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1.  Uptake of evidence in policy development: the case of user fees for health care in public health facilities in Uganda 
Background
Several countries in Sub Saharan Africa have abolished user fees for health care but the extent to which such a policy decision is guided by evidence needs further exploration. We explored the barriers and facilitating factors to uptake of evidence in the process of user fee abolition in Uganda and how the context and stakeholders involved shaped the uptake of evidence. This study builds on previous work in Uganda that led to the development of a middle range theory (MRT) outlining the main facilitating factors for knowledge translation (KT). Application of the MRT to the case of abolition of user fees contributes to its refining.
Methods
Employing a theory-driven inquiry and case study approach given the need for in-depth investigation, we reviewed documents and conducted interviews with 32 purposefully selected key informants. We assessed whether evidence was available, had or had not been considered in policy development and the reasons why and; assessed how the actors and the context shaped the uptake of evidence.
Results
Symbolic, conceptual and instrumental uses of evidence were manifest. Different actors were influenced by different types of evidence. While technocrats in the ministry of health (MoH) relied on formal research, politicians relied on community complaints. The capacity of the MoH to lead the KT process was weak and the partnerships for KT were informal. The political window and alignment of the evidence with overall government discourse enhanced uptake of evidence. Stakeholders were divided, seemed to be polarized for various reasons and had varying levels of support and influence impacting the uptake of evidence.
Conclusion
Evidence will be taken up in policy development in instances where the MoH leads the KT process, there are partnerships for KT in place, and the overall government policy and the political situation can be expected to play a role. Different actors will be influenced by different types of evidence and their level of support and influence will impact the uptake of evidence. In addition, the extent to which a policy issue is contested and, whether stakeholders share similar opinions and preferences will impact the uptake of evidence.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-014-0639-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s12913-014-0639-5
PMCID: PMC4310169  PMID: 25560092
User fees; Health care; Public facilities; Policy development; Knowledge translation; Uganda
2.  The roles and influence of actors in the uptake of evidence: the case of malaria treatment policy change in Uganda 
Background
Uganda changed its malaria treatment policy in response to evidence of resistance to commonly used antimalarials. The use of evidence in policy development—also referred to as knowledge translation (KT)—is crucial, especially in resource-limited settings. However, KT processes occur amidst a complex web of stakeholder interactions. Stakeholder involvement in evidence generation and in KT activities is essential. In the present study, we explored how stakeholders impacted the uptake of evidence in the malaria treatment policy change in Uganda.
Methods
We employed a qualitative case study methodology involving interviews with key informants and review of documents. A timeline of events was developed, which guided the purposive sampling of respondents and identification of relevant documents. Data were analysed using inductive content analysis techniques.
Results
Stakeholders played multiple roles in evidence uptake in the malaria treatment policy change. Donors, the Ministry of Health (MoH), service providers, and researchers engaged in the role of evidence generation. The MoH, parliamentarians, and opinion leaders at the national and local levels engaged in dissemination of evidence. The donors, MoH, researchers, and service providers engaged in the uptake of evidence in policy development and implementation. Stakeholders exerted varying levels of support and influence for different reasons. It is noteworthy that all of the influential stakeholders were divided regarding the best antimalarial alternative to adopt.
Conclusion
Our results showed a diverse group of stakeholders who played multiple roles, with varying levels of support and influence on the uptake of evidence in the malaria treatment policy change. For a given KT processes, mapping the relevant stakeholders and devising mechanism for their engagement and for how to resolve conflicts of interest and disagreements a priori will enhance uptake of evidence in policy development.
Electronic supplementary material
The online version of this article (doi:10.1186/s13012-014-0150-8) contains supplementary material, which is available to authorized users.
doi:10.1186/s13012-014-0150-8
PMCID: PMC4193992  PMID: 25294279
Knowledge translation; Stakeholders; Malaria; Treatment policy change
3.  Malaria treatment policy change in Uganda: what role did evidence play? 
Malaria Journal  2014;13(1):345.
