Generating Political Priority for Newborn Survival in Bolivia

Stephanie L. Smith, Ph.D.

Assistant Professor

School of Public Administration

University of New Mexico

Albuquerque, NM, USA

smith.unm.spa@gmail.com

Ramiro Llanque Torrez, M.D., M.P.H.

Technical Health Manager

Consejo de Salud Rural Andino

La Paz, Bolivia

Final Report, January 13, 2011

This study is the fourth in a series of papers examining the state of political priority
for newborn survival globally and in four low-income countries: Bangladesh, Bolivia,
Malawi and Nepal. These are funded by the Saving Newborn Lives (SNL) program of
Save the Children USA. However, they constitute independent research and
represent the analysis and conclusions only of the authors themselves, and do not
necessarily reflect the views of Save the Children USA or SNL. The authors take sole
responsibility for all errors.

We would like to thank the Gates Foundation-funded Saving Newborn Lives program
of Save the Children USA for their generous support of this study. We would also like
to thank Bertha Pooley and the Saving Newborn Lives program staff in Bolivia for the
time and energy that they devoted to supporting our efforts. We owe a tremendous
debt of gratitude to all of the individuals in Bolivia that so generously shared their
time and insights with us in the process of gathering data for this report and to those

1
that provided critical feedback in the review process. Lastly, we would like to thank
Huong Nguyen for her technical support during interview transcription and data
collection.

Abstract

Newborn survival is a significant child health and survival issue in

Bolivia. An estimated 7,000 neonates die each year in Bolivia. Some
progress has been made in alleviating the problem, but the neonatal
mortality rate has held steady in recent years and increased as a
proportion of infant and child deaths. Declining infant and under-5 child
mortality rates between 2003 and 2008 suggest that Bolivia should
also be making progress on reducing its neonatal mortality rate.

A number of newborn health advocates, including health professionals,

health ministry officials, international agency representatives and
international and domestic nongovernmental actors, have worked to
understand the problem in the Bolivian context and to address it
through policy and programmatic action. They made a good deal of
progress on these fronts from the late 1990s through the early 2000s.
They have since faced a number of challenges to effective advocacy
for newborn survival. This study analyzes the extent to which newborn
survival has achieved political priority in Bolivia, and identifies central
challenges to improving its status on the health policy agenda.

Political priority for newborn survival increased through the middle of

the past decade, but has since lost its footing. The level of political
attention and resource allocations needed to effectively address
Bolivias neonatal mortality problem have not been secured. Actors
concerned with the issue face three primary challenges to increasing
political priority for newborn survival: strengthening the network of
actors that is most centrally concerned with the issue; framing the
issue in ways that enhance support within the network and among
authoritative actors who control resource allocations; and, adapting to
an evolving political context in order to attain and sustain a level of
priority for newborn survival that is equal to the severity of the
problem.

We hope that this report will help those concerned with newborn
survival in Bolivia to think systematically about how to enhance and
institutionalize priority for this important issue so that attention and
resources commensurate with the severity of the problem become
more secure and sustainable.

2
 Introduction

More than 7,0001 newborns lost their struggle for survival each year
between 1998 and 2008 in Bolivia. Though the countrys neonatal
mortality rate decreased from 43 to 27 deaths per 1,000 live births
between 1998 and 2003, it held steady between 2003 and 2008
(Ministerio de Salud y Deportes et al. 2009). Infant and under-5 child
mortality rates continued to fall between 2003 and 2008, suggesting
that Bolivia should also be making progress on reducing its neonatal
mortality rate.

Neonatal mortality has been recognized as a problem by health

professionals, within the Bolivian health ministry, among researchers,
international development agencies and representatives of
nongovernmental organizations since at least the mid-1990s. They
have worked to understand the causes of the problem from biomedical
and cultural perspectives and developed policy and program solutions
to address the problem at the various levels of health service delivery
and at the community level.

These solutions have not gained a level of focused attention or

resource allocations that is commensurate with the severity of the
problem. Further, sustainability of what attention and resources have
been allocated (as through neonatal IMCI programming in the early
2000s) is uncertain. Efforts to reduce neonatal mortality in Bolivia face
what political scientists term the challenge of generating political
priority for an issue this is the focus of this report. Political priority is
indicated by the extent to which authoritative actors give sustained
attention to an issue and reinforce it with the provision of financial,
human and technical resources equal to the severity of the problem.
The higher the level of political priority, the more likely technically
sound and effective policy and program solutions are to contribute to
alleviation of the problem.

We used a process-tracing methodology to investigate the problem of

generating political priority for newborn survival in Bolivia. We
analyzed multiple sources of data, including interviews, documents and
researcher observations in order to identify patterns of causality and
1
Calculated based on Table 1 of UNICEFs 2010 State of the Worlds
Newborns report (number of births) x NMR of 27 in 2008.

3
minimize bias in this qualitative case study (Yin 1994). The
perspectives of informants are critical to understanding largely
undocumented causes of shifts in levels of attention and resources to
health issues. The consistency of data across multiple sources
suggests that the findings are valid and reliable. We conducted
interviews with twenty-six individuals with close knowledge of newborn
survival initiatives and service delivery in Bolivia, including
representatives of the health ministry, international agencies and
donors, domestic and international nongovernmental organizations,
and health professionals in July and August of 2009. We collected and
analyzed approximately 75 documents, including government policy
documents, donor reports, published research on neonatal mortality in
Bolivia, media reports, health and other surveys. We also visited rural
and urban implementation sites. Our systematic analysis of interview
transcripts and documents assessed the level of political priority for
newborn survival in Bolivia and identified factors facilitating and
hindering its generation since the mid-1990s. Though the
programmatic challenges of implementation are of significant import,
this study focuses on determinants of political priority.

We analyze determinants of political priority for newborn survival in

Bolivia based on a framework for analyzing priority for health initiatives
published in the international medical journal The Lancet in 2007
(Shiffman & Smith 2007). The framework proposes four categories of
factors for analysis: the power of involved actors, the ideas they use to
promote the issue, the nature of the political contexts in which they are
embedded, and the characteristics of the issue itself.

We find that political priority for newborn survival in Bolivia grew from
the late-1990s through the early 2000s. A network of individuals and
organizations concerned with the problem of neonatal mortality in
Bolivia helped to collect data establishing the problem, to identify
solutions, and to provide technical and financial support for developing
neonatal health programs. They found opportunities to advance the
cause alongside priority for child health and survival as IMCI programs
were scaled up and the government committed to achieving the United
Nations Millennium Development Goals during this time period.

Conditions that once supported development of political priority for

newborn survival in Bolivia have changed in the past few years and the
level of attention and resources going to address the problem has
declined. There are several challenges to reversing this trend:

1. Strengthening the network of actors that is most centrally

concerned with the issue

4
 2. Framing the issue in ways that enhance support within the
network and among authoritative actors who control resource
allocations
3. Adapting to an evolving political context in order to attain (and
then sustain) a level of priority for newborn survival that is equal
to the severity of the problem

The sections that follow describe our framework for analyzing levels
and determinants of political priority, assess the state of political
priority for newborn survival in Bolivia with reference to this
framework, and identify challenges to enhancing political priority for
the issue.

The Analytical Framework

The analysis of political priority presented in this report is based upon a

framework developed by Shiffman and Smith (2007) to understand
why networks of actors concerned with attracting attention and
resources to alleviate significant health problems are more or less
successful. The framework was developed based upon research on
collective action initiatives2 and is reproduced in Table 1. The
framework proposes four categories of factors that affect the likelihood
of initiatives gaining political support for their issues: the power of
actors concerned with an issue; the power of ideas to motivate action
on behalf of the issue; the strength of the political context to facilitate
or inhibit support from authorities; and the power of certain
characteristics of the issue. The more and stronger the factors, the
more likely collective action initiatives are to attract support.

Table 1: Framework on determinants of political priority for collective action

initiatives

2
Please see Shiffman and Smiths original article published in The
Lancet in 2007 for a more extensive discussion of the framework and
for references to scholarly work on collective action initiatives. Readers
may also be interested in Shiffmans discussion of implications for
understanding priority generation in terms of social construction
theories (2009, WHO Bulletin) and his report on priority generation for
newborn survival globally in The Lancet in 2010. See references for
details.

