Safe Motherhood in the Age of Antimicrobial Resistance: From Evidence to Health-System Action

An effective antibiotic can be lifesaving for a woman experiencing a serious infection during pregnancy. But what if the antibiotics don’t work? What does that mean for the woman and the child she is carrying? These questions remind us that maternal health and antimicrobial resistance (AMR) are more closely connected than they are treated.

Safe motherhood depends, among other things, on the ability to prevent infections, recognise them early and treat them effectively. As AMR continues to grow as a global health challenge, it is increasingly necessary to preserve the effectiveness of medicines used to prevent and treat infectious diseases in women during pregnancy, childbirth and the postpartum period.

Maternal infection

Although progress has been made in reducing maternal mortality, the challenge persists in many parts of the world. In 2023 alone, about 260 000 women died during and following pregnancy and childbirth. About 92% of these deaths occurred in low- and lower-middle-income countries.

While there are numerous causes of this challenge, infection deserves attention. The World Health Organisation defines maternal sepsis as a life-threatening condition resulting from infection during pregnancy, childbirth, after an abortion or during the postpartum period. It remains one of the leading direct causes of maternal mortality globally.

The scale of maternal infection provides more perspective. The Global Maternal Sepsis Study (GLOSS) conducted across 52 countries shows that about 70 pregnant or recently pregnant women per 1,000 live births had an infection requiring hospital management. Approximately 11 per 1,000 experienced a severe maternal outcome associated with infection, rising to as many as 15 per 1,000 in low- and middle-income countries. Most of these infections can be treated. But that depends on having antimicrobials that still work.

Antimicrobial resistance

Antimicrobial resistance occurs when microorganisms no longer respond to medicines designed to treat them. As resistance develops, infections can become harder and sometimes impossible to treat. This could increase the risk of severe illness, complications and death.

In maternal care, serious infections can progress quickly and have adverse consequences. For example, a woman who develops sepsis cannot always wait for lengthy laboratory processes before treatment begins. Clinicians may need to start empirical antibiotic treatment immediately while diagnostic investigations are underway. The World Health Organisation has warned that AMR can compromise the management of sepsis because effective empirical antibiotic treatment is often needed early. This means that AMR is not simply a problem of medicine use; it is also a health system challenge.

The answer is not simply “more antibiotics”

Women with serious bacterial infections need timely access to effective antibiotics. Delaying appropriate treatment in sepsis can be dangerous. At the same time, unnecessary or inappropriate antibiotic use contributes to antimicrobial resistance.

The solution, therefore, cannot be indiscriminate restriction of antibiotics. Nor can it be routine expansion of antibiotic use “just in case.” The aim should be the right antibiotic, for the right patient, at the right time, for the right indication and for the right duration, supported by good clinical judgement, diagnostics and local evidence.

WHO guidance recommends preventive antibiotics for specific obstetric needs, while limiting unnecessary use to reduce antibiotic resistance. This means that the careful and appropriate use of antibiotics should be part of routine, high-quality maternal healthcare.

From evidence to health-system action

If we want to protect mothers while preserving the effectiveness of antibiotics, action is required at several levels.

1. Strengthen infection prevention and control in maternity care

Preventing infections reduces maternal harm and lowers the need for antibiotic treatment. Hand hygiene, safe caesarean and delivery practices, sterilisation, environmental cleanliness, appropriate prophylaxis, and adequate water, sanitation and hygiene infrastructure are therefore central to both safe motherhood and AMR control.

2. Build stronger diagnostic and surveillance systems

Health workers need information that helps them move from broad empirical treatment towards targeted therapy when appropriate. Having data is only the beginning. It must be used by clinicians, programme managers and policymakers when decisions need to be made.

3. Support health workers to practise antimicrobial stewardship

Doctors, nurses, midwives, pharmacists and laboratory professionals need training, diagnostics, essential supplies, supportive supervision and clear referral systems. A technically competent health worker may still struggle to provide high-quality care when the system around them is weak.

This is why workforce strengthening must go beyond recruitment. The conditions in which health professionals work directly influence their ability to translate evidence into safe patient care.

