Achieving Universal Health Coverage (UHC) is one of the objectives in the Sustainable Development Goals (SDGs) agenda target three of improving maternal and child health by reducing the maternal mortality ratio to less than 70 per 100,000 live births and ending preventable to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births by 2030 [1]. UHC is considered a vital component of the SDGs specifically for goal 3 which seeks to ensure healthy lives and promote well-being for all [1, 2]. UHC is when all individuals and communities have equal access to key promotive, preventive, curative, and rehabilitative health interventions without financial constraints [3]. UHC is targeted at protecting people from the financial burden of paying for health services out of pocket and thus, reducing the risk of people being pushed into poverty due to unexpected illness that may require them to spend their life savings, and/or sell their assets to cover medical bills [4, 5].

Most of 48 of Sub-Saharan Africa (SSA) countries showed progressive gains on the UHC effective coverage since its initiation as a way to improve the health people especially maternal and child health [6]. Nevertheless, there are still many countries in the sub-region that show lagging performance on effective coverage of maternal and child health [7]. Nations in SSA have also committed and put measures in place to attaining the SDG declaration and their policies are directed towards principles of the UHC 2030 Compact, initiatives of UHC 2030 and the Political Declaration of UHC adopted at the UN High Level Meeting in September 2019 together with other principles including African Union Agenda 2063 [8, 9]. The common challenges faced in attaining the UHC in many countries include inadequate capital investment for health services and their equitable distribution, fiscal space to finance UHC policies and programs [10, 11].

While maternal mortality ratio declined globally by 44% from 1990 to 2015, the 75% reduction target was not met, and many countries especially in SSA fell short of achieving the Millenium Development Goal (MDG) 5 targets of reducing maternal mortality [12]. As indicated by WHO [12], there were still high maternal mortality with an estimated 303,000 maternal death annually where majority was found in SSA. After the expiration of the MDG in 2015, it was replaced with the 17 SDGs [13]. The commitment of ending preventable maternal mortality (EPMM), released by WHO in 2015 [14] as the MDG agenda was integrated into the maternal and child health target which was listed at the top of SDG target 3 [1]. Emphasis has therefore been placed on the importance of antenatal care to maternal and child survival [15]. However, in SSA, accessibility and coverage of essential maternal and child health services are low [16] especially with lowest antenatal care utilization among women [15].

Recent study by Bain, Aboagye, Dowou, Kongnyuy, Memiah and Amu [17] revealed that the prevalence of maternal healthcare utilisation among young women in SSA was 55.2%, 78.8%, and 40% for antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) respectively. Similarly, Amu, Aboagye, Dowou, Kongnyuy, Adoma, Memiah, Tarkang and Bain [18] found that the prevalence of maternal healthcare utilisation in SSA was 58%, 70.6% and 40.7% for ANC, SBA and PNC, respectively. Poverty, poor health insurance coverage and remote place of residence from health facilities were shown by studies as the major determinant of maternal and childcare utilization by women in SSA. For instance, Amu et al. [18] noted that women covered by health insurance were 1.48, 1.37 and 1.42 more likely to utilise ANC, SBA and PNC and similarly indicated that women from rural settings were less likely to utilise maternal healthcare.

The Universal Health Monitoring Framework (UHMF) is adopted in this paper as the underpinning framework. The framework was adopted to underpinned this study because it to facilitates the analysis of progress and performance about public policies instituted to improve maternal and child health as way to achieve UHC by 2030 in SSA, the generation of evidence that could help in decision-making for the renovation or consolidation of health systems [19]. Also, UHMF forms an integral part of national processes of planning, monitoring, evaluation, and reporting of health system performance as a way in stimulation changes that contribute to improvement health outcome of people [19]. The framework has four dimensions including impacts, outcomes, outputs, and strategic actions. The dimension of UHMF help to track health status and well-being including maternal and child health. And also, it helps to measure progresses in universal access to health through a set of tracer indicators of magnitude and barriers to access to health services including maternal and child health services, use of health services, and access to intersectoral interventions that impact maternal and child health (Fig. 1).

Universal Health Monitoring Framework. Source: PAHO (2021)

The monitoring framework as adopted in this study describes the extent to which the health systems influence progress toward universal health. Strategic actions and outcomes are the areas in which the health sector has a greater degree of influence. In the context of universal health, strategic actions and their effect on outputs are the elements for which the health sector is largely responsible, although even these results are influenced by external factors and the health system context [19].

Strategic actions refer to health policies, interventions and programmes implemented by the government, health institutions and other stakeholders in an effort to strengthen or transform health systems with the goal of achieving universal health [20]. The strategic actions focus on improving comprehensive, quality, and community-centered health service. This tenet pinpoints the need to increase the stewardship and governance that could lead to political commitment and technical capacity building of healthcare providers geared towards promoting health system transformation aligned with the values of universal health [19]. Furthermore, the strategic actions involve increasing and improving financing with equity and efficiency and advancing toward the elimination of direct out-of-pocket payments by patients that mostly constitute a barrier to utilization of health service [20].

