Capital sat down with Susan De, Deputy Director for Health and Nutrition at the Bill & Melinda Gates Foundation’s Ethiopia Country Office, to discuss the 2025 Goalkeepers report, the state of maternal health, and what it will take for Ethiopia to meet its 2030 targets. In this wide-ranging conversation, Susan explains the risks posed by shrinking development assistance, highlights what is working in primary health care and maternal health, and outlines the reforms and innovations that could save thousands of mothers’ and children’s lives in the years ahead. Excerpts
Capital: The 2025 Goalkeepers report paints picture of despair but optimism as well, showing that in 2024, 4.6 million children died before their 5th birthday and that number is projected to rise by just over 200,000 this year especially as the global development assistance for health fell sharply this year. Talk us through the risk of losing hard-won gains against diseases like malaria, HIV, and polio.
Susan De: Absolutely. And the modeling in the report shows that if these funding cuts persist,16 million more children could die by 2045, reversing decades of progress against malaria, HIV, and polio. Despite this sobering picture, the report also shows that the world still has a path forward. Targeted investments in proven tools, strong primary health care, routine immunization, better vaccines and next-generation innovations could save millions of children even in a constrained budget environment. We know that sustained support to mechanisms like the Global Fund and Gavi has already saved tens of millions of lives and remains essential to protecting gains against the world’s deadliest diseases. If we look at Ethiopia in particular, the suddenness of the shifts in development assistance was a shock to all of us working in Ethiopia’s health sector – precisely for the reasons you noted. Ethiopia had already been battling many shocks in recent years – due to climate pressures, COVID-19, conflict, along with several disease outbreaks, including malaria. The sudden reduction in donor spending was yet another challenge the country had to contend with. Predictability of funding will greatly enable country governments to not only address health sector shocks, but to ensure that hard-won gains are maintained and possibly even accelerated. Without predictability as well as visibility of external support, sudden shifts have a disruptive effect. To mitigate, we saw the Ministry of Health in Ethiopia do its best to pivot to prioritize critical life-saving service delivery, strengthen efficiencies, and mobilize more resources domestically while diversifying external funding sources.
Capital: As a follow up to this, the report does also bring out opportunities to scale what is already working. What interventions have worked in Africa when we look at primary health care, routine immunizations, better vaccines, and use of data?
Susan De: Fortunately, as noted by the report, we have a wealth of evidence on what works. If these interventions could be prioritized given limited resources, we can still achieve significant health gains. Ethiopia is a case in point of a low-income country facing many shocks that is focusing its limited resources on investments with the greatest potential to save lives. For example, as noted by the report: for less than $100 per person per year, strong primary health care systems can prevent up to 90% of child deaths. On this, Ethiopia’s health sector budget has prioritized over 60% of its spending on primary health care; PHC has been a major priority of the sector for over 20 years. Immunization is another proven tool to reduce and/or even eliminate diseases relating to diarrhoea, pneumonia, and measles. For every $1 spent on vaccines, we see returns of $54 in economic and social benefits. Through Gavi, the Vaccine Alliance, more than 1.2 billion children have received lifesaving vaccines since 2000. In Ethiopia, a recent national measles ‘catch-up’ vaccination campaign reached over 18 million children – to reach those most at risk. To prevent cervical cancer, the country’s HPV campaign reached more than 71 million girls and so expanded protection by reaching those previously missed girls in hard-to reach communities. That said, challenges remain. The country still has around 768,000 children who remain completely unimmunized. While this is an improvement from past years, these numbers demonstrate the urgency to reach un-reached children with life-saving vaccines. Under the Ministry’s leadership and together with other key stakeholders like Gavi, ourImmunization support is striving to help close gaps in immunization coverage. Another cost-effective intervention that could be a game-changer if scaled is Food Fortification. For every $1 invested generating $27 in economic return from prevented disease, increased income, and enhanced labor productivity. Research in Ethiopia recently showed that folic acid fortification of salt can nearly eliminate folate deficiency, which currently drives one of the highest rates of birth defects in Africa, at the cost of less than $0.02/person/year. As resources are limited, it is critical to rely on data to help guide the prioritization of health sector support. Ethiopia’s information revolution and digital health is doing just that. Together with our support, the country is leveraging predictive analytics and models to target for example, vaccine resources to areas most vulnerable to outbreak. For example, by analysing 2011–2024 surveillance and routine immunization data with advanced modelling techniques, the Government was able to pinpoint extremely high-risk measles hotspots—particularly in pastoral, border, and certain urban woredas—and this evidence directly informed Ethiopia’s 2025 targeted mass vaccination campaigns and national outbreak response planning.
Capital: How would you characterize the current state of maternal health in Ethiopia compared to previous years?
Susan De: Because of investment in the health sector, primary health care including strong community health systems — maternal mortality has been thankfully on the decline over the past 25 years. At the start of the century, for every 100,000 live births, 870 mothers would die. Today, the latest figures from the 2023 UN estimates show that we are at 195. This reduction is not enough – we need to get to zero. To do so, it is important to address the drivers of maternal mortality. Postpartum haemorrhage is the leading cause of deaths among women during childbirth – accounting for a staggering 60% of deaths. This is one area the Gates foundation is targeting its support.
Capital: What are the main challenges currently affecting maternal mortality and morbidity in Ethiopia and are there examples of what is working elsewhere in Africa that we can borrow ideas from?
Susan De: As mentioned earlier, while Ethiopia has made great progress in reducing maternal mortality, we haven’t yet made it to 0 deaths. What’s really heartbreaking is that most mothers are dying from causes we can prevent, things like postpartum haemorrhage (mother bleeding excessively after delivery), pregnancy-related high blood pressure, and infections. These are conditions we know how to detect early and treat. The challenge is that health system gaps make this harder. Emergency obstetric care isn’t always available, there’s a shortage of skilled health workers, and essential medicines and blood products aren’t consistently accessible. On top of that, maternal death surveillance needs strengthening. Then there are socioeconomic and cultural barriers such as poverty, traditional norms that delay care-seeking, and high rates of maternal undernutrition and anemia. And if you look at geographic disparities and humanitarian crises, like conflict and displacement, they really limit access to timely, quality care, especially in remote areas. So, while progress is real, addressing these systemic and social challenges is critical if we want to make sure no mother dies from preventable causes. There are great examples of ‘what is working in Africa.’ In Tanzania, the Safer Births Bundle of Care, which combines frequent on-the-job simulation training for healthcare workers with innovative clinical tools for monitoring and resuscitation, cut maternal deaths by 75% and newborn deaths by 40%. In Ghana, introducing Point-of-Care Ultrasound and emergency transport improved care in remote areas and reduced delays. We can also look at leveraging technology, like AI-enabled ultrasound in lower-level facilities or AI-powered fetal monitoring in high-burden maternity wards, to detect complications early and save lives. Ethiopia’s government deserves recognition for its bold commitment to harnessing artificial intelligence, standing among the few African nations with a dedicated institute to maximize AI’s use and impact. This forward-looking investment will undoubtedly accelerate advancements across sectors, with especially transformative benefits for health.
Capital: How has the economic situation, including budget constraints, impacted maternal health services both in Africa and Ethiopia in particular?
Susan De: The tight fiscal environment has indeed been challenging and makes it difficult to provide easy health facility access everywhere in the country, for example in the form of a hospital or comprehensive health post. However, this has not deterred health sector stakeholders. We have emerging data that shows what else could be done – ‘frugal’ innovations in service delivery approaches — to meet Ethiopia’s women and children where they are by ramping up community-based engagement in health and adding nurses to health posts staffed by community health workers (health extension workers). Also, the country is pioneering an unprecedented approach to increasing resources for reproductive, maternal, newborn and child health. The Government together with donors, are joining up to potentially unlock $224M (Approximately 75%) toward the estimated $300M three-year gap for needed critical medicines and commodities for women and children. This momentum is also strengthened by the rapid growth of local pharmaceutical manufacturing, with market share increasing from 8% to 41% and targeting 52% by 2025/26.
Capital: What role does Ethiopia’s primary healthcare system play in improving maternal health outcomes?
Susan De: It has been critical to improving institutional-based deliveries in the country! By investing in primary health care and scaling up PHC facilities and its health workforce, including over 40,000 community health workers otherwise known as health extension workers – more women now have access to needed care than before in Ethiopia In the early 2000s, only 5% women delivered in health facilities with most women enduring significant risk while delivering at home. In 2016, according to the national demographic and health survey, the number improved to 48%, and now the latest Ministry of Health annual report shows that we are at 80%. Again, the job is not done. Considerable work is still needed to protect and improve maternal health outcomes in the country.
Capital: How effective are Ethiopia’s current maternal health policies and programs in reaching rural and underserved populations?
Susan De: Ethiopia has always prioritized equity in its health policies, and you can see this in programs that explicitly focus on communities — like the Health Extension Program, Community-Based Health Insurance, Mobile Health and Nutrition Teams for pastoralist areas, and initiatives like Village Health Leaders. These efforts have been effective and brought maternal health services closer to communities. But despite these major strides, rural and underserved populations still face big gaps. For instance, facility delivery rates vary widely, with stark urban–rural and regional disparities. These challenges are driven by systemic, financial, and contextual barriers. So while there are still gaps, Ethiopia has a strong foundation to build on. With continued commitment, smarter investments, and innovative approaches, it’s possible to close these disparities and ensure every mother has access to safe, quality care, no matter where she lives.
Capital: Are there gaps in healthcare infrastructure or workforce that hinder quality maternal care in Ethiopia?
Susan De: Yes, there are significant gaps in both infrastructure and workforce that affect the quality of maternal care in Ethiopia. While the country has made commendable progress in expanding services and increasing coverage, rural and pastoralist areas still face major challenges. Many facilities lack essential equipment and emergency obstetric capacity such as surgical services, blood transfusion, and laboratory support making timely, life-saving care difficult. On the workforce side, shortages, uneven distribution and adequate compensations of skilled professionals remain critical issues. These challenges are compounded by limited opportunities for advanced training and mentoring in remote areas, as well as weak referral systems and transport barriers. Importantly, these gaps are not unique to Ethiopia. They reflect systemic challenges faced by many countries striving toward Universal Health Coverage (UHC), where resource constraints and workforce shortages continue to hinder progress.
Capital: What innovative approaches or technologies have been introduced recently to enhance maternal health services in Ethiopia?
Susan De: One of the most impactful innovations recently introduced in Ethiopia is called the Postpartum Hemorrhage Bundle of Care. Postpartum hemorrhage – which is severe bleeding after childbirth- is the number one cause of mothers dying during child birth, responsible for about 60% of maternal deaths. The Bundle approach to addressing PPH — is a standardized package of care that combines the use of calibrated drapes with prompt, appropriate treatment to enable timely detection and management of PPH. Previously, interventions were done separately in sequence and not together. One big challenge has been measuring blood loss accurately. In the past, it was mostly a subjective measurement, which delayed diagnosis. And even after diagnosis, treatment was given step by step, which took time. This bundle approach is a simple but powerful idea. Studies show it can reduce severe blood loss and related deaths by about 60%. A simple plastic sheet labelled with measurements is used to make it easy for health workers to see when a mother is bleeding too much, diagnose quickly, and then give all the treatments together to stop the bleeding before it becomes life-threatening. That means problems are caught early and treated fast—often saving a mother’s life.The impact has been huge. Just this year, over 52,000 women received this care in 135 woredas with a goal to reach 1.7 million women in the next four years. It’s a great example of how smart, practical innovations can make childbirth safer for every mother.
Capital: How is Ethiopia leveraging data and digital tools to improve maternal health tracking and service delivery?
Susan De: Before 2017, Ethiopia had a fragmented data system that made it very difficult to track service provision at the national level. In 2017, with support from our Data Use Partnership, the Ministry of Health took a bold step toward establishing a unified national data system through the adoption of DHIS2. Today, the platform has full coverage across all public health facilities and captures all service delivery data, marking a major milestone in achieving visibility at every level of the health system. We are also supporting the Ministry of Health and Regional Health Bureaus to strengthen data quality and analysis through interactive dashboards that enable them to monitor reproductive maternal newborn and child health performance more effectively. Moreover, because spot-check surveys are critical for validating coverage indicators and informing health system performance, we worked with the Ministry of Health to support Addis Ababa University in conducting a national RMNCH survey, which has been highly valuable for the Ministry’s health programming and planning.
Capital: How do socio-cultural factors and gender dynamics influence maternal health and healthcare access in Ethiopia?
Susan De: Socio-cultural norms and gender dynamics significantly influence maternal health in Ethiopia by shaping when and how women seek care. The journey to motherhood is often dictated by traditions and expectations that run deep. Decisions about pregnancy and childbirth rarely rest with the woman herself. Husbands, mothers-in-law, and elders hold the power to decide if care is sought, while women shoulder heavy workloads and struggle with transport costs. Traditional beliefs often favor home births, as birth is seen as a natural family event best managed at home with reliance on unskilled birth attendant rather than in a facility where complications if arise can be managed. Gender roles further limit women’s decision-making power, requiring approval from husbands or elders to access services. Economic constraints and low literacy delay care-seeking, while cultural expectations such as needing male accompaniment make reaching facilities harder, especially in rural areas. These realities are not just traditions—they are delays, missed chances, and lives lost.
Capital: What role do community health workers and local initiatives play in supporting pregnant women and newborn care?
Susan De: In Ethiopia, Health Extension Workers are the frontline link between families and the health system for maternal and newborn care. They do three big things: find pregnancies early, support safe birth, and protect mothers and babies after delivery. Through home visits, they identify pregnant women, counsel on nutrition and danger signs, encourage antenatal care, and help families plan for facility delivery including maternity waiting homes where needed. Around birth and in the early postnatal period, they check mothers for bleeding or infection, promote breastfeeding, assess newborns for danger signs, ensure immunization and postnatal care, and refer complications quickly. Beyond that, they lead health education and prevention like malaria control, hygiene, and sanitation working with community groups to shift norms toward skilled birth and early care. Simply put, Health Extension Workers are central to whether a mother and her baby survive and thrive. Another interesting new initiative that will be a game changer – is Ethiopia’s launch of multiple micronutrient supplementation (MMS) to help improve women’s nutritional status during pregnancy and birth outcomes for their baby. Daily MMS supplements during pregnancy can reduce the risk of an undernourished (low birth weight) newborn by 14% and reduce the risk of infant mortality in undernourished mothers by 29%.
Capital: What partnerships and international collaborations are critical for advancing maternal health programs in Ethiopia?
Susan De: Partnerships are paramount to meeting the health needs of Ethiopians. The GOE recognizes this and is intentional about shaping productive and impactful partnerships. Achieving the 2030 targets and beyond requires sustained domestic leadership paired with strong global collaboration to ensure that proven interventions are scaled equitably and effectively. The Gates Foundation role aims to nurtures bold ideas, generates evidence, and de-risks innovations. We work collaboratively with governments and multilaterals like the World Bank, the Global Fund, GAVI, UN, UAE and other philanthropies [CIFF, SBTF, ELMA] to accelerate local adaptation and scale of innovations. We do this by intentionally aligning resources, strengthening the country’s capacity, and supporting the Government to crowd in with larger financing partners. At the country level, there are several government-led collaborative platforms we are really excited about: One is the SDG Performance fund – where 13 other donors contribute to a pool that commits to funding under-financed areas for reproductive maternal and child health services. A large portion goes towards funding pharmaceuticals and other critical health commodities in addition to health systems strengthening. Pooling really helps weather the shocks should any one donor’s funding suddenly drop. Another emerging initiative is Government 1:1 match to recruit and retain critical frontline health workers in areas most in need. It is called the HRH compact. We are supporting this together with another donor; we are excited that other partners are also interested to support. Through partnerships at the global and country level, we are hoping to ensure that catalytic efforts transition into sustained, government-led impact on a national scale.
Capital: What are the most urgent actions Ethiopia should take to reduce maternal mortality and improve maternal well-being by 2030?
Susan De: This is a great question. We have been supporting the Government to analyse trends in Ethiopia and model out different scenarios to inform what to prioritize in order to achieve SDG-3 goals. For maternal health, this analysis is showing that increasing effective coverage (right intervention, right time, sufficient quality) of a focused maternal package can avert ~4,000 maternal deaths in 2030.These results assume the health system can deliver the package with reliable functionality and quality (staff, supplies, service readiness, referral). If those conditions aren’t strengthened, then the realized impact will be lower. Under the modelled scale-up, several interventions account for >85% of lives saved, these include – PHC continuum of care for labor & delivery (including the PPH bundle), quality post-abortion care, pre-eclampsia/eclampsia prevention & management, timely caesarean delivery & ectopic pregnancy management, Clean birth environment, Modern contraceptive use, Maternal sepsis case management. If such high-impact interventions could be rapidly scaled as a maternal health ‘bundle’, with clear targets and accountability across PHC, hospitals, and regional systems – we will see significant reduction in maternal mortality and improvement in maternal well-being by 2030. This is predicated upon continued investment and focus on health-system strengthening So to summarize – Ethiopia can meet its maternal mortality target by 2030 if we do two things in parallel: 1) rapidly scale a small, evidence-based ‘maternal survival bundle’ across the PHC-to-hospital continuum and 2) strengthen the health-system capabilities that make effective coverage possible.
