title: Governing the implementation of emergency obstetric care: experiences of rural district health managers, Tanzania.
abstract: BACKGROUND
  Many health policies developed internationally often become adopted at the national level and are implemented locally at the district level. A decentralized district health system led by a district health management team becomes responsible for implementing such policies. This study aimed at exploring the experiences of a district health management team in implementing Emergency Obstetric Care (EmOC) related policies and identifying emerging governance aspects.
  
  
  METHODS
  The study used a qualitative approach in which data was obtained from thirteen individual interviews and one focus group discussion (FGD). Interviews were conducted with members of the district health management team, district health service boards and NGO representatives. The FGD included key informants who were directly involved in the work of implementing EmOC services in the district. Documentary reviews and observation were done to supplement the data. All the materials were analysed using a qualitative content analysis approach.
  
  
  RESULTS
  Implementation of EmOC was considered to be a process accompanied by achievements and challenges. Achievements included increased institutional delivery, increased number of ambulances, training service providers in emergency obstetric care and building a new rural health centre that provides comprehensive emergency obstetric care. These achievements were associated with good leadership skills of the team together with partnerships that existed between different actors such as the Non-Governmental Organization (NGO), development partners, local politicians and Traditional Birth Attendants (TBAs). Most challenges faced during the implementation of EmOC were related to governance issues at different levels and included delays in disbursement of funds from the central government, shortages of health workers, unclear mechanisms for accountability, lack of incentives to motivate overburdened staffs and lack of guidelines for partnership development.
  
  
  CONCLUSIONS
  The study revealed that implementing EmOC is a process accompanied by challenges that require an approach with multiple partners to address them and that, for effective partnership, the roles and responsibilities of each partner should be well stipulated in a clear working framework within the district health system. Partnerships strengthen health system governance and therefore ensure effective implementation of health policies at a local level.
authors.affiliation: Department of Clinical Nursing, School of Nursing, Muhimbili University of Health and Allied Sciences, 901 85 Umeå, Sweden. mkokamalinga@yahoo.co.uk.
authors.forename: Dickson Ally
authors.initials: DA
authors.lastname: Mkoka
authors.forename: Angwara
authors.initials: A
authors.lastname: Kiwara
authors.forename: Isabel
authors.initials: I
authors.lastname: Goicolea
authors.forename: Anna-Karin
authors.initials: AK
authors.lastname: Hurtig
mesh_terms: D036861:Delivery, Obstetric; D004632:Emergency Medical Services / Q000458:organization & administration*; D005260:Female; D017144:Focus Groups; D006284:Health Plan Implementation; D006291:Health Policy; D006301:Health Services Needs and Demand; D006801:Humans; D008427:Maternal Health Services / Q000458:organization & administration*; D011247:Pregnancy; D036301:Qualitative Research; D019035:Rural Health Services / Q000458:organization & administration*; D013636:Tanzania
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