Health
Address Drivers of Non-compliance to COVID-19 Guidelines, Researchers Urge Government
By Joseph Odoi
Makerere University researchers and local leaders have asked government and other key stakeholders in refugee management to address community drivers of non-compliance to COVID-19 guidelines as increased cases continue to be registered across the country.
This call was made at the dissemination event of a study conducted by Makerere University titled Refugee Lived Experiences, Compliance and Thinking (REFLECT) in COVID-19. The REFLECT dissemination was undertaken at multiple sites in Kisenyi (Kampala), Kyaka II Refugee Settlement (Kyegegwa) and Adjumani (West Nile) on 14th December 2020.
The REFLECT study observed that compliance levels around COVID-19 guidelines drastically declined between May-August 2020 and continue going down despite increased infections from community transmission. The stakeholders at this event cautioned that addressing the drivers of non-compliance was necessary in light of the overwhelmed health system, currently ongoing political campaigns and massive social gatherings in the Christmas season and beyond.
Since March 2020 the Uganda government and its partners have conducted a fairly successful awareness campaign on the prevention of COVID-19. However, this knowledge has not translated into sustainable behavioural change and while there was strict observance of COVID-19 at the start of the pandemic, compliance has drastically dropped due to a number of reasons. This is why all prevention efforts should now focus on addressing the barriers to non-compliance as the country enters into the second wave and peak period of COVID-19 transmissions.
A study conducted from among 2,092 people in refugee settlements in Uganda has found a serious disconnect between the high knowledge levels and levels of compliance with the recommended COVID-19 preventive measures. A total of 13 settlements were considered for this study including Kisenyi in Kampala, Kyaka II in Kyegegwa district and 11 settlements in Adjumani district, West Nile.
Presenting findings of the study at Kyaka II Refugee Settlement in Kyegegwa, South-Western Uganda, the research team led by Dr Gloria Seruwagi observed that compliance levels had declined over time (between March/April and July/August); unfortunately coinciding with increasing number of COVID-19 cases and deaths.
Inappropriate use of masks was found prevalent in some of the study sites – including sharing of masks, and only wearing them when the refugees meet the Police. Researchers say these practices constitute a source of risk for infection, rather than being protective.
Scarcity of Facemasks
Sifa Mubalama, a Woman Councillor in Kyaka II while speaking to study investigators at Kyaka II Refugee Settlement in Kyegegwa, South-Western Uganda late last year, revealed that there is non-compliance to COVID-19 guidelines due to inadequate masks and materials at the settlement.
“We were all given one mask each in Kyaka II settlement which you have to wash often and use again, hence becoming too old getting torn after some time. There is also inconsistent supply of soap and water. Because of this, some of the community members have not been washing their hands consistently’’ Mubalama revealed.
According to Mubalama, each family gets Shs. 22,000 every month, which is she says is not adequate to sustain the families. As a result, majority refugees go out in the communities to do manual work, to supplement on the income citing that this puts their lives at risk of COVID-19 infection.
Mubalama further contends that children in the settlements were not adhering to the Standard Operating Procedures (SOPs) because their parents were not.
“It would be easier to implement these guidelines if the parents were adhering to them. Because the parents are not adhering to the guidelines, most children are also not. It’s really important that if we are to implement the SOPs, it should start from the parent,” she said.
According to Happy Peter Christopher, the Kyegegwa Sub County Speaker, ever since the lockdown restrictions were eased, the refugees abandoned following the COVID-19 guidelines like social distancing, wearing masks, sanitizing or frequent washing of hands with soap.
“People are not putting on masks and are careless. Refugees also buy food from the nationals and there are intermarriages. So, the spread of COVID-19 is very possible. For us we would like, if possible, to ask government to bring back the total lockdown so that we are protected”.
He also reported that, up to now, some areas in Kyegegwa had still not received the government distributed masks and called upon government to deliver masks to all refugees and also add more efforts in enforcing SOPs.
It is against this background that researchers at Makerere University and local leaders have appealed to government and other stakeholders in the refugee management to address the community drivers of non-compliance to COVID-19 guidelines as cases continue to surge in Kyaka II refugee settlement in the South Western district of Kyegegwa.
