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.

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.