4. Generate maternal-specific AMR evidence

Researchers need to generate more maternal-specific AMR evidence that answers important questions: Which organisms are commonly associated with maternal infections in different settings? What are their resistance profiles? How do these patterns vary geographically and between levels of care? Are current empirical treatment guidelines aligned with local susceptibility patterns? What happens to women who develop resistant infections? These are questions that clinical research and routine surveillance can help answer.

5. Translate national AMR commitments into maternal care

Nigeria’s One Health Antimicrobial Resistance National Action Plan 2024–2028 provides a national framework encompassing surveillance and research, infection prevention, antimicrobial stewardship, public awareness and improved evidence-based decision-making. The opportunity now is to ensure that these priorities reach specific areas of care, including maternal, newborn and reproductive health.

Our InSight

At InSight Health Group, we see the movement from evidence to action as central to stronger health systems: clinical research helps generate and strengthen evidence; health consulting helps translate evidence into policy, programmes and implementation; and community engagement helps ensure that health interventions remain connected to the people they are intended to serve. This evidence-to-impact pathway shapes our broader approach to health-system strengthening.

The future of safe motherhood will depend not on whether women can reach health facilities and receive skilled care. It will also depend on whether those facilities can prevent infection, identify it quickly and treat it with effective medicines.

In the age of antimicrobial resistance, protecting mothers also means protecting the effectiveness of the medicines they may one day depend on.

How Can We Improve the Skills of Health Workers in Low-Resource Settings?

Health workers are the backbone of every healthcare system. They play a pivotal role in ensuring quality healthcare delivery by helping to prevent diseases, sensitizing community members on health and safety issues, providing treatment, and promoting healthy lifestyles. In low-resource settings, many health workers deliver these services under difficult and often challenging circumstances. Consequently, there are numerous reports of physical, psychological, and professional burdens experienced by health workers, particularly those working in hard-to-reach areas.

While acknowledging the many health system challenges affecting healthcare delivery in low-resource settings (i.e., such as workforce shortages, inadequate infrastructure, and supply chain constraints), it is important to discuss practical ways of improving the skills of health workers. This is because the competence and capacity of health workers significantly influence the quality of healthcare services delivered to the population.

Furthermore, it is widely recognised that strengthening the skills and knowledge of health workers increases the likelihood of better health outcomes and contributes to stronger healthcare systems. The persistent shortage of health workers in many low-resource settings makes it even more important to adequately equip the available workforce. The critical question, however, is which areas and practical strategies are most effective in improving health workers’ skills and performance.

Some key strategies include supportive supervision, increased government and stakeholder investment in healthcare education, the use of digital technology for learning, mentorship programmes, and continuous professional training.

Supportive Supervision

The quality of healthcare delivery is often influenced by the level of supervision and support available to health workers. Supportive supervision focuses on improving performance through coaching, guidance, and problem-solving rather than fault-finding. It can take two main forms:

• Internal Supportive Supervision

This occurs within the health facility, unit, or ward and focuses on coaching, constructive feedback, and collaborative problem-solving. Internal supervision helps build staff capacity, improve confidence, and enhance the quality of care provided to patients.

• External Supportive Supervision

This is usually provided by district health officers, roving mentors, professional associations, or non-governmental organizations. These supervisors periodically observe frontline workers, provide technical support, assess adherence to care standards, and facilitate the sharing of best practices across facilities.

Investment in Healthcare Education

There is a need for increased government and stakeholder investment in healthcare education and training. Such investments are essential because they generate long-term returns by strengthening the health workforce and improving healthcare delivery. A well-trained and resilient workforce contributes to improved health literacy, better service provision, and progress towards achieving Universal Health Coverage (UHC).

Use of Digital Health Technology for Learning

Digital Health Technologies (DHTs) offer significant opportunities for improving health workers’ skills, particularly in low-resource and rural settings. Their use can enhance treatment adherence, healthcare utilization, and community engagement while helping to address infrastructural barriers and geographical constraints.

Digital technologies can also reduce operational challenges such as logistical difficulties, limited access to training opportunities, medical errors, and delays in accessing specialist support. As a result, health workers can strengthen their skills through innovative approaches such as telemedicine, virtual simulation training, e-learning platforms, and mobile learning applications.

Mentorship Programmes

Mentorship programmes are important for facilitating the transfer of skills, building confidence, and providing intentional guidance for health workers. Effective mentorship strengthens structured co-learning and helps bridge the gap between classroom training and independent professional practice.

