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Africa is sick of its health system
GFO issue 434

Africa is sick of its health system


Christian Djoko

Article Type:

Article Number: 6

Increasing domestic health financing in Africa: the challenges and the need

This article highlights the need for African countries to build resilient and sustainable healthcare systems that are essentially, if not entirely, dependent on domestic funding. It is in their best interests to do so.




With 1.3 billion inhabitants, or 17% of the world’s population, the African continent has the highest burden of disease in the world. 25% of the world’s sick, all diseases combined, are African. In a document published in 2019, entitled A Heavy Burden: The Productivity Cost of Illness in Africa, the WHO estimates that the loss of productivity due to diseases and epidemics affecting the population of the 47 countries in the African region amounts to $2.4 billion a year, or 630 million years of working life lost.


The same report reveals that 14 million Africans are pushed into poverty every year because of ever-increasing healthcare costs. “With around a hundred health emergencies a year, the costs are exploding for Africans, whose per capita out-of-pocket payments rose from $15 in 1995 to $38 in 2014“. The least we can say is that the economic cost of poor health is extremely high for the vast majority of the continent’s poor and vulnerable populations.


The absence of a pan-African medicines policy is also part of this disastrous situation. Although the drugs market is worth nearly $1.2 billion dollars, the continent produces only 3% of the drugs consumed by its inhabitants. What’s more, almost all (99%) of the vaccines administered in Africa come from outside the continent. Added to this is the very high prevalence of counterfeit medicines. This represents an average of 20% to 40% of medicines in circulation.


More generally, Africa is sick of its health system. In Abuja in 2001, African countries committed themselves in the Abuja Declaration to devoting at least 15% of their annual budget to improving the health sector. However, in 2018, only two countries had achieved this target in any given year. Nigeria, the host country of the famous declaration, devoted just 4.1% of its total expenditure to health. Between 2001 and 2015, “public spending on health, as a proportion of total spending, [even] decreased in 21 African countries“.


Indeed, GFO has published numerous articles on this topic, the most recent being in February this year (Determining, analysing and increasing domestic financing for health) but see also  Increase in domestic health financing in Africa will be hard amid COVID-19, Mobilizing Parliamentarians to help garner support for increasing Domestic Financing of Health, to give you a flavour of the various articles.


This chronic under-funding of the healthcare system in Africa in general, and in West and Central Africa in particular, necessarily has a major impact on the system’s performance. As can be seen from the table below, while coverage of fourth-line antenatal care varies from 40% to 90%, domestic funding is low, as are human resources for health (HRH), laboratories, data and supply chain systems – resulting in poor availability and delivery of services.


Figure 1. Health system performance in West and Central Africa

In this context, the emergence of the COVID-19 pandemic has only exacerbated an already harmful situation.


COVID-19 highlighted the under-investment and vulnerability of healthcare systems in Africa


In fact, as well as exposing global health inequalities, “every man for himself” and vaccine nationalism, the COVID-19 pandemic also served to put a spotlight on the glaring weakness of African health systems. There was a huge gap between rich and poor countries, between countries that were able to buy or produce vaccines, drugs or medical equipment and those with extremely limited resources.


Far from being considered a global public good, the COVID-19 vaccines were distributed according to the law of the highest bidder. Wealthy countries made advance purchases of doses far in excess of what was needed to vaccinate their entire populations. Canada, for example, purchased stocks equivalent to 9.6 doses per citizen. These trade agreements between the pharmaceutical industry and the rich countries exerted upward pressure on vaccine prices, thereby reducing the number of doses available to other nations, in this case poor countries.


“While it is recognized that countries have a primary moral responsibility towards their own populations, this does not exempt them […] from the duty not to undermine the efforts of other countries and their ability to fulfill their responsibility towards their own populations.”

Commission éthique de la science et de la technologie du Québec



At one point during the crisis, almost all African countries were dependent on deliveries of vaccines distributed under the COVAX programme. India and South Africa lobbied unsuccessfully for a temporary waiver of World Trade Organization (WTO) rules to speed up vaccine production and accessibility to poor and low-income countries. In February 2021, “seven countries accounted for 80% of the doses administered worldwide, while nearly 130 countries had not yet administered any doses“.


