Abstract
Despite Uganda and other sub-Saharan African countries missing their maternal mortality ratio (MMR) targets for Millennium Development Goal (MDG) 5, limited attention has been paid to policy design in the literature examining the persistence of preventable maternal mortality. This study examined the specific policy interventions designed to reduce maternal deaths in Uganda and identified particular policy design issues that underpinned MDG 5 performance. We suggest a novel prescriptive and analytical (re)conceptualization of policy in terms of its fidelity to '3Cs' (coherence of design, comprehensiveness of coverage and consistency in application) that could have implications for future healthcare programming. We conducted a retrospective study. Sixteen Ugandan maternal health policy documents and 21 national programme performance reports were examined, and six key informant interviews conducted with national stakeholders managing maternal health programmes during the reference period 2000-2015. We applied the analytical framework of the 'three delay model' combined with a broader literature on 'policy mixing.' Despite introducing fourteen separate policy instruments over 15 years with the goal of reducing maternal mortality, by the end of the MDG period in 2015, only 87.5% of the interventions for the three delays were covered with a notable lack of coherence and consistency evident among the instruments. The three delays persisted at the frontline with 70% of deaths by 2014 attributed to failures in referral policies while 67% of maternal deaths were due to inadequacies in healthcare facilities and trained personnel in the same period. By 2015, 37.3% of deaths were due to transportation issues. The piecemeal introduction of additional policy instruments frequently distorted existing synergies among policies resulting in persistence of the three delays and missed MDG 5 target. Future policy reforms should address the 'three delays' but also ensure fidelity of policy design to coherence, comprehensiveness and consistency.
Highlights
This paper argues that policy reforms undertaken in Uganda to reduce maternal mortality during the Millennium Development Goal (MDG) period (2000-2015) were underpinned either explicitly or implicitly, by design or accident, in ways that reflect the 3D model as a theory of change, the MDG 5 targets of 131 deaths per 100 000 live births (a 75% reduction in the maternal mortality ratio (MMR)) were missed and policy failure observed.[18]
Mapping the Relevance of 3D onto Uganda MDG According to the Uganda Maternal Death Review (MDR) report 2009-2011, Phase I delays in seeking care were reported in 70% of MDG maternal deaths
In the Ugandan case, it appears that the repeated failure by policy to achieve MDG 5 arose from unsuccessful attempts to reconcile what were, irreconcilable basic, comprehensive, and high impact policy packages
Summary
Few would dispute there are many social, economic and political factors at play when trying to understand why maternal mortality ratios (MMRs) did not decline sufficiently to meet Millennium Development Goals (MDGs) targets.[1,2] The more insurmountable issues involve navigating welltrodden paths that regard the endemic nature of poverty, associated health issues of pregnant women, or more openended and difficult to influence discussions regarding investment in health services and maternal health.[3,4,5] Notwithstanding the challenging context, this paper momentarily shifts gaze away from what can be considered the uncontestable ‘technical’ details about maternal health, to the more contestable technical details regarding the actual policies politicians and policy-makers introduced to alleviate maternal mortality. We are not arguing that looking through the lens of policy design is the only answer to a myriad of problems but rather it offers a different and creative perspective in looking at health policy. By examining maternal health policies introduced to tackle the high MMR in Uganda during the MDG period albeit their suboptimal performance, we hope to deconstruct policy design issues that underpin policy performance. Despite the centrality of policy design to performance (and its pre-eminence in the policy sciences literature), this theme has received surprisingly limited attention from studies on maternal health.[6] According to Caprano and Howlett, policy design refers to the mixture of “instruments expected to more or less comprehensively attain a set of goals.”[7] The literature on policy design is important because extant studies have
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