Government has been asked to address the drivers of non-compliance, as a necessity in light of the overwhelmed health system, by the currently ongoing political campaigns and the massive social gatherings during the festivities.
Dr. Misaki Wayengera the Chairperson of the Scientific Advisory Committee on the COVID-19 Taskforce in the Ministry of Health explained why some districts did not get enough masks, saying there was an urgency to distribute to candidates returning to school.
“We intended to distribute masks to the entire 139 districts of Uganda. However, this was not possible because we opened up schools. As the Ministry [of Health], we had to negotiate with the Ministry of Education to prioritise the candidate students who were going to school; every student receiving 2 masks. As a result, we have not been able to distribute masks across the entire country,” he explained.
According to Dr. Wayengera, there is a need for all stakeholders dealing with refugees to appreciate that they are equally susceptible to COVID-19 like any other person.
“In terms of providing support, we must ensure that we provide things like masks, soap, sanitizers and also educational materials around the SOPs,” he said.
Adding that; “there are targeted efforts to make sure that we roll out Rapid Diagnostic Tests to make sure that we can screen the populations especially as children go back to school, we screen them but most importantly know who is infected and pull them out from the community”.
Discussion of Study Results
Dr. Gloria Seruwagi, also the Principal Investigator notes that whereas more than half (about 60 percent) of the members of the refugee community are well informed about COVID-19; up to 40% were found to have knowledge gaps on the nature, transmission, symptoms and dangers of COVID-19.
The study results also showed that between 1-40% of the refugee population across the different study sites adopt at least one risk behaviour likely to lead to transmission of COVID-19 including behaviours related to hygiene and social interactions including related to hygiene, congestion, and physical activity.
While men appeared more knowledgeable about the virus compared to women and children, women were found to be more compliant than men. Also, refugees who were Muslims were more compliant to COVID-19 guidelines compared to their Christian counterparts while younger refugees appeared more knowledgeable about COVID-19 than the elderly.
A wide knowledge gap was found among the children and adolescents, with up to 75% not fully knowledgeable on causes, transmission, risk/protective factors and management of Covid-19.
The Myths
Study results show that refugee communities had a belief that Africans have immunity against COVID-19; and that COVID-19 is not real but is instead a fabrication of scientists and politicians; and that their religious faith would protect them.
On threats and opportunities towards compliance, social media and the diaspora were reported as the key knowledge agents among refugee communities whose effect is divisive by simultaneously encouraging both compliance and non-compliance.
While a lot of information about COVID-19 has been provided by government and other stakeholders including implementing partners from civil society, UN bodies and local leadership, researchers revealed that children, youths and s the elderly and people with disabilities were not particularly targeted with appropriate information; and had largely not been reached.
Children and COVID-19
During the investigations, researchers found that despite government and other key and agencies churning out COVID-19 related information, it largely focused on adults and missed out children and adolescents.
“The fact that they (children and adolescents) have not been targeted means that no one has even given them masks. The masks which are on the market are all big and if a child wears it, it is going to fall down. We decided to channel some of the study resources into making customised and re-usable masks for some of the older children,” explains Dr. Gloria Seruwagi.
Behavioural change messages needed
The REFLECT study team observed during the study that there was a great and urgent need for engaging leadership at all levels as well as developing Behavioral change messages to positively influence behavior.
During the dissemination exercise, the REFLECT Study Team donated masks to support the refugees “walk the compliance talk” in the fight against COVID-19.
The study team physically sensitised and demonstrated to the refugees on proper wearing of masks. They strongly discouraged the improper use of masks including “chin” masking, partial masking, inconsistent masking, sharing of masks as well as wearing ill-fitting masks.
On the whole, researchers applauded government and development partners’ efforts on undertaking a largely successful awareness campaign around COVID-19.
They note however that this awareness has not translated into positive change, emphasising the need for more effort towards behavioural change, building on from the COVID awareness campaign.
The research team recommends thus;
- Government and all stakeholders should focus on addressing the drivers of non-compliance and enforcement fatigue. These drivers include:
- Reviewing the feasibility of interventions: Guidelines like physical distancing are not feasible in crowded refugee settings and need to be revisited. For crowded settings emphasis needs to be put on some guidelines and not others, for example handwashing and consistently wearing fitting face masks instead of physical distancing or sanitizing.
