Political settlements and the delivery of maternal health services in rural Uganda

Technical questions, such as systems development and management; governance, the role of service users in financing and decision-making and resource availability, have long dominated research on healthcare provision in developing countries. The importance of the broader political context, specifically the way power is organised and exercised and the extent to which it meets the acceptance of a country’s ruling elites, or, more specifically, the prevailing political settlement, is usually disregarded (DFID, 2010:22). This ESID-commissioned research explored whether, and the extent to which, ‘the balance or distribution of power between contending social groups and classes, on which [the Ugandan] state is based’ (di John and Putzel, 2009:4) matters with regard to government capacity for delivering maternal health services. Findings indicate that within Uganda’s weak-dominant political settlement, sub-national level settlements exert a profound effect on the capacity and commitment of local government to deliver services. Since the mid-2000s, the health sector in Uganda has been governed for political ends, rather than geared towards higher levels of performance. This has undermined any system-wide efforts to improve service delivery. Case study material from two otherwise very similar districts, Ssembabule and Lyantonde, which record very different levels of progress in reducing maternal mortality, illuminates this argument. At the district level, good performance is driven by developmental coalitions of local politicians, bureaucrats, health sector professionals and civil society organisations with the capacity and commitment to devise and enforce innovative approaches to governing the sector.