) or Uganda community health workers, to conduct postnatal home visits within three days of a newborn’s discharge. These visits equip caregivers with life-saving information on danger signs, feeding, hygiene, and vaccinations. The model builds trust, encourages community participation, and most importantly, ensures newborns don’t just survive delivery, but thrive in their early days of life.
Evidence from the pilot sites is compelling. In areas where H2H has been implemented, exclusive breastfeeding rates increased from 6.6% to 42%, while vaccination completion rose from 76.9% to 88.5%. A recent study conducted in North Central Uganda showed that H2H is not only feasible but highly acceptable to communities, caregivers, and health workers alike.
This is an important model for continuity of care, especially in line with WHO’s Every Newborn Action Plan, which calls for integrated community and facility care pathways.
If we are to truly tackle neonatal mortality, we must stop asking, “What’s the problem?” and start asking, “What is already working that needs to grow?” Uganda’s experience with the H2H model gives us a tested, community-rooted pathway to reduce neonatal mortality. This model should be scaled up as it has been shown to work in Uganda.
Uganda’s First Human Milk Bank at Nsambya hospital- A Lifesaving Innovation Under Uganda Newborn Programme
Picture of Human Milk in a Bank at Nsambya Hospital
As part of the RIB (Resuscitation, Infection Control, and Breast Milk Banking) Project under the Uganda Newborn Programme, Uganda really stepped up! We now have the first human milk bank at Nsambya Hospital, plus lactation centers in Mengo and Lubaga. The initiative is pioneered by a hardworking exemplary local neonatologist, Dr Victoria Nakibuuka. This milestone comes at a critical time when the world is pushing for better and more equitable neonatal care. The World Health Organization (WHO) recommends donor human milk as a vital alternative when a mother is unable to breastfeed, particularly in neonatal intensive care units (NICUs), where preterm and low-birth-weight infants require the most support.”
The best part is that Ugandan mothers are embracing breast milk donation with open hearts. Despite lingering cultural myths, the project’s intensive community engagement starting in antenatal clinics has inspired a culture of generosity and solidarity among mothers.
From October to December 2024 alone, thanks to this intervention 38 liters of donor milk were collected across Nsambya, Mengo, and Lubaga hospitals.
This activity saw over 270 mothers voluntarily donate their milk thus supporting more than 275 babies born too soon or too small with milk which is a life-saving nutrition.
For sustainability, the project also established strong neonatal resuscitation teams in Naguru and Kibuli, trained health workers, mentored staff across five participating hospitals of (Mengo, Nsambya, Lubaga, Naguru, and Kibuli), and even bought resuscitation equipment and a refrigerated vehicle for safe milk transport. Infection rates, asphyxia cases, and mortality have all gone down in the facilities where the project runs.
The success of the RIB Project shows that people will respond positively when we involve them from the start of programmes. It also proves that sometimes-saving newborn lives doesn’t only need high-end tech, it needs systems that work, health workers that are trained and supported, and mothers who are empowered. We call upon stakeholders to support the scale up of the human milk bank to other regions of Uganda, especially the more hard to reach.
Learning from the Field on What Works and What Still Doesn’t?
While the achievements are remarkable, the Uganda Newborn Programme’s story is also one of humility and learning. One hard truth is that many health facilities in Uganda were never designed with Newborn Care Units (NCUs) in mind. Even in facilities where NCUs exist, power outages, drug stock-outs, and inadequate staffing hinder consistent care. Moreover, the rotation of trained nurses to unrelated departments dilutes the impact of capacity-building efforts.
Another key insight is the value of district leadership engagement. Facilities that shared performance dashboards with District Health Officers (DHOs) and Chief Administrative Officers (CAOs) reported higher levels of ownership and accountability. Leadership matters not just at the Ministry, but in every hospital, every health facility and sub-county.
The programme also shows that addressing one part of the system is never enough. Equipment without skilled staff, or staff without drugs and supplies, results in a hollow shell of care. That’s why the UNP adopted a regional approach strengthening systems across multiple facilities within a region to ensure referral linkages, quality consistency, and knowledge-sharing platforms such as Local Maternity and Neonatal Systems (LMNS).
Extending care into the household ensures that small and sick newborns are not forgotten after hospital discharge which is a very critical time when they are most vulnerable.
This programme has also shown that Community Health Workers/Village Health Team members (VHTs) are the backbone for newborn care in the community if well trained, motivated and supported.
The programme has also demonstrated that Empowering Caregivers through VHTs can lead to Better Newborn Outcomes as it equips mothers with capacity to support their newborns to survive and thrive at home.
A Blueprint for Africa?
What makes the Uganda Newborn Programme especially noteworthy is that it offers a replicable blueprint for other countries grappling with high neonatal mortality. Its combination of facility-based care, community engagement, innovation, and government ownership offer a model that could be adapted across similar low-resource settings.
As global health experts search for scalable, sustainable approaches to maternal and newborn care, Uganda’s experience through UNP offers a hopeful yet grounded example of what can be achieved when evidence, systems thinking, and human-centered design come together.
If Uganda is to meet its neonatal health targets under the Sustainable Development Goals and Every Newborn Action Plan, it must invest in what works. But to be sustainable in these days of funding cuts, the government and partners must step up with increased funding. Without this, all learning will go when the project funding ends, with a resulting human capital development loss.
Dr. Peter Waiswa is an Associate Professor at Makerere University School of Public Health and the Global Health Division of Karolinska Institutet in Sweden. He leads the Maternal and Newborn Center of Excellence at Makerere University and is widely recognized for his work in maternal, newborn, and child health across Africa and globally.
Email: pwaiswa@musph.ac.ug | peter.waiswa@ki.se