- Debunk myths and negative perceptions: Majority of the community has not fully bought into the seriousness of COVID-19 and think it is not only a joke but is also a political and monetary ploy advanced by politicians, some scientists, supremacists or population control enthusiasts. These myths need to be debunked and instead replaced with factual information about COVID-19.
- More profiling of COVID-19 trends and cases should be undertaken for behavioural change impact. This is because more than 90% of study participants had not seen a single COVID case. However, stigma and other potentially related dilemmas should be carefully managed.
- Leaders, implementers and enforcers of COVID-19 guidelines should be consistent and “walk the talk”. This is especially needed now with the political campaign season where masses are gathering and politicians are not leading by example.
- The issue of livelihoods and food security must be resolved as a key bottleneck to compliance.
- Culture: Local leaders, cultural leaders and grassroots organisations should be recognised and engaged more in behavioural change campaigns – for instance to engage their communities identify alternative social norms for greetings, for showing love and kindness etc., without put their lives at risk.
- The timeliness and critical role of the recently launched 2020 Community Health Engagement Strategy (CES) should be leveraged whereby:
- Local health system capacity is strengthened to effectively take up the implementation and enforcement of SOPs for COVID-19 prevention.
- Community health systems and other enforcement structures are equipped with knowledge, skills, supplies and adequate infrastructure.
- Key sociodemographic factors and COVID-19 risk should guide tailored impact messaging and other interventions.
- Children, adolescents and youth should be effectively targeted in COVID-19 interventions. They need awareness, products (e.g. fitting face masks), visibility, voice and protection from the effects of COVID-19 including being witnesses and victims of different forms of violence.
- The awareness message found high among adults should be reinforced and consolidated – equitably this time.
“We believe that these are low-cost interventions but which will bring about high impact in a very short time and reverse not only the trend of COVID-19 transmission but also its negative effects across the health socioeconomic spectrum” Dr Seruwagi said.
Kyegegwa Authorities Speak Out
Jethro Aldrine, the Kyegegwa District Assistant Resident District Commissioner said government was committed to inclusive dissemination of information on MOH SOPs in order to mitigate the spread of the pandemic.
“As the COVID-19 district task force, we move from door to door to sensitize people on COVID-19 including children,” he disclosed.
He also noted that government was also sensitising the masses through radio stations to create awareness that COVID-19 is real and needs to be prevented. He thanked the REFLECT Project for carrying out the study that will help the district fight the current pandemic.
At a radio talk show conducted jointly with the study team, district officials and refugee community leaders, Mr Thomas Mugweri the Surveillance Officer in the District Health Office of Kyegegwa District Local Government also thanked the REFLECT Study Team for giving it new direction.
“While we as a district have been massively sensitizing on awareness, now we know that people are not using the message they know about COVID. We are now going to start using all our behavioural change techniques to make sure that we bring out the desired behavioural change,” observed Mugweri
He urged the politicians to stop recklessly endangering the masses by calling them to campaign rallies and instead called upon them to donate masks and lead by example through observing COVID SOPs during their campaigns.
Youth Voices on COVID-19 in Refugee Settings
As part of increasing the visibility and voice of young people in COVID-19, the REFLECT Study organised an engagement session with children, adolescents and youth during the dissemination. The engagement sessions were led by Francis Kinuthia Kariuki and Grace Ssekasala of Centre for Health and Social Economic Improvement (CHASE-i) who were supported by Catherine Nakidde Lubowa and Dr Gloria Seruwagi the study PI.
During this exercise, the REFLECT Team discussed Coronavirus and it emerged that a number of issues are affecting the children and youth which needed to be addressed alongside COVID-19 prevention. Most critical, children and adolescents reported defilement, rape – leading to teenage pregnancies and a lot of other SRH challenges that affected their sexual health.
Many confessed they lacked information on menstruation hygiene products which citing that some of their families could not afford. Others decried inaccessibility of contraception despite being sexually active and access to youth-friendly counselling on SRH matters affecting them.
Both male and female youths agreed that the high level of teenage pregnancies has been attributed to high poverty levels and being out of school. ‘’Sex is being used as a tool for economic gain and survival. This is not limited to the girl child only – two cases were reported where boys are being married by older women who lure them with money and soft life’’ explained Mr. Francis Kinuthia from his engagement with adolescent boys and youth.