5
Category Description Factors shaping political priority

Actor power The strength of 1. Policy community cohesion: The degree of coalescence
the individuals among the network of individuals and organizations
and centrally involved with the issue
organizations 2. Leadership: The presence of individuals capable of
concerned with
uniting the policy community and acknowledged as
the issue
particularly strong champions for the cause
3. Guiding institutions: The effectiveness of organizations
or coordinating mechanisms with a mandate to lead
the initiative
4. Civil society mobilization: The extent to which
grassroots organizations have mobilized to press
political authorities to address the issue
Ideas The ways in 5. Internal frame: The degree to which the policy
which actors community agrees on the definition of, causes of and
understand and solutions to the problem
portray the issue 6. External frame: Public portrayals of the issue in ways
that resonate with external audiences, especially the
political leaders who control resources
Political The 7. Policy windows: Political moments when conditions
contexts environments in align favorably for an issue, presenting opportunities
which actors for advocates to influence decision-makers
operate 8. Governance structure: The degree to which norms and
institutions operating in a sector provide a platform for
effective collective action
Issue Features of the 9. Credible indicators: Clear measures that demonstrate
characteristi problem the severity of the problem and that can be used to
cs monitor progress
10. Severity: The size of the burden relative to other
problems, as indicated by objective measures such as
mortality levels
11. Effective interventions: The extent to which
proposed means of addressing the problem are clearly
explained, cost-effective, backed by scientific evidence,
simple to implement, and inexpensive

Source: Shiffman & Smith (2007)

Political Priority for Newborn Survival in Bolivia

Milestones in attention for newborn survival in Bolivia

Policy and program attention to neonatal health has increased in

Bolivia since the late 1990s. Three successive national health
insurance strategies assuring free access to health care, including the
National Insurance for Motherhood, Infancy and Childhood (SNMN)3

3
Please see Appendix A for a full list of acronyms used in this report
and their translations in English and Spanish.

6
introduced in 1996, Basic Health Insurance (SBS) in 1998, and the
Maternal and Child Universal Health Insurance (SUMI) in 2003,
expanded coverage of maternal and newborn health interventions for
impoverished families (PAHO/WHO 2007; UDAPE & UNICEF Bolivia
2006).4 Evaluation of these health strategies suggests that they have
helped to alleviate economic barriers to care (PAHO/WHO 2007).
However, it is important to note that wealthier, urban, and better-
educated women continue to access maternal and newborn health
services at significantly higher rates than their poorer, rural and less-
educated counterparts (Ministerio de Salud y Deportes et al. 2009; see
Table 2).

Table 2: Rates of access (%) to maternal and newborn health

care by select demographic characteristics, 2008

Urban / Secondary / Highest /

Rural No education Lowest
income
quintile
Any prenatal 95 / 84 95 / 73 97 / 78
care
Delivery in a 88 / 44 86 / 35 99 / 31
health
institution
Neonatal 68 / 51 68 / 42 68 / 47
tetanus
vaccination
Source: Ministerio de Salud y Deportes et al. 2009

The governments newest health strategy, the Bono Juana Azurduy

introduced in 2009, aims to further eliminate economic barriers to
healthcare by providing cash incentives to families without health
insurance when they access maternal and early child health care
(Estado Plurinacional de Bolivia 2009b). Bolivia also has three national
plans that address neonates alongside maternal health and survival:
they cover the 2000-2002, 2004-2008, and 2009-2015 time periods
(Estado Plurinacional de Bolivia 2009a; Ministerio de Salud y Deportes
2004; Ministerio de Salud y Previsin Social 2000). Development and
implementation of clinical and community based neonatal IMCI in 2002
and 2004 respectively mark the most significant programmatic
advances for neonatal survival in the country. The Saving Newborn

4
Specifically identified neonatal health interventions expanded from
four in the SNMN to nine in the SBS to 67 in the SUMI insurance plan
(UDAPE & UNICEF Bolivia 2006, pp. 102-121).

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Lives initiative of Save the Children provided significant support for
development of the latter. A BCC (Behavior Change Communication)
campaign endorsed by the health ministry and supported by the
Neonatal Alliance, UNICEF, PAHO, USAID, PROCOSI and Saving
Newborn Lives between 2004 and 2006 (and still in use) is also
significant.

National attention to newborn survival was facilitated in the early

2000s by the emergence of new data surrounding the problem,
national and international political commitments to improve child
health, domestic advocacy and the support of international agencies.
Important developments included:

Demographic and health survey statistics released in 1998 and

2003 (and later 2008) indicating that neonatal mortality
comprised a disproportionate burden of infant and under-5 child
mortality (see Table 3). Neonatal mortality made up 50 percent
of infant and 37 percent of under-5 child mortality in 1998
reporting, 50 and 36 percent respectively in 2003 reporting, and
54 and 43 percent in 2008 (Ministerio de Salud y Deportes et al.
2009).
Bolivias commitment to achieve the Millennium Development
Goals, with MDG 4 calling for a reduction of child mortality by
two-thirds by 2015 taking on special significance in drawing
attention to newborn health alongside maternal and broader
child health goals (Estado Plurinacional de Bolivia 2009a; Navarro
2005).
Child health researchers and concerned health ministry officials
recognizing that IMCI programs introduced in the late 1990s did
not address the needs of neonates in the first seven days of life
and initiating plans to adapt child health programs to the more
specific needs of newborns for the first time.

Table 3: Newborn and child health indicators 1998, 2003 and

2008

1998 2003 2008

Neonatal Mortality 34 27 27
Rate
Infant Mortality Rate 67 54 50
Under-5 Child Mortality 92 75 63
Rate

Source: Ministerio de Salud y Deportes et al. 2009

8
The early 2000s were an important time for the emergence of
attention to neonatal health. Research coming out of the BASICS
program (sponsored by USAID) and Warmi project (piloted by Save the
Children and expanded to approximately 500 communities in eight of
nine of Bolivias departments in the later 1990s) helped to inform
government plans for adapting IMCI to neonatal health and survival
needs (ACCESS Program Community Mobilization Working Group 2007).
Neonatal IMCI with a clinical focus was introduced in 2002.
Interventions that could improve neonatal health and survival at the
community level, including addressing cultural barriers to care, were
not included in the original clinically based program though experts
recognized a need for such efforts. Save the Children initiated the
Saving Newborn Lives (STC/SNL) program in Bolivia in 2002 and
working to address this need was one of its key contributions.
The Saving Newborn Lives initiative began with an in-depth analysis of
the state of neonatal health in Bolivia, important stakeholders, policies
and programs that addressed the problem and proposals for improving
newborn health in the country. The report, The State of Newborns:
Bolivia (Saving Newborn Lives 2002) was launched with the support of
the health minister and first lady and suggested that community-based
and culturally sensitive approaches to addressing the problem needed
particular attention. The initiative supported Bolivias government in
developing community-based neonatal IMCI in 2004 and the
Motherhood and Safe Birth National Plan, Bolivia 2004-2008. STC/SNL
also supported significant community-based research, education and
training programs through partnerships with the health ministry and
PROCOSI, a network of 36 NGOs5 in Bolivia, between 2002 and 2005
(Saving Newborn Lives Bolivia 2005). Beginning in 2006, the second
phase of SNL was scaled back somewhat, primarily supporting research
into appropriate, cost-effective and feasible postnatal care
interventions to support maternal and newborn health (Saving
Newborn Lives undated).

In the latter half of the decade, fewer stakeholders participated in

important meetings, attention and resources from key support
agencies decreased, training and the use of neonatal protocols
declined, and the government turned its attention to other priority
health and development issues. Newborn health was not completely
neglected, however. The government unveiled a law to promote
breastfeeding in 2006 (Law No. 3460, Ley de Fomento a la Lactancia
Materna y Comercializacin de sus Sucedneos, August 2006), the
Bono Juana Azurduy for Mothers Day in 2009, and a new national plan
5
The number of NGOs affiliated with PROCOSI changes over time. It
was reported as 36 in Saving Newborn Lives Final Program Report
Bolivia on phase 1 (2005), the period we are referencing here.

9
to improve maternal, perinatal and neonatal health in late-2009 into
2010. Announcing the Bono in May 2009 La Prensa, a major Bolivian
newspaper, reported that then health minister Ramiro Tapia considered
the Bono Juana Azurduy incentive program and the Breastfeeding
Promotion Law of 2006 to be Bolivias primary strategies for reducing
infant and maternal mortality (La Prensa 2009). The Bono faces
challenges, however. Payments were suspended between January and
June of 20106 and many technical experts question its logic, efficacy
and financial sustainability.