Universal access to maternal and child health and universal maternal and child health coverage is the two distinct however complementary bases of an equitable health system. Universal access to health services reduces all geographical, economic barriers [20]. Reiterated, the delivery of essential maternal and child health services to achieve UHC in SSA requires strategic actions such as policies, plans and programs with focus on maternal and child health. These actions are interdependent, hence the achievement of UHC results requires an integrated and comprehensive approach. It is essential for these processes to be integrated by governments in SSA to expand the coverage of critical system resources, ensure access to health services, and have an impact on health outcomes [19].

These strategic actions could prevent about two-thirds of child deaths, half to two-thirds of newborn deaths and many maternal deaths [21]. Investment of SSA countries in the expansion of equitable access to comprehensive and community centered health services could contribute to the improvement of maternal and child health leading to achieving SDG3. For example, Ghana implemented a Community-based Health Planning and Services (CHPS) that was based on task-shifting from institutional to outreach delivery of health services by training community health officers and volunteers to render home-based essential health services including life-saving maternal and child health services especially in rural communities [22,23,24]. This strategy has been reported to have contributed to an increased access and utilization of maternal and child health services in Ghana [25,26,27]. Similarly, implementation of the task shifting and sharing policy by the Nigerian Government through the training and capacity building and deployment community health workers, community health extension workers (CHEWs) and junior community health workers (JCHEWs) coupled with introduction of community midwifery at primary healthcare level have been crucial for promoting maternal, newborn and child health in Nigeria with consequence of reduction in the country’s maternal and neonatal mortality [28, 29].

Therefore, increasing investment in maternal and child health services, with equity and efficiency, and advancing toward the elimination of direct out-of-pocket payment and strengthening intersectoral coordination to address the social determinants of health is essential in achieving UHC. Strategic actions such as national health insurance scheme (NHIS) that directly incorporates free maternal and child health care could strengthen maternal health services or transform health systems in order to achieve UHC in SSA.

These constructs involve critical health system resources such as human resources for health, financing, and health technologies, organization of health services and intersectoral interventions that impact health [19, 20]. Despite of myriad of governmental and organizational efforts by various governments and international organization to improve the health outcome of women and their children over the last three decades, SSA continue to be one of the regions in the world where relatively maternal mortality ratios and under-5 mortality rates are still high [30]. Universal health coverage of maternal and child health through universal access to maternal and child health are prerequisite conditions for achieving health and well-being for all mother and their children require determining and implementing policies and actions with a multisectoral approach to address the issues in SSA [31].

To address the gap in universal access to maternal and child health care delivery, UHC was entrenched in SDGs with the target of providing financial risk protection by improving access and quality of healthcare delivery including improved access to safe, effective, quality, and affordable essential medicines and vaccines for all individuals [1]. Expanding coverage through access is necessary to improve people’s health status and overall well-being [32, 33].

The impact of health system is to promote health status and well-being of the population. Achieving this impact of universal health involves the formulation of innovative policies with action of political commitment that accelerate health systems transformation [20]. Maternal and child health issues have been at the center of international discourse over the past five decades. Maternal and child health status and wellbeing of all is central to achieving the 2030 Agenda for Sustainable Development Goals to which some SSA countries are signatories [1]. Major objectives of policies and interventions are to improve the health and wellbeing of mothers and their children focus on the determinants and systems that operate and maintain the health, safety, well-being, and appropriate development of children and their families in countries and societies in order to enhance the future health and welfare of societies and subsequent generations [34, 35]. Hence, UHC and maternal and child health have been linked together and remain a key area of focus in the third of the SDGs that relate to health [1, 36].

The SDGs recognize the significance of women's and children's health by adopting indicators for Goal 3 achievement which focused specifically on women's and children's health [36]. The first three indicators of the SDG three relate to maternal mortality, skilled delivery care, and the preventable deaths of newborns and children under five [37]. In other words, this means coverage of essential services based on interventions that include reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases and service capacity and access, at population level especially the underserved population [38].

The delivery of maternal and child health services in all settings requires adequate, competent, and motivated health workers with optimal skills mix at facility, outreach, and community level, and who are equitably distributed, adequately supported and enjoy decent work conditions [4]. However, there is a relative neglect for prioritizing investment in women’s and children’s health in the vision for primary health care thus the efforts to achieve UHC becomes questionable in achieving the health for all agenda [35]. This situation calls for immediate increase investment in training and deployment of qualified health professionals to all areas to render essential services to mothers and children [39].