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Background: Based on the realization that Uganda is not on track to achieving Millennium Development Goals 4 and 5, Makerere University School of Public Health in collaboration with other partners proposed to conduct two community based maternal/newborn care interventions aimed at increasing access to health facility care through transport vouchers and use of community health workers to promote ideal family care practices. Prior to the implementation, a stakeholder analysis was undertaken to assess and map stakeholders’ interests, influence/power and position in relation to the interventions; their views regarding the success and sustainability; and how this research can influence policy formulation in the country. Methods: A stakeholder analysis was carried out in March 2011 at national level and in four districts of Eastern Uganda where the proposed interventions would be conducted. At the national level, four key informant interviews were conducted with the ministry of health representative, Member of Parliament, and development partners. District health team members were interviewed and also engaged in a workshop; and at community level, twelve focus group discussions were conducted among women, men and motorcycle transporters. Results: This analysis revealed that district and community level stakeholders were high level supporters of the proposed interventions but not drivers. At community level the mothers, their spouses and transporters were of low influence due to the limited funds they possessed. National level and district stakeholders believed that the intervention is costly and cannot be affordably scaled up. They advised the study team to mobilize and sensitize the communities to contribute financially from the start in order to enhance sustainability beyond the study period. Stakeholders believed that the proposed interventions will influence policy through modeling on how to improve the quality of maternal/newborn health services, male involvement, and improved accessibility of services. Conclusion: Most of the stakeholders interviewed were supporters of the proposed maternal and newborn care intervention because of the positive benefits of the intervention. The analysis highlighted stakeholder concerns that will be included in the final project design and that could also be useful in countries of similar setting that are planning to set up programmes geared at increasing access to maternal and new born interventions. Key among these concerns was the need to use both human and financial resources that are locally available in the community, to address supply side barriers that influence access to maternal and child healthcare. Research to policy translation, therefore, will require mutual trust, continued dialogue and engagement of the researchers, implementers and policy makers to enable scale up. © 2013 Namazzi et al; licensee BioMed Central Ltd.
The stakeholder analysis was carried out in March 2011 at the national and district level in Uganda. Local level participants came from four districts of Buyende, Kamuli, Iganga, and Pallisa where the study projects will be conducted. The stakeholder analysis was undertaken through three major phases 1) Identification of stakeholders, 2) Assessing and mapping out their interests and attitudes, power/influence, position in relation to the political resources they possess [22], and 3) Development of an appropriate strategy on how best to interact and engage these stakeholders. This step involved brainstorming amongst the research team members to identify categories of stakeholders, how they may be affected, who were likely to be direct beneficiaries, the potential impact of the project upon stakeholders, and their numbers. A list of categories of stakeholders was then prioritized based on: potential to benefit, weaken or strengthen the intervention; at national, district, and community level (Table 1) within 11 major categories. Stakeholders identified and interviewed for the Uganda project FGDs = Focus group discussion, IDIs = Key informant interviews. Data were collected from the respondents indentified in Table 1. Data collection techniques involved mainly qualitative methods and these included: Focus group discussions with mothers and their spouses, and transporters; Key informant interviews with national level participants, community leaders, district health team members and administrators; and a stakeholders’ workshop with 12 representatives from the district health teams from the districts of Buyende, Kamuli, Iganga, and Pallisa. Data were collected by researchers with experience in qualitative data collection techniques. National and district level interviews were conducted in English while at the community level the interviews and discussions were in Lusoga, the local language. Two Lusoga speakers independently translated interviews into English. All interviews were digitally recorded and transcribed. Key informants were purposively selected and key informant interview guides were used to collect data from 4 national, 8 district and 4 community level representatives as shown in Table 1. Questions and discussions focused on topics such as factors affecting utilization of maternal child health services, strengths and weaknesses of the proposed study, how integration into existing health and community services can be accomplished, challenges, potential solutions, and sustainability strategies. Focus group discussions (FGDs) were conducted to explore opinions, attitudes and perceptions on the feasibility of implementation, and sustainability of a maternal/newborn care research project at the community and household levels [23,24]. Participants included mothers and their spouses (men). Four FGDs of women and four FGDs for men in the intervention areas of Buyende and Pallisa, and the comparison areas of Kibuku and Kamuli were conducted. The discussion with mothers who are the program’s primary beneficiaries focused on barriers to service utilization [25,26], opinions regarding the proposed intervention, how the intervention can successfully be integrated into existing structures, potential implementation challenges and sustainability strategies. Transporters (motorcycle riders) were also interviewed to seek their views, the challenges they face and possible solutions for the use of transport vouchers for maternal and newborn services. Two focus group discussions were held with transporters in the intervention area and two focus group discussions with those in the comparison area. The participants in all the FGDs were purposively selected. The groups were homogenous in composition (mothers aged 18–35 years, men aged 18–35 years, and transporters aged 35 – 50 years). The discussions were guided by an FGD guide and focused on challenges in transporting mothers, information the transporters would like to share, means of communication and possible community contributions for sustaining the scheme. Ethical approval to conduct the study was provided by the Institutional Review Board at the Makerere University School of Public Health and Uganda National Council for Science and Technology (UNCST). Voluntary informed consent was then individually obtained from all the study participants. Assessing and mapping the power/influence of the stakeholders involved identifying who owns what resources (tangible or intangible), who possesses privileges, and who can directly or indirectly take action for or against the project or be able to mobilize for or against it. This assisted in the organization of stakeholders according to their likely influence over decisions to be made, and the likely impact of project decisions upon them. During this phase a stakeholder analysis grid was formulated and the stakeholders were characterized according to the following pre-existing categories as predicted in Figure 1. The categorization was based on the interview findings, the positions they held, and previous roles they played in the pilot studies. Stakeholder analysis grid. Ref: FHS2/Stakeholder Analysis/Hyder et al.[27]. Drivers: A person or group that has high influence and champions the cause Blockers: A person or group that has high levels of power, but opposes the proposal Supporters: Those that support the proposal, but whose influence may be limited (on their own) Bystanders: Those with low influence and support. Abstainers: Those who are neutral to the proposal, but may or may not have influence. The classification of the stakeholders was further categorized as high, moderate or low, considering their varied levels of alignment and influence. A table was used to present the findings since most of the stakeholders were supporters (same category of the grid), secondly this allowed the inclusion of other results and strategies to deal with the stakeholder. Such strategies were classified into: (1). Empowerment: Strategies that would economically empower communities, encourage saving or raise awareness (2). Continuous engagement: Keep the stakeholders updated of the implementation process in order to take action (3). Involve further: Engage in planning or implementation (4). Consult further: Agree on working relations Thematic analysis of interviews and mapping of stakeholders by their level of power, influence, and level of agreement was conducted. The researchers, who are considered internal analysts [21] led this process. Although we used a framework that highlighted the key areas of investigation, we also looked out for new themes emerging outside this framework [28,29]. The themes identified were in line with the key issues that the research sought to address, such as concerns and interests of stakeholders, sustainability challenges and suggestions for promoting sustainability and uptake of the research findings.
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