In addition, mentorship programmes promote professional growth, encourage mental health awareness, improve job satisfaction, enhance leadership and managerial skills, and foster a culture of continuous learning within healthcare systems.

Continuous Training

Continuous training is a critical component of professional development and lifelong learning. It ensures that health workers remain updated on current evidence-based practices, emerging medical protocols, and new healthcare technologies.

Regular training opportunities enhance the capacity of health workers to respond effectively to routine and emergency health situations. Continuous professional development is particularly important for health workers operating in high-demand and resource-constrained environments, where maintaining up-to-date knowledge can directly influence patient outcomes and quality of care.

Summary

Investing in the skills development of health workers is a strategic investment in the health and well-being of society. The benefits of a skilled health workforce are numerous and include improved disease prevention and management, higher job satisfaction, reduced morbidity and mortality, and stronger healthcare systems that support the attainment of UHC.

Therefore, governments, policymakers, development partners, and healthcare stakeholders must prioritize the training, support, and continuous capacity building of health workers, particularly in low-resource settings. Strengthening the skills of health workers is not only essential for improving healthcare delivery today but also for building resilient healthcare systems capable of meeting future health challenges.

InSight Health Group was pleased to collaborate with the Department of Sociology and Anthropology at the University of Nigeria, Nsukka, to host the Researching Africa Conference 2026, held under the theme “Researching Africa in the Context of the Sustainable Development Goal.” The conference took place from 20–21 May 2026, with a pre-conference workshop held on 19 May 2026, bringing together scholars, researchers, students, practitioners, and development stakeholders to reflect on Africa’s development realities through the lens of research and the Sustainable Development Goals.

The conference provided an important opportunity to listen, learn, and reflect on how African research can speak more directly to African problems. The sessions demonstrated that development challenges across the continent are not isolated. Health, poverty, gender inequality, insecurity, climate change, education, and weak institutions are deeply connected, and meaningful solutions require evidence that is locally grounded, interdisciplinary, and responsive to lived experiences.

Figure 1: Courtesy call to the Vice Chancellor, University of Nigeria, Nsukka

Rethinking Development from an African Lens

One of the strongest messages from the conference came from Dr. ChiChi Aniagolu, the keynote speaker, whose presentation, “Beyond the Blueprint: A Sociological Analysis of the SDG Development Paradigm,” challenged participants to think critically about the Sustainable Development Goals (SDG). Her paper reminded the audience that the SDGs are should not be treated as a simple checklist of global targets, but as a development framework that must be interrogated within Africa’s historical, political, economic, and social realities.

A key takeaway from the presentation was that development is not neutral. While the SDGs provide a useful global language for measuring progress, they also carry assumptions about growth, modernization, markets, and what societies should aspire to become.

Furthermore, she highlighted the contradictions within the SDG framework, especially where economic growth, environmental protection, poverty reduction, and decent work do not always move in the same direction.

For InSight Health Group, this was an important reminder that evidence-based development must also be justice-based. Research should not only ask whether targets are being met; it should also ask who benefits, who is excluded, and whether development models are rooted in local realities.

Figure 2 Presentation by Dr ChiChi Aniagolu, Ford Foundation

Health Systems as Foundations for Sustainable Development

The presentation by the guest speaker, Prof. George Ugwu, Honourable Commissioner for Health, Enugu State, provided a practical example of how state-level health reforms can contribute to the SDGs. His presentation, “Strengthening Healthcare for Sustainable Development,” outlined Enugu State’s ongoing reforms across primary, secondary, tertiary, and emerging quaternary healthcare.

This presentation shows that healthcare infrastructure is not only about buildings. It is about access, workforce, quality of care, referral systems, emergency readiness, data, trust, and continuity of services. The Enugu example showed how investments in health systems can contribute to the SDG.

For us at InSight Health Group, we believe that strong evidence is needed to track whether infrastructure investments translate into better service use, improved quality of care, reduced out-of-pocket expenditure, and better health outcomes for communities.

