African Journal of Reproductive Health Women's Health and Action Research Centre ISSN: 1118-4841 Vol. 8, Num. 3, 2004, pp. 6-10

Commentaries

Generating Political Priority for Safe Motherhood 

Jeremy Shiffman*

* This paper was presented by Jeremy Shiffman on November 18, 2004 at the 38 Annual General Meeting and Scientific Conference of the Society of Gynaecology and Obstetrics of Nigeria (SOGON) in Makurdi, Benue State, Nigeria.  Jeremy Shiffman, Ph.D., is Associate Professor of Public Administration at the Maxwell School of Syracuse University in the United States. 

Code number: rh04038

Introduction

In 1987 a conference on safe motherhood in Nairobi, Kenya, drew international attention to alarmingly high levels of maternal death in childbirth in developing countries.  Global levels are estimated to be between 500,000 and 600,000 per year, with approximately one-tenth of these deaths occurring in Nigeria alone.  The conference ended with a call for a reduction in maternal mortality by half by the year 2000. 

In the decade following the conference, advocates made considerable progress in understanding the medical and technical dimensions of maternal mortality.  They determined its primary biomedical causes, developed indicators to measure safe motherhood outcomes, identified interventions to avoid maternal death in childbirth, and considered ways to surmount socioeconomic obstacles to  obstetric care for women.

They made little progress, however, in institutionalizing political priority for the cause of maternal mortality reduction in Nigeria and other countries.  This shortcoming in part explains why, as the year 2000 passed, the world was nowhere near to achieving the 50 % reduction goal.

The national-level political dimensions of safe motherhood deserve as much attention as its medical and technical dimensions.  Attention to generating political priority will be particularly critical as safe motherhood advocates pursue the Millennium Development Goals that call for a reduction in the maternal mortality ratios of 1990 by three-quarters by the year 2015.

Generating such priority can be approached systematically.  Political scientists and public policy scholars have identified factors that increase the likelihood that an issue will receive meaningful attention by national political elites.  In this presentation I would like to highlight four such factors, and illustrate how they interacted in two countries where safe motherhood became a political priority in the 1990s: Indonesia and Honduras.  The four factors are:

• The existence of an indicator to mark   the severity of the problem
• The presence of effective national political entrepreneurs to push the cause
• The organization of attention-generating focusing events that promote widespread concern for the issue.
• The availability of policy alternatives that enable national leaders to understand that  the problem is surmountable

These factors do not constitute a prescription for generating political priority for safe motherhood at the national level.  Rather, they are a partial explanation for how safe motherhood emerged on the national agendas of these two countries.  I present the factors to highlight two points:

• There are systematic features to  policy agenda-setting.
• Institutionalizing political priority for safe motherhood can be accomplished.  To do   so national and international safe        motherhood advocates must negotiate political landscapes strategically, taking   into account each country’s unique socioeconomic and political context. 

Factors that have Shaped Political Priority for Safe Motherhood 

The existence of an indicator 

Scholars studying policy agenda setting have shown that among the factors that shape whether an issue rises to the attention of policy - makers is the presence of a clear indicator to mark that issue.

Why should indicators make such a difference?  After all, they are in many ways trivial items, often unreliable and inaccurate, and unable to portray the complexity of difficult social problems.   All too frequently they over-simplify matters that deserve far more nuanced treatment.  On the other hand, they have a uniquely powerful effect of giving visibility to that which has remained hidden.  For instance, in the population field, studies that have highlighted high total fertility rates and population growth rates have served to bring to light population problems, and contributed to the mobilisation of national states and international agencies for population control.  Prior to the existence of such reports, many national political figures were unaware that any problem existed at all, making it difficult to generate action.  The deeper significance of indicators as agenda setting factors is that they serve not only monitoring purposes, the way they are traditionally understood.  They also function as catalysts for action.