Mental health issues were reported to be affecting adolescents largely boys who expressed worry about their future especially, now, that schools had been closed, and they are in a foreign country.
Increasing crime rates were also reported and, following unemployment plus school closure, majority youths especially males have now resorted to drugs and substance abuse.
In regard to COVID-19 the adolescents in general reported that they had experienced the negative effect of the pandemic in their lives such as reduction on monthly hand-outs, harassment by police and enforcers of COVID -19 guidelines, increased domestic violence, SGBV, teenage pregnancy, increased levels of drug and substance abuse, poor mental health and high cost of living among others.
Asked what could be done to solve some the challenges they were facing; youth recommended the following;
- Establishment of skill development centres to empower them and make them less dependent on hand-outs
- Creation of employment opportunities by authorities
- Identification, support and nurturing talent among them refugees and youths
- Constant supply of sanitary towels/pads and other SRH products including contraception
- Health education on contraception methods and having in place youth-friendly services at health facilities
- Continuous awareness campaign on COVID-19 which involve youth and punitive policies or by-laws to severely punish the perpetrators of teenage pregnancies, rape and child marriages.
The dissemination attracted members of the academia from Makerere, Gulu and other universities, central and district Government representatives, Refugee Representatives including their leadership from OPM, Refugee Welfare Committees (RWC), Village Health Teams (VHT), Youth, Women and Sub-County representatives, local politicians, Development and Implementing Partners like Save the Children, Red Cross Society, UNHCR, Nsamizi Institute for Social Development and the Private Sector.
Research Team
The REFLECT Study is funded by Elrha/R2HC (Research for Health in Humanitarian Crises) supported by UKAID, Wellcome and National Institute for Health Research (NIHR). The Study Team is led by Dr. Gloria Seruwagi.
The full team has Prof. Stephen Lawoko of Gulu University, Dr. Denis Muhangi, Dr. Eric Awich Ochen, Dr. Betty Okot all from Makerere University, Andrew Masaba of Lutheran World Federation (LWF), Dunstan Ddamulira from Agency for Cooperation and Research in Development (ACORD and John Mary Ssekate from the National Association of Social Workers of Uganda (NASWU) Others are Brian Luswata and Joshua Kayiwa all from the Ministry of Health and Catherine Nakidde Lubowa, the Project Coordinator.
Article originally posted on MakSPH
A new study conducted in Wakiso district has determined the ideal waist circumference for detecting metabolic syndrome among Ugandan women. Study findings closely align with the International Diabetes Federation (IDF) cut-off for predicting ill health risks.
The researchers at Makerere University’s School of Public Health (MakSPH) aimed to establish an ethnically appropriate waist circumference cut-off point for Ugandan women to enhance early detection and prediction of metabolic syndrome. About 2 in 10 of the women studied in Wakiso district, Uganda, suffer from metabolic syndrome, which is associated with diabetes and heart disease.
Findings indicated that for women aged 18–49 years in the Wakiso district, 80.3 cm is the optimal waist measurement to flag potential metabolic syndrome risks.
The threshold increases with age:
• 79.9 cm for young women (25-34 years)
• 85.6 cm for mid-life (35-44 years)
• 91.1 cm for pre-menopausal women (45-49 years)
Unlike the Body Mass Index (BMI), a calculated measure of weight relative to height used to assess an individual’s weight status and potential health risks, waist measurement better detects dangerous abdominal fat linked to diabetes and heart disease.
Dr. David Lubogo, a lead researcher on this study and Senior Lecturer in the Department of Community Health and Behavioral Sciences at Makerere School of Public Health, noted that with hormonal and physiological changes making women particularly vulnerable during reproductive years, these Uganda-specific benchmarks will help clinics identify at-risk patients earlier, using just a measuring tape.
“Our findings confirm waist measurement as a powerful, low-cost tool for preventive care. While aligning with global standards, we have refined thresholds for Uganda’s context,” Dr. David Lubogo notes.
A cross-sectional study was carried out in Wakiso District from June to August 2021, involving 697 randomly selected women aged 15–49. Participants had lived in Wakiso for at least a year and underwent physical, biochemical, and anthropometric tests to help determine the prevalence of metabolic syndrome (MetS). “We excluded pregnant and postpartum women, alcoholics, smokers, and those with chronic or infectious diseases to ensure accurate results,” explained Dr. David Lubogo.
