Examining the variations in the implementation of interventions to address stillbirth from the national to subnational levels: experiences from Uganda

Abstract

Background The current global burden of stillbirth disproportionately affects regions such as sub-Saharan Africa, where Uganda is located. To respond to this burden, policies made at the national level were diffused from the centre and translated into service delivery at the district level, which is charged with implementation under the decentralization of health services arrangement. Variations emerge whenever policy recommendations are moved from national to subnational levels, with some aspects often lost along the way. Tools are available to facilitate knowledge of determinants of policy and innovation implementation within the healthcare system. However, the extent to which these have been applied to explain variations in implementation of interventions to address stillbirth reduction in Uganda remains scant. The aim of this article was to examine the variations in the implementation of interventions to address stillbirth from the national to the subnational levels in Uganda using the Consolidated Framework for Implementation Research (CFIR). Methods The study adopted a qualitative case study design. Data were collected from a purposively selected sample of key informants drawn from both the national and subnational levels. All interviews were conducted in English and transcribed verbatim. ATLAS.ti was used to guide the coding process, which used a codebook developed following the CFIR domains as codes and constructs as sub-codes. Analysis followed a content analysis technique. Results National-level factors that favoured implementation of interventions to address stillbirth included the desire to comply with global norms, incentives to improve performance for stillbirth reduction indicators for better comparison with global peers, and clear policy alternatives as process implementation advanced by champions. Variations at the subnational level revealed aspirations to address service delivery gaps which fell within maternal health routine standard of care and ongoing health systems strengthening initiatives. Coalescing existing networks around maternal and child health was a key mobilization factor for advocacy and programming, with a promise that the set targets would be operationalized at the subnational level. The key champions were defined by their official roles within the district health systems, which enhanced accountability. Feedback and reflection were distinguished from the national to subnational through joint assemblies and formal audit reviews, respectively. Conclusions A heavy influence of the global events directed national-level adaptation of interventions to address stillbirth. Implementation context at the subnational level led to local adaptation and translation of policy provisions from the national level to suit the context, which to a greater extent explains the variations in the final content of policy provisions delivered.

Translating lessons to reinforce national stillbirth response; multi-stakeholder perspectives regarding priorities and opportunities to deliver quality evidence-based interventions within a limited-resource context in Uganda

“…Intentional and reflective learning from project implementation has the potential to unveil negative health systems responses to some of the introduced high-impact evidence-based interventions and tools [ 25 , 46 ]. Early recognition of this can inform timely revision to align with the implementation context [ 47 ]. Delays in responding to negative health systems responses equally have the potential to derail intervention leading to the inability to achieve intended outcomes [ 48 ].…”

Support after stillbirth: Findings from the Parent Voices Initiative Global Registry Project

“…Changes between neighbouring hospitals, localities, and countries in level and type of care provided again feeds into inequalities in support provision, with implications for outcomes (Arroyave et al, 2021). In many contexts, this was perceived to be underpinned by a lack of prioritisation of stillbirth at policy levels, and a lack of sustainable policy implementation (Ssegujja, 2021).…”

National-level key stakeholders’ perspectives regarding intervention progression and emerging challenges within the national stillbirth reduction response in Uganda

“…Subnational-level health systems responded by adapting recommendations into their routine service delivery [21] with health workers too leveraging resources within their midst including support from professional networks to ensure proper implementation [22]. Despite variations in implementation along the way from the national to the subnational level [23]. However, challenges continue to be encountered with anecdotal evidence documenting some of the shocks that make it difficult for the health systems to respond to all stillbirth risks [15].…”