Maternal health has rarely become a political priority at national levels, with policy uptake and implementation proving relatively disappointing. Existing studies focus on uptake, but there has been little work on implementation.
In this project, we relate maternal health policy uptake and implementation to the countries’ political settlements. The research is guided by two questions:
- How do political settlements influence progress in maternal health?
- How can better results be acquired under different types of political settlement?
Rwanda has the best record of reducing maternal mortality, a fact that can be attributed to its dominant, development political settlement, which drives effective policy implementation through hierarchical performance mechanisms, complemented by diagonal and bottom-up approaches. Ghana, by contrast, has the worst record, explained by the way in which its competitive political settlement encourages undisciplined public sector expansion and populist policymaking, prioritising visible infrastructural investments over functioning systems. Uganda and Bangladesh turn out to be less clear cases of a more intermediate type, yet the relationship between a non-dominant political settlement and a largely ineffective public sector still holds.
Our cross-case comparative analysis points to the considerable similarities between Ghana, Uganda and Bangladesh and the exceptionalism of Rwanda. Rwanda is different from the other countries in terms of dominance of its ruling group, the weakness of lower-level groups and the inclusiveness of its development vision and ideas. It is these factors that drive the policy, funding and governance arrangements that result in better outcomes.
However, in less dominant settlements, pockets of effectiveness can be found in each, where visionary political or health leaders, sometimes with multi-stakeholder support, are able to encourage and enforce performance measures.
It is important to stress that, although we believe the nature of the political settlement influences progress on maternal health, it does not determine it in any straightforward way. This is because the deep forces of the political settlement interact with the more contingent aspects of what we call the policy domain. The policy domain encompasses actors such as the global partnership around maternal health, as well as other international and domestic actors. The political dynamics of this arena, in combination with those of the political settlement itself, will co-determine the level of political commitment devoted to this issue. The coalition and settlement need to be aligned. This happened in Rwanda, where the two converged on strong political commitment and good outcomes, in contrast to Ghana, where clear policies around maternal health in the policy domain appeared to be undermined by competitive populist and patronage pressures emanating from the political settlement. This combination of forces will manifest itself in three key areas: policy design and choice; funding levels; and whether human resource governance arrangements are appropriate to effective implementation.
Policy implications include the need to try and optimise results within the context of the settlement that already exists. In the case of dominant settlements like Rwanda, this implies lining up behind and generously supporting the government’s development strategy. In the other country cases, external actors may be best advised to work on narrower issue areas or at sub-national levels, leveraging state, NGO and private actors to build channels or pockets of effectiveness in or around otherwise poorly performing administrations.