THREE ESSAYS ON HEALTH SYSTEM BARRIERS TO WOMEN’S ACCESS TO HIGH‑QUALITY HEALTH CARE IN SUB‑SAHARAN AFRICA

Abstract

Despite remarkable progress in reducing maternal and newborn mortality over the past 20 years, 800 women and 6,500 newborns still die every day globally during delivery or in the days and weeks afterward. These deaths are preventable with high-quality care provided throughout the lifecycle from preconception to childhood. Yet, women-newborn dyads often fall through the cracks of a weak continuum of care, especially after birth. Various factors contribute to these challenges, ranging from individual-level determinants to health-system constraints, such as limited health financing and low quality of care. In particular, postnatal period has received less focus than other periods, and its quality of care remains under-measured. More evidence is needed to identify the key factors that prevent women from accessing life-saving care during this critical time. The following three chapters investigate how different components of health system influence variations in postnatal care quality and access to reproductive health services. By employing both quantitative and qualitative methodologies, I provide a comprehensive understanding of the health system barriers that impede women’s access to high-quality care. Following the introduction, Chapter 2 uses data from direct delivery observations in public facilities in Dire Dawa Administration, Ethiopia to examine health system competency on risk detection and management for newborns. Results find that both at-risk and healthy newborns receive similarly low quality immediate postnatal care, with non-clinical factors like mother’s education contributing to variation in care quality. Chapter 3 further investigates barriers to care quality for women and newborns after discharge from delivery facilities in Kakamega, Kenya. Employing an explanatory sequential mixed method, the study shows that the content of care received before discharge influences mothers’ decisions to seek routine postnatal care. Key drivers include trust in the provider’s supervision, counseling on the importance of postnatal care, and the formal scheduling for the next postnatal visits. Chapter 4 used Demographic Health Surveys to investigate the impact of disruptions in development assistance for health in social marketing programs, a key health financing scheme in low resource settings, on women’s reproductive health behaviors in Zambia. Analysis adopting difference-in-difference method supplemented by a synthetic control approach shows that funding discontinuation do not affect overall modern contraceptive use or pregnancy rate but do lead to decline in using condoms and oral contraceptives. Together, this dissertation demonstrates that health systems underperform by providing low levels of routine care quality throughout the postnatal period and by reflecting weakness in health financing that hinder the consistent medical supplies. Findings can be used to design future interventions to improve service quality during the postnatal period and to develop strategies that enhance financing resilience in low-resource health systems.