Generating political will for safe motherhood in Indonesia

Abstract

In 1987 an international conference brought global attention to an issue that previously had been ignored: the world's alarmingly high number of maternal deaths in childbirth. The conference ended with a declaration calling for a reduction in maternal mortality by at least half by the year 2000.

As the deadline approached, safe motherhood activists lamented the fact that the world was nowhere near to achieving this objective. They attributed this failure to a variety of causes, but were in agreement that the medical technology was available to prevent maternal deaths in childbirth, and the key was generating the political will to make such technology widely available to women in developing countries.

What ‘political will’ means, however, has been left as an unopened black box. What causes governments to give priority to the issue of safe motherhood, given that national political systems are burdened with thousands of issues to sort through each year? In marked contrast to our extensive knowledge about the medical interventions necessary to prevent maternal death, we know little about the political interventions necessary to increase the likelihood that national leaders pay meaningful attention to the issue.

Drawing from a scholarly literature on agenda setting, this paper identifies four factors that heighten the likelihood that an issue will rise to national-level attention: the existence of clear indicators showing that a problem exists; the presence of effective political entrepreneurs to push the cause; the organization of attention-generating focusing events that promote widespread concern for the issue; and the availability of politically palatable policy alternatives that enable national leaders to understand that the problem is surmountable.

The paper presents a case study of the emergence, waning and re-generation of political priority for safe motherhood in Indonesia over the decade 1987–1997, to highlight how these four factors interacted to raise safe motherhood from near obscurity in the country to national-level prominence. While there are contextual factors that make this case unique, some elements are applicable to all developing countries. The paper draws out these dimensions in the hope that greater knowledge surrounding how political will actually has been generated can help shape strategic action to address this much neglected global problem.

Introduction

Several recent works have expressed concern that despite widespread global attention to safe motherhood, insufficient progress has been made in reducing the number of maternal deaths in childbirth in the developing world (Maine & Rosenfield, 1999; Weil & Fernandez, 1999). The World Health Organization and UNICEF estimate that there were nearly 600,000 such deaths in 1990 (WHO & UNICEF, 1996), an alarmingly high figure that meant that almost one in every 200 births in the world resulted in the death of the mother. In 1987, an international conference on safe motherhood was held in Nairobi, Kenya, bringing together dozens of international organizations, NGOs and country representatives. The conference resulted in a declaration of global commitment to reducing the number of maternal deaths by half by the year 2000. Expectations were high that in the ensuing decade significant progress could be made in fighting this long-neglected issue. These hopes have not been met: it was clear at the end of 2000 that the world was nowhere near to achieving this goal, and it is not even certain that global maternal mortality levels have declined in the past decade to any significant degree.

Studies have attributed this lack of progress to multiple factors, but are in agreement on certain fundamental points (Maine, 1993; Maine & Rosenfield, 1999; Weil & Fernandez, 1999): the major medical causes of maternal death in childbirth are well understood, the interventions are well-established to prevent such deaths, and the most critical of these is ensuring access to essential and emergency obstetric medical care in the event of complications arising during childbirth. What is lacking, it is commonly acknowledged, is not technical knowledge, but political will.

In marked contrast to our extensive knowledge about the medical and technical interventions necessary to prevent maternal death—a positive legacy of the past decade—we know little about the political interventions necessary to increase the likelihood that national leaders pay meaningful attention to the issue.¹ There is one exception to this statement: past experience indicates how to get the subject on to the global policy agenda. The Nairobi conference itself was an exemplary example. Safe motherhood advocates worked together to arrange an international conference, involving all the world's major institutional actors in the health policy arena, and succeeded in grabbing the world's attention for an issue that had long been neglected. Maternal mortality, once hidden, suddenly burst on to the global policy agenda, if only for a moment. The problem is that between global attention and national action lies a major gap.

This paper presents a case study concerning safe motherhood efforts in Indonesia in the decade that followed the Nairobi conference. It traces the emergence, waning and re-generation of political priority for the cause through the year 1997. The case study begins with Nairobi, but this is only the starting point. Thereafter, a significant number of developments took place within the domestic political system that brought the issue to national prominence. Nairobi was enough to jump-start the process, but not enough to sustain it. The purpose of presenting the case study is to distill elements that may help us understand how political priority for safe motherhood may be sustained at the level of the nation-state. Indonesia is unique in many respects and no claim is made that all aspects of the experience of this country are relevant for the great diversity of countries facing safe motherhood crises. Nevertheless, there are certain dimensions of the case that may be of use for safe motherhood efforts in other countries, as well as for other public health causes such as infectious disease control, health sector reform and family planning promotion.

In exploring the case the paper draws extensively from a long-standing literature in the field of policy studies on the subject of agenda setting. Agenda setting is that stage in the public policy process in which certain problems rise to the attention of policy-makers while others recede or are ignored completely.² It is the first stage in this process and precedes three others: the formulation of policy, the enactment of authoritative decisions, and the implementation of policy (Kingdon, 1984). The central importance of agenda setting in the public policy process is expressed forcefully in a famous statement by Schattschneider (1960) that, ‘the definition of the alternatives is the supreme instrument of power’. It is only those possibilities that become salient to national political actors that stand a chance of actualization.

In the past decade scholars concerned with safe motherhood have made considerable gains in terms of raising maternal mortality as an issue of global proportions (Rosenfield & Maine, 1985; WHO & UNICEF, 1996); identifying the medical causes of maternal death in childbirth (Glazener et al., 1995); delineating the cultural and socioeconomic dynamics surrounding pregnancy care (Ministry of Health Republic of Indonesia, UNDP and WHO, 1991a; Tinker & Koblinsky, 1993); and, especially, specifying the medical and policy interventions needed to ensure that pregnancy is safe and that complications, when they arise, are treated (Maine, 1993; Maine, Akalin, Chakraborty, De Francisco, & Strong, 1996; Maine & Rosenfield, 1999; Ronsmans, Vanneste, Chakraborty, & Van Ginneken, 1997; Thaddeus & Maine, 1990; Tinker & Koblinsky, 1993; Weil & Fernandez, 1999). This paper adds to this literature a fifth concern that has been neglected—how political will gets generated for safe motherhood—so that the fight to surmount the global maternal mortality crisis may be approached strategically on this dimension as well.