From centralised policy development to uneven implementation: a qualitative study of adolescent reproductive health policy processes at the national level and in Southwestern Uganda

Abstract

Background: Adolescent pregnancy remains a significant public health and health systems concern in Uganda and across sub-Saharan Africa. Although Uganda has developed several adolescent reproductive health policies and strategies, implementation remains uneven. Less is known about how policy development and implementation processes, financing arrangements, institutional structures, and frontline discretion shape translation of adolescent reproductive health policy into practice. This study examined how adolescent reproductive health policies in Uganda are developed and implemented, and how policy actors and frontline implementers cope with related constraints. Methods: A qualitative study was conducted between 14th July and 30th October 2025 at the national level and in Kabale and Mbarara study areas in southwestern Uganda. Twenty-eight key informants were purposively selected, including eight policymakers at national and subnational levels and twenty frontline implementers involved in adolescent reproductive health service delivery. Semi-structured interviews were recorded, transcribed, and analysed using thematic analysis combining inductive and deductive approaches, guided by Braun and Clarke’s six-phase process. Themes were developed inductively and subsequently mapped onto Walt and Gilson’s Health Policy Triangle domains, while Street-Level Bureaucracy theory informed interpretation of frontline discretion and coping practices Results: ARH policy development followed a structured, ministry-led process shaped by centralised decision-making and donor-dependent financing. Although institutional frameworks and development partner support facilitated policy formulation, limited subnational influence, delayed policy revision, and dependence on external funding constrained responsiveness and sustainability. At the implementation level, weak dissemination, resource shortages, limited supervision, and ambiguity around adolescents’ consent expanded frontline discretion, contributing to variable service delivery. Policymakers and implementers adopted coping strategies, including service integration and resource improvisation, phased implementation, and community engagement, which sustained services but also risked normalising systemic gaps. Conclusions: Uneven implementation of adolescent reproductive health policy in Uganda does not simply reflect operational failure at the facility level. It is shaped by the interaction of financing arrangements, centralised governance, policy ambiguity and frontline discretion within a resource-constrained health system. Strengthening implementation requires stable domestic financing, clearer operational guidance, stronger subnational engagement, and institutional mechanisms that connect policy development with frontline realities.