LSE100 fellow Alice Evans discusses her latest research on maternal health care in Zambia, presented at a recent LSE Africa seminar.

The LSE Africa seminar series takes place every Wednesday during term-time in room CLM 2.05 (Clement House, The Aldwych) from 4 to 5.30pm and is open to all academic staff, research students, researchers and policy makers at LSE and beyond.

Make an educated guess. Which of the following accounts for the recent prioritisation of maternal health care in Zambia?

(1)    Bottom-up accountability: complaints from communities and civil society;

(2)    Capacity-building: clinical and managerial training workshops for civil servants;

(3)    Performance-based management: top-down pressure on clinics and district health management teams to improve maternal health indicators; or

(4)    Donor-led advocacy: sensitisation of parliamentarians, traditional leaders and bureaucrats at the Ministry of Health.

The question is pressing. Few countries are likely to meet Millennium Development Goal Five (reducing the maternal mortality by three quarters and ensuring universal access to reproductive health by 2015). In order to understand how these objectives might be achieved, I have explored what has worked thus far, in Zambia.

An untitled painting given to Alice by Honourable Christopher Mulenga, Deputy Minister of Health

This qualitative, postdoctoral research was undertaken in three, rural Copperbelt districts and also at national level, where I interviewed senior civil servants, parliamentarians and donors. It was greatly aided by the incredibly generous support of Ministry of Health staff – many of whom had already seen me discussing safe motherhood on ZNBC (state TV) in fluent Bemba.

During my fieldwork I found minimal evidence that bottom-up accountability has resulted in improved service-delivery. Rural communities, like urban-based civil society organisations, have been relatively quiet and peripheral.

Far more significant, for health workers and district managers, was the growing pressure from central government to improve maternal health indicators. Commitment also seems to be enhanced when workers feel that their efforts are valued and appreciated. But when supportive supervision and workers’ intrinsic commitment wavers, capacity-building efforts (donor clinical or managerial training workshops) are seldom sufficient to motivate the implementation of skills learnt.

Likewise, at national level, safe motherhood champions are rarely created through sensitisation. Empathy is more commonly due to personal experience in this sector. With a critical mass of such individuals now in the executive and strong macroeconomic performance, sector budget allocation has increased. Additionally, maternal health indicators are strongly emphasised, from national to district level, in light of looming failure to achieve Millennium Development Goal 5. International benchmarking and consequent awareness of comparatively poor national performance appears to have increased attention to maternal health indicators within the Ministry of Health. Of particular significance is the desire to be “developing” (i.e. achieving shared socio-economic targets) on par with other countries, not lagging behind. There is also a financial incentive to improve, with some donor funding being contingent upon the annual number of institutional deliveries by trained personnel. The private media has also played a role here; high-level political attention has been triggered as journalists have exposed inadequate maternal health care.

Since maternal mortality reduction is lagging globally, such concerns are widely shared. This has created a conducive international environment, with increased funding for reproductive health in the run up to 2015. By contrast, safe motherhood was historically overshadowed by overwhelming international attention to, and funding for, HIV/AIDS, TB and malaria.

These narratives share a common thread, indicating the effectiveness of rewarding, or otherwise celebrating, the achievement of those results that are already prioritised by government institutions and personnel.

Alternative interpretations are also welcome.

For more information: Lessons from the effective promotion of safe motherhood in Zambia – Alice Evans – Working Paper

The LSE Africa seminar takes place every Wednesday during term-time in room CLM 2.05 (Clement House, The Aldwych) from 4 to 5.30pm and is open to all academic staff, research students, researchers and policy makers at LSE and beyond.