The health ministry also unveiled a new national plan, The National
Strategic Plan to Improve Maternal, Perinatal and Neonatal Health in
Bolivia 2009-2015 in late 2009 (Estado Plurinacional de Bolivia 2009a).
Only the executive summary of this plan was widely available into
September 2010. The executive summary offered few specifics on how
to achieve goals set out in the new plan. The ministry sponsored
national and regional workshops during the first few months of 2010 to
discuss and improve the plan in consultation with local health officials
and civil society actors, aided by technical support from such
international agencies as PAHO, FCI, USAID, Save the Children, UNICEF
and UNFPA.7 A health ministry official and a Safe Motherhood Neonatal
Board member close to the process suggested that release and
implementation of the full plan was delayed by these consultations,
changes in key health ministry personnel (including the health
minister) and discussions surrounding whether to publish demographic
and health survey data on maternal mortality from 2003 or 2008 in the
plan8 (personal communication, August 2010).

Table 4: Milestones in attention for newborn survival

1996, National health insurance strategies successively give

1998, more attention to newborn health and survival
2003 interventions, including SNMN (1996), SBS (1998) and
SUMI (2003)

6
In an editorial in Los Tiempos newspaper, the Bolivian vice president
was cited denying that the Bono was held up by funding problems,
pointing to delays in renewing contracts with the doctors responsible
for registering women for the Bono instead (Los Tiempos, February 26,
2010). A news article in May 2010 documented the governments
request to the Inter-American Development Bank for loans to fund the
Bono Juana Azurduy (La Razn, May 17, 2010).
7
The Safe Birth and Motherhood Committee consulted with at the
departmental level to develop and adapt the plan to local conditions.
8
The 2003 data was used, indicating a maternal mortality ratio (MMR)
of 229 deaths per 100,000 live births. The 2008 data puts MMR at 310
(Ministerio de Salud y Deportes et al. 2009).

10
Late- The Bolivian government supports piloting and expansion
1990s of IMCI programs to improve under-5 child health
into
2000s
1998, Data on neonatal survival from demographic and health
2003 surveys indicate that neonatal mortality is a significant
problem and barrier to reducing infant and child mortality;
Bolivia-based studies, including those under the BASICS
and Warmi projects, identifying the scope of the problem,
causes and potential intervention strategies
2000 Bolivia commits to the Millennium Development Goals,
including MDGs 4 and 5 to reduce under-5 child and
maternal mortality
2002 Clinically-based neonatal IMCI is introduced, focusing on
the hospital level
2002 STC/SNL unveils its State of Newborns: Bolivia report;
STC/SNL sponsors research on community-based neonatal
health and survival interventions in partnership with the
PROCOSI NGO network through 2005, the Neonatal Alliance
emerges
2004 Community-based neonatal IMCI is adopted; the Neonatal
Alliance merges with the Safe Motherhood Board to form
the Safe Motherhood Neonatal Board
2006 Evo Morales of the MAS party is elected president and the
government adopts a new approach to social development;
the health ministry develops SAFCI; Nutritional IMCI and
the Zero Malnutrition program experience a significant
increase in political priority related to the governments
new approach to social development, rising to the top of
the health agenda
2009-10 The Bono Juana Azurduy is introduced, put on hold for six
months, and then re-started
2009-10 The executive summary of the National Strategic Plan to
Improve Maternal, Perinatal and Neonatal Health in Bolivia
2009-2015 is unveiled and consultations are held to inform
the full plan

Actor power and newborn survival in Bolivia

Initiative for newborn survival in Bolivia has come from a number of

sources, including the health ministry, United Nations agencies
(PAHO/WHO, UNICEF, UNFPA), international and domestic
nongovernmental organizations (Save the Children and the PROCOSI
network), bilateral and multilateral donor agencies (USAID), and others
(Pediatric Society of Bolivia). Between the mid- to late-1990s and 2010,

11
these organizations with the support of a number of health experts
specializing in neonatology, pediatrics and maternal health have
undertaken research to understand the extent and nature of the
problem and to identify effective interventions; provided technical and
financial support for policy and program development, as well as
training and development of educational materials; and participated in
forums to support policy and program recommendations on maternal
and newborn health to the government, including the Safe Motherhood
Board (1996-2004), the Neonatal Alliance (2002-2004) 9 and later the
Safe Motherhood Neonatal Board (2004-present).

Several actors engaged in coordinated advocacy and dedicated

resources to alleviating the specific problem of neonatal mortality in
the early 2000s. These actors formed a less organized network once
the Neonatal Alliance dissolved mid-decade. The Safe Motherhood
Neonatal Boards power to affect policy change was also limited in the
latter part of the decade. No very cohesive, sustainable policy
community focuses on neonatal survival exclusively, a challenge
discussed in relationship to the issues connection to maternal and
child health and the continuum of care framework in the paragraphs
below . The network of concerned actors had an impact in the early
2000s as evidenced by neonatal IMCI programming, but its
cohesiveness and support declined in the latter part of the decade as
government priorities shifted to a broader social development agenda.

As noted earlier, in the mid to late 1990s, health researchers and

ministry officials (including the director of the child health unit)
became concerned that IMCI programs focusing on children did not
adequately address the needs of newborns, especially those up to
seven days old, and started pressing for programming to address this
gap (int. nos. 7, 13). Their concern emerged alongside growing
evidence related to the problem and the Bolivian governments
political commitments to the Millennium Development Goals. It was in
this context that successive health ministers supported development
of neonatal IMCI with a clinical focus as introduced in 2002,
programming that focused on neonatal health care interventions at the
hospital level.

Some of the technical experts that were engaged in promoting

programmatic attention to newborns at the time identify the Saving
Newborn Lives initiative as a significant support for generating political
priority for neonatal survival in Bolivia (int. nos. 7, 13). The health

9
The last meeting records of the Neonatal Alliance are dated 2006, but
nearly all interviewees that discussed it recalled its activities falling off
and integration with the Safe Motherhood Board commencing from
2004.

12
ministry, PAHO, UNICEF and the Pediatric Society of Bolivia were
working on the problem, but with few resources in the late 1990s and
into 2001. Support from the BASICS program of USAID to research and
adopt IMCI programming was an exception (see Cordero & Mejia 2002).
But when SNL came with funding, it helped them to do more (int. no.
13). STC/SNL provided substantial technical and financial support for
development of neonatal IMCI programming, training and research
focused at the community level, including community health workers
and families, in partnership with the health ministry and members of
the PROCOSI network and Neonatal Alliance (Saving Newborn Lives
Bolivia 2005; int. no. 1, 4, 7, 9, 12).

Though maternal and newborn health were integrated in national plans

dating to 2000, the issues were not well integrated in the Safe
Motherhood Board a potential guiding institution for the initiative
that tended to focus on maternal health problems and solutions. The
Neonatal Alliance formed in 2002 and supported by STC/SNL was an
important forum for focusing attention on problems of neonatal
mortality and developing plans of action to support its alleviation
(Neonatal Alliance 2002; int. nos. 4, 12, 13). A formal meeting group
with the express purpose of furthering newborn health goals had not
existed prior to this. Rather, concerned actors had connected through
their involvement in the Safe Motherhood Board and broader child
survival research and programs. Core members of the Neonatal
Alliance included the health ministry, STC/SNL, PAHO/WHO, UNICEF,
UNFPA, USAID, the Bolivian Pediatric Society, some NGOs (including
PROCOSI) and other international actors (Neonatal Alliance 2002;
Saving Newborn Lives 2005). The Alliance was formed at least in part
because some of the representatives of these organizations perceived
a need for a space to only discuss neonatal issues because there was
much to learn and do (int. nos. 4, 12).

The Neonatal Alliance and Safe Motherhood Board merged just a short
time later. The reconstituted group, the Safe Motherhood Neonatal
Board, was formed surrounding the continuum of care approach to
understanding and addressing maternal, newborn and child health
(Safe Motherhood Board 2007, 2008; int. nos. 12, 13). The continuum
of care model was widely accepted among board members and
adopted in government health policies. However, many of the
concerned actors understand neonatal health to be severely
underrepresented in the new Safe Motherhood Neonatal Board
meetings (int. nos. 3, 4, 9, 10, 12, 13, 14, 25). Representing a common
perception, one pediatrician that used to participate in the meetings
said:

13
 There were a couple of [integrated] meetings. Without much
success because the motherhood board, they were really not
interestedin the neonatal problem (int. no. 13).

A number of neonatal advocates scaled back their participation in the

meetings (int. nos. 4, 10, 12, 13). Since the decline of the Neonatal
Alliance there have been fewer conversations and less emphasis on
neonates within the health ministry and in the Safe Motherhood Board
(int. nos. 4, 12). An NGO representative with strong maternal health
interests explained that there is an imbalance in attention at the
meetings because many institutions work on safe motherhood and just
a few for neonates (int. no. 14). She identified Martha Mejia of PAHO
and Bertha Pooley of STC/SNL as the primary voices for neonates,10
and the rest of the group, we are more focused in womens health
(int. no. 14). A health ministry official said, the voices that demand
attention for maternal problems right now are stronger (int. no. 4).

