on Monday, 26 April 2021.

Dear Colleagues,

Here is a discussion on health financing in Africa. It is one of our most challenging barriers to UHC.

Annual budget negotiations with national parliaments are going on right now in a number of African countries. Difficult decisions are being made on which aspects of health budgets should be prioritized for funding. This gives us an opportunity to contribute to these ongoing national and regional budget discussions.

Let us start by gaining a common understanding of health financing. It is defined here as “the raising, pooling and spending of financial resources with the primary intention of improving health”. The sources of health financing are the general tax, donor aid, deficit funding (or borrowing), ear-marked taxes, and social and private health insurance. This should exclude out-of-pocket spending by individuals at the point of receiving health care. Expenditures are made in health facilities, on community and out-reach services, pharmacies, drug shops, sanitation, nutrition, training and research. Today, health financing remains the most intractable challenge for the health and development globally. Indeed, some have argued that Universal Health Coverage (UHC) in poor countries cannot be funded internally.


Yet the health of the people is central to everything as it is a precondition for their well-being and productive lives. The right to life is also a right to health and a right to a responsive health system. The second foundation is our innate humanity of feeling for each other so that the pain and suffering of one is felt, shared and addressed collectively and “no one is left behind” to suffer alone. On top of these moral arguments is the new evidence that health is no longer perceived as a cost but is an investment with high social and economic returns. The health economy on its own contributes to economic growth, employment and Gross Domestic Product (GDP). Indeed, the purpose of all Sustainable Development Goals (SDGs) is to contribute to the health and well-being of people and of our planet. Last but not least, voters value their health and investing in the health and well being of the population has high political returns.

Africa made major gains in health indices during the Millennium Development Goals (MDG) period. However Africa still lags far behind other regions of the world in health indices. The opportunity of SDGs and UHC should be used for Africa to catch up. This is why UHC is a political choice made by governments to provide citizens with the health services that they need without financial barriers. Strong government leadership is essential to create the conditions that enable people to live healthy lives. This includes marshaling actors from all government sectors and the whole of society to deliver integrated people-centered PHC by enacting enabling laws and regulations, providing access to information, healthy food, clean water, decent housing, quality education and other resources.

Many poor countries have proved that a country should not wait to become rich to attain quality universal health care. Studies have shown that poor quality of health care linked to low level health financing causes more deaths than disease itself. Furthermore, the Alma Ata Declaration on Health for All states that “Primary health care is the essential health care made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development”. The World Health Organization has recommended an annual per capita health expenditure of US$86. Countries can therefore take immediate progressive steps towards reaching this expenditure target. The Abuja Declaration which called for 15% of national budgets need to be applied with caution. Finance ministers do not find it workable, if each sector claims a percentage of the budget which add up to over 100%.

Existing resources in any nation can be used in such a way that a package of basic health care can be provided to everyone. The illustrious examples of poor countries are Costa Rica, Sri Lanka, Cuba, Kerala of India, Vietnam, Thailand and Indonesia. These countries took 20-30 years to attain universal health care and reduced their mortality to as low as that of the wealthy nations. The achievement of good health at low cost is possible based on the principles of political commitment to health as a social goal, a strong societal value of equity, political participation and community involvement, high investment in primary health care and other community based services, universal education, especially of women, and inter-sectoral collaboration for health.

African political leaders are called upon to commit to UHC and embark on this journey resolutely starting now with available resources and growing over time along the following five point plan:

(i) Through open national dialogue enact health financing laws,

(ii) Reorganize the governance of the health system to provide capabilities to implement the enacted health laws effectively and efficiently,

(iii) Agree a basic package of community-based promotive and curative health services based on the burden of disease and other mutually agreed criteria. Basic package services should be provided free at the point of service delivery, paid from general taxes and delivered through integrated, inter-sectoral, people centered PHC,

(iv) Provide services beyond the basic package by introducing a menu of financing mechanisms including ear-marked taxes, community, social and private health insurance schemes. These must be well governed to minimize inefficiency, waste and corruption,

(v) Monitor and review the performance of the health system regularly and make adjustments to grow the size of the basic package over time matched with the economic growth.

What do you all think?


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