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The Role of Strategic Governance in Reducing Infant Mortality Under Crisis Conditions Portland State University PDXScholar Dissertations and Theses Dissertations and Theses 6-4-2020 The Role of Strategic Governance in Reducing Infant Mortality Under Crisis Conditions Lynn Christine Finley Portland State University Follow this and additional works at: https://pdxscholar.library.pdx.edu/open_access_etds Part of the Public Health Commons, and the Public Policy Commons Let us know how access to this document benefits ou.y Recommended Citation Finley, Lynn Christine, "The Role of Strategic Governance in Reducing Infant Mortality Under Crisis Conditions" (2020). Dissertations and Theses. Paper 5475. https://doi.org/10.15760/etd.7347 This Dissertation is brought to you for free and open access. It has been accepted for inclusion in Dissertations and Theses by an authorized administrator of PDXScholar. Please contact us if we can make this document more accessible: [email protected]. The Role of Strategic Governance in Reducing Infant Mortality Under Crisis Conditions by Lynn Christine Finley A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Public Affairs and Policy Dissertation Committee: Bruce Gilley, Chair Lindsay Benstead Birol Yesilada John Gallup Portland State University 2020 © 2020 Lynn Christine Finley Abstract The infant mortality rate (IMR) in some developing countries has decreased faster than the global average even though these countries lack strong economic growth, good governance, and democracy (often acknowledged precursors to improved health outcomes). What accounts for the improvement of the IMR in the absence of these traditional pathways to health gains? Some scholars suggest that the concept of “strategic governance” might help direct attention to intermediary factors that reduce neonatal deaths in countries that experience crisis conditions. The main objective of this dissertation is to investigate the set of governance practices that have reduced IMR in two such cases. In particular, what “strategic governance” practices, if any, can be identified as contributing to the IMR decline in such cases? Using case studies to explore the significant reduction in IMR in Republic of Congo (ROC) and Republic of Yemen (ROY), this dissertation finds that micro-strategic governance interventions such as decentralization, international partnerships, funding, performance-based funding and cultural change can mitigate the macro- structural crisis that threatens IMR in developing countries. i Acknowledgments I cannot begin to express my deepest gratitude to Dr. Bruce Gilley for his unparalleled support and invaluable contribution to this dissertation. I am also indebted to my committee members: Dr. Birol Yesilada, Dr. Lindsay Benstead, Dr. John Gallup, and Dr. Shawn Smallman for their insightful suggestions and time. In addition, I had the great pleasure to work with the following: Dr. David Kinsella, Dr. Christopher Shortell, Dr. Meoldy Valdini, Dr. Craig Shinn, Dr. Jack Corbett, and Dr. Phillip J. Cooper during my enrollment at Portland State University. Thanks also go to Dr. Laurie Drapela, Dr. M. Jahi Chappell, Dr. Paul Thiers, Dr. Mark Stephan, and Dr. Dana Baker for their guidance during my studies at Washington State University, Vancouver. ii Table of Contents Abstract ........................................................................................................................................................... i Acknowledgments ..................................................................................................................................... ii of Figures .............................................................................................................. ........................ viii List .... Chapter 1: Introduction to the Dependent Variable ................................................................... 1 What is the infant mortality rate? .................................................................................................................. 1 Why IMR matters .................................................................................................................................................. 5 Puzzle: ........................................................................................................................................................................ 6 Gaps in Research ................................................................................................................................................... 8 Chapter 2: Literature Review on Causes of IMR Improvement .......................................... 10 The direct or proximate physiological mechanisms of infant mortality ................................... 13 The indirect health mechanisms that alleviate the physiological mechanisms of infant mortality ................................................................................................................................................................ 15 1. Breastfeeding ............................................................................................................................................. 15 2. Delivery ........................................................................................................................................................ 17 3. Primary Care .............................................................................................................................................. 19 4. Vaccines ....................................................................................................................................................... 20 The indirect social and policy mechanisms that alleviate the physiological mechanisms of infant mortality ................................................................................................................................................... 21 1. Community Health Workers ............................................................................................................... 22 2. Community Interventions .................................................................................................................... 23 3. Health education ...................................................................................................................................... 25 iii 4. Health Protocols ....................................................................................................................................... 29 5. Preventative Actions Against Risk Factors ................................................................................... 31 6. Women’s Health Groups ....................................................................................................................... 33 Macro Structural Determinants ................................................................................................................... 38 1. Democracy .................................................................................................................................................. 40 2. Governance and Public Spending ..................................................................................................... 42 3. economic Growth .................................................................................................................................... 44 Macro-negative (structural pessimism) vs. Micro-positive (agency optimism) .................... 47 Research Question ............................................................................................................................................. 53 Chapter 3: Research Design and Case Selection ........................................................................ 54 Research Paradigm ........................................................................................................................................... 54 Case Studies .......................................................................................................................................................... 56 Analytic narrative .............................................................................................................................................. 58 Case selection ...................................................................................................................................................... 60 Data sources ......................................................................................................................................................... 67 Research Strategy .............................................................................................................................................. 68 Chapter 4: Republic of Congo ............................................................................................................ 68 a. Country background .................................................................................................................................... 69 Pre-colonial ..................................................................................................................................................... 69 Colonial ............................................................................................................................................................. 71 Cold War ..........................................................................................................................................................
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