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Background: Uganda, a low resource country, implemented the skilled attendance at birth strategy, to meet a key target of the 5th Millenium Development Goal (MDG), 75% reduction in maternal mortality ratio. Maternal mortality rates remained high, despite the improvement in facility delivery rates. In this paper, we analyse the strategies implemented and bottlenecks experienced as Uganda’s skilled birth attendance policy was rolled out. These experiences provide important lessons for decision makers as they implement policies to further improve maternity care. Methods: This is a case study of the implementation process, involving a document review and in-depth interviews among key informants selected from the Ministry of Health, Professional Organisations, Ugandan Parliament, the Health Service Commission, the private not-for-profit sector, non-government organisations, and District Health Officers. The Walt and Gilson health policy triangle guided data collection and analysis. Results: The skilled birth attendance policy was an important priority on Uganda’s maternal health agenda and received strong political commitment, and support from development partners and national stakeholders. Considerable effort was devoted to implementation of this policy through strategies to increase the availability of skilled health workers for instance through expanded midwifery training, and creation of the comprehensive nurse midwife cadre. In addition, access to emergency obstetric care improved to some extent as the physical infrastructure expanded, and distribution of medicines and supplies improved. However, health worker recruitment was slow in part due to the restrictive staff norms that were remnants of previous policies. Despite considerable resources allocated to creating the comprehensive nurse midwife cadre, this resulted in nurses that lacked midwifery skills, while the training of specialised midwives reduced. The rate of expansion of the physical infrastructure outpaced the available human resources, equipment, blood infrastructure, and several health facilities were not fully functional. Conclusion: Uganda’s skilled birth attendance policy aimed to increase access to obstetric care, but recruitment of human resources, and infrastructural capacity to provide good quality care remain a challenge. This study highlights the complex issues and unexpected consequences of policy implementation. Further evaluation of this policy is needed as decision-makers develop strategies to improve access to skilled care at birth.
We conducted our study in Kampala, Uganda’s capital city, where national level policy makers and key actors in policy formulation, including the Ministry of Health that is responsible for coordinating all health policies, are based. The other study areas were Mpigi and Rukungiri districts. We purposively selected these to represent the district level, which is responsible for policy implementation. Mpigi district is in central Uganda, 38 km west of Kampala, while Rukungiri district is in Western Uganda, 373 km southwest of Kampala. We utilised a case study approach to investigate Uganda’s implementation of the skilled birth attendance policy as perceived by mid-level national policy makers and district managers. The case study methodology is particularly well suited to analyse policy implementation, which is deeply embedded in the local context [24]; and to study the complex relationships between actors, and the influence of these relationships on implementation over time [25]. The Walt and Gilson health policy triangle [26], which focuses on an examination of the context, key actors and implementation activities, guided the development of data collection tools and our analytical approach. We traced the shifting interpretations and assumptions about who skilled birth attendants are, and what the implementation of the skilled birth attendance policy has entailed at the national and district levels over time. In addition, we utilised a principal agent perspective which views gaps in implementation as a result of the way governments usually operate, with policy makers delegating functions to other officials or ‘agents’ that are only indirectly under their control and therefore difficult to monitor. Typically, these agents make their own decisions on how they operate on behalf of the ‘principal’, which affects how a policy is implemented [27]. We conducted internet searches and snowballed our search of Ugandan policy documents, as well as documents on global and African regional maternal and reproductive health. For example, we searched the Ministry of Health Uganda website, the websites of key organisations related to maternal health such as United Nations Population Fund (UNFPA), and hand searched selected documents in the Ministry of Health Uganda library. We analysed relevant documents to clarify the ‘skilled birth attendant’ concept within the local Ugandan context, and the strategies (and outcomes of these strategies), the actors, and the key events that played a role in providing skilled birth attendance in Uganda. Information obtained from the document review guided the formative phase of this study and supplemented the data during analysis. We purposefully selected key informants from a preliminary list of key actors identified from the document review. We selected key informants that had a role in developing and/or implementing Uganda’s maternal health policy, and had served in their organisation for at least 2 years. In addition, we made a list of our assumptions about the implementation of maternal health policy in Uganda, and used some of these to guide the selection of the informants (see Additional file 1). We assumed, for example, that policy implementation by the private and not-for-profit sector would be different from the public sector and selected informants from both sectors. Two of the authors (SMB and HN) who previously worked as clinicians in Uganda, and are currently health systems researchers, conducted the interviews. The questions focussed on the content and emergence of the skilled birth attendance policy in Uganda and the strategies implemented (see Additional file 2). We conducted interviews in English, for 1–1.5 h, at the workplaces of the key informants, between June and August 2014. Due to the busy schedule of the key informants, prolonged engagement and follow-up interviews were not possible. All the interviews were audio recorded by a research assistant and a moderator (either SMB or HN) took field notes. The moderators probed for information on new ideas arising during the interview or from previous interviews, until no new information arose from the subsequent interviews. Research assistants transcribed all the audio recordings. One author (SMB) crosschecked the transcripts against the audio records to ensure accuracy. We used a thematic analysis approach when analysing the data [28]. Two authors, working independently, read and reread the transcripts to familiarise themselves with the data and identify emerging themes. Three authors (SMB, HN, and DA) discussed the emerging themes to identify linkages and define the boundaries of the term ‘skilled birth attendant’ in the Uganda context, how the policy evolved, the strategies implemented, and any bottlenecks experienced during the policy implementation. As part of the analysis, we triangulated the interview data with information obtained from the policy documents to clarify concepts.