The Safe Motherhood Neonatal Board has other challenges that affect
its ability to advocate for its core issues effectively. The board has lost
voice with government decision makers in recent years (int. no. 14).
The original Safe Motherhood Board was established in 1996 by
executive order and led by Bolivias first ladies for a number of years.
The first ladies used their status and office to draw attention to
maternal and newborn survival issues among policymakers and health
care professionals (int. no. 14). The status of the board and its favor in
the first ladys office changed between 2004 and 2006 when the board
was reconstituted as the Safe Motherhood Neonatal Board in concert
with the Motherhood and Safe Birth National Plan, Bolivia 2004-8 and
under the authority of the health ministry rather than by executive
order (int. no. 14). The office of the first ladies was also discontinued
during this time period as President Carlos Mesas wife declined a
formal role (2005-2006) and President Evo Morales was unmarried
(2006 to present), removing a traditional ally (int. no. 12). The leader
of a technical unit in the health ministry chaired the board at the time
of our interviews in 2009. Maternal and newborn health advocates
considered this individual to be an ally an important leader in
developing the 2009-2015 strategic plan for maternal and newborn
health but they recognized the limited power of technical officials to
gain attention and allocate resources commensurate with the severity
of the problem (int. nos. 12, 14).

Turning to leadership and guiding institutions, health policy experts

view leadership and coordination from the health ministry as essential

10
The SNL Bolivia initiatives leader, Pooley, is widely recognized
among her colleagues as a champion for neonatal health (int. nos. 1, 2,
3, 14).

14
to achieving impact and sustainability (int. nos. 1, 2, 4, 12). Health
policy and program experts in Bolivia see four key challenges along
these lines: no individual point person for neonatal health at a higher
level of authority in the ministry; turnover of officials in the ministry;
responsibility and interest lying more with technical officials than
policymakers; and competing priorities that vie for the ministrys
attention.

As in the case of the Safe Motherhood Neonatal Board, some experts

are concerned about newborn health being lost among the many
responsibilities under child health programs in the health ministry. One
long-time newborn health advocate suggested that having newborn
health fall under child health programs contributed to weak neonatal
programming, noting that follow-up of neonatal IMCI, its very weak
because of this (int. no. 3). A concerned pediatrician said, that is why
it is so important to have supportat an international level, as from
PAHO with regional meetings focusing on newborns (int. no. 13),
suggesting that external attention and resources could help to fill a gap
in attention internally.

Another problem for generating and sustaining priority for newborn

and other health issues is the revolving door through which political
and technical leaders regularly come and go (Saving Newborn Lives
2005; World Bank 2009; int. nos. 5, 12). There had been some five or
six health ministers in the past four or five years, according to
individuals informing this study. In fact, the health minister and
technical official chairing the Safe Motherhood Neonatal Board, both
instrumental in bringing the National Strategic Plan to Improve
Maternal, Perinatal and Neonatal Health in Bolivia 2009-2015 to
fruition, were replaced in the past year. One newborn health advocate
added some insight to the situation:

You have to do two types of advocacy: with the technical

persons and the political persons. The political person is the one
that changes. The technical changes also, but less. But you have
to play with both and thats much a lot of time. You have to be
patient (int. no. 12).

Others suggested that the technical staff of the ministry is strong, but
political officials are the ones with the power to affect change and
they are not talking about newborn health and survival (int. nos. 3, 12,
14, 25).

When we conducted interviews in the summer of 2009, there was a

general consensus that the health ministrys primary mandate at the
time and for the past few years had been to alleviate the problem of
malnutrition this was squeezing out priority for newborns (int. nos. 3,

15
4, 7, 9, 12, 17, 23). The health ministry developed a nutritional IMCI
program that was introduced in 2007 and this consumed much of the
attention and resources going to child health programming. Whatever
competition for attention presented by initiative for safe motherhood,
many of the health policy and program experts informing this study
perceived malnutrition to be an issue that overshadowed both
(interview nos. 3, 4, 12, 23). We discuss this in greater depth in the
section on the political context in Bolivia.

The issue here is that in terms of institutional guidance, the health

ministry establishes the agenda for the organizations that support it,
including United Nations agencies, NGOs, donors and the vast network
of government sponsored health institutions throughout the country. A
representative of one well-established NGO that has been supporting
newborn health programs for a number of years said:
Now we have made a change because according to the new
health policy were now with the IMCI-NUT [nutritional IMCI] (int.
no. 9).

A few savvy newborn survival supporters suggested that they need to

be working strategically to attach newborn health training and
interventions to nutritional programs (int. nos. 3, 12, 15), but no
coordinated strategy or actions had emerged.11

Lastly, policy attention to neonatal survival has been largely confined

to a small group of technically oriented actors in the health sector.
Lawmakers and the president supported the breastfeeding promotion
law and Bono Juana Azurduy, but none of our informants identified
these actors as champions for neonatal health. Concerned actors
informing this study failed to identify a single parliamentarian, ministry
official (outside health), or other political representative with a
demonstrated commitment to improving neonatal health and survival.
No allies with authoritative power were readily identifiable, a factor
likely limiting the scope of attention to and support for neonatal
survival issues in Bolivia.

Issue characteristics, ideas and newborn survival in Bolivia

11
One interviewee showed us a draft document in December 2010
during review of this report indicating that neonatal and nutritional
IMCI were being integrated as part of a revised strategy based on the
continuum of care model. There was no evidence of coordinated
advocacy to advance this cause at the time of our interviews and no
policy or programmatic change had been made public at the end of
2010.

16
Prior to 1998, neonatal mortality in Bolivia was a problem lacking
credible indicators of its severity and intervention strategies. The first
point changed with the 1998 demographic and health survey. The
survey indicated that neonatal mortality accounted for half of infant
mortality and more than one third of under-5 child mortality (Ministerio
de Salud y Deportes et al. 2009; see Table 3). Current and former
health ministry officials and other concerned actors recall the 1998
data as being pivotal to establishing the existence of the problem and
its importance to addressing under-5 child mortality (int. nos. 4, 7, 9,
10, 14). It was difficult to advocate for alleviation of a problem with
little data to back it up (int. nos. 14, 24), but this changed between
1998 and 2008.

BASICS-sponsored IMCI research and PAHO studies identifying causes

of neonatal mortality in Bolivia in the late 1990s to early 2000s, as well
as later STC/SNL-sponsored research with PROCOSI NGOs in the 2003
to 2005 period, helped to confirm with local data what international
research was revealing about the scope and nature of the problem in
the early days of the initiative (int. nos. 3, 4, 7, 12, 13; Cordero & Mejia
2002; Saving Newborn Lives Bolivia 2005). These data spurred health
ministry officials and other actors concerned with newborn health in
the medical, international and NGO communities in Bolivia to begin
calling for action on newborn survival in the late 1990s, resulting in
development of the clinical neonatal IMCI program introduced in 2002
and later community-based neonatal IMCI in 2004.

Demographic and health survey data reported in 2003 showed some

decline in neonatal, infant and under-5 child mortality (Ministerio de
Salud y Deportes et al. 2009; see Table 3), but Bolivias burden was still
high relative to other countries in Latin America and the Caribbean
(OPS/PAHO 2008). Of twenty-six countries in the regions, only Haiti
featured a higher infant mortality rate than Bolivia (OPS/PAHO 2008).
The combination of Bolivias lagging performance relative to other
Latin American countries and the neonatal contribution evidenced by
the 1998 and 2003 surveys drew attention from health ministry
officials (int. nos. 2, 24).

The demographic and health survey data and especially the 2008
data showing no change in the neonatal mortality rate between 2003
and 2008 are used to describe the scope and establish the ongoing
nature of the problem in the executive summary of the National
Strategic Plan to Improve Maternal, Perinatal and Neonatal Health in
Bolivia 2009-2015 (Estado Plurinacional de Bolivia 2009a). Authored by
then health minister Ramiro Tapia, the vice minister of health, the
general service director, and the director of the service and quality
unit, the document suggests that these data, as well as data gathered
in studies by PAHO/WHO in 2000 and Management Sciences for Health

17
with the support of STC/SNL Bolvia in 2004 establishing causes of
neonatal deaths in hospitals and communities, receive attention from
government health officials and inform their decision making
surrounding the problem.

