Boosting domestic financing for health in Africa

Date published on source: 
20 July 2015
Chukwuma Muanya
Source organisation: 
The G
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Worried that the huge successes recorded in recent times in the control and treatment of diseases such as Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS), tuberculosis (TB) and malaria may be lost as international donor funding begins to dwindle and limited resources are focused on the most urgent needs, stakeholders have made recommendations on how to improve domestic financing for health in Africa.

The experts at the ongoing 'Third International Conference on Financing and Development' in Addis Ababa, Ethiopia said since most African countries depend largely on donor funds to run their health and development programmes, they must now identify sustainable alternatives that are not donor-driven, resources to support health systems.

The stakeholders said countries like Nigeria, Ghana, Namibia, Kenya, South Africa do not need donor funds to run their health programmes; African countries need to spend $86 per capita for minimum health care; $186 billion spent on Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) in 14 years to put 15 m people on treatment with 55 per cent of the money coming from domestic funding especially in Africa; and that only six countries-Niger, Zambia, Burkina Faso, Malawi, Rwanda and South Africa- have met Abuja Declaration that all African countries should allocate at least 15 per cent of national budgets for health.

The stakeholders include African Union Commission (AUC), Global Fund to Fight AIDS, TB and Malaria, United Nations Economic Commission for Africa, World Health Organisation (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), UN Sustainable Development Solutions Network, Health Policy Project, United States Agency for International Development (USAID) among others.

UNAIDS announced that the goal of 15 million people on life-saving HIV treatment by 2015 has been met nine months ahead of schedule. The world has exceeded the AIDS targets of Millennium Development Goal (MDG) 6 and is on track to end the AIDS epidemic by 2030 as part of the Sustainable Development Goals (SDGs).

The WHO estimates that $86 per person per year is the minimum spending required to provide essential health-care.

Heads of State in Africa met from April 26 to 27, 2001 at a special summit in Abuja to address the exceptional challenges of HIV/AIDS, tuberculosis and other related infectious diseases. At this meeting, the governments committed to allocating at least 15 per cent of their total annual government budgets to the health sector. They also called upon donor countries to meet their commitment of devoting 0.7 per cent of Gross National Product (GNP) as official development assistance and cancel African external debt in order to allow increased investment in the social sector.

According to the World Health Organisation (WHO), since 2001, a number of countries have made progress in increasing their domestic funding towards the Abuja 15 per cent target. The WHO states that only Rwanda and South Africa have reached 15 per cent, while the African Union Commission (AU) reports that six African Union (AU) member states have met the 15 per cent benchmark- Rwanda (18.8 per cent), Botswana (17.8 per cent), Niger (17.8 per cent), Malawi (17.1 per cent), Zambia (16.4 per cent), and Burkina Faso (15.8 per cent).

Nigeria worse than even war-torn countries in health care performance

The Guardian investigation revealed that since the Abuja Declaration in 2001 Nigeria has never spent more than 8 per cent of its annual national budget on health. In fact it the country has been spending an average of six per cent of its budget on health in the last six years.

Also, Nigeria and 27 other countries have worse health care systems than Liberia's. A report from the nonprofit organization Save the Children, published in March 2015, ranked 72 countries on six measures of health-care provision for children, including the newborn mortality rate, the number of health-care workers per 10,000 population, immunizations and skilled birth attendance. The result, Save the Children found, is that 28 nations fared more poorly than Liberia (which ranked 44th), including Nigeria (70th), Haiti (68th), Pakistan (57th), India (55th) and Kenya (47th). The two other Ebola-ravaged countries, Sierra Leone (46th) and Guinea (65th), also fell below Liberia. Somalia is last at 72nd.


Meanwhile, the stakeholders at a side event on 'Domestic Financing for Health in Africa' provided hands on examples of tools and how to use data effectively for costing and analyzing expenditures in national and local governments; and creative examples of successful social media and local advocacy to monitor and support accountable health expenditures.

