Beyond the Pledge: Why Political Will and Domestic Financing Hold the Key to Ending Preventable Maternal Deaths in Africa

Across Africa, hundreds of women lose their lives every day to causes that modern medicine has long known how to treat. Postpartum haemorrhage can often be managed with a medicine that costs only a few dollars. Eclampsia, a dangerous rise in blood pressure during pregnancy, can often be stabilized with a compound that has been in clinical use for nearly a century. For many women, the risk never needs to arise at all — a contraceptive implant no larger than a matchstick can make an unplanned, high-risk pregnancy avoidable in the first place. These are not questions of scientific capability; the interventions exist and are well proven. What remains is ensuring the right commodity reaches the right woman at the right moment, and the evidence increasingly points to financing and sustained political prioritization as the decisive factors in making that happen.

A Region Making Progress, Yet Still Carrying the Greatest Burden

Sub-Saharan Africa (SSA) continues to bear a disproportionate share of the world's maternal deaths, accounting for close to 70% of the global total, with an estimated 287,000 to 300,000 women dying each year.[1] The region has made meaningful progress, with maternal mortality declining by 40% between 2000 and 2023, from 727 to 442 deaths per 100,000 live births.[2] However, this progress, while real, still leaves the region carrying a substantial burden, and reaching the Sustainable Development Goals target of fewer than 70 deaths per 100,000 live births by 2030 would require a roughly twelvefold acceleration in the current annual pace of decline.[2]

The causes are well understood and remarkably consistent across the continent: severe haemorrhage, infection, hypertensive disorders of pregnancy such as pre-eclampsia and eclampsia, complications during childbirth, and unsafe abortion.[3] All of them are largely preventable with timely, facility-based care and a short list of essential, low-cost medicines.

The Commodities That Could Close the Gap

In 2012, the UN Commission on Life-Saving Commodities for Women and Children (UNCoLSC) identified 13 underused, high-impact commodities spanning the reproductive, maternal, newborn, and child health continuum — commodities that, if reliably available and properly used, hold the potential to save millions of lives at a strikingly modest cost.[4] The Commission estimated that scaling up these 13 commodities over five years would cost less than $2.6 billion, while saving more than 6 million lives, including well over 200,000 mothers.[5]

Recognizing that commodities alone are not sufficient, the UNCoLSC also put forward recommendations for strengthening the wider health systems needed to support them, from procurement and regulatory processes to supply chains and up-to-date training for health workers.[4] Among the commodities prioritized were treatments and preventive medications for postpartum haemorrhage, treatments for pre-eclampsia, eclampsia, and other hypertensive disorders, injectable antibiotics for sepsis, and contraceptive implants and other family planning commodities. Their impact remains dynamic, continually shaped by the strength of the systems around them. It is in reinforcing these systems that financing and political will become most consequential.

Financing the Solution: A Shared Responsibility

It is worth noting that this is not primarily a story about insufficient foreign aid. A majority of global maternal health funding today comes from domestic government budgets rather than international donors, a welcome shift that places African governments not as recipients of external generosity, but as the primary architects of their own health outcomes.

The continent set its own benchmark for this responsibility over two decades ago. In 2001, African Union member states signed the Abuja Declaration, pledging to allocate at least 15% of national budgets to health.[6] Progress toward this target has been uneven: only a handful of countries — Rwanda, Botswana, and Cabo Verde among them — have consistently met or exceeded it, while many others continue to allocate well below 10%, and some as low as 5%.[7] This gap matters less as a measure of shortcoming than as an indicator of where the greatest opportunity for impact now lies: modest increases in domestic health financing, sustained year over year, could meaningfully close the region's maternal mortality gap.

Nigeria offers a useful illustration of how this plays out in practice. The country's proposed 2026 federal health budget stands at ₦2.48 trillion out of a ₦58.47 trillion total national budget — around 4.2% of federal spending, and less than a third of the Abuja Declaration's 15% commitment.[8] Meeting that target at the current budget size would require closing a gap of more than ₦6 trillion.[8] This illustrates how, even where nominal health spending grows year on year, its share of the overall budget can remain far below the continental commitment, underscoring the value of tracking allocations proportionally, not just in absolute terms.

