The political economy of maternal
health care in developing countries
DFID, 27 April 2016
Tim Kelsall, ODI
Frederick Golooba-Mutebi, ESID and Independent
Sam Hickey, ESID/GDI, University of Manchester

Overview
1. Introduction to ESID
2. Researching the Politics of Health Care
3. Key findings from the case studies
4. Policy implications
5. Discussion

1. Introduction

ESID
www.effective-states.org
 Global Development Institute, University of
Manchester
 A DFID-funded research centre, 2011-2016
 Sub-Saharan Africa, South Asia, Latin America
Key research question
 Under what political conditions do developmental
forms of state capacity and elite commitment
emerge and become sustained?

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Political
settlement
Competitive
clientelist
Dominant coalition
Country Ghana Bangladesh South
Africa
Rwanda Uganda
Accumulat-
ion
Growth/SBRs Growth/
SBRs
Growth/
SBRs
Growth/SBRs Growth/SBRs
Hydrocarbons/
Mining
Hydrocarbons
Redistribut-
ion
Education
Health
Education
Health
Education Education
Health
Social protection
Education
Health
Social protection
Recognition Gender
Spatial inequity
Gender Gender Gender Gender
Spatial inequity
Global PEA
PSR
PEA
PSR
PSR PEA
PSR

2. Researching the Politics of Health Care

The countries
Country PS Type Key features
Rwanda Dominant Long time-horizon, strong
coordination capacity
Ghana Competitive Short-time horizon, weak
coordination capacity
Uganda Dominant (interstitial) Short-time horizon, mixed
coordination capacity
Bangladesh Competitive (interstitial) Short-time horizon, mixed
coordination capacity

Our causal model
POLICY DOMAIN
POLITICAL COMMITMENT TO
MATERNAL HEALTH
HR AND GOVERNANCE
ARRANGEMENTS
MATERNAL HEALTH
PROGRESS
POLITICAL
SETTLEMENT
POLICY ADOPTION AND
DESIGN FUNDING

Our approach
• Political settlement mapping
interviews/exercises at national and sectoral
level
• Analytical narratives linking evolution in PS
to health policy, implementation, and
performance
• Comparison of better and worse performing
districts (MMR) for additional insight
• Advice about how to work, developmentally,
in different political contexts

3. Key findings from the case studies

Rwanda
• Dominant settlement facilitates sound policies
and rigorous implementation
– Top-down (performance contracts ) and diagonal
(league tables) accountability
– Problem solving approach, eg TBAs>midwives;
SMS; antenatal wards
– Joined up approach

Ghana, Uganda, Bangladesh
• Competitive or intermediate settlements lead to
populist policy making and/or slipshod
implementation
– Ghana: NHIS bankrupting local health facilities; CHPS
compunds lack basic equipment and staff; 90% budget
spent on salaries
– Uganda: Districtization leads to proliferation of local
health depts w/o qualified or experienced staff
– Bangladesh: ‘Elite consensus’ around doctor
absenteeism; mushrooming of CCs w/o proper
facilities

However
• All three poorer performers have some
pockets of effectiveness and successful
multistakeholder initiatives
– Ghana, Upper East: P of E around Regional MO
– Uganda, Lyantonde: dominant local coalition
enforced performance and leveraged sons of the
soil
– Bangladesh: vigorous NGO and private sector

MMR trends in our case study countries
0
200
400
600
800
1000
1200
1400
1600
1990 1995 2000 2005 2010 2013
Bangladesh
Ghana
Rwanda
Uganda

4. Policy implications

Health system strengthening
• In dominant settlements like Rwanda,
traditional health system strengthening
approaches are likely to pay dividends
• In other types of settlement, there is
insufficient national level political
commitment for conventional approaches to
work well. Maternal health policy needs to be
more innovative, building out from pockets of
effectiveness

‘Best fit’ strategies
Type of settlement Best ‘fit’ approach
Dominant developmental Government supporting
Competitive or intermediate Government connecting/brokering
Dominant predatory? Government substituting?

5. Discussion