Using Normalization Process Theory (NPT) to explore implementation of the Maternal Perinatal Death Surveillance and Response (MPDSR) Policy in Uganda: A reflection

Background The implementation of the maternal perinatal death surveillance and response (MPDSR) policy is among the envisaged strategies to reduce the high global burden of maternal and perinatal mortality and morbidity. However, implementation of this policy across various contexts is inconsistent. Theoretically informed approaches to process evaluation can support assessment the implementation of policy interventions such as MPDSR, particularly in understanding what the actors involved actually do. In this article, we reflect on how the Normalization Process Theory (NPT) was used to explore implementation of the MPDSR Policy in Uganda. NPT is a sociological theory concerned with the social organization of the work (implementation) of making practices routine elements of everyday life (embedding) and of sustaining embedded practices in their social contexts (integration). Methods This qualitative multiple case study conducted across eight districts in Uganda and among ten health facilities (cases) representing four out of the seven levels of the Uganda health care system. NPT was utilized in several ways including informing the study design, structuring the data collection tools (semi-structured interview guides), providing an organizing framework for analysis, interpreting and reporting of study findings as well as making recommendations. Study participants were purposively selected to reflect the range of actors involved in the policy implementation process. This included direct care providers located at each of the cases, the Ministry of Health, and from agencies and professional associations. Data were collected using semi-structured, in-depth interviews and were inductively and deductively analyzed using NPT constructs and subconstructs. Results and conclusion NPT served useful for process evaluation, particularly in identifying factors that contribute to variations in policy implementation. Considering the NPT focus on the agency of people involved in implementation, additional efforts are required to understand how recipients of the policy intervention influence how the intervention becomes embedded within the various contexts.