Universal Health Coverage, Health System Capacity and Maternal Mortality in Sub-Saharan Africa in the Post-COVID Era Using Dynamic Panel and Threshold Models

Universal Health Coverage, Health System Capacity and Maternal Mortality in Sub-Saharan Africa in the Post-COVID Era Using Dynamic Panel and Threshold Models | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Universal Health Coverage, Health System Capacity and Maternal Mortality in Sub-Saharan Africa in the Post-COVID Era Using Dynamic Panel and Threshold Models Okechukwu Alexander Okeke, Seun Adebanjo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9118672/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background Maternal mortality remains a major public health challenge in Sub-Saharan Africa despite global progress in maternal healthcare and increased policy commitments toward improving reproductive health outcomes. Weak health systems, limited healthcare infrastructure, and inadequate access to essential maternal health services continue to contribute to preventable maternal deaths across many countries in the region. Universal Health Coverage (UHC) has been widely promoted as a key strategy for improving maternal health outcomes by expanding access to essential healthcare services without financial hardship. However, the effectiveness of UHC may depend on the capacity of national health systems, including healthcare financing, workforce availability, and service infrastructure. This study investigates the combined effects of universal health coverage and health system capacity on maternal mortality in Sub-Saharan Africa during the post-COVID era. Methods The study utilises a longitudinal panel dataset encompassing 25 Sub-Saharan African countries from 2000 to 2024, resulting in a balanced sample of 625 country-year observations. The Maternal Mortality Ratio (MMR) is used as the outcome variable, while key explanatory variables include the UHC Service Coverage Index and health system capacity indicators, such as health expenditure, physician density, hospital beds, and skilled birth attendance. Socioeconomic controls include 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, and Cross-Sectionally Augmented Autoregressive Distributed Lag (CS-ARDL) models to capture dynamic, nonlinear, and cross-country relationships. Results The findings reveal significant persistence in maternal mortality across countries. Universal health coverage and health expenditure are associated with reductions in maternal mortality in both the short and long run. Threshold analysis indicates that the effectiveness of UHC improves when health system infrastructure surpasses a critical capacity level. Urbanisation also contributes to improved maternal health outcomes. Conclusion Strengthening universal health coverage alongside investments in healthcare infrastructure and financing is essential for reducing maternal mortality and achieving maternal health targets across Sub-Saharan Africa. Maternal Mortality Universal Health Coverage Health System Capacity Dynamic Panel Analysis Sub-Saharan Africa Full Text Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 05 May, 2026 Reviews received at journal 02 May, 2026 Reviews received at journal 26 Apr, 2026 Reviews received at journal 25 Apr, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviewers agreed at journal 20 Apr, 2026 Reviewers agreed at journal 18 Apr, 2026 Reviewers invited by journal 15 Apr, 2026 Editor invited by journal 23 Mar, 2026 Editor assigned by journal 21 Mar, 2026 Submission checks completed at journal 21 Mar, 2026 First submitted to journal 21 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9118672","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":627735438,"identity":"f60b965d-6aa9-4f2d-9a4f-71056c22a6dc","order_by":0,"name":"Okechukwu Alexander Okeke","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYDACHiD+wHCAQYKB+eADEJ+PGC2MM8Ba2JINQHw2YrQw84C18JhJgAQIauHnOXxMmqfmTuLM/jNmlV9z7GTYGJgfPrqBR4tkb1ua5JxjzxJnS6SV3Zbdlgx0GJuxcQ4eLQbnge5523A4cZ4E87bbktuYgVp42KTxa+H/JsEL0sJ/wKxYcls9EVrO9rBJgrTMZkgxY/y47TBhLZI9x4wtZxw7bDxzRlqyNOO24zxszAT8ws+T/PDGh5rDsjPOHz748ee2ant+9uaHj/FpAQIWCRiLmQdM4lcOVvIBxmL8QVj1KBgFo2AUjEAAABmOSflZQJOqAAAAAElFTkSuQmCC","orcid":"","institution":"University of Port Harcourt","correspondingAuthor":true,"prefix":"","firstName":"Okechukwu","middleName":"Alexander","lastName":"Okeke","suffix":""},{"id":627735439,"identity":"e139b290-1770-4b8e-9ee2-b06b9d7b580d","order_by":1,"name":"Seun Adebanjo","email":"","orcid":"","institution":"Statistical training and consultation","correspondingAuthor":false,"prefix":"","firstName":"Seun","middleName":"","lastName":"Adebanjo","suffix":""}],"badges":[],"createdAt":"2026-03-14 00:38:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9118672/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9118672/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107707146,"identity":"b7f6a59b-02cd-45c9-80f0-f906ea9e870f","added_by":"auto","created_at":"2026-04-24 09:19:38","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":308819,"visible":true,"origin":"","legend":"","description":"","filename":"OkekeManuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9118672/v1_covered_b4d2c1a3-4762-4394-87fc-89931cb7a65d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Universal Health Coverage, Health System Capacity and Maternal Mortality in Sub-Saharan Africa in the Post-COVID Era Using Dynamic Panel and Threshold Models","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Maternal Mortality, Universal Health Coverage, Health System Capacity, Dynamic Panel Analysis, Sub-Saharan Africa","lastPublishedDoi":"10.21203/rs.3.rs-9118672/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9118672/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMaternal mortality remains a major public health challenge in Sub-Saharan Africa despite global progress in maternal healthcare and increased policy commitments toward improving reproductive health outcomes. Weak health systems, limited healthcare infrastructure, and inadequate access to essential maternal health services continue to contribute to preventable maternal deaths across many countries in the region. Universal Health Coverage (UHC) has been widely promoted as a key strategy for improving maternal health outcomes by expanding access to essential healthcare services without financial hardship. However, the effectiveness of UHC may depend on the capacity of national health systems, including healthcare financing, workforce availability, and service infrastructure. This study investigates the combined effects of universal health coverage and health system capacity on maternal mortality in Sub-Saharan Africa during the post-COVID era.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study utilises a longitudinal panel dataset encompassing 25 Sub-Saharan African countries from 2000 to 2024, resulting in a balanced sample of 625 country-year observations. 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