Exploring Variations in the Implementation of a Health Systems Level Policy to Improve Maternal and Child Health

Uganda is among the countries with the highest burden of maternal mortality. Despite efforts to reduce this burden, the implementation of the maternal and perinatal death review (MPDR) lately known as the maternal and perinatal death surveillance and response (MPDSR) policy has had variable success. The aim of this study was to explore variations in the determinants of the implementation of the MPDR policy among selected health facilities in Uganda. This was a multiple case study informed by the Normalization Process Theory (NPT). It included actors involved in the implementation of the policy such as front-line health workers – (doctors, nurses, and midwives) (32), District Health Officials (7), Ministry of Health staff (3), as well as representatives from agencies and professional associations (6). The study was conducted across 8 districts in 10 health facilities. Data were collected using semi-structured in-depth interviews (48). Transcripts were analyzed using thematic content analysis as well as the constructs of NPT. The observed variations in MPDR policy implementation at the various levels of care were potentially explained by differences in the levels of efforts invested by the actors, influence of contextual factors, presence or absence of implementing partners and lack of awareness about the policy. Across the top and bottom performing districts, the variations were explained by differences in understanding of the implementation process, influence of the cognitive participation efforts, the resource allocation and appraisal work around implementation of the policy as well as the differences in the barriers encountered across different contexts. Exploring the sense-making, relational, operational and appraisal efforts that actors invest in implementation of complex interventions is critical to understanding why and how such interventions become embedded and sustained in some settings, yet they struggle or completely fail in others. Evidence generated from this study may be used to inform efforts to develop, design, modify and or scale up implementation of the MPDR policy