Power/influence and position of stakeholders
All the stakeholders interviewed were found to be in agreement with the proposed study, although there were varying levels of power/influence. On the whole, community level stakeholders were found to be supportive of the intervention but most of them had little influence due to the limited resources under their control.
Pregnant and newly delivered mothers were found to be highly in agreement of the proposed study (Table ). In general, mothers applauded the intervention given that it offered them an opportunity to deliver at health facilities at the hands of skilled birth attendants. These thoughts are captured in one of the quotations below from one of the participants of a focus group discussion.
Stakeholders characteristics, power/influence regarding the implementation of an integrated maternal/newborn care project
“....long ago we used to deliver from banana plantations and on the way which made us get problems while giving birth. So it saved us from all those problems, we are now very happy, let the project continue.” [FGD women]
However, due to the limited resources mothers were found to control, their power and influence was considered to be low, hence they were characterized as supporters (Figure ).
During the FGDs, men revealed that they support the programme strongly and would love to see it continue for a longer time. The burden of paying for transport costs, buying the supplies and requirements for the mothers and their newborn babies usually rests on the men as household heads. Financial contributions from the project will therefore enable them to reallocate their meager resources towards other basic pressing needs such as school fees, food and general welfare of the family. The men were also characterized as supporters due to their high level of agreement with the intervention but rather limited influence.
The level of support of the motorcycle riders, who were involved in the transport business and had been engaged by the existing safe delivery study, was also analyzed. Since they transported pregnant and newly delivered mothers for a fee, they were also considered beneficiaries. This group was very supportive of the maternal/newborn study project. These transporters were found to have moderate influence since their participation is critical for the successful implementation of the transport voucher scheme.
The local council (LC) which is the administrative structure of the community starting with the village (LC 1), the parish (LC 2), the sub-county (LC 3) and the district level (LC 5) had varying resources; least at the lowest level with marginal increases as the level of administration rises. The local leaders were eager to get involved in the implementation of the study, especially through mobilization and sensitization of the local community. They were cognizant of the challenges mothers face in the community such as high poverty levels and they welcomed the study project. The quote below highlights their views.
“….the money they (mothers) have been paying in the hospital was a burden to them and even transport, so if the project comes in, then there will be no problem.” [LC 1 women representative]
Table summarizes the stakeholders’ classification regarding the power and influence towards the planned study project.
At the district level, one of the technical departments is health, which is run by the District Health Team (DHT) headed by the District Health Officer (DHO). The DHOs realized how their communities and health facilities were likely to benefit, hence they strongly approved of the intervention, as illustrated in the quote below.
“..Our community will truly benefit and also at the end of the day our health workers will be trained, which we probably cannot afford as a district to keep training them. I think am happy, I have a strong go ahead for it. I only see a challenge of sustainability.” [District Official]
The DHOs had high influence; they are in charge of the district’s health care system and they approve health interventions that are implemented in the districts. However, due to the limited resources they could commit to the implementation of the intervention they were characterized as supporters rather than drivers.
Level of agreement with the proposed maternal/newborn care study for the various national level stakeholders was analyzed and was found to be predominantly high for most of the stakeholders. However, the MOH representative was skeptical of the success and sustainability of the proposed interventions given the ‘high’ costs of implementation of the transport voucher scheme as emphasized by the following quote.
‘..every research is to inform policy but you are putting in a lot of resources, you are using a lot of money which the government cannot afford. You can’t sustain it….it becomes a very big issue, the government will not put money as direct as you are doing….the way you are doing it’. [MOH official]
The MOH representative provides oversight over health activities and programmes in the country, but since MOH had limited funds for scale up they were characterized as supporters.
The Member of Parliament is a policy maker and therefore key for influencing budget allocations. The development partners, such as DFID who funded the Safe Deliveries Study, indicated a desire to be involved in the research to policy translation process, and to share the research findings with other development partners at various forums. However the agent was found to be with moderate influence in the implementation process, hence a supporter and not a driver.
Implementation challenges and solutions highlighted by the stakeholders
The stakeholder analysis also aimed at assessing the stakeholders’ views regarding potential challenges and strategies for sustaining a transport voucher scheme, a health worker incentive scheme and strong community engagement. There were varied suggestions in this regard as summarized in Table .
