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Universal Health Care in Africa: Will things be different this time?

Most of Africa’s public health care systems resemble overburdened, under-resourced and sick donkeys. They are often a major epidemic away from collapse.

  • In the Democratic Republic of Congo (DRC), the World Health Organisation recently declared the Ebola outbreak a global public health emergency due to its “concerning geographic spread”.
  • In Madagascar, a measles outbreak, affecting more than 110,000 people, killed more than 1,200.

Policy-makers know what ails the donkey – a legacy of poor staffing, no drugs or equipment, and dilapidated infrastructure. From the DRC to Madagascar, health ministries’ shelves are groaning under the weight of policy documents aimed at addressing these problems.

But, the donkey is still sick.

Dreaming big

Compelled by domestic or international pressure, African politicians will sometimes declare big dreams for the donkey.

  • In Kazakhstan’s largest city, Almaty in 1977, they announced “Health for All by 2000”.
  • In New York in 2012, they proclaimed Universal Health Coverage (UHC) by 2030. The UHC tenets are noble: financial risk protection; equitable health access; and quality health care for all.

More than 100 million people are pushed into extreme poverty each year due to catastrophic health expenditures, and 3.7 billion people don’t have access to all essential health services. It is imperative that we learn from past mistakes to succeed. Our people’s lives depend on it.

Unfortunately, there is a common theme to past failures, some of which the UHC has begun to replicate.

  • Completion dates are often set far into the future when the signatories are, conveniently, no longer on the scene. This suggests an ambivalent political will.
  • When the initiatives fail, they are silently shelved. The reasons behind the flops are rarely analysed.
  • Unrealistic financing expectations pay little attention to competing domestic priorities, threatening to sink the UHC agenda.

External funding accounts for nearly half the health budgets of some African countries. Future funding is precarious, with increasing donor fatigue.

  • To attain these basic UHC standards, Zambia, for example, needs to spend an additional $3.1bn annually. That’s roughly the same amount of money it owes China.
  • Oil-dependent Nigeria’s 2019 health budget is $1.7bn. It needs an extra $24.7bn to meet the UHC standards, while also seeking funds to fight Boko Haram.

Will history repeat itself?

African governments will have to look internally for money to fund UHC programmes. But, if history repeats itself, it is unlikely that health budgets will increase. In 2001, prompted by a raging HIV/AIDS epidemic, African leaders meeting in Abuja, Nigeria, pledged to set aside 15% of their annual budgets to strengthen the health sector. Nigeria has never reached the target set by the Abuja Declaration. Only a handful of countries have attained it. Most have since relapsed.

Those who argue that this time things will be different should take a quick look at African political leadership since 2001. A number of Abuja Declaration signatories like Uganda’s President Yoweri Museveni are still in power. Across the continent, most opposition parties struggle to gain a meaningful foothold. The status quo leadership remains, and it is unclear when that  ‘Road to Damascus’ moment may occur.

Agenda building

In the meantime, a few things can be done:

  • The little money we have should be used well.
  • Health ministries should produce evidence to guide the selection of programmes that are covered under UHC.
  • Parliaments should set cost thresholds for health programmes.
  • Cost-benefit evaluations are required before major investments are made, akin to the system in the United Kingdom.
  • Focus should be on delivering the basics – immunisations, safe births and early malaria diagnosis and treatment.

The recent cholera outbreak in one of Kenya’s leading private hospitals is a good indicator of the folly of ignoring primary care services. It makes little sense to buy or lease fancy medical equipment if the majority of the population has no access to clean water.

At the same time, corruption must be rooted out. For example, a receptionist with the Kenya National Health Insurance Fund who charters helicopters to beat traffic should be dealt with severely. To be sure, this is easier said than done. Yet, there are encouraging signs that some African governments are taking corruption seriously.

Once this is done, then the politically tricky choices of raising taxes can be considered. Raising personal income or corporate tax rates may not be viable given high unemployment rates. A better option would be to hike sin taxes on alcohol and cigarettes, or processed foods like sodas. Governments will also need to evaluate the impact of these taxes on revenues, or on inducing the consumption of poor-quality substitutes.

The bottom line: If common sense does not prevail, universal health coverage will join past initiatives in the donkey dung heap of global health history.


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