Universal health coverage in developing countries and its impact on improving access to antenatal care and maternal health outcomes: A systematic review

Simbiat Olayinka Lawal recently completed the Master of Public Health (MPH) programme at ScHARR. Simbiat chose to study the MPH to gain more knowledge on the role of healthcare policy and management and also to develop her research skills, especially in health services research. In particular, the course developed Simbiat's knowledge of healthcare financing systems and enabled her to develop and refine her research skills. Taking part in the MPH program at ScHARR also equipped Simbiat with several other skills such as team work, time management and an ability to strive. Simbiat believes that the new skills she has obtained from studying the MPH  will enable her to work in a role that will help Africa, and particularly her home country, Nigeria, to achieve universal health coverage and health equality as well as working towards sustainable development goals. In the future, Simbiat plans to pursue a doctorate degree in public health policy and management, alongside conducting research into the Nigerian healthcare system.

The title of Simbiat's dissertation project was: Universal health coverage in developing countries and its impact on improving access to antenatal care and maternal health outcomes: A systematic review.


Background: Universal health coverage (UHC) refers to equal access to healthcare services across all socio-economic quintiles and reduction in financial risk incurred from the utilisation of health services. It is an important goal which would help reduce maternal mortality rates. However, the effectiveness of different healthcare financing (UHC) schemes on improving access and utilisation of maternal health services and on selected pregnancy outcomes amongst women of different socio-economic, educational and residential (rural or urban) backgrounds in developing countries, is not well understood.

Aim: This study aimed to examine the utility of UHC in improving access, utilization and pregnancy outcomes in women in developing countries.

Method: A systematic literature review was performed to answer the research question. Electronic databases; Medline, ASSIA, Cochrane library, TRIP, PubMed REMINER, CINAHL and Google scholar were used to retrieve all relevant studies on universal health coverage. Also, references of included studies and online resources of organisations such as WHO, UN and WORLD BANK were also searched to avoid omission of important literature. The inclusion and exclusion criteria were developed using the PICO (population, intervention, comparator and outcome) framework.

Result: A total of 13 studies were included in the review; of which 2 studies were from Bangladesh, 6 from Ghana, 1 from Uganda, 1 from Congo and 3 studies from two or more of the following countries: - (Ghana, Rwanda, Philippines, Senegal and Mali). There was a positive association between UHC and improved access, utility of antenatal health services and better increased access to emergency obstetric care (e.g. C-sections) despite women socioeconomic status, educational and residential (rural and urban) backgrounds: Antenatal health care (three to four or more ANC visits); NHIS (OR=1.182, p=0.05, OR=1.09, p=<0.01), other insurance (OR=2.37, p=<0.05 and OR=2.41, p=<0.05), voucher (OR=2.787, p=<0.001, OR=1.913, p= ≤0.001, (OR=0.2855, p=<0.001). Delivery at a healthcare facility; free delivery policy increased facility delivery by 2.3%, p=0.015, CI 0.50-4.05, NHIS policy increased facility delivery by 7.5%, p= ≤0.001, CI 4.97-9.92, other insurance coverage (e.g. CBHI) (OR=4.74, p= <0.10), and vouchers (OR=2.539, p= ≤0.001). Births attended by a skilled birth attendant; free delivery policy (OR=1.67, p= <0.01), NHIS policy (OR=1.65, p =<0.01 and OR=1.375, p=0.05), other insurance policy (free ANC policy) (OR=1.17, p= <0.01) and voucher scheme (OR=3.582, p= ≤0.001) and (OR=0.2119, p= <0.001). Emergency obstetric care (e.g. C-section); Fee exemption (OR=0.329, p= <0.0001), other insurance OR=1.13 vs. OR=1.26, p=<0.001, vouchers (OR=1.536, p= <0.01).

Conclusion: Universal health coverage through various strategies, if implemented adequately, sufficiently increases the utilization of maternal health care services. More women on UHC received emergency obstetric care such as C-section than those without. Future studies should endeavour to examine whether these benefits spill over to reducing maternal mortality. There should also be efforts to find out the barriers to universal adoption of UHC policies by developing countries, such as sources of funding, suitability of different policies in different developing economies.