Background
Although increasing attention is being paid to knowledge translation (KT), research findings are not being utilized to the desired extent. The present study explores the role of evidence, barriers, and factors facilitating the uptake of evidence in the change in malaria treatment policy in Uganda, building on previous work in Uganda that led to the development of a middle range theory (MRT) outlining the main facilitatory factors for KT. Application of the MRT to a health policy case will contribute to refining it.
Methods
Using a case study approach and mixed methods, perceptions of respondents on whether evidence was available, had been considered and barriers and facilitatory factors to the uptake of evidence were explored. In addition, the respondents’ rating of the degree of consistency between the policy decision and available evidence was assessed. Data collection methods included key informant interviews and document review. Qualitative data were analysed using content thematic analysis, whereas quantitative data were analysed using Excel spreadsheets. The two data sets were eventually triangulated.
Results
Evidence was used to change the malaria treatment policy, though the consistency between evidence and policy decisions varied along the policy development cycle. The availability of high-quality and contextualized evidence, including effective dissemination, Ministry of Health institutional capacity to lead the KT process, intervention of the WHO and a regional professional network, the existence of partnerships for KT with mutual trust and availability of funding, tools, and inputs to implement evidence, were the most important facilitatory factors that enhanced the uptake of evidence. Among the barriers that had to be overcome were resistance from implementers, the health system capacity to implement evidence, and financial sustainability.
Conclusion
The results agree with facilitatory factors identified in the earlier developed MRT, though additional factors emerged. These results refine the earlier MRT stating that high-quality and contextualized evidence will be taken up in policies, leading to evidence-informed policies when the MoH leads the KT process, partnerships are in place for KT, the WHO and regional professional bodies play a role, and funding, tools, and required inputs for implementing evidence are available.
Electronic supplementary material
The online version of this article (doi:10.1186/1475-2875-13-345) contains supplementary material, which is available to authorized users.
doi:10.1186/1475-2875-13-345
PMCID: PMC4164770  PMID: 25179532
Malaria treatment policy change; Evidence; Knowledge translation
4.  Advancing the application of systems thinking in health: exploring dual practice and its management in Kampala, Uganda 
Background
Many full-time Ugandan government health providers take on additional jobs – a phenomenon called dual practice. We describe the complex patterns that characterize the evolution of dual practice in Uganda, and the local management practices that emerged in response, in five government facilities. An in-depth understanding of dual practice can contribute to policy discussions on improving public sector performance.
Methods
A multiple case study design with embedded units of analysis was supplemented by interviews with policy stakeholders and a review of historical and policy documents. Five facility case studies captured the perspective of doctors, nurses, and health managers through semi-structured in-depth interviews. A causal loop diagram illustrated interactions and feedback between old and new actors, as well as emerging roles and relationships.
Results
The causal loop diagram illustrated how feedback related to dual practice policy developed in Uganda. As opportunities for dual practice grew and the public health system declined over time, government providers increasingly coped through dual practice. Over time, government restrictions to dual practice triggered policy resistance and protest from government providers. Resulting feedback contributed to compromising the supply of government providers and, potentially, of service delivery outcomes. Informal government policies and restrictions replaced the formal restrictions identified in the early phases. In some instances, government health managers, particularly those in hospitals, developed their own practices to cope with dual practice and to maintain public sector performance. Management practices varied according to the health manager’s attitude towards dual practice and personal experience with dual practice. These practices were distinct in hospitals. Hospitals faced challenges managing internal dual practice opportunities, such as those created by externally-funded research projects based within the hospital. Private wings’ inefficiencies and strict fee schedule made them undesirable work locations for providers.
Conclusions
Dual practice prevails because public and private sector incentives, non-financial and financial, are complementary. Local management practices for dual practice have not been previously documented and provide learning opportunities to inform policy discussions. Understanding how dual practice evolves and how it is managed locally is essential for health workforce policy, planning, and performance discussions in Uganda and similar settings.
doi:10.1186/1478-4505-12-41
PMCID: PMC4142472  PMID: 25134522
5.  Health systems performance assessment in low-income countries: learning from international experiences 
Background
The study aimed at developing a set of attributes for a ‘good’ health system performance assessment (HSPA) framework from literature and experiences in different contexts and using the attributes for a structured approach to lesson learning for low-income countries (LICs).
Methods
Literature review to identify relevant attributes for a HSPA framework; attribute validation for LICs in general, and for Uganda in particular, via a high-level Ugandan expert group; and, finally, review of a selection of existing HSPA frameworks using these attributes.
Results
Literature review yielded six key attributes for a HSPA framework: an inclusive development process; its embedding in the health system’s conceptual model; its relation to the prevailing policy and organizational set-up and societal context; the presence of a concrete purpose, constitutive dimensions and indicators; an adequate institutional set-up; and, its capacity to provide mechanisms for eliciting change in the health system. The expert group contextualized these attributes and added one on the adaptability of the framework.
Lessons learnt from the review of a selection of HSPA frameworks using the attributes include: it is possible and beneficial to involve a range of stakeholders during the process of development of a framework; it is important to make HSPA frameworks explicit; policy context can be effectively reflected in the framework; there are marked differences between the structure and content of frameworks in high-income countries, and low- and middle-income countries; champions can contribute to put HSPA high on the agenda; and mechanisms for eliciting change in the health system should be developed alongside the framework.
Conclusion
It is possible for LICs to learn from literature and the experience of HSPA in other contexts, including HICs. In this study a structured approach to lesson learning included the development of a list of attributes for a ‘good’ HSPA framework. The attributes thus derived can be utilized by LICs like Uganda seeking to develop/adjust their HSPA frameworks as guidelines or a check list, while taking due consideration of the specific context. The review of frameworks from varied contexts, highlighted varied experiences which provide lessons for LICs.
doi:10.1186/1744-8603-10-5
PMCID: PMC3943387  PMID: 24524554
Health systems; Performance assessment framework; Low-income countries; Uganda
6.  The impact of Fogarty International Center research training programs on public health policy and program development in Kenya and Uganda 
BMC Public Health  2013;13:770.
Background
The Fogarty International Center (FIC) has supported research capacity development for over twenty years. While the mission of FIC is supporting and facilitating global health research conducted by U.S. and international investigators, building partnerships between health research institutions in the U.S. and abroad, and training the next generation of scientists to address global health needs, research capacity may impact health policies and programs and therefore have positive impacts on public health. We conducted an exploratory analysis of how FIC research training investments affected public health policy and program development in Kenya and Uganda.
Methods
We explored the long term impacts of all FIC supported research training programs using case studies, in Kenya and Uganda. Semi-structured in-depth interviews were conducted with 53 respondents and 29 focus group discussion participants across the two countries. Qualitative methods were supplemented by structured surveys of trainees and document review, including a review of evidence cited in policy documents.
Results
In the primary focal areas of FIC grants, notably HIV/AIDS, there were numerous examples of work conducted by former FIC trainees that influenced national and global policies. Facilitators for this influence included the strong technical skills and scientific reputations of the trainees, and professional networks spanning research and policy communities. Barriers included the fact that trainees typically had not received training in research communication, relatively few policy makers had received scientific training, and institutional constraints that undermined alignment of research with policy needs.
Conclusions
While FIC has not focused its programs on the goal of policy and program influence, its investments have affected global and national public health policies and practice. These influences have occurred primarily through strengthening research skills of scientists and developing strong in-country networks. Further success of FIC and similar initiatives could be stimulated by investing more in the training of policy-makers, seeking to better align research with policy needs through more grants that are awarded directly to developing country institutions, and grants that better incorporate policy maker perspectives in their design and governance. Addressing structural constraints, for example supporting the development of national research agendas that inform university research, would further support such efforts.
doi:10.1186/1471-2458-13-770
PMCID: PMC3851767  PMID: 23964653
Research capacity; Policy influence; HIV/AIDS
7.  Perspectives on the role of stakeholders in knowledge translation in health policy development in Uganda 
Background
Stakeholder roles in the application of evidence are influenced by context, the nature of the evidence, the policy development process, and stakeholder interactions. Past research has highlighted the role of stakeholders in knowledge translation (KT) without paying adequate attention to the peculiarities of low-income countries. Here we identify the roles, relations, and interactions among the key stakeholders involved in KT in Uganda and the challenges that they face.
