Table 3 Implementation barriers and challenges cited in studies included in the systematic review for each research question
Implementation barriers & challenges | Community participation in quality improvement | Community participation in MNH programme planning & implementation |
|---|---|---|
Not-so-enabling environment | ||
Need more supportive maternal health policies | 1, 2 | |
Low status of women, gender inequity | 18, 19, 26 | 14, 28 |
Discrimination against indigenous people, ethnic groups, poor people | 29 | |
Conflict, insecurity and violence against women | 18, 19, 29 | 14 |
Politicians do not collaborate when they see no benefit for themselves | 16 | |
Urban environment highly politicized | 16 | |
Urban setting negatively affects time available to participate, especially for men; recruitment and retention of community health volunteers is also more challenging. | 16, 21, 22 | |
Community capacity | ||
Community leadership | ||
Changes in leadership | 15 | |
Community leadership doesn’t prioritize maternal health or health more generally. | 19 | |
COMMUNITY GOVERNANCE & MANAGEMENT | ||
Community capacity to plan and work together is limited. Takes time to develop. | 20 | 16, 20, 21, 22, 23, 24, 28 |
Trust issues exist among different groups. | 18, 19 | 16, 18, 22 |
• Lack of transparency in management of community funds. | 18, 19 | 18 |
Ineffective structures | ||
• Existing structures are dysfunctional | 27 | 27 |
• At sub-district level, organizational structures are less defined and many different local groups exist. (Dinajpur Safe Motherhood Initiative chose to develop a Community Support System structure to address this challenge.) | 18, 19 | |
Health system | ||
Managing resources & resource constraints | ||
• Human resource constraints of public health system | 15 | |
• Health services supervision system weak, irregular | 27 | 27 |
• Services lack “modern equipment and advanced technology” | 18, 19 | 18, 21, 22 |
Health facility data inconsistent and incomplete – difficult to plan effectively and difficult to assess attribution of programme outcomes; limited capacity for data management | 18, 20, 29 | 18, 20 |
Service provider attitudes are resistance to change | 29 | 21, 22 |
Wider health system issues such as ineffective referral system (outside of local control) | 29 | |
Community -health system interaction | ||
MANAGEMENT OF RESOURCES & RESOURCE CONSTRAINTS | ||
• Limited access to facilities (distance, difficult terrain) | 20 | 17, 20 |
• Lack of funds (for transport) | 20 | 20 |
• Lack of financial and technical resources (MOH, community) | 20 | 20, 23, 24 |
• Rotation of health personnel doesn’t allow time to develop trusting relationships with community | 29 | |
• Expectations of community health workers are unrealistic; too many tasks | 15 | |
Poor communication | 20 | 20 |
Need to improve linking/interface of communities with services | 18, 19 | 18, 23, 24 |
Intercultural sensitivity/competence | ||
Cultural traditions of women delivering and residing in other homes outside of study area for postnatal period affects birth preparedness plans and postnatal follow-up care. | 15 | |
Reluctance of families to travel long distances for neonatal care (cultural practice and security issues underlie this reluctance) | 15 | |
Increasing empowerment of youth led to conflict at times | 21, 22 | |
Reaching and including people with low literacy and numeracy skills | 29 | 17 |
May not be reaching the poorest and most vulnerable with the strategies used, strategies may not be effective for these groups | 18, 19 | 18 |
General programme design/implementation challenges | ||
Proxy indicators have some limitations (e.g., utilization of EmOC for “met need”) | 18, 19 | 18 |
Expansion and scaling up | 20, 26, 29 | |
Low coverage and high complexity of the intervention | 15 | |
Volunteers taking on too many tasks | 15 | |