Figure 3 Presentation by Prof. George Ugwu, Commissioner for Health, Enugu State

Artificial Intelligence and Africa’s Development Future

The lead paper 1 by Prof. Chukwuedozie K. Ajaero, titled “Artificial Intelligence and the Sustainable Development Goals in Africa: Opportunities, Risks, and Governance Challenges,” expanded the conversation into the future of technology and development. His presentation explored how artificial intelligence can support progress across the SDGs, while also warning that Africa must not become only a consumer of technologies designed elsewhere.

The presentation highlighted opportunities for AI in health diagnostics, education, public service delivery, climate adaptation, data systems, and economic innovation. It also emphasized the growing AI ecosystem in Africa, including investments, talent development, business adoption, and emerging national AI strategies.

However, the presentation also raised important governance concerns. These included weak policy frameworks, ethical risks, algorithmic bias, inadequate data infrastructure, regulatory lag, limited technical capacity, funding constraints, and the exclusion of marginalized groups from AI policy discussions.

For InSight Health Group, this presentation was particularly relevant because health systems, clinical research, monitoring and evaluation, and community programmes increasingly depend on data and digital tools. AI has the potential to improve decision-making, but only if it is governed responsibly, locally adapted, ethically deployed, and designed to reduce rather than reproduce inequality.

Figure 4 Presentation by Prof. Chukwuedozie K. Ajaero, University of Nigeria, Nsukka

Mental Health as an SDG Investment

The lead paper presentation by Dr. Nnenna Mba-Oduwusi, delivered by Ifesinachi Eze, brought the discussion directly into InSight Health Group’s work in mental health. The presentation, “How InSight Health Group is Bridging the Gap in Access to Mental Health Care: An SDG Investment,” highlighted the toll-free mental health hotline system implemented through the InSight Initiative for Health and Development in collaboration with the Suicide Research and Prevention Initiative Nigeria (SURPIN).

The presentation showed that mental health is deeply connected to the SDGs. It affects health and well-being, poverty, education, productivity, inequality, peace, and social resilience. It also drew attention to the scale of the mental health challenge, including suicide, limited access to specialist care, and the shortage of mental health professionals in Nigeria. The hotline model presented at the conference demonstrated how a practical, technology-enabled, confidential support system can help close access gaps.

For InSight Health Group, the key lesson was clear: mental health is not a side issue in sustainable development. It is central to human dignity, productivity, education, family stability, community peace, and health system strengthening. The session also showed the importance of turning service delivery data into research evidence that can inform policy, improve quality, and strengthen national mental health response systems.

Figure 5 Ifesinachi Eze presents on behalf of Dr Nnenna Mba-Oduwusi, InSight Health Group

Lessons from the Parallel Sessions

Beyond the keynote and lead presentations, the parallel sessions showed the depth and diversity of research being conducted across SDG-related themes. Papers addressed health system inequalities, social support for older adults, suicidal ideation among university students, patient narratives, substandard drugs, diabetes treatment barriers, reproductive health, telehealth, gendered violence, poverty, insecurity, climate change, education, corruption, workplace structures, and social protection.

A major learning point was that Africa’s development challenges are interconnected. Health cannot be separated from poverty. Gender cannot be separated from work, politics, family systems, and health outcomes. Security cannot be separated from economic life and community trust. Climate change cannot be separated from livelihoods, migration, urban planning, and public health.

The conference, therefore, reinforced the need for interdisciplinary research. Solving Africa’s development challenges requires sociologists, public health experts, economists, clinicians, policymakers, technologists, community actors, and development practitioners to work together.

Key Reflections for InSight Health Group

From InSight Health Group’s perspective, the conference offered five important reflections.

• First, African research must be grounded in African realities. The conference repeatedly showed that imported frameworks must be questioned, adapted, and interpreted through local experience.
• Second, health is a development anchor. Whether the discussion focused on PHCs, mental health, reproductive health, ageing, health workforce, or emergency response systems, it was clear that strong health systems are essential for achieving multiple SDGs.
• Third, mental health must be treated as a core development issue. The InSight/SURPIN hotline example demonstrated that scalable, confidential, and quality-assured mental health support can help bridge major access gaps.
• Fourth, technology must be governed with equity in mind. AI and digital health tools can strengthen systems, but without strong governance, they can widen existing inequalities.
• Finally, partnership is essential. The collaboration between InSight Health Group and the Department of Sociology and Anthropology, University of Nigeria, Nsukka, demonstrated the value of linking academic institutions with implementation-focused organisations.