Methods
This study employed qualitative approaches to examine the roles of and links among various stakeholders in KT. In-depth interviews were conducted with 21 key informants and focused on the key actors in KT, their perceived roles, and challenges.
Results
Major stakeholders included civil society organizations with perceived roles of advocacy, community mobilization, and implementation. These stakeholders may ignore unconvincing evidence. The community’s role was perceived as advocacy and participation in setting research priorities. The key role of the media was perceived as knowledge dissemination, but respondents noted that the media may misrepresent evidence if it is received in a poorly packaged form. The perceived roles of policy makers were evidence uptake, establishing platforms for KT and stewardship; negative roles included ignoring or even misrepresenting evidence that is not in their favor. The roles of parliamentarians were perceived as advocacy and community mobilization, but they were noted to pursue objectives that may not be supported by the evidence. The researchers’ main role was defined as evidence generation, but focusing disproportionately on academic interests was cited as a concern. The donors’ main role was defined as funding research and KT, but respondents were concerned about the local relevance of donor-supported research. Respondents reported that links among stakeholders were weak due to the absence of institutionalized, inclusive platforms. Challenges facing the stakeholders in the process of KT were identified.
Conclusions
Our investigation revealed the need to consider the roles that various stakeholders are best placed to play. Links and necessary platforms must be put in place to achieve synergy in KT. Relevant capacities need to be built to overcome the challenges faced by the various stakeholders.
doi:10.1186/1472-6963-13-324
PMCID: PMC3751734  PMID: 23958173
Research; Uptake; Policy; Practice; Roles; Stakeholders; Uganda; Low-income countries
8.  How does investment in research training affect the development of research networks and collaborations? 
Background
Whether and how research training programs contribute to research network development is underexplored. The Fogarty International Center (FIC) has supported overseas research training programs for over two decades. FIC programs could provide an entry point in the development of research networks and collaborations. We examine whether FIC’s investment in research training contributed to the development of networks and collaborations in two countries with longstanding FIC investments – Uganda and Kenya – and the factors which facilitated this process.
Methods
As part of two case studies at Uganda’s Makerere University and Kenya’s University of Nairobi, we conducted 53 semi-structured in-depth interviews and nine focus group discussions. To expand on our case study findings, we conducted a focused bibliometric analysis on two purposively selected topic areas to examine scientific productivity and used online network illustration tools to examine the resulting network structures.
Results
FIC support made important contributions to network development. Respondents from both Uganda and Kenya confirmed that FIC programs consistently provided trainees with networking skills and exposure to research collaborations, primarily within the institutions implementing FIC programs. In both countries, networks struggled with inclusiveness, particularly in HIV/AIDS research. Ugandan respondents perceived their networks to be more cohesive than Kenyan respondents did. Network cohesiveness was positively correlated with the magnitude and longevity of FIC’s programs. Support from FIC grants to local and regional research network development and networking opportunities, such as conferences, was rare. Synergies between FIC programs and research grants helped to solidify and maintain research collaborations.
Conclusions
Networks developed where FIC’s programs focused on a particular institution, there was a critical mass of trainees with similar interests, and investments for network development were available from early implementation. Networks were less likely to emerge where FIC efforts were thinly scattered across multiple institutions. The availability of complementary research grants created opportunities for researchers to collaborate in grant writing, research implementation, and publications. FIC experiences in Uganda and Kenya showcase the important role of research training programs in creating and sustaining research networks. FIC programs should consider including support to research networks more systematically in their capacity development agenda.
doi:10.1186/1478-4505-11-18
PMCID: PMC3671195  PMID: 23688105
Bibliometrics; Case study research; Collaborations; Global health; Kenya; Networks; Research capacity development; Research training; Uganda
9.  Aid alignment: a longer term lens on trends in development assistance for health in Uganda 
Background
Over the past decade, development assistance for health (DAH) in Uganda has increased dramatically, surpassing the government’s own expenditures on health. Yet primary health care and other priorities identified in Uganda’s health sector strategic plan remain underfunded.
