Uganda's Newborn Resuscitation Training Outruns the Oxygen Supply
Uganda has trained thousands of health workers in newborn resuscitation over the past decade, but the oxygen concentrators and cylinders those workers need sit idle or broken in many district hospitals. The result is a contested gap between skills and supplies that health planners have not resolved. This piece examines why the training scaled faster than the equipment, what the evidence says about oxygen in newborn care, and what district teams can do about it.
Training Outpaces Oxygen in Uganda
Uganda's Ministry of Health, with partners including the American Academy of Pediatrics and local universities, has rolled out newborn resuscitation training across much of the country. The programme targets midwives, nurses, and doctors who attend births in health centres and district hospitals. By most accounts, the training itself works. Participants learn to clear airways, stimulate breathing, and apply positive pressure ventilation when a newborn does not start breathing on its own.
The problem is what happens after the training ends. A health worker who can bag a newborn still needs a functioning bag-valve-mask, a source of oxygen, and a way to monitor the baby's response. In many Ugandan facilities, at least one of those is missing. Oxygen concentrators break and stay broken. Cylinders run empty and refills can cost more than a facility's quarterly budget for supplies. Power cuts interrupt concentrator function without warning.
This gap is not unique to Uganda, but the country's aggressive training scale-up makes it unusually visible. A related piece on this site about Tokyo hospitals training nurses for wards that no longer exist makes a similar point about skills that outrun their setting, though the Japanese case turns on demographic change rather than equipment failure.
What Resuscitation Training Actually Delivers
Neonatal resuscitation supports roughly 10% of newborns who do not readily begin breathing after birth. Most of those infants respond to simple stimulation and airway positioning. A smaller share need positive pressure ventilation, and a smaller share still need chest compressions. The procedure is not exotic; it is a standard part of delivery-room care in any well-equipped facility.
Training in these skills reduces some deaths from perinatal asphyxia, the condition caused by oxygen deprivation during birth. But the evidence for training alone, without reliable oxygen and functioning equipment, is weaker. A health worker who has learned the steps but cannot deliver oxygen is limited to bagging room air. That can help in some cases, but it is not equivalent to the full protocol.
The disagreement among experts is not about whether resuscitation works. It is about how to sequence investment. Dr. Sarah Kiguli, a paediatrician at Makerere University who has led resuscitation training in Uganda, argues that training should come first because it builds demand for equipment and creates a cadre of workers who will use oxygen properly when it arrives. On the other side, some district health officers argue that training without equipment is wasted money and can demoralise staff who feel unprepared for the emergencies they face. The tension surfaced at a 2019 Ministry of Health review meeting, where district reports showed that training had reached most facilities but equipment audits were missing.
The Oxygen Gap in Practice
Oxygen concentrators are the workhorse of newborn care in low-resource settings. They run on electricity, require relatively little maintenance, and produce oxygen from room air. When they work, they are cheaper than cylinders over time. When they break, they often stay broken because the biomedical technician who could repair them is stationed at a regional referral hospital, not at the district level.
Cylinders present a different problem. They are reliable when full, but refilling requires transport to a supplier, which can take days and cost money that district facilities do not have. A facility may receive a donation of cylinders and regulators but no budget line for refills. The equipment sits as furniture.
Power reliability compounds both problems. Concentrators need consistent electricity. In districts with frequent outages, a concentrator without a backup battery or solar connection is only as reliable as the grid. Referral delays make all of this worse: a newborn who needs oxygen at a health centre may wait hours for transport to a facility that has it.
At Mbarara Regional Referral Hospital, a biomedical engineer reports that roughly half of the oxygen concentrators in the region's district facilities are non-functional at any given time, mostly due to worn-out sieve beds or compressor failures. The hospital runs a repair workshop that serves surrounding districts, but turnaround times stretch to weeks because spare parts must be imported. This pattern is echoed in other regions, though comprehensive national data on equipment functionality are scarce.
Evidence for Oxygen in Newborn Care
Oxygen therapy is standard treatment for hypoxemia, the condition of low blood oxygen that accompanies severe perinatal asphyxia and other newborn illnesses. The World Health Organization includes oxygen in its essential medicines list and in guidelines for newborn care. The physiological rationale is straightforward: without oxygen, brain and organ injury progresses.
The evidence base for oxygen in low-resource newborn care is thinner than the guidelines suggest. Few randomised trials have been conducted in district hospitals in sub-Saharan Africa, and most of what exists comes from referral settings with better monitoring. This matters because oxygen is not risk-free. Hyperoxia, or too much oxygen, can damage newborn lungs and eyes, particularly in premature infants. Without pulse oximetry to guide delivery, clinicians are guessing.
Experts split on how to handle this uncertainty. Some argue for routine oxygen use in resuscitation because the risk of hypoxia outweighs the risk of hyperoxia in a crashing newborn. Others argue for tighter monitoring and targeted use, even if that means some babies go without. The disagreement is genuine and reflects a real trade-off between access and safety. A 2020 study in The Lancet Global Health found that in some low-resource settings, oxygen was used inappropriately in more than half of cases, underscoring the need for better monitoring.
What Uganda's Clinicians Report
Clinicians who have completed resuscitation training consistently report improved confidence. They know what to do when a newborn does not breathe. That confidence matters, because delivery-room emergencies are chaotic and hesitation costs time. Training also appears to improve teamwork and communication during births, which has spillover effects on maternal care.
But confidence does not fix a broken concentrator. Clinicians in district facilities describe a familiar sequence: the machine fails, the technician is unavailable, the facility lacks spare parts, and the newborn is bagged on room air or referred. Some facilities have resorted to borrowing concentrators from neighbouring wards, which works until both wards need them at once.
District-level disparities remain stark. Regional referral hospitals in Kampala and a few other cities have better equipment and maintenance capacity. District hospitals and lower-level health centres, where most births occur, have the least. A related piece on this site about fatty liver disease progressing faster on low incomes makes a comparable point about resources shaping outcomes, though the disease and setting differ.
Practical Steps for Health Planners
Planners who want to close the gap can start with a simple audit. Count working oxygen concentrators, cylinders, and pulse oximeters at every facility that attends births. Record how often each is functional. That baseline is usually missing, which makes it hard to know whether training or equipment is the binding constraint.
Fund maintenance, not just training. A budget line for spare parts, technician travel, and concentrator repair is less visible than a training workshop, but it determines whether the training has any effect. Pair every resuscitation training cohort with a commitment to fix the equipment in the facilities those workers return to.
Train biomedical technicians alongside clinicians. A technician who understands concentrator repair can keep a district facility running. A clinician who understands what a broken concentrator looks like can report it before it fails completely. The two roles need each other.
Integrate oxygen into newborn care plans rather than treating it as a separate procurement item. Monitor power reliability at each facility and invest in backup batteries or solar where outages are frequent. None of this is glamorous, but it is what determines whether a trained health worker can actually save a newborn who is not breathing.
This article is informational and does not constitute personalised medical or professional advice. Readers should consult qualified health planners or clinicians for decisions about specific facilities or programmes.