Data surrounding the scope and causes of neonatal mortality in the

late-1990s helped concerned actors to confirm the existence of the
problem in Bolivia and to develop solutions applicable to the country.
The government supported under-5 child health IMCI programming that
was being integrated into public health services during the same time
period (Cordero & Mejia 2002; Cordero, Salgado & Drasbeck 2004).
This provided advocates an opening to coalesce surrounding solutions
to the problem and frame them as addressing a gap in child survival
efforts specific neonatal survival interventions addressing the first
seven days of life were neglected in the earliest (mid-1990s to 2002)
IMCI programs (Cordero & Mejia 2002). The government viewed (and
continues to view) IMCI programs as a key strategy to meet child
survival goals (Navarro 2005; Tapia 2010). Those involved in early
under-5 child health IMCI programming and neonatal mortality
research through projects sponsored by such organizations as PAHO,
BASICS (USAID), STC/SNL and the health ministry, portrayed clinical
neonatal health interventions as an important missing component of
IMCI programs that would help Bolivia meet its broader child survival
goals (int. nos. 3, 4, 13). The message resonated with health officials
and the government introduced clinically based neonatal IMCI to its
health system in 2002.

As noted previously, international research was around the same time

confirming the existence of effective, low-cost community-based
interventions for neonatal mortality reduction. While early policy
efforts to alleviate the problem in Bolivia focused on hospital level
care, the STC/SNL programs advocacy for community-based solutions
(supported by evaluation of early IMCI work see Cordero & Mejia
2002) ushered in an another approach that other newborn survival
advocates readily supported (int. nos. 1, 2, 7, 9, 12). With only 57
percent of deliveries in facilities, 25 percent of women accessing
postnatal care, and a significantly greater burden of neonatal mortality
in rural areas in 2003 12 (Ministerio de Salud y Deportes et al. 2009),
concerned actors recognized the need for intervention strategies that
addressed a significant unmet need among populations that faced
12
The 2008 demographic and health survey results indicated some
improvement in these figures with 68 percent of deliveries in health
facilities and 54 percent of women accessing postnatal care. The rural-
urban divide remained significant, however, with 88 percent of urban
births occurring in health facilities compared to only 44 percent of rural
births (Ministerio de Salud y Deportes et al. 2009).

18
barriers to accessing clinically based care (Saving Newborn Lives
Bolivia 2005). SNL 1 supported these efforts between 2002 and 2005
with release of its State of Newborns: Bolivia report and partnerships
with the health ministry and PROCOSI network of NGOs to introduce
and assess the effectiveness of community-based neonatal health
strategies, as well as promote neonatal health training and education.
SNL 1s impact among local health workers and officials has not been
sustained in all areas, though educational materials developed with
STC/SNL support and endorsed by the health ministry remain a
resource (Saving Newborn Lives Bolivia 2005; int. no. 17).

The existence of the problem and the need for clinical- and community-
based solutions were relatively easy to establish, however, the
continuum of care paradigm that focuses on the interrelated nature
of maternal, newborn and child health needs and interventions
presents challenges for priority generation surrounding each of the
issues. The continuum of care approach is widely accepted among
actors concerned with maternal and newborn health and survival in
Bolivia (int. nos. 2, 10, 12, 13, 14, 23, 25). It is supported by
government policies (Estado Plurinacional de Bolivia 2009a). It was a
central reason for integrating the Neonatal Alliance into the Safe
Motherhood Board in 2004 (int. no. 12). But health ministry officials,
medical professionals, and NGO and donor representatives are
concerned that framing maternal and newborn health needs in terms
of the continuum weakens their respective positions for advocacy (int.
nos. 4, 10, 13, 14, 23, 25).

The Safe Motherhood Neonatal Board the main forum for advocacy
surrounding maternal and newborn health issues for instance, is in
principal formed surrounding the continuum of care approach. But in
practice neonatal issues receive less attention (int. nos. 10, 12, 13, 14,
25). Some attribute this to the composition of the board, others to who
attends, advocacy skills of those in attendance, and a relatively weaker
evidence base upon which to base advocacy and decisions.

Many of the concerned actors feel conflicted about the continuum of

care model. One health ministry official spoke to a perceived need to
separate the mother and newborn because of their differing needs:

Then this subject in realityhas to be seen as separate, or

rather, separate in quotation marks, because it is continuous,
no? (int. no. 23).

She was expressing recognized tensions between working within the

continuum of care model and a need to address certain health and
survival needs of women and newborns that do not overlap while the
continuum emphasizes their overlapping needs.

19
Speaking to challenges of using the continuum of care approach
among actors with different perspectives, an international donor
representative said:

We know theres a continuum, but there are pediatricians,

obstetricians and its difficult (int. no. 25).

The question is one of emphasis. Among the group of concerned

maternal and newborn health policy actors, there are challenges
coming to agreement on the right approach to solving the problems
whether in more or less integrated ways. Maternal health is winning
the battle for attention to their issue, if only by default and if only
within the primary forum for addressing maternal and newborn health
issues (the Safe Motherhood Neonatal Board). But both maternal and
newborn survival have been facing a bigger battle for attention in the
broader political arena over the past few years, since the 2006 election
that ushered in a new government approach to addressing human
development challenges in Bolivia. As explained in the next section of
this report, targeted program solutions to pressing public health
problems resonate less with Bolivias political leadership and neonatal
health advocates have not adapted to the changing political
conditions.

Political contexts and newborn survival in Bolivia

An issue with very little evidence of political priority in Bolivia prior to

the late-1990s, newborn survival made significant gains in terms of
drawing policy and programmatic attention and resources since then
and extending into the middle of the next decade. Political priority for
the issue has since declined, however, and certain structural features
of and events in the political context were instrumental in defining
these trends (see Table 4 above and Figure 1 in the next section of this
report).

A policy window opened in 2000 with Bolivias political commitment to

achieve the United Nations Millennium Development Goals. The
maternal and child survival goals (MDGs 4 and 5) are noted in national
plans addressing maternal and newborn health developed since that
time, including the Motherhood and Safe Birth National Plan, Bolivia 2004-2008, and
the National Strategic Plan to Improve Maternal, Perinatal and Neonatal
Health in Bolivia 2009-2015 (Ministerio de Salud y Deportes 2004;
Estado Plurinacional de Bolivia 2009a). Health officials also connect
Bolivias commitments to the MDGs with the countrys health
insurance plans and other strategies introduced in the 2000s, such as
SUMI and the Bono Juana Azurduy (Ramos 2005; Tapia 2010).

20
Close on the heels of Bolivias commitment to the child health MDG,
emerging research on neonatal mortality and IMCI program
developments (especially beginning to recognize and address newborn
health needs in this context), significant technical and financial support
from the Saving Newborn Lives program helped to advance the issue
on the health ministrys agenda through 2005. During this period
STC/SNL supported the health ministry in cooperation with other
NGOs, international organizations and donors, and newborn health
experts in developing and disseminating key messages and protocols
on newborn survival practices, in developing the community-based
IMCI program, and in implementing and studying community-based
newborn survival interventions (Saving Newborn Lives Bolivia 2005).
The first phase of SNL support (mainly aimed at putting neonatal
issues on the public health agenda) ended in 2005, transitioning from
2006 to a narrower program primarily of research support (Saving
Newborn Lives undated) not because of any developments within
Bolivia but at the direction of its funder (The Bill and Melinda Gates
Foundation). More significantly, a new era in Bolivian politics and
governance began in 2006.

The election of Evo Morales, Bolivias first indigenous president, in late-

2005 (taking office in early-2006) marked a new approach to social
development policy in the country, as detailed in Bolivias National
Development Plan 2006-10 (Estado Plurinacional de Bolivia 2009b;
PAHO 2007; Repblica de Bolivia 2006). The health ministry, in its
Sectoral Development Plan 2006-10, followed suit, introducing SAFCI
(Modelo de Salud Familiar Comunitario Intercultural or Bolivian Family,
Community and Intercultural Health Plan). SAFCI features five guiding
principals for government-supported health policies and programs,
including: promotion of a culturally sensitive and community based
health system; stewardship of the health sector through a stronger
health ministry; social mobilization to foster community participation in
healthcare; addressing social determinants of health; and government
leadership of the health system (solidarity in health governance) to
eliminate such problems as malnutrition, violence and child abuse
(Ministerio de Salud y Deportes SAFCI webpage; PAHO 2007). SAFCI
has guided health policymaking and programming since 2006 (Estado
Plurinacional de Bolivia 2009a; Estado Plurinacional de Bolivia 2009b;
Silva et al. 2009; Tern 2008), affecting the level of priority given to
various health issues.

