Generating political priority to reduce maternal mortality

Why do some serious health issues receive significant attention from political leaders and others get very little? To achieve the Millennium Development Goal target of reducing maternal mortality, governments must prioritise this issue.

Research led by Syracuse University (USA) investigated how far maternal mortality reduction is up the political agenda in five developing countries: Guatemala, Honduras, India, Indonesia and Nigeria.

The degree to which political leaders actively pay attention and allocate resources to this issue varies considerably across the countries:

• very high in Honduras
• high in Indonesia
• moderate in India (with a recent rise)
• low in Guatemala and Nigeria.

A number of factors shape the degree to which maternal mortality reduction emerges on national policy agendas. International actors, such as aid agencies and multilateral organisations, first put the issue on the global agenda, promoting a norm that maternal death was unacceptable and generating the interest of national health officials with financial resources. Prior to this global advocacy, little national attention existed.

National advocates have achieved varying degrees of success in promoting the cause. They were most successful when they:

• formed cohesive policy communities and were led by respected national political champions, such as in Indonesia where the minister for women developed the idea for a national campaign for pregnant women
• developed credible indicators to show a problem existed, as with Guatemala's 1989 Reproductive Age Mortality Survey
• organised focusing events such as national forums to promote the cause, including a march to the Taj Mahal in 2000 organised by the White Ribbon Alliance of India
• developed clear policy alternatives to demonstrate to national leaders that the problem could be overcome. One midwife was placed in nearly all of Indonesia's 68,000 villages.

Many factors in their political environments shaped the effectiveness of advocates' efforts, but two were key: major political reforms such as democratisation in Nigeria or decentralisation in Indonesia that altered the policy-making process and the degree of resource competition with other priorities, for instance HIV and AIDS in Nigeria.

While each country is different, there are systematic features to the agenda-setting process that increase the likelihood that national health advocates will be able to influence political elites to act. Advocates must develop political, not just technical strategies, to promote the issues that concern them.

Jeremy Shiffman
Maxwell School of Citizenship and Public Affairs, Syracuse University, 306 Eggers Hall, Syracuse, New York, USA
jrshiffm@maxwell.syr.edu

Sources

'Generating Political Priority for Maternal Mortality Reduction in Five Developing Countries', American Journal of Public Health 97, pages 796-803, by Jeremy Shiffman, 2007

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