In Honduras, for instance, the appearance in 1990 of a credible study revealing a maternal mortality ratio nearly four times the previously accepted figure shocked health officials and moved them to action on safe motherhood.  In Indonesia, a 1994 survey reported a maternal mortality ratio of 390 deaths per 100,000 births, making it appear that despite six years of attention, maternal deaths were almost as common as they had been a decade earlier.  The study contributed to renewed safe motherhood attention on the part of national political officials.

The presence of political entrepreneurs

A second factor that researchers have identified is political entrepreneurship.  Whether an issue rises to the attention of policymakers is not simply a matter of the flow of broad structural forces that stand beyond the reach of human hands.  Much depends on the presence of individuals and organisations committed to the cause. 

Generating Political Priority for Safe Motherhood      

Not just any person can be an agenda setter, however.  Research has shown that effective political entrepreneurs possess certain distinct features.  They have a claim to a hearing; they are persistent; they are well connected and have excellent coalition-building skills; they articulate vision amidst complexity; they have credibility that facilitates the generation of resources; they generate commitment by appealing to important social values; they know the critical challenges in their environments; they infuse colleagues and subordinates with a sense of mission; and they are strong in rhetorical skills.

In Indonesia, Abdullah Cholil, a medical doctor and assistant minister for women’s roles who over 25 years developed a reputation as one of the most effective public servants in the social development sector, became alarmed at the high maternal mortality levels revealed in the survey noted above.  In 1996 he took the problem directly to the country’s president, convincing Suharto to launch a new national safe motherhood campaign.  In Honduras in the early 1990s, mid-level Ministry of Health doctors and donor officials of Honduran nationality persistently cultivated national political and health leaders, convincing them to launch a safe motherhood campaign.  The campaign contributed to a decline in maternal mortality levels of 40 % from 1990 to 1997.

The organisation of attention-generating focusing events

A third factor is the occurrence of focusing events.  These are large-scale happenings such as crises, conferences, accidents, disasters and discoveries that attract notice from wide audiences.  They function much like indicators, bringing visibility to hidden issues.  Birkland has demonstrated that disasters, including hurricanes, earthquakes, oil spills and nuclear power plant accidents lead to heavy media coverage, interest group mobilisation, policy community interest and policy-maker attention, causing shifts in national issue agendas.

The Nairobi conference was the first of such focusing events for safe motherhood.  Immediately after this international conference a series of safe motherhood seminars commenced in Indonesia and continued throughout the 1990s.  The watershed event was Indonesia’s first national seminar on safe motherhood, held in 1988.  President Suharto delivered the keynote address.  Seventeen major organisations participated in this initial seminar, including a number of international agencies involved in safe motherhood, and pledged to reduce the country’s maternal mortality rate.  That this was more than an idle commitment was reflected in the fact that for the first time in the country’s history, the national development plan included official maternal mortality reduction targets. Similarly, in Honduras, after the completion of the 1990 study showing shockingly high levels of maternal death in childbirth, mid-level health officials and donor representatives of Honduran nationality organised major seminars to publicise the results, inviting senior political officials to ensure they would notice and take action.

The availability of policy alternatives

A fourth factor is the presence of feasible policy alternatives to address the issue at 4hand. Political leaders prefer to focus on issues that they perceive to be resolvable. 

African Journal of Reproductive Health          

This perception is shaped by the existence of clear proposals for action.  Unfortunately, safe motherhood advocates presently are confusing policymakers with multiple and competing proposals, conveyed in unclear and complex medical terminology.  Policymakers have hundreds of issues to consider at any given time, and will ignore issues where policy communities behave and communicate in this way.  Proposals that convey a simple message to policymakers concerning cost-effective means of making obstetric care accessible to pregnant women will be critical mechanisms for generating political attention and workable solutions.

For instance, the flurry of Indonesian safe motherhood activity following the national conference noted above was due in large part to political entrepreneurship and feasible policy alternatives coming from officials in the Ministry of Health.  A village midwife program, begun in 1989, was the first and most significant intervention.  Reflecting a concern that women in rural Indonesia had poor access to skilled medical care during their pregnancies, the ministry managed to gather the resources to place one midwife in most of Indonesia’s 68,000 villages to ensure that pregnant women could get delivery assistance.  The village midwife program was a clear, cost-effective, sensible policy alternative that convinced political leaders that something could be done about the country’s high levels of maternal death in childbirth.