Methods
Using data available from the Creditor Reporting System (CRS), National Health Accounts (NHA), and government financial reports, we examined trends in how donors channel DAH and the extent to which DAH is aligned with sector priorities. The study follows the flow of DAH from the donor to the implementing organization, specifying the modality used for disbursing funds and categorizing funds based on program area or support function.
Findings
Despite efforts to improve alignment through the formation of a sector-wide approach (SWAp) for health in 1999 and the creation of a fund to pool resources for identified priorities, increasingly DAH is provided as short-term, project-based support for disease-specific initiatives, in particular HIV/AIDS.
Conclusion
These findings highlight the need to better align external resources with country priorities and refocus attention on longer-term sector-wide objectives.
doi:10.1186/1744-8603-9-7
PMCID: PMC3599223  PMID: 23425287
Foreign aid; International cooperation; Health policy; Health financing; Sector-wide approach; Paris declaration
10.  Research, evidence and policymaking: the perspectives of policy actors on improving uptake of evidence in health policy development and implementation in Uganda 
BMC Public Health  2012;12:109.
Background
Use of evidence in health policymaking plays an important role, especially in resource-constrained settings where informed decisions on resource allocation are paramount. Several knowledge translation (KT) models have been developed, but few have been applied to health policymaking in low income countries. If KT models are expected to explain evidence uptake and implementation, or lack of it, they must be contextualized and take into account the specificity of low income countries for example, the strong influence of donors. The main objective of this research is to elaborate a Middle Range Theory (MRT) of KT in Uganda that can also serve as a reference for other low- and middle income countries.
Methods
This two-step study employed qualitative approaches to examine the principal barriers and facilitating factors to KT. Step 1 involved a literature review and identification of common themes. The results informed the development of the initial MRT, which details the facilitating factors and barriers to KT at the different stages of research and policy development. In Step 2, these were further refined through key informant interviews with policymakers and researchers in Uganda. Deductive content and thematic analysis was carried out to assess the degree of convergence with the elements of the initial MRT and to identify other emerging issues.
Results
Review of the literature revealed that the most common emerging facilitating factors could be grouped under institutional strengthening for KT, research characteristics, dissemination, partnerships and political context. The analysis of interviews, however, showed that policymakers and researchers ranked institutional strengthening for KT, research characteristics and partnerships as the most important. New factors emphasized by respondents were the use of mainstreamed structures within MoH to coordinate and disseminate research, the separation of roles between researchers and policymakers, and the role of the community and civil society in KT.
Conclusions
This study refined an initial MRT on KT in policymaking in the health sector in Uganda that was based on a literature review. It provides a framework that can be used in empirical research of the process of KT on specific policy issues.
doi:10.1186/1471-2458-12-109
PMCID: PMC3305540  PMID: 22316003
Research; Policy; Practice; Implementation gap; Uganda; Low income countries
11.  Building the Field of Health Policy and Systems Research: An Agenda for Action 
PLoS Medicine  2011;8(8):e1001081.
In the final article in a series addressing the current challenges and opportunities for the development of Health Policy and Systems Research (HPSR), Sara Bennett and colleagues lay out an agenda for action moving forward.
doi:10.1371/journal.pmed.1001081
PMCID: PMC3168867  PMID: 21918641
12.  Building the Field of Health Policy and Systems Research: Social Science Matters 
PLoS Medicine  2011;8(8):e1001079.