Such disparity is both a challenge and a call to action. What action? If there is one thing that the pandemic has (re)taught us, it is the need for the African continent to move away from its dependence and inordinate expectations of international solidarity, and gradually but resolutely move towards increased, independent funding of its own healthcare systems. To achieve this, governments must first and foremost stop perceiving health allocations as financial sinkholes or optional expenses that can be slashed when the time comes to finance prestige projects. Health is one of the vital and essential sectors in which Africa must invest if it wants to free itself from the dependence that still structures humanitarian aid and North/South relations in many respects. The scale of the consequences of future crises will depend on current investment in this sector. As Shakespeare said, “The wise man never grieves for present evils, but uses the present to prevent others”.


Global Fund investments and co-financing


With regard to HIV, tuberculosis and malaria, the Global Fund’s Strategy 2023-2028 calls on governments to invest in strengthening health systems: see the first “mutually reinforcing contributory objective” in the diagram below.

Source: The Global Fund


For the Global Fund, it is more important than ever to invest in resilient and sustainable systems for health (RSSH). Disease surveillance systems, laboratory networks, supply chains and community health workers are essential to defeating HIV, TB and malaria. Very concretely, the Global Fund’s strategic directions for the 2023-2025 allocation period suggest that countries eligible for Fund financing should invest in RSSH as a priority. The aim is to:


  1. Strengthen integrated, people-centred, quality health services to improve outcomes in relation to HIV, tuberculosis and malaria.
  2. Ensuring alignment with “critical approaches” for the management of health products, laboratories and HRH systems.
  3. Contributing to pandemic preparedness by strengthening laboratory, surveillance, human resources, health product management and medical oxygen systems.
  4. Improve the measurement of RSSH using the revised Modular Framework (modules, interventions, indicators and monitoring measures in the work plan).
  5. Take account of protection from sexual exploitation, abuse and harassment (PSEAH) and child protection (see guidance note).


The Global Fund is destined to disappear, as French President Emmanuel Macron recently emphasized during his speech at the Seventh Replenishment Conference in New York in September 2022. One of the aims of the Global Fund’s Sustainability, Transition and Co-Financing Policy is to help countries gradually free themselves from subsidies, with a view to strengthening their capacity to finance and manage programs to combat these diseases themselves. Here are some of the key points of this Policy:


  • Additionality or complementarity of resources: The Policy follows the principle of complementarity of Global Fund resources, which means that countries must mobilize additional resources to supplement Global Fund grants.
  • Planning: The Policy encourages countries to plan for future sustainability challenges, including transition, well in advance of their occurrence.
  • Co-financing: The Policy encourages countries to co-finance programs to combat these diseases, which means that they must contribute financially to these programs.
  • Strengthening health systems: The Policy encourages countries to strengthen their health systems so that they can manage their own programmes to combat these diseases.
  • Evaluation: The Policy provides for regular evaluation of the progress made by countries in implementing the Policy.


There are many issues and challenges associated with co-financing. These have often attracted our attention, as can be seen in the examples of our articles mentioned above as well as The uncertainty of co-financing. In the meantime, the Global Fund’s Sustainability, Transition and Co-financing Policy looks at co-financing in terms of both requirements and incentives. Thus, “to access the amount allocated to them by the Global Fund, countries must demonstrate a progressive increase in public spending on health and a gradual assumption of the main costs of programmes, particularly those supported by the Global Fund“. In concrete terms, they must contribute at least 15% of their allocation.


More broadly, the Global Fund is encouraging the countries that benefit from its grants to develop resilient and sustainable healthcare systems, firmly backed by domestic financing. This is a laudable objective. It is desirable for the Global Fund to disappear because diseases will have been defeated as public health threats, but above all because states, in this case African states, will have developed genuine resilient and sustainable systems for health.


The task is immense, even insurmountable, some might object. Indeed, there should be no illusions about the Herculean task involved in realizing such a prospect. Deteriorating global economic conditions, rising inflation, poverty, food shortages and concerns about excessive debt could even serve as an excuse for some governments to cut health spending. However, it is important to remember that the health budget should never be seen as an expense, but always as an investment. All economists agree that a healthy society and a robust healthcare system are guarantees of sustainable economic and human development. If you doubt this, re-read the WHO report (A Heavy Burden: The Productivity Cost of Illness in Africa) mentioned at the beginning of this article.


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