title: Health system capacity: maternal health policy implementation in the state of Gujarat, India.
abstract: BACKGROUND
  The Government of Gujarat has for the past couple of decades continuously initiated several interventions to improve access to care for pregnant and delivering women within the state. Data from the last District Family Heath survey in Gujarat in 2007-2008 show that 56.4% of women had institutional deliveries and 71.5% had at least one antenatal check-up, indicating that challenges remain in increasing use of and access to maternal health care services.
  
  
  OBJECTIVE
  To explore the perceptions of high-level stakeholders on the process of implementing maternal health interventions in Gujarat.
  
  
  METHODS
  Using the policy triangle framework developed by Walt and Gilson, the process of implementation was approached using in-depth interviews and qualitative content analysis.
  
  
  RESULTS
  Based on the analysis, three themes were developed: lack of continuity; the complexity of coordination; and lack of confidence and underutilization of the monitoring system. The findings suggest that decisions made and actions advocated and taken are more dependent on individual actors than on sustainable structures. The findings also indicate that the context in which interventions are implemented is challenged in terms of weak coordination and monitoring systems that are not used to evaluate and develop interventions on maternal health.
  
  
  CONCLUSIONS
  The implementation of interventions on maternal health is dependent on the capacity of the health system to implement evidence-based policies. The capacity of the health system in Gujarat to facilitate implementation of maternal health interventions needs to be improved, both in terms of the role of actors and in terms of structures and processes.
authors.affiliation: Division of Global Health (IHCAR), Department of Public Health, Karolinska Institutet, Solna, Sweden. linda.sanneving@ki.se
authors.forename: Linda
authors.initials: L
authors.lastname: Sanneving
authors.forename: Asli
authors.initials: A
authors.lastname: Kulane
authors.forename: Aditi
authors.initials: A
authors.lastname: Iyer
authors.forename: Bengt
authors.initials: B
authors.lastname: Ahgren
mesh_terms: D036861:Delivery, Obstetric / Q000706:statistics & numerical data; D005260:Female; D006284:Health Plan Implementation / Q000458:organization & administration*; D006291:Health Policy; D006301:Health Services Needs and Demand / Q000458:organization & administration*; D006801:Humans; D007194:India; D008427:Maternal Health Services / Q000458:organization & administration*; D010465:Perception; D011247:Pregnancy; D011295:Prenatal Care / Q000706:statistics & numerical data
keywords: Gujarat; India; health system capacity; implementation; maternal health; policy