Department of Social Work and Social Administration, Makerere University Kampala, P.O Box, 7062, Kampala, Uganda.
Independent Researcher and Honorary Research Fellow, University of Manchester, Uganda.
Soc Sci Med. 2020 Jul;256:113066. doi: 10.1016/j.socscimed.2020.113066. Epub 2020 May 19.
Available evidence on maternal mortality rates (MMR) reveals stark differences not only between but also sub-nationally within countries. However, the causes of sub-national variation in MMR remain under-researched and under-theorised. This is a serious problem given the widespread reliance on local authorities to deliver health services in developing countries, which means that sub-national efforts to curb MMR are critical. We propose a multi-level political economy analysis framework which, when applied in Uganda, usefully explained the sub-national differences. Drawing on process tracing and rigorous comparative case study analysis of two otherwise similar districts, this approach was able to identify certain political economy factors as being critical to shaping different levels of progress on MMR. The key variables that matter at district level are not necessarily the 'formal' factors identified in the literature, such as levels of democracy and citizens' power. Rather, the character of the local ruling coalition influences how they play out in practice. This analysis of local power relations needs to be located within a similar understanding of the political economy of health provisioning at a national level, which in many developing country contexts is itself profoundly shaped by international actors. Since the early 2000s, political developments have catalyzed a growing sense of vulnerability within Uganda's ruling coalition leading to political capture of the health ministry and undermining efforts to prioritise maternal health at the national level. With development agencies further undermining the emergence of a coherent centralized strategy, performance at the local level has become dependent on whether 'developmental coalitions' of political, bureaucratic and social players emerge to fill the vacuum. The paper concludes that the large variance in capacity and commitment to reduce maternal mortality within subnational levels of government has to be understood in relation to the local political settlement within which health service provision operates.
现有关于孕产妇死亡率（MMR）的证据不仅揭示了国家之间的巨大差异，也揭示了国家内部的差异。然而，孕产妇死亡率的国家内差异的原因仍未得到充分研究和理论化。鉴于发展中国家普遍依赖地方当局提供卫生服务，这是一个严重的问题，这意味着国家内遏制孕产妇死亡率的努力至关重要。我们提出了一个多层次的政治经济学分析框架，该框架在乌干达得到应用，有助于解释国家内的差异。通过对两个原本相似的地区进行过程追踪和严格的比较案例研究分析，这种方法能够确定某些政治经济学因素对于塑造孕产妇死亡率在不同层面上的进展至关重要。在地区层面上重要的关键变量不一定是文献中确定的“正式”因素，如民主和公民权力的水平。相反，地方统治联盟的性质影响着这些因素在实践中的表现。对地方权力关系的这种分析需要放在对国家一级卫生服务提供的政治经济学的类似理解中，在许多发展中国家的背景下，国家一级的政治经济学本身深受国际行为体的影响。自 21 世纪初以来，政治发展促使乌干达统治联盟内部产生了越来越强烈的脆弱感，导致卫生部被政治控制，并破坏了在国家一级优先重视孕产妇健康的努力。发展机构进一步破坏了协调一致的集中战略的出现，地方一级的表现取决于政治、官僚和社会行为体的“发展联盟”是否出现来填补空白。本文得出的结论是，必须根据卫生服务提供运作的地方政治解决办法来理解国家内各级政府在减少孕产妇死亡率的能力和承诺方面的巨大差异。