Concluding Thoughts and Considerations for Nigeria

Scholars working in the agenda setting field have identified clear patterns concerning the ascendance of issues to national prominence. 

An issue is more likely to appear on a national policy agenda if it is marked by a salient indicator, if it is backed by effective political entrepreneurs, if it is given attention through a focusing event and if policy communities develop clearly communicated and feasible proposals to address the problems.

In light of the findings of this body of research and the Indonesian and Honduran experiences, Nigerian safe motherhood promoters may want to consider the following questions:

• To what extent have indicators from    the many studies in Nigeria documenting the scope of the maternal mortality crisis been used not simply as     measures of the extent of the problem, but as tools for political mobilisation?
• There have been many safe motherhood seminars in Nigeria, but how well have      these been used as attention-generating focusing events to generate political priority for the cause?
• To what extent do Nigerian safe   motherhood professionals move beyond   their traditional roles as technical experts    to engage in political entrepreneurship,   proactively and persistently cultivating  political elites who have control over   resources and who shape policy  priorities?
•   How clearly are policy alternatives explained to these political elites?  Are  Nigerian obstetricians and gynaecologists confusing political leaders with competing maternal  mortality reduction proposals conveyed in complex medical terminology?
• How can the network of professional  associations, NGOs, donors and state organisations concerned with safe    motherhood in the country be tightened to become a unified national political force and surmount the fragmentation             that may presently exist?

   To conclude, there is no uniform strategy for generating national-level political priority for safe motherhood.  The four factors I have discussed do not represent a prescription, but rather a partial explanation for the rise of safe motherhood on to the Indonesian and Honduran national agendas, and a starting point for thinking about the issue in other settings.  A critical need in Nigeria and other countries is the development and implementation of strategic plans not just for the provision of safe motherhood services, but also for the cultivation of political priority for the cause.  By doing so we may have reason to hope that the maternal mortality objectives of the Millennium Development Goals will be achieved by the target year of 2015.

Notes

 1.    WHO and UNICEF, 1996, Revised 1990 Estimates of Maternal Mortality, WHO and UNICEF. 

2.     H. Roberts, 2003, Reproductive Health Struggles in Nigeria, The Lancet 361, 1966. 

3.     In the passages that follow I draw heavily from two published articles: J. Shiffman, 2003, Generating Political Will for Safe Motherhood in Indonesia, Social Science & Medicine 56(6), 1197-1207; and J. Shiffman, C. Stanton and        A.P. Salazar, 2004, The Emergence of Political Priority for Safe Motherhood in Honduras, Health Policy and Planning 19(6), 380-390.

4.     Numerous scholars of agenda-setting have commented on one or more of these four factors.  I draw from the works of J.L. Walker, 1974, Performance Gaps, Policy Research, and Political Entrepreneurs: Toward a Theory   of Agenda Setting, Policy Studies Journal 3(1), 112-116; J.W. Doig and E.C. Hargrove (eds.), 1987, Leadershipand Innovation: A Biographical Perspective on Entrepreneurs in Government, Baltimore and London: The   Johns Hopkins University Press; J.W. Kingdon, 1984, Agendas, Alternatives and Public Policies, Boston and Toronto: Little, Brown and Company; M. Schneider and P. Teske, 1992, Toward a Theory of the Political   Entrepreneur: Evidence from Local Government, American Political Science Review 86(3), 737-747; S.A. Waddock and J.E. Post, 1991, Social Entrepreneurs and Catalytic Change, Public Administration Review 51(5), 393-401; and T.A. Birkland, 1997, After Disaster: Agenda Setting, Public Policy, and Focusing Events, Washington, D.C.: Georgetown University Press.

©Women's Health and Action Research Centre 2004