The significance of Bolivias new approach to social development

(represented by such developments as SAFCI and the new national
constitution adopted in 2008) is that the government began to
dedicate its attention and resources to a more broadly defined social
development mission. Some of the newborn and maternal health

21
experts, representatives of international organizations and local health
officials we interviewed expressed concerns about the approachs early
impacts its lack of specific direction for health priorities, clear
indicators and targets made it difficult to support (technically) and to
implement (interview nos. 4, 10, 16, 25, 26; Silva et al. 2009). But its
influence was without question among informants. In 2006, the health
ministry turned its efforts toward reducing malnutrition, a goal that cut
across population groups to support social development in line with
SAFCI (Tapia 2010; World Bank 2009; int. nos. 9, 12;). As a result,
nutritional IMCI eclipsed the two neonatal IMCI programs under the
ministrys umbrella, shifting policy attention and limited resources to
broader child nutritional needs and away from more specific neonatal
survival activities.

Reducing malnutrition was the most commonly identified high-level

government health priority among respondents (int. nos. 3, 4, 9, 12,
15, 17). Describing the level of political priority for newborn survival in
Bolivia in mid-2009, one NGO representative with more than a decade
of experience related to the problem summarized the situation thus:

What Im seeing right nowis great investments in the Zero

Malnutrition program, which is where children two months and
older are. So, to say right now, lets work with the neonatal
part, its a little like, where do we get the resources? (int. no.
9).

This interviewee and other NGO and international organization

representatives indicated that the health policy priorities set by the
government guide the work of NGOs, international agencies and
donors (int. nos. 7, 9, 12, 25). The government takes the lead one of
the tenets of SAFCI and this has important implications for levels of
priority given to various health problems from the government and
support organizations alike.

The shift toward a broader social development agenda has meant a

move away from some narrowly targeted programs, such as the
neonatal IMCI programs, but when you have a lot of areas that are still
weak, for example, maternal mortality, child mortality, infectious
diseases you need specialized programming to adequately address
them, one donor representative explained (int. no. 25). Newborn health
advocates understood that a policy window closed for them in 2006.
Opportunities to advance the cause became fewer and narrower.

A former health minister reflected on the situation since 2005, stating:

as a government it was focusing on a different model of

attention with more focus going towards families in the rural
areas. They have set it [neonatal programming] aside and let it

22
 flow merely by inertia. The neonatal aspect was not a priority,
although we do need to recognize that indirectly, as I have said
before, with the Bono [Juana Azurduy] and with those types of
actions [health insurance benefits] there are achievements being
made (int. no. 26).

Other informants agreed that the Bono, as concerned actors refer to

it in Bolivia, offers some support to neonatal survival goals (int. nos. 2,
4). The Bono offers cash incentives to women without health insurance
to access health care services related to pregnancy and for children up
to two years of age. But like the former health minister, other
informants were concerned that the Bono was not enough because
they felt the health system could not sufficiently meet demand created
with quality services and/or because the Bono did not address neonatal
survival needs to the extent they believed sufficiently supported and
more fully developed neonatal IMCI programs would (int. nos. 2, 4, 11,
12, 14, 23, 26).

Concerned newborn and maternal health actors considered the Bono to

be a product of the political environment (int. nos. 2, 11, 12, 14, 26).
Indeed, the first two pages of the declaration establishing the Bono,
Supreme Decree No. 0066 (June 2009), lay out the justification for the
Bono on the basis of the new state political constitution and the
related National Development Plan 2006-10 (Estado Plurinacional de
Bolivia 2009b). These documents establish the right to healthcare for
all, as well as government responsibility for ensuring no social groups
are excluded (Tern 2008). A right to maternal health care, including in
the prenatal and postnatal periods is included in Article 45 of the
Constitution (Estado Plurinacional de Bolivia 2009b). A policy window
opened for safe motherhood with the new constitution. And, by virtue
of the connection between the governments emphasis on socially
inclusive policies and the continuum of care, a policy window may have
opened for infant and child health in relationship to maternal health.
Publicly announcing the Bono in May 2009, then health minister Ramiro
Tapia stated that one of the health ministrys main goals was to reduce
neonatal mortality by 30 percent by 2013 (La Prensa, May 12, 2009).

The Bono came out of these opportunities provided by the political

context post-2005, but it was a policy that the largely technical group
of concerned actors with expertise concerning maternal and newborn
health were not consulted on. One member of the Safe Motherhood
Neonatal Board, concerned about this lack of consultation and the
potential negative impacts on safe motherhood because of it, said:

We have not been able to get to the minister nor president or a

ministers meeting to show them our concerns. So this is proof of

23
 how the Board has lost, completely, the ability to make an
impact politically (int. no. 14).

Another member of the Board, concerned that the Bono was not
technically sound, said, We dont like the Bono but we cannot oppose
it. We dont have the strength to oppose it [at a political level] (int. no.
12). The Bono came about with the support of Bolivias president and
ruling party, Movimiento al Socialismo or MAS (MAS 2009; Morales
2009). That the Safe Motherhood Neonatal Board was left out of the
loop when the Bono was being developed and introduced is evidence
that the more technically oriented group of concerned actors was
detached from Bolivias politically driven governance structures.

Challenges to Enhancing Political Priority for Newborn Survival

in Bolivia
Political priority for newborn survival in Bolivia increased over the
course of a decade beginning in the mid-1990s. National and
international commitments to support IMCI programming to improve
child health and survival, as well as commitments to achieve the
Millennium Development Goals, opened windows of opportunity to
advocate for increased attention and resources to newborns. Emerging
data concerning the scope and nature of Bolivias neonatal mortality
problem helped concerned actors to come to agreement surrounding
the existence of the problem and to develop solutions that the health
ministry and a network of supporting organizations could rally behind.
These led to significant programmatic achievements on behalf of
newborn health and survival, most notably development of the clinical-
and community-based neonatal IMCI protocols, training and
educational materials and outreach efforts concentrated between 2000
and 2005.

Political priority for newborn survival has since declined. It never

reached a very high level as would be indicated by attention from the
highest levels of government (executive and legislative leadership) and
significant and sustainable resource allocations. The issue has not
completely fallen off the agenda, as suggested by its inclusion in the
National Strategic Plan to Improve Maternal, Perinatal and Neonatal
Health in Bolivia 2009-2015 and the Bono Juana Azurduy benefit
strategy. However, it remains to be seen whether the government and
support organizations will allocate attention and resources
commensurate with the severity of the maternal, newborn and early
childhood problems they are designed to address.

Our framework for analyzing political priority for health initiatives

offers insights to supports and challenges to enhancing attention and
resources for newborn survival in Bolivia. In terms of the political

24
context, a clear and direct policy window opened related to child health
and survival in the late-1990s into the early 2000s. Neonatal mortality
posed a key challenge to improving under-5 child health indicators.
Child health programming was prioritized through national and
international commitments and concerned neonatal health advocates
in Bolivia effectively argued for expansion of IMCI programming to this
target group.

During the period this policy window was open it was enough for
concerned actors and organizations to draw upon their technical
expertise and financial resources to inform and support program
design and implementation. But things changed when the policy
window closed. Problems emerged with respect to cohesion among the
network of actors most centrally concerned with newborn and maternal
health. Neonatal survival lacked individual and organizational leaders
capable of uniting the network behind the issue and framing it in ways
that resonated with higher-level decision makers. And, concerned
actors appreciated but failed to sufficiently adapt to opportunities
presented by a shifting political environment in which a broader social
development agenda gained priority. We discuss these challenges
further and offer some recommendations for enhancing political
priority for newborn survival in Bolivia in the paragraphs that follow.

Strengthen the network of actors concerned with newborn survival

The network of actors most centrally concerned with improving

neonatal health and survival in Bolivia faces several challenges. In the
first half of the decade (2000-2006), members of the network
organized to press Bolivian authorities for increased attention and
resources to newborn survival issues they formed a policy
community. The policy community was comprised of health ministry
officials, PAHO, UNICEF, the Pediatric Society of Bolivia, STC/SNL,
PROCOSI and other concerned individuals and organizations. The Safe
Motherhood Board and Neonatal Alliance provided officially recognized
and respected forums for policy community members to communicate
about the problem, to come to agreement surrounding policy solutions
and to formulate strategies to advance the cause. The policy
community had the ear of Bolivias first ladies and, by extension, the
nations political leadership.

