How to… advocate for political change on obstetrical and gynaecological issues facing low-income countries


  • J Shiffman

    1. Associate Professor of Public Administration, The Maxwell School of Syracuse University, 306 Eggers Hall, Syracuse, NY, USA; Non-Resident Fellow, Center for Global Development, Washington, DC, UK
    Search for more papers by this author

Dr J Shiffman, Associate Professor of Public Administration, The Maxwell School of Syracuse University, 306 Eggers Hall, Syracuse, NY 13244-1020, USA. Email

Low-income countries face many problems of concern to specialists in obstetrics and gynaecology, including high levels of maternal mortality and morbidity (e.g. obstetric fistula), high prevalence of cervical cancer, and high levels of neonatal mortality including still births. Surmounting these problems requires more than technical solutions. Also critical is political priority: ensuring that leaders of international organisations and national political systems devote attention to the issue, and back up that attention with the provision of resources appropriate with the problem’s severity. Political priority alone will not solve these problems, but without such priority the problems are far less tractable. In this note I offer three lessons, grounded in research from the discipline of political science, on how to increase the likelihood that politicians will prioritise these kinds of problems.

Build a strong policy community for the issue

A strong policy community is critical to generating political attention for an issue.1,2 A policy community is a network that links individuals concerned with a particular problem. These individuals may come from several kinds of organisations, including academic institutions, hospitals, government ministries, non-governmental organisations, donor agencies and UN agencies. Some policy communities are cohesive and gain the ear of senior politicians. Other policy communities are fragmented. They rarely meet, and when they do, members fight over evidence, intervention strategies, and the right to lead on the issue. Such communities seldom command the respect of politicians, and therefore rarely are able to get them to act.

In the 1980s, under the leadership of former UNICEF head James Grant, a strong global policy community for child survival formed that was able to move many national political systems to prioritise the issue.3 More recently, a global network of individuals concerned with newborn survival, working in concert, have managed to convince a number of UN agencies, donor agencies and low-income countries to prioritise neonatal survival.4 In contrast, global safe motherhood proponents were embroiled in disagreements on intervention strategy and leadership through much of the 1990s and 2000s.5 These disputes prevented them, until recently, from forming a cohesive policy community capable of capturing the attention of international and national political leaders.

Develop issue frames that resonate

Policy communities are more likely to move politicians to act if they develop issue frames that resonate.6–8 An issue frame is how a problem is positioned publicly. Any issue can be framed in multiple ways. For instance, HIV/AIDS has been positioned, among other ways, as a public health problem, a development issue and a problem of national security. An influential factor shaping the growth in resources and attention for HIV/AIDS has been the ability of its policy communities to convince political leaders that the disease is more than a public health problem; it is an issue that affects the world’s development and security prospects.9,10

Different frames may convince different political leaders. On maternal mortality, for instance, a minister of finance may respond to an argument concerning the adverse effects of high levels of maternal death in childbirth on economic growth; a minister of health may be convinced by an argument concerning the issue’s high mortality burden; a parliamentarian may respond to a gender equity-based argument surrounding the right to safe delivery. Policy communities must consider carefully political leaders’ concerns and interests in presenting their issues, rather than presuming, as so many do, that it is self-evident their issues are important.

Cultivate allies

Finally, policy communities concerned with obstetrical and gynaecological issues must think strategically about alliances.11,12 Advocates working alone on single issues such as cervical cancer or obstetric fistula rarely have sufficient political clout to put these issues on national policy agendas. They need support from women’s groups, parliamentary caucuses, key ministers, presidential aids and others. Also, they may need to link their issues with other problems in order to convince leaders that they have an agenda worthy of political attention.

Globally and in several low-income countries, for instance, newborn survival advocates have built alliances to generate attention for their issue, rather than go it alone.13 Specifically, they have linked with advocates for maternal and child survival. In part this has been a decision driven by the nature of the issue: they believe that reducing neonatal mortality is intimately linked with improving services for women and children. It is also a strategic decision: alone they are few in number and politically weak; in alliance with maternal and child survival groups, they command global attention.

A concluding thought

Communities of medical professionals often think of themselves in technical rather than political terms: as knowledge experts rather than political actors. However, time and time again we see that these communities, when they decide to act politically, carry great moral authority because of their expertise and pursuit of a humanitarian cause.14 Health professionals concerned with obstetrical and gynaecological issues may be surprised to find how much political power they might wield on behalf of the poor, if they only choose to exert it in a strategic way.

Disclosure of interest