The study, published in PLOS Global Public Health, underscores the importance of age-sensitive screening in tackling metabolic diseases in sub-Saharan Africa. In response, health officials in the study area should explore practical ways to weave these findings into everyday programs for community health screening.
The study was funded by the Government of Uganda through the Makerere University Research and Innovation Fund (MakRIF) and the Strengthening Education and Training Capacity in Sexual and Reproductive Health and Rights (SET-SRHR) Project in Uganda. Other investigators included Dr. Henry Wamani, Dr. Roy William Mayega, and Professor Christopher Garimoi Orach.
Kampala, 09 April 2025— Makerere University has officially launched the Social Innovation in Health Initiative Community of Practice (SIHICOP)—a new platform designed to connect local health innovators with policymakers, donors, and researchers. The goal: to turn scattered success stories into a powerful, nationwide movement that reimagines healthcare from the ground up.
The launch, held during the 6th National Social Innovation in Health Stakeholders’ Workshop at Hotel Africana in Kampala, drew a dynamic mix of changemakers, health innovators, academics, donors, and government leaders, all rallying around one idea: that equitable, sustainable healthcare must be rooted in communities.
While Uganda has made notable progress, cutting under-five deaths by 66% since 2000, challenges remain. Fifty out of every 1,000 children still die before their fifth birthday. Nearly half suffer from stunting due to malnutrition. In rural areas, pregnant women walk for hours to reach clinics. Across the country, hospitals battle frequent drug shortages.
Dr. Phyllis Awor, Director of the SIHI Uganda Hub at Makerere University’s School of Public Health (MakSPH), emphasized the critical role of social innovation in closing healthcare gaps. “Half of Ugandan children lack basic vaccinations, and 40% face stunting. These challenges demand creative, inclusive solutions co-created with communities,” she said.
“We’ve spent a decade identifying, studying, and strengthening grassroots innovations. Through our six-month fellowship program, we train innovators in monitoring and evaluation, research, communication, impact assessment, and fundraising so their work doesn’t just survive but scales,” she said. “Today, we’re awarding them completion certificates and launching them into a vibrant community of practice.”
Dr. Awor, who is also a Lecturer and Researcher maintains Social Innovation is about solving these real problems with real people. With the support of the Swedish Embassy and the World Health Organization’s TDR program, SIHICOP, she says, will foster peer learning, capacity-building, and scaling of innovations like mobile health platforms and community-based maternal care.
Since 2017, Uganda’s SIHI hub has supported 30 homegrown innovations, impacting tens of thousands of lives. “We’ve identified 21 standout solutions so far,” Dr. Awor shared. “But if we want them to go national, we need enabling policies.”
Globally, SIHI was founded in 2014 to bring together innovators, communities, policymakers, and academics across the Global South. With 15 hubs, including Uganda’s, SIHI has documented over 200 innovations and 40 case studies that demonstrate the power of grassroots solutions to improve health systems.
Dr. Olaro Charles, Uganda’s Acting Director General of Health Services, acknowledged that bureaucracy often stifles good ideas. “Sometimes, a small change in how you look at a problem can produce the best and most marketable solution,” he said.
He spoke from experience. As a clinician, Dr. Olaro led efforts to curb drug theft and stockouts by tightening distribution and boosting accountability. “It’s not like people walk off with whole boxes,” he explained. “But if you have 300 employees and each takes just one dose… that adds up. We introduced medicine returns, round-the-clock pharmacies, and ward-level audits. At first, there was resistance, but it worked.”
Another one of his most memorable innovations was setting up a neonatal unit for premature babies while he was a Medical Superintendent. “I remember a baby who weighed less than a kilo, barely six months old, and survived. We pushed survival rates to 85%. Eventually, we ran out of space. We began asking ourselves: Where had these children been going before? Previously, these children may have died within the community. These are innovations that create real, tangible impact. And I’m sure many of the things you’re doing here are creating similar results.”
He urged the Fellows to treat their innovations like living systems: “If they survive infant mortality, they’ll live longer. These ideas deserve to grow.”