Figure 6 Group photographs

 Conclusion

The Researching Africa Conference 2026 was a timely and important gathering. It created space to question dominant development models, showcase practical reforms, discuss emerging technologies, and highlight community-centred health and social research.

For InSight Health Group, participating as a collaborator reaffirmed our commitment to evidence generation, health systems strengthening, mental health access, responsible innovation, and Africa-led development solutions.

The most important lesson from the conference is that researching Africa must go beyond describing Africa’s problems. It must help shape fairer systems, stronger institutions, better health outcomes, and more inclusive futures.

As Africa continues to work toward the SDGs, conferences like this remind us that progress will depend not only on targets and indicators, but on context, collaboration, and a clear commitment to improving lives.

In many low- and middle-income countries (LMICs), particularly across sub-Saharan Africa, community health governance structures have become a central feature of primary health care governance. Although they vary in form, authority, and effectiveness, they are all inspired by the World Health Organisation and the Alma-Ata Declaration, which emphasised community involvement in health governance. They usually have the mandate of strengthening accountability, improving service delivery, and bridging the gap between communities and health providers. But a critical question remains; do these groups deliver on accountability?

This question is not just theoretical. It sits at the heart of ongoing debates about health system strengthening, especially in contexts where weak oversight, absenteeism, and informal practices continue to undermine the quality of care.

Understanding the Accountability Promise

Community health governance structures are typically composed of local representatives tasked with overseeing health facility operations, mobilising community participation, and ensuring that health workers remain responsive to local needs. In principle, they embody what is often described as social accountability; a process through which citizens collectively hold service providers and policymakers to account.

Embedding community oversight within PHCs meant that they would:

• Monitor staff attendance and performance

• Report misconduct or corruption
• Facilitate dialogue between providers and users
• Ensure that services reflect local priorities

The Reality on the Ground: Between Potential and Constraint

Evidence from multiple studies suggests that while these structures can contribute to accountability, their effectiveness is highly uneven and context-dependent.

A recurring pattern is that CHCs function less as formal enforcement bodies and more as relational intermediaries. They do not have the power to sanction, so they often rely on negotiation, persuasion, and social pressure.

This has both strengths and limitations.

On one hand, relational accountability can:

• Foster trust between providers and communities
• Encourage voluntary compliance by health workers
• Enable context-sensitive problem-solving

On the other hand, it may:

• Limit the willingness of committees to challenge entrenched power dynamics
• Reduce their capacity to address systemic issues like chronic absenteeism
• Lead to selective enforcement, especially where committee members have personal ties to health workers

Power, Capacity, and Legitimacy

Three interrelated factors consistently shape the effectiveness of community health governance structures in promoting accountability:

1. Power Relations
   Community members may feel constrained in confronting health workers, who are often perceived as more educated or socially elevated. In some cases, health workers themselves dominate committee structures, blurring lines of accountability.
2. Capacity and Knowledge
   Many committee members lack the technical knowledge required to effectively monitor service quality or interpret health data. Without adequate training, their oversight role becomes symbolic rather than substantive.
3. Institutional Linkages
   Perhaps most critically, CHCs are often poorly integrated into formal health system governance. When reports or complaints do not trigger action from higher authorities, community monitoring loses credibility.

When Do CHCs Work?

Despite these constraints, there are contexts where community health governance structures have demonstrated tangible impact. Their effectiveness tends to improve when:

• They are supported by clear legal mandates and defined roles
• There are functional feedback mechanisms linking them to higher-level authorities
• Members receive continuous training and capacity building
• There is external facilitation (e.g., NGOs) to strengthen their voice and autonomy
• Community awareness and engagement are high

In such settings, they can play a crucial role in identifying service delivery gaps, improving responsiveness, and even reducing informal payments.

Conclusion

Community health governance structures hold significant promise, but their impact on accountability is neither automatic nor guaranteed. They operate within complex social and institutional environments where power, relationships, and resource constraints shape their effectiveness. Ultimately, improving accountability in health systems is less about creating structures and more about ensuring that those structures are empowered, connected, and capable of action.

Chika had heard about it all her life: childhood immunisation is free. So, when she delivered her first baby, she did what the system expects of every responsible mother; she went to a public facility for routine vaccination. After hours of waiting, she was finally called in and asked to pay ₦200 for a syringe used in administering the vaccine.

