Nairobi — Thirteen years ago this month, member states of the African Union met in the Nigerian capital and adopted binding commitments to spend at least 15 percent of their national budgets on health and urges donor countries to increase financial support for the continent's heath sector. What is now known as the Abuja Declaration recognized that Africa's future rests on the health of its people. In this guest column Dr. Githinji Gitahi, head of one of Africa's leading health organizations, looks back at that goal and forward at what needs to be done.
The Abuja Declaration gives a clear and measurable target, leaving little room for debate. It provides a straightforward metric to assess which countries have met the 15 percent goal, those that haven't, and those worthy of celebration for their achievements. However, while the spending benchmark serves as a tangible indicator of a government's commitment to healthcare, it falls short in addressing the broader determinants of population health.
While its demand for a 15 percent allocation is unequivocal, that target often diverts attention from the fact that this measurement primarily focuses on financing healthcare service delivery. Yet, crucial factors that significantly impact health outcomes, disease reduction, and cost burdens like water, sanitation and nutrition remain costed and accounted for elsewhere.
Analysis reveals that approximately 60 percent of the 15 percent allocation goes towards inpatient care, outpatient care, and medical goods, with the remainder spent on health system governance and administration. While some funds trickle down to maternal and child health services, this allocation fails to take into account the broader spectrum of health determinants.
Further, while the percentage seems to be a single powerful measure, it is weak, because it assumes that 15 percent of a chicken can achieve the same as 15 percent of an elephant. Let's do some math.
The GDP of sub-Saharan Africa stands at US$2 trillion (2024). Since social services like health are paid for largely through taxes, applying a 15 percent tax-to-GDP ratio puts total tax collections at $300 billion. A 15 percent allocation of these taxes to health would produce $45 billion. Dividing this figure by the region's population of 1.2 billion in 2024 yields a crude calculation of what may be available on average as Government General Expenditure on health per capita.
A meagre $37.5!
It's about population and economics.
This starkly contrasts with Europe, where a GDP of $20 trillion, a tax-to-GDP ratio of 41 percent, a population of 448 million and a similar 5 percent allocation to health results in a significantly higher per capita expenditure of $2,600. The disparity is evident, with many European countries allocating up to $4000 per capita, while lagging nations like Bulgaria and Romania allocate approximately $1000.
It becomes evident that, given the GDPs of sub-Saharan African countries, no percentage, let alone the 15 percent target, can adequately address healthcare needs under the current biomedical approach of waiting for people to get sick and treat. None!
This reality is reflected in the fact that 15 percent of the world's population in high-income countries accounted for 80 percent of total global health spending in 2020 One country, the United States of America, accounts for 44 percent of all spending, while low-income countries, with 8 percent of the world's population, accounted for just 0.2 peercent. It's population and economics.
The real building blocks of health lack the same attention that spending targets receive.
The fixation on the 15 percent benchmark, while crucial as a gauge of government dedication, poses the risk of directing all health advocacy efforts solely towards the proportion of healthcare funding, thereby diverting attention from the actual problem, which is health.
True health is the asset that stems from investments in education, particularly for girls, as well as in good nutrition, access to clean water and sanitation, unpolluted air, and an active lifestyle. However, none of these vital components receive adequate funding within the confines of the 15 percent allocation. A singular focus on financing leads to sub-optimal focus on such critical sectors as agriculture, water and sanitation, energy, security, and community empowerment – the real building blocks of health.
Hospitals in Africa are inundated with children suffering from preventable diseases like diarrheal diseases, pneumonia, and malaria, requiring significant care costs, while significant healthcare expenses are also directed towards managing maternal and neonatal complications.
Additionally, there's a rising burden of admissions for intensive care due to cardiovascular diseases, along with escalating costs associated with renal dialysis units and preventable cancers like cervical cancer. Despite these pressing challenges, little or no part of the 15 percent Abuja target is used to address the causes behind these challenges.
Health advocates are distracted by the focus on 'health financing' instead of 'financing health'.
Africa must look beyond its borders across the Mediterranean Sea to observe that average healthcare expenditures are still inadequate, despite over $4000 per capita expenditure. There are long waiting times to access care.
Will only 15 percent of total government outlays allocated to Africa's health ever be affordable. The answer is clear – not in this generation or the next!
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Africa cannot afford to provide adequate healthcare to its people unless it refocuses spending on the building blocks of health.
Given this realization, Africa must acknowledge its inability to afford healthcare and must shift focus towards investing in health, which proves to be a more economical approach. This includes not only the core components outlined by the World Health Organization's Health System building blocks – such as Service Delivery, Health Products and Technologies, Health Workforce, Health Information Systems, Health Financing, and Leadership and Governance – but also encompass a holistic approach.
This holistic approach involves maintaining healthy populations through disease prevention, health promotion, community awareness and empowerment, universal access to clean water and sanitation, and ensuring good nutrition. Furthermore, it necessitates safeguarding citizens from harmful foods and beverages through the implementation of pro-health food policies.
This imperative underscores the need for a new health order where planning for health starts with addressing the social and commercial determinists of health. Such a transformative approach should be our interpretation of the World Health Day theme; 'My Health, My Right'!
Dr. Githinji Gitahi is Group CEO of Amref Health Africa.