To boost domestic financing for health in Africa, the stakeholders recommended among other things: using new technologies to make health systems more effective and cheaper; increasing taxation on alcohol and tobacco products; increasing national budgets on health to meet the Abuja Declaration for 15 per cent of national budgets; introduction of AIDS tax, which has been very successful in Zimbabwe.

Other recommendations include: pursuing universal coverage using health insurance, a pre-paid mechanism; proliferation of sharing of knowledge and experiences; increased global partnerships; establishing private sector trust fund for health; encouraging high network individuals to step their contributions to health; improved domestic leadership and ownership of programmes; accelerating innovative financing mechanisms for health.

They, however, said a lot of progress has been made in domestic investments in health. For instance, Africa is mobilizing more domestic resources in health than foreign development investments. In the last four years, African countries have increased their domestic resources to respond to HIV by 150 percent.

The stakeholders concluded: "Failure to sustain and increase domestic finances would result in losing the historic opportunity to defeat diseases such as HIV, tuberculosis and malaria, which are now in retreat. Besides increasing countries' ability to respond to diseases and outbreaks, increased domestic resources will foster country ownership and improve sustainability of country programmes."

An earlier panel put together by the AU had said Africa has what it takes to pull together domestic resources to finance its health sector, starting with the continent's characteristically high growth rate which has given it worldwide attention in the past years.

The panelists enumerated a number of strategies that would help gather internal resources for the health sector. These include, amongst other things, long term planning, campaigning for the buy-in of wider society of such plans in each country, increasing resources for acquiring health inputs by laying emphasis on agriculture, education and mining. Such a strategy also needs better tax collection mechanisms, human resource upgrading in view of the structural transformation of economies, improving transparency in the extractive industries and reviewing tax regimes to help stem tax evasion.

Increasing domestic funding for health

Executive Director of UN Sustainable Development Solutions Network, Mr. Guido Schmidt-Traub, said: "The good news is that the main constraint on health is financing and achieving it will require international co-financing for low income countries. Domestic resources alone cannot solve all the problems in low-income countries. We need more leadership to make more case for investment in health in Africa."

Schmidt-Traub said it costs health system $86 per capita spending on health to provide minimum care per capita and the best Abuja Declaration of 15 per cent of yearly budget for health can give any African country is $30 per capita. He said countries like Nigeria, Ghana, and Kenya have about $2.5 per capita and do not need significant international financing.

He added: "Global vaccine alliance (GAVI) and Global Fund have shown that pooling resources is the way to go. Their investments have led to technological innovation in preventive and treatment measures such as the insecticide treated nets, rapid malaria diagnostic tests. This is unprecedented development but the real challenge is to sustain the financing. Even the countries that do not need donor funds, like Namibia, need the knowledge and international cooperation. We need to sustain the innovation and the fight. Without good health, there is not going to be sustainable development."

Commissioner for Social Affairs at the AU, Dr. Mustapha Sidiki Kaloko, said: "We really neeed to take care of health and everything would take care of itself. Renewed initiative on nutrition and immunization is one way we can sustain ourselves without donor funds. The roadmap places finances at the heart of stopping AIDS, TB and malaria. There is need to diversify sources of funding to sustain progress. Agenda 2063 lays out seven priorities.

"Accelerating innovative financing mechanism for health is key. Alcohol and tobacco levy. Increased global partnership to ensure that we end AIDS, TB and malaria by 2030; if we increase our finances for health. We are advocating for domestic financing but we still need external funds with domestic financing leveraging external funds. The problem we have been dealing with before now is member states with different ideas. We came up with putting levies on tourism and hotel rooms but some countries ran it down. We also came up with alcohol and tobacco levies and levy on mobile phones. The major problem is that 70 to 80 per cent of the African populations are on rural economy. Africans are very poor on paying taxes and it is only 20 per cent on official employment that are paying tax. But we can only make recommendations. We come up with decisions which are not always favourable."

