Universal health coverage, health system capacity and maternal mortality in sub-Saharan Africa during the post COVID era

Maternal mortality remains a major public health challenge across Sub-Saharan Africa despite sustained global efforts to improve maternal healthcare systems and expand access to reproductive health services. Weak healthcare infrastructure, inadequate healthcare financing, limited healthcare workforce capacity, and inequalities in access to essential maternal healthcare services continue to contribute to preventable maternal deaths across the region. Universal Health Coverage (UHC) has increasingly been promoted as a critical strategy for improving maternal health outcomes by expanding equitable access to essential healthcare services without imposing financial hardship on households. However, the effectiveness of universal health coverage may depend substantially on the underlying capacity and resilience of national healthcare systems, particularly in the post-COVID era characterised by significant healthcare disruptions and structural healthcare pressures. This study, therefore, investigates the dynamic relationship between universal health coverage, health system capacity, and maternal mortality across Sub-Saharan Africa. The study utilises a balanced longitudinal panel dataset comprising 25 Sub-Saharan African countries covering the period from 2000 to 2024, resulting in 625 country-year observations. The dependent variable is the logarithm of the Maternal Mortality Ratio (logMMR), while the principal explanatory variables include the Universal Health Coverage (UHC) Service Coverage Index and key health system capacity indicators, including health expenditure, physician density, hospital infrastructure, and skilled birth attendance. Socioeconomic control variables include log GDP per capita, female secondary school enrollment, urban population share, and fertility rate. The analysis applies Dynamic System-Generalised Method of Moments (System-GMM), panel threshold regression, Cross-Sectionally Augmented Autoregressive Distributed Lag (CS-ARDL), and Dumitrescu–Hurlin panel Granger causality techniques to capture dynamic persistence, nonlinear relationships, long-run equilibrium dynamics, cross-sectional dependence, and reverse causality within the panel framework. Data were obtained from the World Bank World Development Indicators (WDI) and World Health Organisation (WHO) databases. The findings reveal significant persistence in maternal mortality dynamics across Sub-Saharan African countries. Universal health coverage and healthcare expenditure consistently exhibit significant negative relationships with maternal mortality across the dynamic panel estimations, indicating that improvements in healthcare accessibility and healthcare financing contribute meaningfully to reductions in maternal mortality. The threshold regression results further demonstrate that the effectiveness of universal health coverage improves when healthcare infrastructure surpasses a critical healthcare system capacity threshold. The CS-ARDL results confirm the existence of stable long-run equilibrium relationships among maternal mortality, healthcare service coverage, and healthcare financing variables. The Dumitrescu–Hurlin causality analysis further indicates that skilled birth attendance and female educational attainment contain predictive information relevant to future maternal mortality dynamics, although the education-related findings should be interpreted cautiously given their divergence from conventional theoretical expectations. The findings suggest that achieving sustainable reductions in maternal mortality across Sub-Saharan Africa requires coordinated investments in universal health coverage, healthcare financing, healthcare infrastructure, and broader healthcare system strengthening. Expanding healthcare coverage alone may be insufficient in contexts characterised by limited healthcare system capacity and infrastructural constraints. Consequently, strengthening healthcare system resilience and improving equitable access to quality maternal healthcare services remain essential for achieving maternal health targets under Sustainable Development Goal 3 in the post-COVID era.