In the second in a series of articles addressing the current challenges and opportunities for the development of Health Policy and Systems Research (HPSR), Lucy Gilson and colleagues argue the importance of insights from the social sciences.
doi:10.1371/journal.pmed.1001079
PMCID: PMC3160340  PMID: 21886488
13.  Building the Field of Health Policy and Systems Research: Framing the Questions 
PLoS Medicine  2011;8(8):e1001073.
In the first of a series of articles addressing the current challenges and opportunities for the development of Health Policy & Systems Research (HPSR), Kabir Sheikh and colleagues lay out the main questions vexing the field.
doi:10.1371/journal.pmed.1001073
PMCID: PMC3156683  PMID: 21857809
14.  Exploring new health markets: experiences from informal providers of transport for maternal health services in Eastern Uganda 
Background
Although a number of intermediate transport initiatives have been used in some developing countries, available evidence reveals a dearth of local knowledge on the effect of these rural informal transport mechanisms on access to maternal health care services, the cost of implementing such schemes and their scalability. This paper, attempts to provide insights into the functioning of the informal transport markets in facilitating access to maternal health care. It also demonstrates the role that higher institutions of learning can play in designing projects that can increase the utilization of maternal health services.
Objectives
To explore the use of intermediate transport mechanisms to improve access to maternal health services, with emphasis on the benefits and unintended consequences of the transport scheme, as well as challenges in the implementation of the scheme.
Methods
This paper is based on the pilot phase to inform a quasi experimental study aimed at increasing access to maternal health services using demand and supply side incentives. The data collection for this paper included qualitative and quantitative methods that included focus group interviews, review of project documents and facility level data.
Results
There was a marked increase in attendance of antenatal, and delivery care services, with the contracted transporters playing a leading role in mobilizing mothers to attend services. The project also had economic spill-over effects to the transport providers, their families and community generally. However, some challenges were faced including difficulty in setting prices for paying transporters, and poor enforcement of existing traffic regulations.
Conclusions and implications
The findings indicate that locally existing resources such as motorcycle riders, also known as “boda boda” can be used innovatively to reduce challenges caused by geographical inaccessibility and a poor transport network with resultant increases in the utilization of maternal health services. However, care must be taken to mobilize the resources needed and to ensure that there is enforcement of laws that will ensure the safety of clients and the transport providers themselves.
doi:10.1186/1472-698X-11-S1-S10
PMCID: PMC3059469  PMID: 21410997
15.  Research translation to inform national health policies: learning from multiple perspectives in Uganda 
Background
Research and evidence can have an impact on policy and practice, resulting in positive outcomes. However, research translation is a complex, dynamic and non-linear process. Although universities in Africa play a major role in generating research evidence, their strategic approaches to influence health policies and decision making are weak. This study was conducted with the aim of understanding the process of translating research into policy in order to guide the strategic direction of Makerere University College of Health Sciences (MakCHS) and similar institutions in their quest to influence health outcomes nationally and globally.
Methods
A case study approach using 30 in-depth interviews with stakeholders involved in two HIV prevention research project was purposively selected. The study sought to analyze the research-to-policy discourses for the prevention of mother-to-child transmission (PMTCT) and safe male circumcision (SMC). The analysis sought to identify entry points, strengths and challenges for research-to-policy processes by interviewing three major groups of stakeholders in Uganda – researchers (8), policy makers (12) and media practitioners (12).
Results
Among the factors that facilitated PMTCT policy uptake and continued implementation were: shared platforms for learning and decision making among stakeholders, implementation pilots to assess feasibility of intervention, the emerging of agencies to undertake operations research and the high visibility of policy benefits to child survival. In contrast, SMC policy processes were stalled for over two years after the findings of the Uganda study was made public. Among other factors, policy makers demanded additional research to assess implementation feasibility of SMC within ordinary health system context. High level leaders also publicly contested the SMC evidence and the underlying values and messages – a situation that reduced the coalition of policy champions.