These conditions no longer exist. The merged Safe Motherhood

Neonatal Board has lost status with decision makers and policy
community cohesion has declined. Though a representative of the
health ministry still chairs the Board, members reported that they were
not consulted on the most recent significant policy development for
maternal, newborn and infant health (the Bono Juana Azurduy
introduced in May 2009) and they were unable to voice their concerns

25
to policymakers. Newborn health and survival advocates need to look
for ways to build stronger relationships with decision makers
(admittedly a challenge in an unstable political environment that
features regular turnover of bureaucratic and political leaders) and find
common cause with other potential allies, such as community based
organizations or other health and human rights policy advocates.

Civil society organizations are natural allies and often-overlooked

sources of strength for health policy communities. Civil society
relationships have been a strong point for newborn survival advocacy
in Bolivia, particularly with members of the PROCOSI network of NGOs.
However, the changing political climate has caused at least some
members of the PROCOSI network to redirect their programmatic
efforts from newborn health specifically to other priority areas, such as
reducing malnutrition. These organizations portray their central
purpose as supporting the health and development priorities of the
government. Thus, their actions reflect consideration of the evolving
political context - with changes since 2006 having a significant impact
on their work. Concerned newborn health actors seem to heed this
lesson independently of each other, but have not worked out a
cohesive plan for coping with and adapting to Bolivias changed and
changing political environment. This challenge is one that must be
addressed to gain support from policymakers. The policy community
needs to clearly establish the connections between newborn and other
health, development and human rights issues in order to sustain
authority and maintain influence across administrations.

Policy community cohesion is another key challenge for those actors

most centrally concerned with newborn survival in Bolivia. As noted
above, these actors used to have an established forum for
communicating about newborn health problems and forming solutions.
The move to integrate the Neonatal Alliance with the Safe Motherhood
Board, thus forming the Safe Motherhood Neonatal Board, was
supposed to reflect the closely intertwined nature of newborn and
maternal health and to facilitate problem solving on both issues. The
implementation of this ideal has not worked out to the satisfaction of
all concerned actors, however, leading some newborn health
advocates to stop participating in the Board. Maternal and newborn
health advocates that informed this study generally agreed that
attention to safe motherhood dominated meetings and other activities
of the integrated board.

Concerned newborn health actors no longer comprise a relatively

cohesive policy community that presses authorities for change. Rather,
a loose network of technical experts acting with little coordination or
power, few resources or political connections, and no clear strategic
direction for improving their ability to act collectively or improve the

26
status of newborn health on Bolivias policy agenda is more
descriptive. In order to enhance political priority for newborn survival,
concerned newborn health actors need to work to address these
issues. In other words, they need to reestablish their capacity to act
collectively, assess and enhance the resources at their disposal,
expand relationships with policy decision makers, and form a strategy
for acquiring attention and resources commensurate with the severity
of the problem.

Framing the issue in ways that enhance support within the network
and externally

Concerned actors came to agreement surrounding the problem of

neonatal mortality, its causes and solutions early on, giving them a
strong foundation upon which to advocate for newborn survival
interventions within the context of priority for child survival goals. This
facilitated introduction of neonate-focused IMCI programs in 2002 and
2004. Two significant framing challenges have emerged since then
one related to the continuum of care approach and one to the shifting
political environment.

The continuum of care is a complicated framing issue. Newborn and

maternal health actors in Bolivia agree with it in terms of value for
understanding the interrelated nature of maternal and newborn health.
They agree that a common strategy is needed to reduce maternal and
neonatal mortality. But they also see a need for more specialized
strategies to address distinctive aspects of each problem. Concerned
maternal and newborn health actors in Bolivia tend to align themselves
more with one problem or the other, often according to their
professional training. Though this is not an inviolable rule it does have
implications for framing the issue(s), particularly its (their) solutions, in
ways that resonate with and are inclusive of all actors concerns.

Shared understandings of problems and their solutions motivate actors

to work together to affect policy change. In the Bolivian case, a
significant proportion of concerned newborn health actors feel that
their concerns are not being adequately addressed within their primary
organizing forum, the Safe Motherhood Neonatal Board recall that the
Safe Motherhood Board and Neonatal Alliance were joined surrounding
the continuum mid-decade. Most interviewees associate adoption of
the continuum of care approach with reduced attention to problem
solving on behalf of newborn survival within the Board. In response,
some actors have reduced their participation in this organizing forum,
thereby weakening the advocacy network and the strength of ideas
about newborn survival to guide and support their work. Concerned
newborn and maternal health actors need to find ways to overcome

27
these framing challenges in order to form a stronger foundation for
their collective actions on behalf of both issues.

In terms of external framing, portraying an issue in ways that resonate

with the authoritative actors who control resources, the challenge is to
adapt messages to Bolivias shifting political environment. Prior to
2006, successful framing of newborn health and survival issues
centered on filling in gaps in child survival strategy through
supplementary IMCI programming. The continuum of care model also
resonated to some extent (as represented in the two national maternal
and newborn health plans since 2004 (Estado Plurinacional de Bolivia
2009a; Ministerio de Salud y Deportes 2004)), but concrete
programmatic and funding outcomes related to the continuum
approach are hard to pin down.
The Bono Juana Azurduy reflects an integrative approach to
incentivizing Bolivias uninsured to access maternal, newborn and early
childhood (up to two years) healthcare, but the network of concerned
maternal and newborn health experts we studied did not play a
significant role in framing or developing the Bono. It emerged from the
political environment. This is important because it suggests that in the
context of a political environment that supports priority for a broader
and more integrative social development agenda, the continuum of
care (and the Bono) may offer a framework for portraying newborn
health and survival issues in ways that resonate with the political
leaders that control resources. Some neonatal survival advocates also
suggested that attention and resources for the issue might successfully
be cultivated alongside priority for malnutrition, an issue that has
resonated with the governments broader social development agenda
in recent years. Concerned actors should consider these and other
ways of framing the issue that are likely to resonate with Bolivias
policy makers.

Adapting to a shifting political environment

Newborn survival first gained attention and resources in Bolivia in

relationship to a policy window opening for child health and survival.
Commitments to scaling up IMCI programming and to the Millennium
Development Goals provided opportunities for concerned neonatal
survival actors to promote their cause. Advocates have been slower to
adapt their strategy in response to the significant shift in Bolivias
political environment that came with the 2006 presidential election and
subsequent moves by the government to embrace a broader social
development agenda. These changes are most notably represented in
the health ministry by adoption of SAFCI, and nationally by the new
constitution.

28
There was a transition period beginning in 2006 during which
informants perceived a lack of specific direction for health priorities
from the government as it grappled with the implications of its new
guiding principals. Coinciding with a period in which the newborn
survival policy community faced significant framing challenges and
their cohesiveness declined, there was almost a sense of paralysis
among centrally concerned actors on how to advance the newborn
survival cause in the post-2005 political climate.

Yet priority for malnutrition and the Bono Juana Azurduy emerged from
this context, suggesting that opportunities to influence the policy
agenda on behalf of newborn survival remain. Indeed, as noted above,
concerned actors have identified opportunities in this emergent
political environment. They have reported work behind the scenes to
maintain some degree of attention and resources for newborn survival,
but they have not benefited from the strength that comes from acting
collectively nor a persuasive framing strategy. Concerned actors will
need to address all three of these issues in order to enhance their
capacity to increase political priority for newborn survival to a point
where it makes a significant impact on the problem.

Conclusion

This report assesses the trajectory of political priority for newborn

survival in Bolivia with reference to a set of factors that research
suggests influence the success of collective action initiatives,
including: the strength of actors, ideas about the problem and its
solutions, and the nature of the political context. The network of actors
concerned with neonatal survival in Bolivia significantly influenced the
countrys efforts to address the problem, especially through IMCI
program development in the early 2000s. Evidence suggests, however,
that political priority for neonatal survival has declined in recent years.
The political environment has changed, the central network of
concerned actors has become less cohesive, and messages that once
resonated within the network and with policymakers have become less
persuasive. These are central challenges for those concerned with
newborn survival in Bolivia and we hope that this report will help them
to think systematically about how to address them in their efforts to
enhance political priority for this important health issue.