The amount may seem small. But multiply ₦200 by dozens of children, twice a week, across thousands of facilities. What appears trivial at the individual level becomes systemic at scale. More importantly, it violates a simple promise: essential immunisation services are free.

This is not an isolated incident. It is a symptom of something deeper: corruption embedded in everyday health system practices.

Corruption Is Not Just About “Bad People”

In health systems research, corruption is broadly understood as the abuse of entrusted power for private gain. Transparency International and the World Health Organization (WHO) have documented how corruption manifests in health systems globally, particularly in low- and middle-income countries.

Common forms include:

• Informal payments or bribes for “free” services
• Procurement fraud and overpricing of supplies
• Diversion or theft of medicines and vaccines
• Absenteeism and ghost workers
• Nepotism in hiring and promotion
• Manipulation of service data to secure funding
• Facility-level extortion (“pay before your file moves”)

While policymakers often frame corruption as individual moral failure, evidence suggests it is frequently a predictable outcome of weak governance structures, distorted incentives, opaque financial flows, and limited accountability mechanisms.

When reform focuses only on punishment and publicity, corruption adapts. It rarely disappears.

Why Policymakers Get It Wrong

Many anti-corruption initiatives emphasize transparency campaigns, disciplinary measures, and public declarations. These are necessary but insufficient.

Three core misunderstandings often undermine reform:

1. Treating Corruption as Exceptional Rather Than Systemic

Corruption in health systems is rarely random. It often thrives where:

• Salaries are delayed or inadequate
• Supervision is weak
• Financial processes are opaque
• Supply chains are unreliable
• Reporting channels are unsafe

In such contexts, informal payments and absenteeism become normalized survival strategies rather than isolated misconduct.

2. Ignoring Structural Incentives

Low motivation, poor working conditions, and unclear career pathways create fertile ground for rent-seeking behaviour. When systems reward loyalty over competence or tolerate absenteeism, governance failure, not individual immorality, becomes the core driver.

3. Overlooking Procurement and Financing

Procurement is technically complex and politically sensitive. Yet this is where the largest financial leakages occur. Weak contract oversight, lack of price benchmarking, and closed bidding processes allow overpricing and supply diversion. Studies consistently show that opaque procurement is a major corruption risk in health sectors globally.

The Human Cost: Who Pays?

Corruption is not abstract. It reshapes health-seeking behaviour and health outcomes.

Women, children, and rural populations are disproportionately affected. When informal fees are attached to free maternal drugs, some women turn to traditional birth attendants. When staff are absent, patients delay care. When drugs are diverted, stock-outs push families toward expensive private alternatives or untreated illness.

Research across sub-Saharan Africa shows that informal payments reduce service utilization and erode trust in public systems. Over time, corruption weakens both access and quality – the two pillars of universal health coverage.

What Actually Works: Moving Beyond Punishment

Replacing one staff member or issuing public warnings may create short-term compliance. Sustainable reform requires system redesign.

Evidence-informed strategies include:

1. Strengthening Financial and Procurement Transparency

• Open contracting and competitive bidding
• Independent price benchmarking
• Digital procurement tracking systems
• Public disclosure of awarded contracts

Digital audit trails reduce discretionary control and create verifiable records of transactions.

2. Making Service Rules Visible

• Publicly displayed service charters
• Transparent fee schedules
• Clear referral and admission protocols
• Real-time stock visibility systems

When patients know what is free and what is not, informal charges become harder to justify.

3. Embedding Routine Accountability

• Independent facility audits
• Mystery patient surveys
• Spot checks
• Procurement red-flag analytics

These mechanisms detect patterns rather than waiting for whistleblower complaints.

4. Protecting Whistleblowers and Complainants

Accountability fails when reporting is unsafe. Confidential grievance systems, fair disciplinary procedures, and visible consequences for misconduct are critical.

5. Addressing Incentives and Workforce Conditions

Improved salary reliability, performance-linked incentives, supportive supervision, and clear promotion pathways reduce reliance on informal income streams. Anti-corruption reform is most effective when it aligns incentives, improves oversight, and reduces discretionary power simultaneously.

