Article Text

Parliaments lead the change for women’s, children’s and adolescents’ health: what have we learnt?
  1. Kadidiatou Toure1,
  2. Gabriela Cuevas2,
  3. Rachael Hinton3,
  4. David Imbago4,
  5. Ulrika Karlsson2,
  6. Cecilia Rocco5,
  7. Miriam Sangiorgio2,
  8. Diana Nsubuga6,
  9. Martin Chungong2,
  10. Helga Fogstad1,
  11. Flavia Bustreo7
  1. 1The Partnership for Maternal Newborn & Child Health, Geneva, Switzerland
  2. 2Inter-Parliamentary Union, Le Grand-Saconnex, GE, Switzerland
  3. 3Rachael Hinton Editing (RHEdit), GENEVA, Switzerland
  4. 4International youth health organization, Quito, Ecuador
  5. 5University of Trieste, Trieste, Friuli-Venezia Giulia, Italy
  6. 6Living Goods, Kampala, Uganda
  7. 7Fondation Botnar, Basel, Switzerland
  1. Correspondence to Kadidiatou Toure; tourek{at}who.int

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Summary box

  • Leadership, gender, multistakeholder partnerships and social accountability facilitate parliamentary action for improved women’s, children’s and adolescents’ health (WCAH) outcomes.

  • Governments and development partners should increase predictable, long-term and flexible funding to support and enhance parliamentary action for WCAH.

  • Multistakeholder partnerships operating at all levels should include parliamentarians and consider parliamentary perspectives, with a view to facilitating and supporting their action for WCAH.

  • Advocacy through parliamentary caucuses should be reinforced, and formal parliamentary institutions should be supported to be more responsive to the needs of women, children and adolescents.

  • Parliaments must be supported to increase female representation, while ensuring that women members are informed, capacitated, and supported to address WCAH issues.

  • Support for parliamentary action must be accompanied by efforts to inform and empower communities to demand their rights, and to give voice to affected communities, including through the use of digital information and communication technologies.

Introduction

The Global Strategy for Women’s, Children’s and Adolescents’ Health (WCAH) (2016–2030) recognises that parliaments and parliamentarians play an important role in improving WCAH.1 Parliamentarians enact legislation and approve budgets, including allocation of resources to priority areas. They also provide oversight to ensure government accountability and transparency and foster the participation of constituencies in policy discourse.2

Over the past decade, parliamentarians have increasingly prioritised WCAH3 4 in the context of achieving universal health coverage and the Sustainable Development Goals.5 More and more development partners are also engaging parliamentarians to support informed decision making, resource allocation and to increase accountability for improved health at all levels.6 Recent publications document parliamentary action for improved health, for example, by passing legislation for sexual and reproductive health and rights (SRHR),7 mental health8 and health coverage for the most vulnerable.9 Increased representation of women in parliaments is known to improve maternal and child health outcomes.10 Studies also point to the importance of multistakeholder partnerships and community engagement in stimulating and sustaining parliamentary action for health, particularly efforts led by civil society organisations.11

However, major knowledge gaps exist. Few studies document the impact of parliamentary action on WCAH, and even less is known about how best to facilitate parliamentary action for improved WCAH outcomes. This paper presents key factors that facilitate parliamentary action for improved WCAH outcomes. It draws on a review of published and grey literature (see more information on the literature review in online supplemental file 1) and on examples from a key multistakeholder partnership that supports parliamentary action for WCAH: the longstanding collaboration between the Partnership for Maternal, Newborn & Child Health (PMNCH)–a global health partnership that brings together over 1000 partners in joint action to improve WCAH12 and the Inter-Parliamentary Union (IPU)–the global organisation of 179 national Parliaments. (The review was complemented by a synthesis of informal discussions with male and female parliamentarians and global health leaders with experience in parliamentary action for health.) This paper makes an important contribution to the evidence base for parliamentary action for WCAH and can inform future efforts for parliamentary engagement. It identifies four key factors that facilitate parliamentary action for improved WCAH outcomes.

