Issue attention in global health: the case of newborn survival

Introduction In many low-income countries newborn babies face diffi cult odds in living past the fi rst month of life. About 3·8 million deaths occur every year in babies younger than 28 days—of which 99% are in the developing world—and deaths in the fi rst month of life account for 42% of deaths in children younger than 5 years. Before 2000, few organisations paid much attention to neonatal mortality. Since that year, several organisations have come to address the problem, including foundations, UN agencies, bilateral development agencies, governments of low-income countries, and non-governmental organ isa tions (NGOs). This wave of attention is surprising: there was no sudden increase in the number of babies dying or swift spread of a virus that alarmed citizens of rich countries. The emergence of attention to newborn survival in a short period of time presents an interesting study in how global health issues attract priority. In this paper, I examine the processes and factors behind the emergence of attention. I also identify challenges that proponents of newborn survival could face in advancing priority. In doing so, I aim to contribute to inquiry concerning how and why some global health issues attract attention, and what this means for the sustainability of priority. In 2007, Stephanie Smith and I presented a framework of four categories that sought to promote inquiry on the determinants of issue attention in global health. I use this framework to organise the examination of newborn survival. First, actor power refers to the collective power of the network of individuals and organisations mobilising around an issue, such as UN agencies, donors, NGOs, and governments. Second, ideas concern how these actors portray the issue. Any issue can be framed in several ways, and some framings could be more conducive to attraction of political support than others. Third, issue characteristics pertain to inherent features of the issue. Problems that are easily measured, cause substantial harm, and have simple evidence-based solutions available are more likely to gain political support than are ones that do not have these features. Last, political context refers to features of the environment that individuals and organisations confront as they seek to advance attention for an issue. These features include other actors who do not yet work on the issue but might be inclined to participate in support or opposition. They also include policy windows: moments in time when global conditions align favourably for an issue. For instance, the Millennium Development Goals (MDGs) have helped to open policy windows for the several health problems included in the goals. I used a case study methodology, triangulating several sources of information to keep bias to a minimum, including interviews, documents, and published reports. In 2008 and 2009 I did 33 interviews, each lasting about 1·25 h, with three groups of individuals: those centrally involved in global eff orts to address newborn survival; those in a position to observe and off er authoritative inform ation about the eff ectiveness of these eff orts; and those critical of these eff orts. Interview (I) numbers are listed in parentheses throughout the text. I identifi ed these individuals through publicly available documents, commentaries, and consultation with individuals working in global health. All interviews were recorded and tran scribed. Respondents came from countries of low and high income, and all had worked with a national government, private foundation, UN agency, donor agency, university, or NGO. Rather than follow a set of structured questions, I sought through open-ended questions to elicit the unique knowledge that each informant held about global eff orts to address newborn survival. Additionally, I undertook archival research on the history of global newborn survival eff orts, gathering and reviewing 120 documents from the archives of several agencies that had participated in eff orts to address newborn survival. Beyond this, I consulted published reports on newborn survival that I had obtained through several Medline searches. I organised the data into the four categories—actor power, ideas, issue characteristics, and political context— which served as a heuristic device to group material, present the history of eff orts to promote newborn survival, and identify themes and factors concerning determinants of issue attention in global health. Several individuals participating in global eff orts for newborn survival checked the draft for factual accuracy. National experiences are critical dimensions of the history of new born survival, and shape and are shaped by global eff orts. For instance, newborn survival eff orts in India have aff ected and have been aff ected by global strategies. With funding from the Saving Newborn Lives pro gramme of Save the Children USA, case studies are being done on political atten tion for newborn survival in Bangla desh, Bolivia, Malawi, and Nepal. The focus of this paper, however, is confi ned to attention by global health actors.