Conclusion

When governance improves, patients experience tangible change: shorter queues, predictable drug availability, respectful care, and genuine free services where promised. Chika’s ₦200 is not just a small informal fee. It represents the gap between policy promise and system reality. Closing that gap demands more than punishment. It demands redesigning the system so that it works for all.

The day-to-day problems people experience in many low- and middle-income countries (LMICs) (i.e. medicine stock-outs, long waiting times, understaffed facilities, weak referral systems, and high out-of-pocket payments) often reflect deeper system challenges. These can include weak infrastructure and maintenance, inconsistent financing, gaps in leadership and accountability, shortages or uneven distribution of skilled health workers, and supply chain problems. A useful way to understand these moving parts is the World Health Organization’s health system “building blocks”: service delivery, health workforce, health information, medicines and technologies, financing, and leadership/governance.

The consequences of these gaps were notable during the COVID-19 pandemic. The pandemic not only increased demand for care but also disrupted routine services in many LMICs.

Thus, governments, NGOs, and international partners often work together to improve performance. One major strategy they use is health system reform. This is the deliberate change in how health services are financed, organised, delivered, and governed, to improve access, quality, and fairness. Health reforms are often linked to the broader goal of universal health coverage, which is to ensure people can get the services they need without financial hardship.

So, if reforms are meant to strengthen systems, why do they so often fail to deliver the results people expect?

1) Reforms look good on paper, but implementation is weak

A reform is not a policy document. It is what changes in clinics, hospitals, and communities. Many reforms stall because the “how” is not clear: who will do what, with which resources, and how progress will be tracked. When accountability is weak, even a well-designed reform can lose direction and become symbolic. This is why it is emphasised that there must be accountable relationships among citizens, providers, and the state regarding how reforms will take place and who will do what.

2) Political commitment fades, but reforms need steady support

Health system reforms usually take years, not months. When leadership changes, budgets tighten, or attention shifts to a new priority, reforms can lose momentum. Over time, implementation becomes inconsistent, supervision reduces, and performance monitoring weakens. One notable challenge in this area is the fact that many countries’ governments sometimes “police” policies rather than build implementation capability.

3) Short-term funding cannot buy long-term system change

Strengthening a health system is expensive and ongoing: salaries, training, supply chains, data systems, facility operations, and quality improvement all require predictable financing. When funding is unstable, as is often the case with many LMICs, or tied to short project cycles, reforms may start strongly but fade before they mature.

This challenge can be bigger in settings where external funding plays a large role. Aid can be volatile relative to country budgets, and donor cycles do not always match the long timelines needed for system reforms.

4) Health workers are central, but reforms sometimes treat them as an afterthought

Reforms succeed or fail at the point of care. This is where health workers provide services, explain decisions, document care, and build trust with patients. When reforms do not address the realities health workers face (workload, pay, supervision, supplies, safety, and career progression), implementation suffers. Health workers may comply on paper without meaningful change in practice.

The idea here is well supported in health reform literature: reforms are highly context-dependent and require attention to workforce realities, not just technical designs.

5) Community involvement is often promised, but not built into the reform

Community engagement is frequently mentioned in reform plans, but it is not always funded, structured, or sustained. Yet communities can help define priorities, report barriers to access, and improve trust, especially when reforms affect costs, service hours, or the way care is delivered.

When communities feel excluded, trust can drop, and people may delay care, self-treat, or stop using services, even when services technically exist. This is part of why quality and trust are treated as central, not optional, to progress in health systems.

What makes reform more likely to succeed?

Identifying gaps is a strong start, but successful reform usually includes:

• A realistic implementation plan: clear roles, timelines, and feedback loops, not just a policy launch.
• Stable financing: funding that supports core system functions over the years, not only short projects.
• Workforce-centred design: fair and timely remuneration, supportive supervision, training, and the tools needed to do the job.
• Accountability: incentives and oversight that make it easier to do the right thing and harder for resources to leak or plans to stall.
• Context-fit solutions: borrowing ideas from other countries can help, but reforms must match local culture, institutions, and community realities.

Conclusion

Health system reforms in LMICs often fail not because reform is pointless, but because systems are complex and change takes sustained effort. Policies must be matched with implementation capacity, stable financing, meaningful involvement of health workers and communities, and accountability that stays strong long after take-off.