Moses Mukuru - Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
Jonathan Gorry - School of Social Sciences, Nottingham Trent University, Nottingham, UK
Suzanne N. Kiwanuka - Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
Linda Gibson - School of Social Sciences, Nottingham Trent University, Nottingham, UK
David Musoke - Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
Freddie Ssengooba - Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda

Background  Despite Uganda and other sub-Saharan African countries missing their maternal mortality ratio (MMR) targets for Millennium Development Goal (MDG) ۵, 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 ۵ performance. We suggest a novel prescriptive and analytical (re)conceptualization of policy in terms of its fidelity to ‘۳Cs’ (coherence of design, comprehensiveness of coverage and consistency in application) that could have implications for future healthcare programming. Methods  We conducted a retrospective study. Sixteen Ugandan maternal health policy documents and ۲۱ national programme performance reports were examined, and six key informant interviews conducted with national stakeholders managing maternal health programmes during the reference period ۲۰۰۰-۲۰۱۵. We applied the analytical framework of the ‘three delay model’ combined with a broader literature on ‘policy mixing.’ Results  Despite introducing fourteen separate policy instruments over ۱۵ years with the goal of reducing maternal mortality, by the end of the MDG period in ۲۰۱۵, only ۸۷.۵% 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 ۷۰% of deaths by ۲۰۱۴ attributed to failures in referral policies while ۶۷% of maternal deaths were due to inadequacies in healthcare facilities and trained personnel in the same period. By ۲۰۱۵, ۳۷.۳% of deaths were due to transportation issues. Conclusion  The piecemeal introduction of additional policy instruments frequently distorted existing synergies among policies resulting in persistence of the three delays and missed MDG ۵ target. Future policy reforms should address the ‘three delays’ but also ensure fidelity of policy design to coherence, comprehensiveness and consistency.

Uganda, Maternal Mortality, Policy Mixes, Three Delay Model, Policy Design