Supplemental material

Parliamentary leadership for WCAH is needed to drive change

Strong leadership facilitates parliamentary action that drives change for WCAH. Parliamentary champions of WCAH are essential for building sufficient political will to pass the necessary laws, budgets and policies. For example, the Parliamentarians for Women’s Health project acts in Kenya, Tanzania, Namibia and Botswana to inspire and support parliamentary champions to drive policy and legislative change as a means of improving health outcomes.13

Lack of parliamentary independence can affect the way in which parliamentarians exercise their statutory functions which also has implications for WCAH outcomes. However, informal structures, such as caucuses and cross-party parliamentary groups, can support parliamentary leadership and objective decision making by providing a platform for information exchange, joint planning and strategising.14 They often work to depoliticise controversial issues in a politically charged environment, transcend political party dynamics, and thus achieve broad ownership. These groups undertake advocacy and effectively maintain momentum for WCAH. For instance, all-party parliamentary groups on population and development exist in nearly 100 countries and successfully ‘promote, review and adopt SRHR legislation’.15 The most effective structures include both men and women, as well as representatives from both ruling party and opposition, and from as many parliamentary committees as possible, particularly budget and finance committees.

While informal caucuses are important drivers of advocacy, formal parliamentary structures, such as parliamentary committees on health, women’s rights and children’s rights, can convert advocacy asks into policy and legislation. For instance, efforts in Uganda to increase the health budget in 2012 were driven by the health committee in collaboration with the Uganda Chapter of the Network of African Women Ministers and Parliamentarians, as described in box 1. Interestingly, the literature review did not yield documented examples of sustained parliamentary action that yielded long-term change to the health budget.

Box 1

How Ugandan members of parliament increased health financing

‘Find 260 billion shillings (US$103 million) for health or we block budget’.36 In September 2012 a group of Ugandan members of parliament (MPs) delayed the national budget for 2 weeks until additional funds were allocated for recruiting and motivating the health workforce. This joint action was in response to a proposed reduction in the health budget from Shs814 billion to Shs761.6 billion37 during a serious health worker crisis in Uganda that was adversely affecting women’s and children’s health.

MPs led the charge, supported by multistakeholder partnerships

The health committee of Uganda’s National Parliament and the Uganda Chapter of the Network of African Women Ministers and Parliamentarians (NAWMP) drove a campaign to get the health workforce crisis onto the national agenda. The MPs were motivated by civil society actors who produced compelling evidence and testimonies from community members about the impact of the weak health workforce, as well as by intense media coverage of dysfunctional health centres. The group of MPs acted as champions for women’s health in their communities and at the global level. The NAWMP and leading health committee members, including the then chair of the health committee, led the non-partisan campaign to increase the budget. They raised support from members of key committees and persuaded influential men to add their voices for what had traditionally been seen as a women’s issue.

Evidence and sustained public pressure

Coordinated action and aligned messaging by civil society, ministries of health and other partners were also identified as factors facilitating success. MPs were supported in their advocacy by clear, strong messaging from civil society on the impact of poorly staffed health centres and from the Ministry of Health on where resources were most needed. These messages came not only from civil society actors, but also from community members who texted short, effective messages to their MPs asking them to block the budget until money for health workers was made available. Journalists were briefed on the conditions of health centres, generating sustained online and print coverage to maintain pressure.

Citizen’s voices and MPs’ responsibility to their constituents

The Reproductive, Maternal, Newborn and Child Health Civil Society Advocacy Coalition led by World Vision Uganda and the African Centre for Global Health and Social Transformation, and supported in part by Partnership for Maternal, Newborn & Child Health organised live testimonies during advocacy engagements, allowing women to describe the impact of the health worker shortage on their own and their children’s health. This played an important role in incentivising parliamentarian engagement. In addition to the responsibility felt by parliamentarians towards their constituents, they were also incentivised by the opportunity to demonstrate the impact they could achieve in improving human resources for health.

