Implementing the skilled birth attendance strategy in Uganda: A policy analysis

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Study Justification:
– The study aims to analyze the implementation of Uganda’s skilled birth attendance policy, which is crucial for reducing maternal mortality rates.
– The study provides important lessons for decision-makers as they develop strategies to improve maternity care.
– The study highlights the complex issues and unexpected consequences of policy implementation, emphasizing the need for further evaluation.
Study Highlights:
– The skilled birth attendance policy received strong political commitment and support from national stakeholders and development partners.
– Efforts were made to increase the availability of skilled health workers through expanded midwifery training and the creation of a comprehensive nurse midwife cadre.
– Access to emergency obstetric care improved to some extent, with expanded physical infrastructure and improved distribution of medicines and supplies.
– However, challenges were faced in recruiting health workers and ensuring the quality of care due to restrictive staff norms and inadequate resources.
– The study emphasizes the need to address these challenges to improve access to skilled care at birth.
Study Recommendations:
– Evaluate and revise the staff norms to facilitate the recruitment of skilled health workers.
– Strengthen the training of specialized midwives to ensure the availability of skilled birth attendants with the necessary skills.
– Address the gaps in infrastructure, equipment, and blood supply to ensure that health facilities are fully functional.
– Continuously monitor and evaluate the implementation of the skilled birth attendance policy to identify and address any emerging issues.
Key Role Players:
– Ministry of Health
– Professional Organizations
– Ugandan Parliament
– Health Service Commission
– Private not-for-profit sector
– Non-government organizations
– District Health Officers
Cost Items for Planning Recommendations:
– Recruitment and training of skilled health workers
– Infrastructure development and maintenance
– Equipment procurement and maintenance
– Blood supply infrastructure
– Monitoring and evaluation activities

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The study provides a detailed description of the methods used, including the case study approach and data collection tools. The authors also discuss the results of their analysis, highlighting the challenges faced in implementing the skilled birth attendance policy in Uganda. However, the abstract could be improved by including more specific information about the findings and recommendations for action. Additionally, the abstract does not mention any limitations of the study, which would be helpful for readers to understand the potential biases or constraints of the research.

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.

Based on the provided description, here are some potential innovations that could be recommended to improve access to maternal health:

1. Strengthening human resources: Address the slow recruitment of health workers by implementing strategies to attract and retain skilled birth attendants. This could include offering incentives such as higher salaries, improved working conditions, and career development opportunities.

2. Enhancing midwifery training: Improve the training of nurses to ensure they acquire the necessary midwifery skills. This could involve revising the curriculum to include more comprehensive midwifery training and providing ongoing professional development opportunities for practicing midwives.

3. Improving infrastructure: Address the issue of physical infrastructure outpacing available resources by investing in the necessary equipment, supplies, and blood infrastructure. This could involve allocating resources to ensure that health facilities are fully functional and adequately equipped to provide quality maternal care.

4. Strengthening policy implementation: Address the complex issues and unexpected consequences of policy implementation by conducting further evaluation of the skilled birth attendance policy. This could involve monitoring and evaluating the policy’s impact, identifying gaps in implementation, and making necessary adjustments to improve access to skilled care at birth.

5. Promoting collaboration: Foster collaboration between different stakeholders, including the Ministry of Health, professional organizations, parliament, health service commission, private not-for-profit sector, non-government organizations, and district health officers. This could involve establishing platforms for regular communication, sharing best practices, and coordinating efforts to improve maternal health outcomes.

It is important to note that these recommendations are based on the information provided and may need to be further tailored to the specific context and needs of Uganda.
AI Innovations Description
Based on the information provided, the recommendation to improve access to maternal health in Uganda would be to address the following key areas:

1. Human resource recruitment and training: The study highlights the slow recruitment of skilled health workers, which has resulted in a shortage of midwives with the necessary skills. To improve access to maternal health, it is important to prioritize the recruitment and training of skilled birth attendants, including midwives, to ensure that there are enough qualified professionals to provide quality care during childbirth.

2. Infrastructure and equipment: The expansion of physical infrastructure, such as health facilities, has outpaced the availability of human resources, equipment, and supplies. It is crucial to invest in the necessary infrastructure and equipment to support skilled birth attendance. This includes ensuring that health facilities are fully functional and equipped with the necessary tools and supplies for safe deliveries.

3. Strengthening emergency obstetric care: While access to emergency obstetric care has improved to some extent, there is still room for further improvement. This includes ensuring that there is adequate availability of emergency obstetric care services, such as blood transfusion services, to handle complications during childbirth. Strengthening emergency obstetric care can help reduce maternal mortality and improve access to life-saving interventions.

4. Policy evaluation and adaptation: The study highlights the complex issues and unexpected consequences of policy implementation. It is important for decision-makers to regularly evaluate the impact of policies and make necessary adaptations based on the findings. This includes monitoring the effectiveness of strategies implemented and addressing any bottlenecks or challenges that arise during implementation.

By addressing these key areas, Uganda can work towards improving access to skilled care at birth and ultimately reduce maternal mortality rates. It is important for decision-makers to consider these recommendations as they develop strategies to improve maternal health in the country.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Strengthening human resources: Address the slow recruitment of health workers by revising staff norms and increasing the availability of skilled health workers through expanded midwifery training and the creation of a comprehensive nurse midwife cadre.

2. Improving infrastructure and supplies: Ensure that the rate of expansion of physical infrastructure is aligned with the available human resources, equipment, and blood infrastructure. Address the issue of non-functional health facilities and improve the distribution of medicines and supplies.

3. Enhancing policy implementation: Develop strategies to address the complex issues and unexpected consequences of policy implementation. Conduct further evaluation of the skilled birth attendance policy to identify gaps and improve access to skilled care at birth.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed using the following steps:

1. Define the indicators: Identify key indicators that measure access to maternal health, such as facility delivery rates, maternal mortality rates, availability of skilled health workers, and functional health facilities.

2. Collect baseline data: Gather data on the current state of access to maternal health, including the identified indicators. This could involve surveys, interviews, and data collection from relevant sources such as health facilities, government reports, and population surveys.

3. Develop a simulation model: Create a simulation model that incorporates the recommended innovations and their potential impact on the identified indicators. This model should consider factors such as population demographics, health worker availability, infrastructure capacity, and policy implementation.

4. Run simulations: Use the simulation model to run various scenarios that reflect the implementation of the recommended innovations. This could involve adjusting parameters such as the number of skilled health workers, infrastructure capacity, and policy effectiveness.

5. Analyze results: Analyze the simulation results to assess the impact of the recommended innovations on improving access to maternal health. Compare the outcomes of different scenarios to identify the most effective strategies.

6. Refine and iterate: Based on the analysis of the simulation results, refine the recommendations and simulation model as needed. Iterate the process to further optimize the strategies for improving access to maternal health.

By following this methodology, decision-makers can gain insights into the potential impact of different innovations on improving access to maternal health and make informed decisions on policy implementation.

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