Mr. Tomas Lundström, Health Counsellor at the Swedish Embassy, spoke with deep conviction about Sweden’s long-standing investment in Uganda’s future. “For decades, Sweden has believed in Uganda’s greatest asset, its people,” he said. “Through Sida, we funded the training of over 500 Makerere staff for PhDs. I didn’t start it. I didn’t train your PhDs. The Swedish taxpayers actually funded the training. Now that wasn’t just investment; it was transformation. It’s one reason Makerere is the powerhouse it is today.”
Lundström also shared a memory that continues to shape his view of development. While inspecting UNICEF projects in Zambia in 1998, he recalled visiting five villages where only one had shown some success. A driver suggested they visit the last village, the 5th. “We went. No one was there. We waited, then a man came running, covered in dirt. He was the village chief,” Lundström recounted. “He said something I’ve never forgotten: ‘Thomas, when the rainy season comes, we can’t take pregnant women to the clinic. Do you know where I can learn to build a bridge’?”
“That was different from what I usually hear—‘Can we have some money?’ Real change doesn’t come from handouts. It starts within communities.”
But Lundström warned that international aid is under strain. “We’ve already lost a lot of funding from U.S. and other donors. Ukraine, Sudan—global crises are pulling resources away. We must get creative. We must find new ways to secure resources.”
Still, he was optimistic. “We’re seriously considering continued support for another year. We’re also pushing for deeper collaboration between Makerere and Karolinska Institutet. But it’s up to you too,” he said.
He praised Dr. Phyllis Awor and her team: “What sets them apart is not just competence, but passion. She doesn’t do this because it’s her job; she does it because she believes in it. Because everyone deserves a fair chance, a seat at the table, a bit of hope.”
Makerere University Vice Chancellor, Professor Barnabas Nawangwe, echoed those sentiments, describing the School of Public Health as the university’s “engine of change.” He noted that the School contributes to nearly 30% of all university publications—and brings in 40% of its research funding.
“That’s no accident,” he said. “Public health is critical. Without health, there is no progress. That’s why donors invest in public health issues.”
He described the social innovation initiative as a model for how academia and communities can work together, not just to publish but to transform lives. “When global rankings name Makerere the most community-impactful university, they’re recognizing what happens when scholars step beyond lecture halls. This is what happens when researchers dig deep into the ground to cultivate solutions that transcend national boundaries.
The Vice Chancellor also paid tribute to Sweden’s role in that transformation. “We cannot thank the people of Sweden enough. Their support through Sida trained over 500 of our staff to the PhD level—the largest staff development initiative I’ve seen at any university, anywhere. It came when we needed it most, after the war. That’s why Makerere stands today as a leading research institution in Africa.”
He congratulated the 2024/25 Fellows, praising their inspiring journeys, and commended Dr. Awor and her remarkable team of researchers for achieving what only world-class institutions can: “melding razor-sharp academia with the wisdom of villages, policy muscle with frontline innovations.”
By Joseph Odoi
Every newborn deserves the best start to life. Yet, in Uganda, the burden of newborn morbidity and mortality remains high. The newborn mortality rate stands at 22 deaths per 1000 live births (UDHS 2022). According to most recent UN annual estimates, Uganda records 62,000 deaths around the time of birth. Of these, 32,000 are neonatal deaths, 26,000 are stillbirths and 4,800 are maternal deaths. Majority of the newborn deaths occur within the first week after delivery- a period considered very vulnerable for both the mother and baby.
Uganda’s high fertility rate translates to about 1.7 million births per year; and of these 250,000 babies need special newborn care as they are either born too small or fall sick within the first month of life. This has placed a huge burden on the country and strained the already limited investment for neonatal care.
Despite national efforts, newborn deaths continue to account for nearly half of all under-five deaths in Uganda, according to the Uganda Demographic and Health Survey (UDHS) 2022.
To contribute to addressing this challenge, a coalition of institutions namely; Makerere University School of Public Health, Baylor Foundation Uganda, Adara Development Uganda, Nsambya Hospital, and the Ministry of Health with funding from ELMA Philanthropies launched a national health systems strengthening initiative known as the Uganda Newborn Programme (UNP) in 2022. This program uses a regional approach to improve newborn care in three regions of Uganda namely Kampala, North Central and Western regions.