Conclusions
This study shows that effective translation of PMTCT and SMC research results demanded a “360 degree” approach to assembling additional evidence to inform the implementation feasibility for these two HIV prevention interventions. MakCHS and similar institutions should prioritize implementation research to guide the policy processes about the feasibility of implementing new and effective innovations (e.g. PMTCT or SMC) at a large scale in contexts that may be different from the research environments.
doi:10.1186/1472-698X-11-S1-S13
PMCID: PMC3059472  PMID: 21411000
16.  Closing the Gaps: From Science to Action in Maternal, Newborn, and Child Health in Africa 
PLoS Medicine  2010;7(6):e1000298.
As part of a series on maternal, neonatal, and child health in sub-Saharan Africa, Sara Bennett and Freddie Ssengooba discuss the challenges of getting science into policy in Africa.
doi:10.1371/journal.pmed.1000298
PMCID: PMC2893953  PMID: 20613861
17.  Health sector reforms and human resources for health in Uganda and Bangladesh: mechanisms of effect 
Background
Despite the expanding literature on how reforms may affect health workers and which reactions they may provoke, little research has been conducted on the mechanisms of effect through which health sector reforms either promote or discourage health worker performance. This paper seeks to trace these mechanisms and examines the contextual framework of reform objectives in Uganda and Bangladesh, and health workers' responses to the changes in their working environments by taking a 'realistic evaluation' approach.
Methods
The study findings were generated by triangulating both qualitative and quantitative methods of data collection and analysis among policy technocrats, health managers and groups of health providers. Quantitative surveys were conducted with over 700 individual health workers in both Bangladesh and Uganda and supplemented with qualitative data obtained from focus group discussions and key interviews with professional cadres, health managers and key institutions involved in the design, implementation and evaluation of the reforms of interest.
Results
The reforms in both countries affected the workforce through various mechanisms. In Bangladesh, the effects of the unification efforts resulted in a power struggle and general mistrust between the two former workforce tracts, family planning and health. However positive effects of the reforms were felt regarding the changes in payment schemes. Ugandan findings show how the workforce responded to a strong and rapidly implemented system of decentralisation where the power of new local authorities was influenced by resource constraints and nepotism in recruitment. On the other hand, closer ties to local authorities provided the opportunity to gain insight into the operational constraints originating from higher levels that health staff were dealing with.
Conclusion
Findings from the study suggest that a) reform planners should use the proposed dynamic responses model to help design reform objectives that encourage positive responses among health workers b) the role of context has been underestimated and it is necessary to address broader systemic problems before initiating reform processes, c) reform programs need to incorporate active implementation research systems to learn the contextual dynamics and responses as well as have inbuilt program capacity for corrective measures d) health workers are key stakeholders in any reform process and should participate at all stages and e) some effects of reforms on the health workforce operate indirectly through levels of satisfaction voiced by communities utilising the services.
doi:10.1186/1478-4491-5-3
PMCID: PMC1800303  PMID: 17270042
18.  Overcoming Access Barriers for Facility-based Delivery in Low-income Settings: Insights from Bangladesh and Uganda 
Women in both Bangladesh and Uganda face a number of barriers to delivery in professional health facilities, including costs, transportation problems, and sociocultural norms to deliver at home. Some women in both the countries manage to overcome these barriers. This paper reports on a comparative qualitative study investigating how some women and their families were able to use professional delivery services. The study provides insights into the decision-making processes and overcoming access barriers. Husbands were found to be particularly important in Uganda, while, in Bangladesh, a number of individuals could influence care-seeking, including unqualified local healers or traditional birth attendants. In both the settings, cost and transport barriers were often overcome through social networks. Social prohibitions on birth in the health facility did not feature strongly in women's accounts, with several Ugandan women explaining that friends or peers also used facilities, while, in Bangladesh, perceived complications apparently justified the use of professional medical care. Investigating the ways in which some women can overcome common barriers can help inform policy and planning to increase the use of health facilities for child delivery.
PMCID: PMC3001147  PMID: 17591340
Maternal health; Delivery; Health services; Healthcare; Health facilities; Comparative studies; Uganda; Bangladesh

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