The political economy of maternal health care in developing countries

DFID, 27 April 2016Tim Kelsall, ODI

Frederick Golooba-Mutebi, ESID and IndependentSam Hickey, ESID/GDI, University of Manchester

Overview

1. Introduction to ESID2. Researching the Politics of Health Care3. Key findings from the case studies4. Policy implications5. Discussion

1. Introduction

ESIDwww.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?

Please add text here Please add text here Please add text here Please add text here Please add text here

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

EducationHealth

EducationHealth

Education EducationHealthSocial protection

EducationHealthSocial protection

Recognition GenderSpatial inequity

Gender Gender Gender GenderSpatial inequity

Global PEAPSR

PEAPSR

PSR PEAPSR

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

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

1990 1995 2000 2005 2010 20130

200

400

600

800

1000

1200

1400

1600

BangladeshGhanaRwandaUganda

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