According to Dr. Monica Okuga, the Uganda Newborn Programme Coordinator at Makerere University School of Public Health (MakSPH), the Uganda Newborn Programme (UNP) made huge strides in providing quality newborn care in 36 health facilities across the three regions of Uganda.
Uganda New Born Programme Achievements
‘’Under the UNP, there have been so far many achievements. Institutional neonatal mortality rate has reduced in the facilities where the program is implemented and this has contributed to overall reduction in neonatal mortality in the regions. For example, Institutional neonatal mortality reduced to 7/1000 and 2/1000 live births by the end of Year 2, down from the baseline rates of 8.4/1000 and 11.9/1000 in Bunyoro and Tooro, representing reductions of 16.7% and 85.3% respectively’’ Dr. Okuga stated.
Dr. Okuga further explained that, ‘’Overall asphyxia case fatality rates across program areas have also reduced from 8.9% to 5%; adherence to infection prevention and control measures has improved across the facilities; and the quality of newborn care provided has also improved.
In addition to revamping many newborn care units, Dr. Okuga revealed that the programme supported the construction of newborn care units, citing Kyegegwa Hospital, Buliisa General Hospital, Masindi General Hospital, and Kyangwali HCIV.
In line with the SDGs programme objectives, specifically SDG 3; Good Health and Well-Being, Makerere University School of Public Health, together with partners including the National Planning Authority (NPA), UNICEF, FHI360, and the Ministry of Health, produced the Situation Analysis of Newborn Health in Uganda-2023 update.
This document has now been taken up by the Ministry of Health and is being used to develop a strategy for implementing the suggested recommendations therein, as well as costing the investment for improving newborn health in Uganda.
The previous newborn situation analysis was conducted 17 years ago in 2008’’ she explained of programme contribution at a multi-sectoral level
Establishment of Uganda’s First Breast Milk Bank
Still under this programme, the first ever Breast Milk bank was established at Nsambya hospital with other donor milk satellite sites at Mengo, Rubaga, Kibuli and Naguru hospitals in Kampala. This donor breast milk has benefited over 275 babies across Kampala and its neighboring districts.
Hospital-to-Home (H2H) Initiative
Another innovation that has been scaled up through the programme is the Hospital to Home (H2H) initiative by Adara Uganda. While many newborn interventions focus primarily on in-hospital care, the Uganda Newborn Programme, in partnership with Adara Development Uganda, pioneered the Hospital-to-Home (H2H) Model, extending its newborn care continuum to the household level. This innovative model ensures that high-risk newborns continue to receive vital support after hospital discharge, addressing the gaps in follow-up care that are common in low-resource settings.
According to Beatrice Niyonshaba, Deputy Director of Maternal, Newborn, and Child Health at Adara Development; “In Uganda, many families struggle to return for follow-up visits due to cost, transport challenges, and lack of caregiver awareness. The H2H model addresses this by involving caregivers early, equipping them with knowledge on newborn danger signs, and ensuring post-discharge follow-up through community health systems like village health teams.”
She adds, “The model not only reduces post-discharge mortality but also builds trust and ownership among families, which is critical but often an overlooked aspect of newborn survival in low-income settings. ‘’We also run regular community sensitization and awareness initiatives about the causes and survivability of small and sick newborns, preventative measures, as well as the services”. The model was initially piloted at Kiwoko Hospital, with strong support from both healthcare staff and the community. This phase allowed for continuous refinement and strengthening of the model, ensuring it met the needs of both families and healthcare providers.’’ Ms. Niyonshaba explained of the H2H Model uniqueness
Currently, the model is being implemented in Nakaseke hospital, a government facility. This will provide insights for scale up to other government facilities. The programme has seen tremendous success due to the engagement and motivation of CHWs, who are provided with incentives, extensive training, and ongoing support. Regular check-ins and monthly meetings ensure these workers remain accountable and connected to the Programme’s objectives.
Challenges in Newborn Care
According to Dr. Monica Okuga and Prof. Peter Waiswa, the Uganda Newborn Programme team lead from MakSPH, in spite of the many achievements, several challenges persist. They explain that many health facilities in Uganda were built without infrastructure to support Newborn Care Units (NCUs). There are no standard floor plans for these units. In many facilities, the neonatal care units are housed in improvised rooms, while in some cases, completely new NCUs are built.
