In 2018, the Lancet Commission on High Quality Health Systems ignited a global shift in focus and investment for maternal, newborn, and child health (MNCH).

Increasing access to care had been a primary focus during previous decades, but the Commission found that as service use increased, “poor-quality care” had become a more significant obstacle to reducing mortality than insufficient access. The Commission also argued that increasing access alone would not achieve Sustainable Development Goal (SDG) 3—ensuring healthy lives and promoting well-being. What the world needed now was an intensified focus on improving quality of care.

The Lancet Commission’s findings were a rallying cry—and the world responded. National governments, multilateral partners, civil society organizations, and donors alike increased their focus and efforts on improving quality of care. In the MNCH world, this effort has manifested primarily in the strengthening of clinical skills and competencies of healthcare providers. This intensified focus on pre-service and in-service training to improve clinical skills certainly has contributed to decreases in mortality and morbidity and improved health outcomes.

Yet focusing on clinical skills and competencies alone will not lead to sustainable improvements in MNCH, any more than previous efforts to improve access to care did. Quality of care is not provided within a vacuum, but, rather, within the broader health ecosystem. It thrives within a supportive healthcare system that includes well-formulated policies and guidelines, sustainable and sufficient financing, and both governments and citizens engaged in accountability and governance.

These complementary investments—known as policy, financing, and governance (PFG)—optimize health systems functions, contributing both to quality of care and to improved outcomes. At Palladium, we believe that PFG investments are the missing pieces in the puzzle of improving MNCH.

Strengthening National Policies for MNCH

Investments in policies are crucial for the health system, especially because of the role they play in delineating national and subnational priorities, strategies, and objectives. Kenya’s Linda Mama program exemplifies a policy reform that advances national priorities and commitments.

The Linda Mama policy reform transitioned the management of Kenya’s free maternity services program from the Ministry of Health (MOH) to the National Health Insurance Fund (NHIF) in order to expand access to services beyond the public sector. Through Linda Mama, all pregnant women are eligible for an insurance card that covers antenatal, delivery, and postnatal care, as well as well-baby care until child’s first birthday. This change reduced the financial burden on mothers and their families, making it more affordable to seek essential MNCH services—and also, therefore, significantly increased facility-based deliveries.

Analytic support from Palladium’s Health Policy Plus project helped estimate the cost of the benefit package so that the government could ensure it had adequate resources to pay for the policy reform. Additional support to the MOH and NHIF facilitated obtaining cabinet approval for increased allocation of funds, implementation guidelines, and a technical policy proposal. While implementation has had challenges, the ongoing Linda Mama program reflects the Government of Kenya’s high-level commitment to developing and implementing policies that reduce maternal and child deaths.

Ensuring Sustainable Funding for MNCH

The global health community largely knows what clinical interventions are needed to reduce maternal, newborn, and child deaths, but a massive financing gap threatens to stall progress. Proven, life-saving interventions can only be effective if there are resources in place to enable their provision.

Nigeria’s Basic Health Care Provision Fund (BHCPF) is a financing intervention designed to put the country on the path to achieving universal health coverage. The fund aims to ensure adequate and sustainable funding to provide quality health services while ensuring financial risk protection efficiently and equitably for all Nigerians, especially the poor and most vulnerable. The fund is poised to achieve this goal through the provision of a basic minimum package of health services that prioritizes MNCH interventions.

With support from Palladium, first under Health Policy Plus and currently under USAID’s flagship Integrated Health Project, Nigeria’s government has established evidence-based fiscal space analyses, health expenditure tracking, and resource mobilization plans for the BHCPF which helps generate additional resources for healthcare at the state level, strengthening the sustainability and scalability of essential MNCH services.

Advancing Governance and Accountability

The World Health Organization defines health system governance as the process of harmonizing strategic policy frameworks with effective oversight, coalition-building, regulation, attention to system-design, and accountability mechanisms. This effort to harmonize health system governance requires engagement from various stakeholders, including government bodies, healthcare providers, and civil society.

The global respectful maternity care movement provides multiple examples of advancing governance and accountability across health system stakeholders. For example, in Malawi and Pakistan, Health Policy Plus partner White Ribbon Alliance has played a pivotal role by facilitating citizen hearings on respectful maternity care. These forums empowered citizens to voice their concerns regarding accountability, abuse, and disrespect experienced by pregnant women directly to policymakers and other influential stakeholders.

Citizen-driven hearings galvanized both national and local actions in these countries, resulting in the creation of sustainable mechanisms for reporting instances of abuse during childbirth. Additionally, they led to the development of new policies aimed at safeguarding the dignity and rights of pregnant women. Notably, in 2021, Malawi was one of the first countries in the world to officially endorse and adopt the updated Respectful Maternity Care Charter: The Universal Rights of Women and Newborns—sending a clear signal that the health system is being held accountable for upholding this critical aspect of care. As a follow-on, the Palladium-led MOMENTUM Tiyeni project is currently supporting the Government of Malawi to implement and scale-up their RMC policy through on-the-job training of healthcare providers.  
Decades of experience and research tell us that improvements in quality of care and MNCH outcomes will not be achieved or sustained without investments in enabling policies, sufficient financing, and effective governance. A systematic review published in BMC Pregnancy and Childbirth in 2011 found that in resource-limited countries, inadequate resource allocation and ineffective leadership and governance are greater contributors to maternal mortality than poverty. Additionally, the review identified three interconnected factors hampering implementation of maternal health interventions: weak leadership, governance, and management; insufficient financial resources, and end-user-related factors.

To achieve SDG 3, we also need interconnected and integrated solutions. Stakeholders must bear in mind that quality of care and a strong policy, financing, and governance environment fit together like pieces of a puzzle—and are essential to achieving sustainable improvements in MNCH outcomes.