Where Political Will Has Made the Difference

A number of countries illustrate what is possible when domestic financing is paired with sustained political commitment.

Rwanda, though not a wealthy country by income level, is among the very few African nations to have repeatedly approached or exceeded the Abuja target.[9] This financing has been paired with strong political prioritization of maternal health, including Mutuelles de Santé, a community-based health insurance scheme that now covers close to 90% of Rwandans and extends deep into rural areas, alongside a dense network of community health workers connecting pregnant women to facility-based care.[10] The combination of financing and political follow-through, more than income level alone, is what analysts point to when explaining Rwanda's outsized progress on maternal survival.

Ethiopia, starting from one of the world's highest maternal mortality burdens, built a government-led Health Extension Program, launched in 2003, that deployed a salaried cadre of community health workers — today more than 40,000 — to reach Ethiopians living in rural areas who had historically been furthest from facility-based care.[11] Progress accelerated markedly after 2010, once infrastructure and workforce investment scaled up, contributing to one of the fastest sustained mortality declines recorded in SSA. Gains have been stronger in urban centers than in pastoralist regions such as Afar and Somali, underscoring the need for equitable delivery alongside national commitment.

Malawi nearly halved its maternal mortality ratio in under a decade — from 439 deaths per 100,000 live births in 2015 to 224 in 2024 — aided by results-based financing that helped facilities maintain essential drug stocks even through periods of economic strain, while facilities outside the program saw stock-outs worsen.[12] Malawi's family planning program also offers a notable domestic-financing success story: sustained advocacy linking contraceptive access to national economic and development goals helped secure increased government budget allocations for family planning commodities, backed by regular coordination between the health ministry, finance ministry, and parliament.[13] Civil society groups reviewing Malawi's most recent national budget have noted that this progress depends on continued, deliberate investment rather than being treated as self-sustaining.

Kenya's recent Cooperation Framework between the Ministry of Health and the Beginnings Fund illustrates a different, complementary model: partner financing structured around country ownership and coordinated planning. Backed by a USD 80 million investment over five years, the partnership will strengthen implementation of the Every Woman Every Newborn Everywhere (EWENE) Acceleration Plan 2026-2028 by improving access to life-saving maternal and newborn health commodities, strengthening health systems, and enhancing service delivery across 21 high-burden counties, with an expected reach of close to six million women and newborns.[14] While external funding provides critical support, the initiative's design underscores a broader principle: sustained progress ultimately depends on strong domestic financing, aligned investment, and government-led efforts to ensure women and newborns have equitable access to quality care.

These examples share a common thread: none of these countries are high-income, however each has shown that consistent political prioritization, translated into protected budget lines, functioning procurement, and supportive policy, can shift outcomes meaningfully, even with modest resources.

What Sustained Commitment Could Look Like

Building on these examples, a few practical steps stand out as opportunities for governments to strengthen progress.

• Progressing toward the 15% Abuja target, with dedicated budget lines for essential maternal health commodities.
• Strengthening domestic revenue systems to build more resilient, self-sustaining health financing, particularly as donor funding becomes less predictable.
• Reinforcing budget-execution and accountability systems, so allocated funds reliably reach frontline facilities.
• Enabling midwives and community health workers, through supportive policy, to administer key life-saving commodities to the populations that need them most.
• Exploring regional and pooled procurement to improve commodity affordability and supply reliability, an approach regional bodies like SADC have proposed formalizing.
• Investing in updated national health financing plans, to ground budgeting in system-wide needs rather than incremental adjustments to the previous year's allocation.

Closing the Distance Between Commitment and Delivery

The commodities needed to prevent the majority of maternal deaths in Africa are already well understood and inexpensive relative to their impact. The experiences of Rwanda, Ethiopia, Malawi, and Kenya show that sustained political commitment and consistent domestic financing, even in resource-constrained settings, can meaningfully change outcomes. The path forward is therefore less about identifying new solutions and more about reinforcing political will and financing consistency around the solutions already at hand — an opportunity the continent has already shown, in several places, that it can seize.