Executive Director Global Funds, Dr. Mark Dybul, said: "How to increase domestic financing for low and middle income countries? We need domestic leadership and ownership. Rwanda fully runs its health response. Declining infection rates are key. Check out countries that are doing innovation like Zimbawe, Senegal, Kenya, Tanzania, Uganda. We have incredible opportunity to end AIDS, TB and malaria with increased domestic financing. It comes down to results. Decreasing infection rates in AIDS, TB and malaria will gear spending on prevention and treatment. There is need for private sector trust fund for health. High network individuals should step up."

Deputy Executive Director UNAIDS, Dr. Luiz Loures, said: "There is no question that we need more drugs for HIV/AIDS. We have made significant progress since 1999. We spent $186 billion between 2000 and 2014 and 55 percent is from domestic sources mainly from Africa. South Africa, Namibia, Botswana are leading in Africa in terms of domestic funding for health. They pay more and more from their own resources. It is very much on the issue of ownership. One African President said, 'if you don't pay then you don't own.'

"Increase domestic funding, increase leadership and governance and increase ownership. We know that not all countries can pay but there is still going to be solidarity. We still need international support but there is need to be a balance. 115 million people are on treatment today according to our latest figures, which would be released later today. In Nigeria the space is there but less political commitment. If we want to see that there is end to AIDS. But there cannot be end to AIDS without Nigeria being involved. For each dollar spent on AIDS, we are gaining 17 dollars. So it is good business to invest in. In the last data three million infections were prevented and at least 80 million deaths because we did the right thing. It is good for business but also good for the people. If you invest in health you are saving lives."

Domestic health investments in Africa continue upward momentum

In a report released February 10, 2015, Friends of the Global Fight Against AIDS, Tuberculosis and Malaria highlighted ways in which Global Fund implementing countries are increasing domestic investments in health. The report, titled Innovation for Greater Impact: Exploring Resources for Domestic Health Funding in Africa, illustrated how, through a variety of approaches, African governments are mobilizing additional resources to fight HIV/AIDS, tuberculosis and malaria.

Friends' President Deb Derrick said: "Impressive global progress has been made against the three diseases in recent decades and African governments are really stepping up. They have increased their domestic health financing by 150 percent.  But the fight is not yet over. To sustain momentum and ultimately defeat these diseases, increased funding will need to come from implementing countries and the Global Fund is working to facilitate this."

Many countries are already taking important steps in this direction. Six African countries - Liberia, Malawi, Rwanda, Swaziland, Togo and Zambia - are on track to reach the agreed Abuja target of allocating 15 percent of government spending on health. Such countries, on average, spend 20 times more of their own resources on health than they receive in assistance.

Several countries included in Friends' report are exploring ways to mobilize new revenue through innovative financing. For example, Kenya, Tanzania and Zimbabwe are developing trust funds to increase resources to combat HIV/AIDS. With a track record of effective use of international funding, Rwanda is pioneering a results-based financing model that allows for self-generated savings to be ploughed back into the country's HIV/AIDS response.

Derrick said: "This report highlights some great examples of innovative domestic financing. The case studies tell a story of collaboration, partnership and progress, and of movement toward a healthier, more sustainable future."

Countries that took charge have produced results

According to the UNAIDS report, countries that rapidly mounted robust responses to their epidemics saw impressive results. In 1980, life expectancy in Zimbabwe was around 60 years of age. In 2000, when the MDGs were set, life expectancy had dropped to just 44 years of age, largely owing to the impact of the AIDS epidemic. By 2013, however, life expectancy had risen again to 60 years of age as new HIV infections were reduced and access to antiretroviral treatment expanded.

Ethiopia has been particularly affected by the AIDS response, with 73 000 people dying of AIDS-related illnesses in 2000. Concerted efforts by the Ethiopian government have secured a drop of 71 per cent in AIDS-related deaths between the peak in 2005 and 2014.

In Senegal, one of the earliest success stories of the global AIDS response, new HIV infections have declined by more than 87 per cent since 2000. Similarly, Thailand, another success story, has reduced new HIV infections by 71 per cent and AIDS-related deaths by 64 per cent.

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* Related: ‘Nigeria’s health sector worse than those of war-torn nations’ (Chukwuma Muanya, The Guardian)