However, even where NCUs are present, they are often let down by an unstable power supply, despite the fact that most equipment in the NCUs require consistent electricity to function. In addition, there are other health system challenges such as insufficient drug supplies from the government, inadequate staffing, and the low involvement of medical officers in neonatal care. Internal rotation of already trained nurses to other units further worsens the situation. Other issues include untimely or late referrals of mothers and babies, as well as challenges with the low quality of data produced in these units.
In terms of lessons learnt while implementing the UNP, The Uganda Newborn Programme team observed and noted several key lessons during the implementation of the programme
- The importance of leadership engagement in the uptake of interventions is very critical. The leaders to be engaged not only include those at the facility level but also those at the district level. The support of political district leaders such as the Chief Administrative Officer (CAO) is also very crucial. One way of engagement is through sharing performance dashboards with key indicators to the District Health Officers (DHOs), CAO, and Health Facility In-charges.
- There is a need for continuous engagement of district leadership for sustainability in public health facilities, especially the human resource aspect for established Newborn Care Units (NCUs).
- There is a need to intervene across the board/spectrum of the health system. Addressing one challenge, for example, the provision of equipment, may not result in the required benefits without addressing human resources and skills.
- Using a regional approach to care, which includes all hospitals and high-volume health centres, is a more rapid and cost-effective way to scale up maternal and newborn care. It also improves access, quality, and referral, thus reducing unnecessary mortality.
- Regional Local Maternity and Neonatal Systems (LMNS) provide avenues/platforms to share lessons and share feedback to teams/facilities on gaps identified.
- Targeted mentorships not only maintain skills but also support teams in innovating for problem-solving.
- Continuous engagement of medical officers in facilities creates buy-in and brings them on board to support and bridge gaps in newborn care in the neonatal care units.
In terms of sustainability, the team stated that the programme’s design took into account the potential for continuation beyond the initial funding from ELMA Philanthropies. From the outset, the Ministry of Health was actively involved in the co-creation of the programme. The programme also made effective use of existing staff and infrastructure to enhance the quality of newborn care. While there was occasional catalytic provisions of drugs and equipment, the programme primarily relied on the government’s drug supply and delivery systems to ensure long-term sustainability.
About The Uganda Newborn Programme (UNP)
The Uganda Newborn Programme (UNP) has been actively working since its launch in July 2022, with the goal of significantly improving the care for small and sick newborns across the country. With support from ELMA Philanthropies, the programme has brought together a consortium of partners, including Makerere University School of Public Health, Baylor Uganda, Adara Uganda, and Nsambya Hospital, in collaboration with the Ministry of Health.
The programme is focusing on 20 high-burden districts across three regions of Uganda ie Western, Kampala, and North-Central, serving approximately 1.5 million births annually. Since its inception, the programme has been making strides in enhancing the capacity of health facilities, including the refurbishment and equipping of 30 specialized neonatal care units. These units are designed to meet the needs of small and sick newborns, in line with the National Essential Newborn Care (NEST) Toolkit.
Key activities that have been rolled out include
- Training and mentorship of Health Workers; More than 800 health workers have been trained and mentored in essential neonatal care practices such as neonatal resuscitation, Kangaroo Mother Care (KMC), Continuous Positive Airway Pressure (CPAP), and infection prevention and control. This has significantly improved the clinical competencies of healthcare providers in the management of small and sick newborns.
- Strengthening Infection Prevention and Control; The programme has focused on improving infection control measures at hospitals, which is critical in managing the high rates of sepsis and other infections among newborns.
- Effective implementation of newborn resuscitation and warm transport: This includes establishing standardized protocols and providing essential equipment like mabu bags plus masks, CPAP machines
- Improving Data Utilization; Efforts have also been made to ensure that health workers are using data-driven evidence for decision-making. Monthly perinatal death audits and support for data quality review have allowed for continuous improvement in service delivery.
- Enhanced Postnatal Care; Community-based postnatal care using Village Health Teams (VHTs) being trained to conduct home visits for newborns discharged from neonatal units. This helps ensure that infants receive timely follow-up care in the critical days after discharge.
The programme is set to run up to July 2025, and by then, it aims to have reached 120,000 small and sick newborns, helping to reduce newborn mortality by 40% in the target regions.
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