Strategies in Using Budget Work to Improve Maternal Health

One of the Sustainable Development Goals (SDGs) is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. Although the world has made significant progress, maternal mortality remains unacceptably high, particularly in developing countries. More than half of all maternal deaths worldwide occur in sub-Saharan Africa, where a lack of skilled health workers and facilities for comprehensive emergency obstetric and newborn care are often cited as key reasons for preventable maternal death. Impoverished and rural areas are particularly lacking in these essential services.

Two IBP case studies, one from Tanzania and another from Uganda, examine civil society campaigns to engage governments and hold them to account in providing maternal health care to their citizens.

Both case studies feature the advocacy work of the White Ribbon Alliance (WRA), an informal coalition of NGOs, donors, and their global partners dedicated to achieving safe and healthy childbirth for all women. WRA’s chief strategy has been to hold governments accountable by mobilizing citizens to demand decent healthcare for all pregnant women. Yet the coalition used two quite different approaches to push for improvements in maternal healthcare in Uganda and Tanzania.

Uganda: Combining Grassroots Mobilization and National Advocacy Efforts

WRA’s campaign in Uganda combined grassroots mobilization and national lobbying efforts, all coordinated and timed to maximize influence on budgetary allocations to maternal health. The Ugandan government has long prioritized budget allocations to so-called “productive” sectors of the economy, such as roads and infrastructure. This has driven chronic underfunding of the country’s health sector. Inadequate health funding has led to shortages of equipment, supplies, and medical workers and resulted in poor services for mothers throughout the country.

At the 66th session of the United National General Assembly the Ugandan government committed to improving maternal healthcare. In response, WRA launched their “Act Now to Save Mothers” campaign to hold the government accountable to these commitments. Campaign goals included ensuring that half of its county-level health centers were equipped with comprehensive emergency obstetric and newborn care, and that basic emergency obstetric and newborn care services would be available in all local health centers by 2015.

WRA Uganda’s strategy consisted of engagement at several levels. They assessed the capacity of local health clinics, held events targeting key decision-makers, tapped relationships with the media and launched a national petition to bring attention to their campaign.

The case study delves into the planning and execution of Uganda’s “Act Now to Save Mothers” campaign and documents and explains the resulting changes in government behavior. It describes the context of the WRA Uganda initiative, the campaign planning and strategy development process, the evidence-gathering phase of the campaign, the dissemination of these findings and advocacy and lobbying activity, and government’s response. Lessons of the campaign in Uganda include the necessity of a carefully coordinated strategy, the value of developing relationships with key decision-makers, and conducting comprehensive, participatory assessments of services.

Tanzania: Strategic Planning and Evidence-Based Advocacy

In Tanzania, WRA’s “Wajibika Mama Aishi” (Be Accountable so a Mother May Survive) campaign targeted key players in the budgetary process. It aimed to win greater transparency of maternal health spending and to convince the government to uphold its commitment to provide emergency obstetric healthcare in half of all local health centers.

The campaign was born from the government of Tanzania’s commitment to ensure that every ward in the country would have a health center, and that half of these health centers would be equipped with facilities for comprehensive emergency obstetric and newborn care. In order to address this commitment, WRA’s strategy in Tanzania included assessments of existing health clinics and engagement at the national and regional levels.

This case study outlines WRA Tanzania’s past work in maternal health care and assesses the Wajibika Mama Aishi campaign itself, reflecting especially on challenges faced and lessons learned. It addresses the planning of the campaign, how relationships with stakeholders and government were managed, and other issues which may have affected the outcome of the campaign.

A number of important lessons emerge from WRA Tanzania’s campaign: the need to aim for achievable and measurable targets gleaned from broad public commitments, the usefulness of marshaling evidence, and the strengths of planning a multi-level campaign through power analysis. But the case study offers warnings too – notably the importance of critically evaluating how promises can be feasibly implemented given the requirements and restrictions imposed by the budgetary process itself.

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