Implementation challenges and solutions suggested by stakeholders in Uganda
The concerns of the community stakeholders ranged from, issues that contribute to the poor quality of services, poor access of transport services especially for referral to higher levels of care, low male involvement as well as implementation challenges experienced during the Safe Deliveries project. The district and national level stakeholders had similar concerns in addition to ensuring the sustainability of such a scheme beyond the study period. Some of the concerns raised are expounded in the sections that follow with selected quotations.
Quality of health care services
The stakeholders pointed out that the poor quality of maternal health care services has for long been one of the deterrents to maternal and child health service utilization. The poor quality of services had previously been attributed to problems such as unofficial payments, the poor attitude of health care workers, insufficient supplies, equipment and medicines among others.
“…. the poor attitude of health workers, then lack of supplies because if a mother comes to the facility and you give her an endless list of supplies to buy, she will end up going home because she doesn’t have the money to buy all those things”. [District Official]
One of the districts shared how they dealt with drug stock outs. This district attempted to redistribute drugs centrally to avoid stock outs in some high catchment facilities and managed over stocking in facilities that were underutilized. Other strategies recommended for overcoming the challenges included capacity building of health workers coupled with supportive supervision.
Transport and referral system
It was noted that the districts had a poor road network. The main mode of transport in the community was the commercial motorcycle (boda bodas). These motorcycles were also used to refer mothers to higher-level facilities since most of the lower level health facilities either did not have an ambulance, or had one that was not functional. Patients were therefore often required to meet either the cost of fuel if an ambulance was available or the entire cost of hiring a vehicle to a referral facility. This made it impossible for some clients to receive health care. These difficulties experienced in accessing transportation from home to health facilities and during referrals featured prominently as one of the concerns for most stakeholders.
“…..we have no transport to bring our expectant mothers from deep villages to trading centers where there is transport, so that’s why we get so many complications during delivery; that’s when mothers produce babies who are tired and at times they produce dead babies due to lack of transport.” [FGD men]
“Transport in this whole district is still a challenge. The ambulances are there but there is no fuel. The ambulances are there and the driver is not facilitated. So I think we have to look into how to incorporate all this. Even the ambulances are very old. They frequently breakdown and the maintenance cost is very high because they are very old.” [District Official]
Most of the district and community level stakeholders felt that male involvement was rather low. This is depicted in the quotation below.
“… Most of our women here in our service area are poor and you have a challenge of male involvement. I really don’t know how we can address that challenge so that we bring the male counterparts on board, so that they come to assist their spouses…. ….” [District Official]
Some stakeholders (women) felt that men had become “lazy” because the project was assisting and providing most of the financial contributions that they were supposed to provide. This could be a potential negative consequence of the transport voucher scheme of the maternal/newborn project and thus may affect the future contribution of households towards birth preparedness.
The DHO’s recommended an intervention that will educate the men about their primary responsibility in caring for their spouses, and one that would compel them to save money and contribute to the scheme for birth preparedness.
“….Sensitize the community well so that men know they should take care of their spouses.” [District Official]
The district stakeholders also suggested giving mothers who come to health facilities with their husbands maama kits (kit of items for delivery) to encourage male involvement. One of the districts shared their experience in which they initiated a project to identify “model families.” A model family is one where critical family support for child survival is given. Such a family provides the basic family needs, has food security, practices family planning, and the husband supports his wife by accompanying her to the facility for maternal/child health care. Model men were used for peer to peer education on health issues such as family planning and service utilization. District officials even recommended passing a ‘by-law’ to enforce male involvement in birth preparedness as an important issue to consider.
The district stakeholders also proposed engaging local leaders and drama groups to sensitize communities on service utilization and birth preparedness.
Transport voucher scheme implementation challenges
Community members shared their experiences during the implementation of the transport voucher scheme of the Safe Deliveries project. They complained that there was high inflation, consequently fuel prices increased dramatically while the transportation voucher charges remained constant. This affected the participation of some transporters and subsequently reduced transport availability in remote areas. These stakeholders recommended an increase in the transport voucher payment rates and regular review of the voucher charges.
The transporters also reported that in some cases they incurred losses. In some circumstances, they arrived and found that mothers had already delivered. In another scenario they were not paid if the health workers did not register the names of the mothers at the facility (they were only paid for clients whose names were found registered in the facility registers). Stakeholders recommended stamping and signing of the transport vouchers by health workers once a mother has been transported to the facility. Delays in payment and insecurity at night were some of the other challenges pointed out. The use of bank accounts was suggested as a means of reducing the delayed payment. Encouraging male involvement where husbands escort their wives to health facilities and the mobilization of community leaders were recommended in order to mitigate problems related to insecurity at night.