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Appendix A
Guide to acronyms used in this report
English
CMR under-5 child mortality rate
FCI Family Care International
IMCI Integrated Management of
Childhood Illness
IMR infant mortality rate
MAS
MDG Millennium Development
Goals
MMR maternal mortality ratio
NGO Nongovernmental
organization
NMR neonatal mortality rate
PAHO PanAmerican Health
Organization
PROCOSI
SAFCI - Bolivian Family,
Community and Intercultural
Health
SBS - Basic Health Insurance
SNMN - National Insurance for
Motherhood, Infancy and
Childhood
STC/SNL Save the
Children/Saving Newborn Lives
SUMI - Maternal and Child
Universal Health Insurance
UDAPE - Social and Economic
Policy Analysis Unit
UN United Nations
UNFPA United Nations Population
Fund
UNICEF United Nations Childrens
Fund
USAID United States Agency for
Spanish
Tasa de Mortalidad del menor de 5
aos (TM<5)
FCI
Atencin Integrada a las
Enfermedades Prevalentes de la
Infancia (AIEPI)
Tasa de Mortalidad Infantil (TMI)
MAS - Movimiento al Socialismo
Objetivos de Desarrollo del Milenio
(ODM)
Tasa de Mortalidad Materna (TMM)
Organizacin No Gubernamental
(ONG)
Tasa de Mortalidad Neonatal (TMN)
Organizacin Panamericana de la
Salud (OPS)
Programa de Coordinacin en
Salud Integral (PROCOSI)
SAFCI - Salud Familiar Comunitaria
e Intercultural
Seguro Bsico de Salud (SBS)
Seguro Nacional de Maternidad y
Niez (SNMN)
Salvando la Vida de los Recin
Nacidos (SVRN)
Seguro Universal Materno Infantil
(SUMI)
UDAPE - Unidad de Anlisis de
Polticas Sociales y Econmicas
Naciones Unidas (NNUU)
UNFPA
UNICEF
USAID
30
International Development
WHO World Health Organization Organizacin Mundial de la Salud
(OMS)

References

ACCESS Program Community Mobilization Working Group (2007).

Demystifying community mobilization: An effective strategy to improve
maternal and newborn health. Technical report. USAID & Access.
www.savethechildren.org/.../ACCESS_Demystifying-Community-
Mobilization.pdf (Accessed 9/12/10).
Cordero, D. & M. Mejia (2002). Estrategia AIEPI: Anlysis del proceso
de implementacin en Bolivia. USAID-OPS/OMS(PAHO/WHO)-BASICSII:
Bolivia.

Cordero, D., R. Salgado & C. Drasbeck (2004). An analysis of IMCI

implementation process in four countries in Latin America. Edited by
T.G. Sanghvi and M. Mather. BASICS II for USAID and the Pan American
Health Organization: Arlington, VA.

Estado Plurinacional de Bolivia (2009a). Plan Estrategico Nacional para

Mejorar la Salud Materna, Perinatal y Neonatal en Bolivia 2009-2015.
Ministerio de Salud y Deportes: La Paz, Bolivia. (Spanish)

Estado Plurinacional de Bolivia (2009b). Decreto Supremo No. 0066:

Bono Juana Azurduy. Ministerio de Salud y Deportes: La Paz, Bolivia.
(Spanish)

La Prensa (May 12, 2009). Bolivia lucha contra la mortalidad infantil

con el Bono Juana Azurduy. http://www.rebelion.org/noticia.php?
id=85199: accessed May 7, 2010.

La Razn (May 17, 2010). Gobierno recurre al BID para mantener Bono
Juana Azurduy de Padilla. La Paz. http://www.la-razon.com/version.php?
ArticleId=1861&a=1&EditionId=78. (Accessed 10/1/10).

Los Tiempos (February 26, 2010). Gobierno admite que hay demora
con bono. Editorial submitted by MAS (Movimiento al Socialismo).
(Accessed 10/1/10).

Ministerio de Salud y Deportes (webpage). Salud Familiar Comunitaria

Intercultural. http://www.sns.gob.bo/index.php?ID=SAFCI: accessed
9/6/10.

31
Ministerio de Salud y Deportes (2004). Programa Nacional de Salud
Sexual y Reproductiva, 2004-8. Republica de Bolivia: La Paz, Bolivia.

Ministerio de Salud y Deportes (MSD), Programa Reforma de Salud

(PRS), Instituto Nacional de Estadstica (INA) y Macro International
(2009). Encuesta Nacional de Demografa y Salud ENDSA 2008. MSD,
PRS, INE y Macro International: La Paz, Bolivia.

Ministerio de Salud y Previsin Social. (2000). Reforma de Salud.

Unidad Nacional de Atencin a las personas. Plan Nacional de Salud
Materna y Neonatal: La Paz, Bolivia.

Morales, Evo (2009). Evo Morales inaugura pago del bono Juana
Azurduy Madre-Nio en el Da de la Madre May 2009.
http://www.youtube.com/watch?v=tyflclNm-vE: accessed 9/8/10.
Navarro, Alvaro Munoz-Reyes (2005). Bolivia: Child survival with
dignity. The Minister of Health and Sportss slides from a presentation
in London in December 2005. Repblica de Bolivia, Ministerio de Salud
y Deportes.

Neonatal Alliance (2002). Boletin del Comite por la Alianza por la Salud
Neonatal, No. 1. La Paz, Bolivia. (in Spanish).

OPS/PAHO (2008). AIEPI en las Amricas: Enfermedades prevalentes de

la infancia en las Amricas. Organizacin Panamericana de la Salud:
Washington, D.C. (in Spanish)

PAHO (2007). Health Systems Profile Bolivia: Monitoring and Analysis

Health Systems Change/Reform, Third Edition. Pan American Health
Organization. new.paho.org/hss/index.php?
option=com_docman&task=doc...gid... (Accessed 9/13/10).

PAHO/WHO (2007). Social Protection in Health Schemes for Mother,

Newborn and Child Populations: Lessons Learned from the Latin
American Region. Pan American Health Organization/World Health
Organization: Washington, D.C.

Ramos, E. (2005). Seguro Universal Materno Infantil: SUMI.

Presentacin sobre la Ley #2426 del 21 de noviembre 2002. Power
Point. Ministerio de Salud y Deportes Republica de Bolivia.

Repblica de Bolivia (2006). Plan Nacional de Desarrollo: Bolivia Digna,

Soberana, Productiva y Democrtica para Vivir Bien, 2006-2010.
www.ae.gob.bo/userfiles/file/pdf/ml/PND.pdf (Accessed 8/22/10).
(Spanish)

Safe Motherhood Board (2007). Bulletin #0, October 2007. La Paz,

Bolivia.

32
Safe Motherhood Board (2008). Bulletin #1, August 2008. La Paz,
Bolivia.

Saving Newborn Lives (2002). The state of newborns: Bolivia. Save the
Children USA.

Saving Newborn Lives (undated). Resumen Investigacion SNL II.

Unpublished SNL program document provided to the authors by SNL
Bolivia in August 2010.

Saving Newborn Lives Bolivia (2005). Saving Newborn Lives Final

Program Evaluation Bolivia. Report dated April 22, 2005 (Final version).

Shiffman, J. (2009). A social explanation for the rise and fall of global health issues.
Bulletin of the World Health Organization, 87, 608-13.

Shiffman, J. (2010). Issue attention in global health: the case of newborn survival. The
Lancet, 375, 2045-49.

Shiffman, J. & Smith, S. (2007). Generation of political priority for global health
initiatives: a framework and case study of maternal mortality. The Lancet, 370, 1370-
1379.

Silva, H.T., W. Soors, P. De Paepe, E.A., Santacruz, M.C. Closon & J.P.
Unger (2009). Socialist government health policy reforms in Bolivia and
Ecuador: The underrated potential of comprehensive primary health
care to tackle the social determinants of health. Social Medicine, 4(4):
226-34.

Tapia, C.H. (2010). Desnutricin Cero: Para que nuestros nios y nias
crezcan hasta alcanzar sus sueos. Presentation slides. Estado
Plurinacional de Bolivia, Ministerio de Salud y Deportes: La Paz, Bolivia.
(Spanish)
Tern, E.A. (2008). La salud en la nueva constitucin poltica del
estado. Ministerio de Salud y Deportes: La Paz, Bolivia. (Spanish)

UDAPE (Social and Economic Policy Analysis Unit) & UNICEF Bolivia
(2006). Evaluacin de Impacto de los Seguros de Maternidad y Niez
en Bolivia 1989-2003. UPDAPE UNICEF: La Paz, Bolivia. (Spanish)

USAID (date unknown). Improving Child Health in Latin America and

the Caribbean: BASICS III. Final report.
http://www.basics.org/finalreport-home.htm (Accessed 8/10/10).

World Bank (2009). Implementation completion and results report (IDA-

35410 IDA-3541A) on a credit to the Republic of Bolivia for a health
sector reform project, second phase. Report No. ICR0000946. Human

33
Development Sector Management Unit, Bolivia, Ecuador, Peru, and
Venezuela Country Management Unit, Latin America and the Caribbean
Region. www-
wds.worldbank.org/.../ICR9460Bolivia10Disclosed0031061091.pdf
(Accessed 8/25/10).

34