Unrelenting advocacy yields results

Despite resistance, including expressions of concern by the president of Uganda38 about the budget block, the campaign was highly effective. Following sustained pressure, the Parliamentary Budget Committee allocated an additional 49.5 billion shillings (nearly US$20 million) for the financial year 2013/2014, primarily to recruit health workers and enhance motivation for doctors. The money for recruitment enabled the addition of over 6000 more medical workers.39

Gender balance in parliament can drive improvements in WCAH

There is a positive correlation between representation of women in parliaments and health outcomes, especially in WCAH. Although confounding factors such as gross domestic product or women’s literacy rate also play a role, women are more likely than men to advocate for social protection policies that reduce inequities and improve health outcomes. For instance, a global study on female political representation notes a positive correlation between increased numbers of women parliamentarians and reduced child mortality.16 A study in Pakistan noted that, although women accounted for only one quarter of MPs, they raised five times more parliamentary questions on health than their male counterparts.17 Additionally, community-based health assessments in Kenya and Namibia showed that female parliamentarians had greater knowledge and understanding of women’s health issues than male parliamentarians, possibly explaining their different levels of engagement with the issue.18

Parliaments represent the interests of all citizens19 and are therefore responsible for achieving gender balance, which has been shown to improve health outcomes. Efforts by parliamentarian champions to improve WCAH also aim to engage male parliamentarians to effect change. Noting that WCAH is not a women’s issue, these initiatives seek to promote responsibility for health outcomes among the broadest number of parliamentarians from the largest number of committees. For example, efforts by Ugandan parliamentarians to increase health financing included a deliberate push to engage male parliamentarians, who were perceived to have more power as members of the budget committee, but who had shown less interest in health (see box 1).

Multistakeholder partnerships can catalyse effective parliamentary action

Effective parliamentary action for WCAH is often stimulated by non-parliamentary stakeholders, particularly civil society organisations. These stakeholders play essential roles by bringing health issues to the attention of parliamentarians, discussing possible policy, budgetary or legislative actions, and providing parliamentarians with evidence to support their efforts.20 These partners also create an enabling environment for parliamentary action by generating pressure from constituents and the media. For example, a case study of parliamentary action in Italy demonstrated that, following the involvement of a multistakeholder partnership, efforts to reduce C-section rates, including the passing of a motion to address the overutilisation of caesarean section, succeeded where previous efforts had failed.11 PMNCH and the IPU have also encouraged links between parliamentarians and advocates, resulting in the development and implementation of parliamentary action plans for WCAH.

Multistakeholder partnerships take many forms but are often informally structured. They are most effective when they are long-lasting, based on trust and combine capacity building, information sharing, champion support and public recognition. A case study found that many parliamentarians lack the ability to access, interpret, and use evidence on health-related topics.21 Therefore, trust-based relationships enable parliamentarians to ask partners for data and information to support their arguments, advocacy and decision making, thereby correcting imbalances in capacities between the executive and legislative arms of government.

Social accountability influences parliamentary action at all levels

Parliamentarians have noted that direct communications from constituents about the issues they face are a strong driver of action.13 Civil society plays a significant role by supporting marginalised citizens to engage collectively with parliamentarians, either through social accountability mechanisms such as community-based citizens’ hearings or by bringing representatives of affected populations to parliament to speak about their health priorities. For example, with funding by PMNCH, Health Alerts, a non-governmental organisation in Sierra Leone, organised townhall meetings and community dialogues in 2018 which enabled young girls to report the challenges they faced in accessing sexual and reproductive health services and commodities to business leaders and members of parliament. Anecdotal evidence suggests that this collective action contributed to the Sierra Leone parliament increasing health spending in its 2019 budget from 9% to 10%, with a specific budget line for procuring and distributing family planning commodities.22

Parliamentarians use various means to ensure that public opinion is heard in parliament. For example, parliamentary committees include public hearings and outreach offices or mobile parliamentary information units have been created to make public hearings more accessible to citizens.23 More than 60% of parliaments use digital communications to engage more citizens in the political process.24

How can parliamentary action for WCAH be strengthened?

