What explains sub-national variation in maternal mortality rates within developing countries? A political economy explanation.

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.