Kelsall, T. (2020) ‘Political Settlements and the Implementation of Maternal Health Policy in the Developing World: A Comparative Case Study of Rwanda, Ghana, Uganda and Bangladesh’. Working Paper 137. Manchester: ESID Research Centre.


Maternal health, and in particular the issue of reducing maternal mortality, has been a prominent feature of the global health policy agenda for the past three decades. However, maternal health has rarely become a political priority at national levels, with policy uptake and implementation proving relatively disappointing.

In this paper, we compare the experience of Rwanda, Bangladesh, Uganda and Ghana in reducing maternal mortality, relating policy uptake and, in particular, implementation to the underlying balance of power and institutions, or political settlement, on which these countries’ politics is based. Rwanda’s ‘dominant-developmental’ political settlement has enabled a vigorous, joined-up approach to maternal mortality reduction, while, at the other end of the spectrum, Ghana’s inclusive-competitive settlement has been less effective in matching policy commitment with implementation. Uganda and Bangladesh’s more intermediate settlements present a more mixed experience. The paper argues that policy reformers should try to optimise their maternal mortality reduction strategies within the context of the political settlement in which they operate. That implies a government-supporting strategy in more dominant developmental settlements, while engaging non-state actors or building out from pockets of effectiveness in other types.