"Crises are a perpetual restart"-A comparative analysis of maternal and newborn health political prioritization across four fragile and conflict affected settings.

Fragile settings account for the highest burden of maternal and neonatal mortality in the world. Although policies and strategies for intervention exist, there are gaps on political prioritization of maternal and newborn health (MNH) by key actors to maximize resources and impact of programs. This study offers a comparative analysis of MNH political prioritization across four fragile national and sub-national settings, and recommendations for improving policies and strategies.Primary data from descriptive case studies conducted in Somalia, Nigeria, Democratic Republic of Congo and South Sudan was analysed comparatively using the Shiffman and Smith (2007) political prioritization framework. In total, eighty-two (82) interviews were conducted with government, international multilateral and non-governmental organizations, national civil society organization, public and private health providers, funders and academic key informants. Across settings, MNH was seen as priority despite the crises and the need to strengthen the health system as a whole. Crisis conditions also created policy windows for transformation of health systems, as evidenced in investments towards universal health coverage (free maternal health services) and community health systems. Transformations were enabled by political championship by local actors, aligned with technical planning, national priorities, and international momentum. Conversely, external actor and budget politics had a negative effect on regulation of the private health sector, inclusivity in decision-making, resource allocation, and policy community cohesion. International actors held significant influence in producing evidence for MNH, mobilizing and distributing resources, and technical program planning.Concerns were raised about their negative impact on local capacities, sustainability, and geographical distribution of services. Across settings, key informants emphasized how involvement of local organizations, civil society, religious and community leaders could enhance accountability, demand for care and political prioritization of MNH. Addressing gender inequities at the provider-patient interface, health facility management and high-level decision-making could also enhance political prioritization and contextualization of programs.