Fertility Care in Low and Middle Income Countries: Policy, Politics, and Macro-Level Influences on Implementation in Uganda.

Abstract

Background: Infertility is a reproductive disease affecting millions globally. In Sub-Saharan Africa, the burden is considerably higher, affecting one in four couples. The psychosocial and economic impacts of infertility remain severe. Furthermore, restricted access to affordable fertility services is justified by international population reduction agendas and limited resources, resulting in inequitable access. Treatment, when available, is primarily through private sector clinics, at catastrophically high costs. For this reason, low-cost IVF (LCIVF) technologies have been developed to simplify and minimize treatment costs. Still, there are limited studies on their adoption and utilization in the region.

Methods: A qualitative case study was used to explore implementation of LCIVF technologies in Uganda's public health system. Macro-level factors influencing implementation of an ART department at Mulago Women's Hospital were assessed through semi-structured interviews conducted with 21 actors, along with hospital observations, field notes and document review. A combination of inductive and deductive thematic analysis techniques were used for data analysis in NVivo 12, guided by the Consolidated Framework for Implementation Research (CFIR).

Results: Following our analysis, several factors facilitated macro-level implementation including acknowledgement of infertility as a reproductive disease, strong political advocacy and oversight, government funding and multi-organizational collaboration. Barriers included poor public knowledge, absence of legislation, limited community leader engagement and diminished political support. Contributions: This study contributed to knowledge on external factors that influence sustainable implementation of LCIVF initiatives in low-resource settings and is one of the first studies to apply CFIR to infertility care implementation in a low-resource setting.