In a few cases, the mothers were not able to reach the health facility and the transporters had to assist them in delivery. Although this was a rare occurrence, the transporters suggested that they should receive emergency supplies such as gloves and basic training on how to deal with such emergencies.
Accountability of financial incentive
It was noted that both financial and non-financial incentives for health workers were inadequate. Monetary incentives for health workers were welcomed; however, they have the potential to create rifts between those who receive such benefits and those who do not. National level stakeholders suggested conditional transfer of funds and performance based bonus payments to health facilities that can be utilized for motivation and purchasing needed materials. The stakeholders recommended strengthening of supervision of the voucher scheme to ensure that redeemed service funds at the health facilities are well utilized.
National level stakeholders, particularly the MOH showed moderate support for the proposed intervention. As already pointed out in the previous sections, MOH stakeholders were particularly concerned about the capacity of the Ministry to scale up the initiative that appeared rather expensive. However, other national level stakeholders (development partners) noted that if the study finds the program to be cost-effective, then the government may be convinced to allocate money to scale up the project.
Most of the suggestions for improving the implementation of the scheme and promoting sustainability revolved around the increased involvement of a wide range of stakeholders. These stakeholders could provide for the successful implementation of the scheme in three main ways: by contributing finances, contributing non monetary resources, and promoting research to policy influence. Most participants highlighted the importance of engaging stakeholders at various levels to increase their awareness and encourage their participation in the project.
Community contribution of finances
The stakeholder analysis also revealed that the national and district level stakeholders wish to see the mothers/communities take responsibility of their own health by contributing financially to the transport scheme. During the interviews it was mentioned that monetary contribution to the project has the potential to improve ownership and to minimize abuse of the vouchers. They also stated that for communities to contribute to the scheme they need to be empowered economically. The opinions of stakeholders about impact on the poor were mixed; some stakeholders acknowledged the presence of poor families and advised their exemption from transport payments. They suggested that the community members should be profiled in order to identify and exempt the poor, as described by the following quote.
“……Government isn’t going to be able to afford services with the current economic trend. If there is a mechanism through which people can pay or contribute this would help. Under such a scheme, the poor should be exempted” [National level KI].
However, other stakeholders such as Member of Parliament pointed out that if community members were to contribute, a flat fee should be set for everyone rather than exempting the poor or having a sliding scale with the poor paying less than the rich. They argued that one of the difficulties with a sliding scale would be to identify and determine who is poor given the subtly different poverty demarcations.
The stakeholders recommended that although the project design should include mechanisms to ensure community contribution and ownership from the start, the government should commit to saving mothers and their newborns. These thoughts are captured in the quotation below
“The study members should keep these stakeholders informed and engaged through consultation but also they must be made to understand that saving mothers and their newborns cannot be achieved without a cost; the programmers and government must be ready to invest in inputs for improving access and health facility strengthening.” [National level KI]
Mobilizing resources from other partners
The district authorities recommended that the project liaises with stakeholders like the ministry of transport and non-governmental organizations to advocate for the provision of vehicles that could be maintained more easily. They suggested the purchase of motorcycles that could be used by the district health team for supervision and motorcycle ambulances for referrals to more distant health facilities.
The districts also shared that it was possible to lobby for resources from other partners working within the district. For example, two of the districts had lobbied and obtained funding for purchasing registers and training village health teams from an NGO partner working in the district.
Research to policy influence
The stakeholders thought that areas where this study could influence policy formulation included: devising strategies for male involvement, improving the capacity of health facilities to deliver quality services, and improving the referral system especially the functionality of ambulances to enable patients reach higher levels of care.
The main problem anticipated to be encountered when trying to promote the translation of the research findings into policy; would be the high cost of implementation of the project vis a vis the outcomes and how to ensure sustainability.
“..of course there is going to be noise about cost. That is going to be the number one. Despite the fact that the policy makers will have the will, the cost remains a constraint”. [District Official]
To overcome the barriers related to the translation of research to policy, stakeholders advised the project management to: bring several partners on board (parliamentary social service committee, MOH representatives and development partners); implement through existing structures; conduct implementation research based on MOH strategic plan; and have continued engagement between researchers, implementers and policy makers through meetings, policy briefs, and regular reports.