This paper supports the long-held view that parliamentary leadership can drive improvements in WCAH. Studies demonstrate that sustained structural, technical, and advocacy support is needed to equip parliamentary champions with sufficient information and confidence to drive necessary changes.13 While much effort has been directed at supporting informal structures for WCAH, other sectors have been prioritising the development of formal committees. For instance, over a decade ago the World Report on Road Traffic Injury Prevention called for the establishment of parliamentary road safety committees.25 These committees, imbued with investigative and scrutiny powers in addition to their advocacy roles, have effected positive changes.26

However, it is difficult to gauge the impact of parliamentary leadership. Parliamentarians’ work can be slow, often spanning multiple budgetary periods. Many of their functions, such as political influence, can be a challenge to measure.27 28 This is also the case for the many partner inputs in support of parliamentary leadership, such as capacity building and advocacy.29 This may help explain the emerging evidence showing reductions in funding for parliamentary engagement despite increased recognition of the importance of parliamentary leadership in improving health outcomes.30 It also points to a need to better assess parliamentary contributions to health outcomes and more mixed-methods research to monitor and evaluate parliamentary influence.

By leveraging partners’ knowledge and capacities, multistakeholder partnerships can effectively increase parliamentarians’ access to data and capacity for action. They can also create an enabling environment for parliamentary action by working with the media, creating citizen’s movements, and advocating to political leaders. However, more needs to be done to support national parliamentary engagement in WCAH partnerships.

Most parliaments still lack the gender balance necessary to improve WCAH outcomes.31 Female representation in parliaments remains insufficient, and gender quotas alone, without the support of likeminded allies to challenge the status quo, do not achieve effective representation. Women in politics need to be empowered and supported to overcome the structural and functional barriers to effective engagement in parliament,32 committed to women’s issues,33 and supported by women’s groups both within parliament and in wider society.34 However, the engagement of male parliamentarians, who also play an important role in improving WCAH, must not be overlooked. Responsibility for upholding women’s rights and gender equality lies, not only with a nation’s women and individual MPs, but with the entirety of its parliament.

While formal mechanisms exist for parliamentarians to consult constituents, including women, children and adolescents, evidence points to the importance of social accountability efforts in voicing the needs of the most marginalised. Civil society-led citizens’ hearings provide important opportunities for parliamentarians to hear directly from people about the problems they face and the solutions they propose.35 To enable a better response to the needs of women, children and adolescents, parliamentarians must be further supported to adopt measures to meaningfully engage with vulnerable and marginalised groups, as well as to use new technologies for outreach and citizen engagement.

Conclusion

Parliamentarians can drive changes for WCAH, but they need support to do so. Our analysis highlights gaps in evidence on the impact of parliamentary action on WCAH outcomes. Better measurement and documentation of the impact parliamentarians’ contributions to improving WCAH requires a mix-methods approach and the development of appropriate indicators.

The literature review did not identify any programme with sustained funding over multiple years that was able to generate multiyear increases in health budget allocation. This is indeed a gap. Given the potential improvements that parliamentary action can bring for WCAH, increased predictable, long-term and flexible funding from government and development partners is needed to support such parliamentary engagement. Multistakeholder partnerships operating at all levels should include parliamentarians and consider parliamentary perspectives, with a view to facilitating and supporting their action for WCAH.

Advocacy through parliamentary caucuses should be reinforced, and formal parliamentary institutions should be supported to be more responsive to the needs of women, children and adolescents. Parliaments must be supported to increase female representation, while ensuring that women members are informed, capacitated, and supported to address WCAH issues.

Finally, support for parliamentary action must be accompanied by efforts to inform and empower citizens to demand their rights, and to give voice to affected communities, including through the use of digital information and communication technologies.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Handling editor Seye Abimbola

  • Twitter @davidimbago

  • Contributors FB initiated the idea and CR and DI conducted the literature review supported by, with inputs from DI, UK, CR, HF and FB. KT held informal discussions with parliamentarians and global health leaders. KT, RH, DI and CR discussed the themes emerging from the literature review and informal discussions as a small group and then with HF, FB and UK. KT wrote the first draft with inputs from RH. All authors provided input, feedback and edits on the first and subsequent drafts. KT revised the drafts. Authors read and agreed the final draft manuscript.

  • Funding This work was made possible with funding from the Partnership for Maternal, Newborn & Child Health.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement The data that support the findings of this paper are openly availble in the paper and in supplemental file.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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