PUBH 6331 Week 4 Actor Map Example

Plenty of People Who Care, Too Few Who Must and Can: An Actor Map Sorting Eight Parties by Obligation and Capacity for Maternal Deaths in a Remote District of a Composite Low-Income Country

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Walden University

PUBH 6331: Global Health and Social Justice

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Month Day, Year

Plenty of People Who Care, Too Few Who Must and Can: An Actor Map Sorting Eight Parties by Obligation and Capacity for Maternal Deaths in a Remote District of a Composite Low-Income Country

The Problem the Map Serves

Kaseya District, a composite rural district in a composite low-income country in East Africa, recorded 41 maternal deaths last year among roughly 9,800 births, a ratio of about 418 per 100,000 live births. District health staff describe the pattern plainly: women in labor who develop bleeding or seizures reach the district hospital too late, or reach it to find no surgeon, no blood and no oxytocin in the refrigerator. These deaths fit a global picture. About 260,000 women died of pregnancy-related causes in 2023, just over 90% of them in low- and lower-middle-income countries, and sub-Saharan Africa accounted for about 70% of the total (World Health Organization [WHO], 2025).

No shortage of people care about these deaths. What the district lacks is a party that both holds a duty to prevent them and has the means to act. This paper maps eight actors along those two dimensions and names the one an argument for change should address first.

Why Delay Organizes the Map

Thaddeus and Maine (1994) explained maternal deaths through three delays: in deciding to seek care, in reaching a facility and in receiving adequate care after arrival. Each delay has its own actors. Families and community members shape the first, transport providers and road conditions the second, and the health system the third. A map that ignores this sequence risks addressing an actor who controls only one delay when the binding problem lies in another. In Kaseya, district records suggest the third delay is now the largest: most women who died had reached a facility.

Defining the Two Dimensions

Obligation means a duty that can be pointed to in law, policy or a formal commitment, not only a moral concern. The right to health places duties on the state to provide maternal care, including emergency obstetric care, and the committee interpreting that right lists reproductive, maternal and child health care as an obligation of comparable priority to the core duties (Committee on Economic, Social and Cultural Rights, 2000, para. 44). Capacity means control over money, staff, supplies or decisions that would change the third delay within a reasonable time.

The Eight Actors

Table 1

Actors Sorted by Obligation and Capacity

Note. Ratings are the writer's judgment from district reports and national policy documents.

How the Ratings Were Made

Each rating draws on three kinds of evidence. National policy documents and the country's treaty reports show where formal duties sit: the health sector strategy assigns emergency obstetric care to district hospitals and names the ministry as responsible for staffing norms. Budget documents show who controls money: the district receives a fixed transfer that covers salaries and little else, while drugs and equipment are bought centrally. Interviews with district staff, summarized in the district's annual review, show who actually acts when something fails, for example who is called when the blood bank runs dry. Where these sources disagree, the rating follows the budget, because a duty without funds rarely changes what happens on a labor ward. The ratings are judgments, and a different analyst could rate the donor fund's obligation higher if its grant agreement contained enforceable service targets. Recording the evidence for each rating lets a reader test them.

Reading the Map

Two actors combine high obligation with real capacity: the Ministry of Health and the Ministry of Finance, acting together as the state. The district team carries the clearest delegated duty but cannot hire an anesthetist or keep a blood bank stocked without money it does not control. The donor fund has capacity but limited obligation; its commitments end when a grant ends. Community actors have neither formal duty nor the means to solve the third delay, and placing responsibility on families, as some health education campaigns implicitly do, misreads the district's problem.

The Party to Address

The argument should be addressed first to the Ministry of Health, with the Ministry of Finance named as the party that must fund its decisions. The ministry sets the staffing norm that leaves the district hospital without a resident anesthetist and the supply list that determines whether oxytocin is stored cold. It also reports to the treaty committee on maternal health, which gives an argument framed in its own obligations a formal route. The maternal health obligation in the right to health describes access to emergency obstetric care as part of what the state owes (Committee on Economic, Social and Cultural Rights, 2000, para. 14), which aligns the duty with the district's third delay.

What Addressing the Ministry Would Look Like

In practice, the argument would take the form of a short brief to the ministry's reproductive health directorate, copied to the budget office, asking for three decisions: a resident anesthetist post at each district hospital, cold storage for oxytocin on the district supply list and a funded blood collection arrangement with the regional transfusion center. Each request is tied to a specific failure in the district's maternal death reviews. Framing the brief around the ministry's own reporting duties gives officials a reason to respond in writing, which creates a record advocates can follow up.

What the Map Does Not Claim

It does not claim donors and nongovernmental groups have no responsibility; they have taken on commitments and their withdrawal could cost lives. It does not claim families' decisions never matter; in subcounties without ambulances, the first and second delays remain real. The map's purpose is narrower. It identifies where an argument for change is most likely to produce action, because the party addressed both must and can respond. Advocates often address whoever is most visible, frequently a donor or an international agency. In Kaseya, the decision that would change most deaths sits in a ministry office, and the map makes that visible.

References

Committee on Economic, Social and Cultural Rights. (2000). General comment No. 14: The right to the highest attainable standard of health (art. 12) (E/C.12/2000/4). United Nations. https://undocs.org/E/C.12/2000/4

Thaddeus, S., & Maine, D. (1994). Too far to walk: Maternal mortality in context. Social Science & Medicine, 38(8), 1091-1110. https://doi.org/10.1016/0277-9536(94)90226-7

World Health Organization. (2025). Maternal mortality [Fact sheet]. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality