Sinikiwe holds a Postgraduate Diploma in Public Health Management, BSc in Biological Sciences and Chemistry and I have completed my MPH-Health Economics and Policy. She has demonstrated expertise in quantitative and qualitative research, with a proven record of meeting and exceeding project/role objectives. With a deep commitment to making a 
positive impact in public health, Sinikiwe is driven by a passion for improving community health, reducing healthcare disparities, and promoting evidence-based policies. She sits in the European Union Delegation to Eswatini Youth Advisory Board in the Social Inclusion theme. Sinikiwe also founded a Fitness and Health Education initiative with 3 years’ 
experience educating about the prevention and management of chronic diseases/non-communicable diseases (NCDs) through physical activity and good nutrition. 

Regional Integration Without Health Gains? Financing Inequalities and Maternal 
Mortality in the Common Monetary Area :

Introduction 
Regional economic integration is often associated with improved social and health 
outcomes through enhanced cooperation and policy coordination. The Common 
Monetary Area (CMA), comprising Eswatini, Lesotho, Namibia, and South Africa, is 
one of Africa’s longest-standing monetary unions. Despite this shared framework, 
significant disparities in maternal mortality and health financing persist across member 
states. Limited comparative research has examined whether monetary integration 
contributes to convergence in health outcomes. This study analyzed the relationship 
between health financing structures and maternal mortality among CMA member 
states, using Botswana as a non-CMA comparator, to generate evidence-based 
recommendations for strengthening regional health financing coordination, equity, and 
sustainability. 

Materials and Methods 
The study adopted a comparative mixed-methods design using panel data from 2015
2024 across Eswatini, Lesotho, Namibia, South Africa, and Botswana. Secondary data 
were obtained from the WHO Global Health Expenditure Database, World Bank World 
Development Indicators, fiscal reports, and national statistical reports. Key variables 
included government health expenditure, out-of-pocket payments, donor funding, and 
maternal mortality ratios. Quantitative analysis involved descriptive statistics, 
regression modelling and two factor analysis of variance (ANOVA), while qualitative 
insights from policy documents and expert perspectives were used to interpret policy 
implementation dynamics influencing health financing effectiveness. 

Results 
The findings revealed substantial disparities in health financing structures across CMA 
countries despite monetary integration. Eswatini and Lesotho demonstrated higher 
dependence on out-of-pocket payments and donor funding, while South Africa and 
Botswana maintained relatively stronger public financing systems and diversified 
funding mechanisms. Regression analysis showed that higher levels of out-of-pocket 
expenditure were significantly associated with elevated maternal mortality and weaker 
health outcomes. Although maternal mortality declined across all countries during the 
study period, improvements were uneven and did not demonstrate convergence among 
CMA countries. Comparative analysis further suggested that regional economic blocs 
such as the European Union have strengthened health system resilience through 
coordinated financing mechanisms including joint procurement and cross-border 
policy frameworks. 

Conclusion 
The study concluded that monetary integration alone does not ensure equitable 
maternal health outcomes. Reliance on out-of-pocket payments and donor funding 
remains a key driver of maternal mortality disparities across the region. The findings 
highlight the need for coordinated regional health financing reforms, stronger domestic 
resource mobilization and strategic purchasing reforms within the CMA.