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Without aid, who will pay for African healthcare?

In Kigali, at the World Health Organisation’s first ever Africa Health Forum, delegates have given themselves one not-so-simple task: to provide universal health care to all Africans.

But even should the assembled diplomats, medical practitioners, policy wonks and conference junkies figure out how to deliver on this ambitious goal, an even bigger question hangs over proceedings: who is going to pay for it all?

We know who is not going to pay for it. Western donors have funded many of Africa’s health initiatives over the years, including government-provided healthcare, but the aid is beginning to dry up, or be diverted to causes closer to home, such as Europe’s own refugee crisis.

Somehow, African countries are going to have to start footing their own medical bills.

“We are innovating new ways of financing apart from the budget and resources from development partners, because we know that development partners are declining,” said Claver Gatete, Rwanda’s finance minister.

World Bank research highlights the scale of this particular challenge. It shows that even though Africa’s health spend per capita has increased in the last 15 years, that increase was mainly driven by development assistance, and not government spending. Take donor funding away, and Africa risks losing the health gains made over the past decade – and stands no chance of introducing universal health care.

Unless something changes, that is.

Gatete says that it is essential to find new ways to finance healthcare – and suggests that his country is a model worth following. Other delegates agree: although activists often raise concerns about Rwanda’s respect for human rights and question the authenticity of the government’s much-lauded development statistics, in this particular forum and on this particular issue there is only praise for Rwanda’s record.

Gatete says that a key factor in Rwanda’s success was the imposition of mandatory health insurance, with a government subsidy to help those who can’t afford it themselves. Another is performance incentives for medical facilities that receive government money, to ensure that it is spent effectively. “We know that you don’t simply provide money. We have to make sure that it’s results-based financing. We give certain benchmarks that hospitals must meet to provide money,” he said.

In the absence of donors, Rwanda is looking at how it can raise funds for this domestically, and is planning to issue a social-impact bond, said Gatete. Social impact bonds only pay out to investors once a certain social impact is achieved. Moreover, Gatete said that the interest generated by any capital raised through the bond would be directed specifically into healthcare.

In neighbouring Uganda, the government is also planning for a decline in development assistance, and is looking for inspiration in an unlikely direction – Zimbabwe. Zimbabwe has instituted a 5% tax on all mobile data and call charges, which is supposed to go straight into a fund to help combat HIV/Aids. “Borrowing a leaf from Zimbabwe, we are now putting in place an HIV trust fund,” said Uganda’s minister of state for health, Sarah Achieng Opendi.

“We are also going to have an immunisation fund. These are some of the interventions we are putting in place. Not forgetting that we have to have our own health insurance scheme in place. Right now we are a finalising the bill in Parliament [to make mandatory health insurance happen].”

For Timothy Evans, the World Bank’s senior director of health, nutrition and population, the key to financing healthcare in Africa lies in small, scalable efficiencies. It’s not necessarily about spending more, but about spending more effectively. “We have to focus on spending existing money well…Nitty gritty interventions have a disproportionate impact on efficiency, and we need to share and scale these efforts,” he said.

Githinji Gitahi, chief executive of Amref Health Africa, Africa’s largest health development NGO, agrees that mandatory national insurance is the most effective way to fund universal health care. “We expect our communities to insure our motorcycles, but you’re okay to go around without insuring your life. The most successful way [of delivering healthcare] I’ve seen is to make health insurance mandatory, and then provide subsidies for the poor, and then mobilise communities to demand their rights,” he said.

This last point is particularly important. “I am yet to see a family in any African country that has lost a child and has gone to court to sue the government for the loss of that child. The day that happens is the day that financing for universal health care will be resolved,” said Gitahi – because then governments will be forced to do something about it.

There is plenty of money, in other words, to fund African healthcare. It’s now up to Africans to demand that their leaders spend it wisely.

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Simon Allison
Simon Allison
Simon Allison is the Africa editor of the Mail & Guardian, and the founding editor-in-chief of The Continent. He is a 2021 Young Africa Leadership Initiative fellow.

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