摘要：I conducted case studies on the level of political priority given to maternal mortality reduction in 5 countries: Guatemala, Honduras, India, Indonesia, and Nigeria. Among the factors that shaped political priority were international agency efforts to establish a global norm about the unacceptability of maternal death; those agencies’ provision of financial and technical resources; the degree of cohesion among national safe motherhood policy communities; the presence of national political champions to promote the cause; the deployment of credible evidence to show policymakers a problem existed; the generation of clear policy alternatives to demonstrate the problem was surmountable; and the organization of attention-generating events to create national visibility for the issue. The experiences of these 5 countries offer guidance on how political priority can be generated for other health causes in developing countries. There is a strong emphasis on health in the Millennium Development Goals (MDGs; poverty alleviation objectives agreed to by United Nations [UN] member countries). 1 Goals 4, 5, and 6 are concerned with child mortality, maternal mortality, HIV/AIDS, and malaria. 2 In 2003, a High Level Forum—a venue for dialogue among senior policymakers from governments, aid agencies, foundations, and other organizations—formed to find ways to accelerate the slow progress toward the realization of the MDGs regarding health. 3 – 5 Many factors undoubtedly stand behind this slow progress, including insufficient donor resources, lack of consensus on intervention strategies, and weak health systems. Another potential contributor, one that has attracted little research attention, may be the difficulty in generating national political support for particular health goals. Even if national policymakers recognize the existence of health problems, have sufficient donor resources, and are cognizant of MDGs, there is no guarantee they will prioritize these issues or take action. Policymakers in developing countries are burdened with thousands of issues and have limited resources to deal with them, as well as conflicting political imperatives. Goals targeting improved health must compete for policy attention and resources in these difficult political circumstances. What are the barriers to political attention for health? How does a lack of political support affect the achievement of health goals? How can such support be generated? Political scientists have referred to these issues as challenges in agenda setting and generating political priority, 6 , 7 ensuring that political leaders consider an issue to be worthy of sustained attention and will back up that attention with the provision of financial, human, and technical resources commensurate with the severity of the problem. We know priority is present when: (1) national political leaders publicly and privately express sustained concern for the issue; (2) the government, through an authoritative decisionmaking process, enacts policies that offer widely embraced strategies to address the problem; and (3) the government allocates and releases public budgets commensurate with the problem’s gravity. Agenda setting is the first stage of the public policy process during which some issues are given attention by policymakers and others receive minimal attention or are neglected completely. Scholars have identified systematic features in the agenda-setting process that shape the likelihood that any given issue will receive policy attention. 6 , 8 , 9 Drawing on this political science scholarship, I examined the state of political priority for maternal mortality reduction in 5 developing countries that have attracted considerable attention from safe motherhood researchers: Guatemala, Honduras, India, Indonesia, and Nigeria (Table 1 ▶ ). The MDGs call for a decrease in the world’s maternal mortality ratio by 75% from 1990 levels by the year 2015. With an estimated 585000 maternal deaths in the year 1990, 10 and little evidence of decline since then, 11 much change is needed over the next decade if the maternal health goal is to be achieved. Between 2003 and 2006, I prepared individual studies for each country on agenda setting for this cause. 12 – 16 I bring together results from these 5 studies to draw out implications for health priority generation in other resource-poor countries. TABLE 1— Safe Motherhood and Economic Indicators, by Country: Mid-1990s to Early 2000s Indicator Honduras 21 , 52 , 53 Guatemala 54 , 55 Indonesia 56 India 57 , 58 Nigeria 39 , 59 , 60 Maternal mortality ratioa 108 153 307 540 704 Percentage of women delivering in health institutions 62 42 40 35 33 Percentage of women delivering with medical attendants 56 41 66 42 35 Most common biomedical causes of death Hemorrhaging, hypertension, infection Hemorrhaging, infection, hypertension NA Hemorrhaging, anemia, infection Hemorrhaging, infection, unsafe abortion GDP per capita (purchasing power parity in 2005) in US $b 2800 5200 3700 3400 1000 Open in a separate window Note. GDP = gross domestic product; NA = not available. aNumber of maternal deaths per 100 000 live births. The Honduran and Guatemalan maternal mortality ratios are highly reliable because they are population figures derived from reproductive-age mortality surveys—the gold standard in maternal mortality measurement—that investigate every death over the course of the year and therefore do not require confidence intervals. The Indonesian, Indian, and Nigerian maternal mortality ratios are estimates from representative surveys. bGDP per capita is 2005 estimate as reported in the Central Intelligence Agency World Factbook . 51
