On August 29, JCIE co-organized an event on Achieving Sustainable Financing for Health in Africa on the sidelines of the Seventh Tokyo International Conference on African Development (TICAD7). Building on commitments made at the Africa Leadership Meeting on Investing in Health (ALM) held in conjunction with the African Union (AU) Summit in February 2019, the event focused on the mobilization of domestic resources for health in African countries and on effective and sustainable use of funding.
Rwanda and Senegal were highlighted for the progress they have made toward strengthening domestic resource mobilization (DRM) and establishing universal health coverage (UHC), with Rwanda’s president, Paul Kagame, having been named a champion of health financing by the AUC. In keeping with the spirit of collaboration and coordination among relevant ministries, the event featured keynote addresses by Rwanda’s Minister of Finance and Economic Planning Uzziel Ndagijimana and Senegal’s Minister of Health and Social Action Abdoulaye Diouf Sarr. Both countries have made significant increases in financing for health, which has led to expanded access to health services among their most vulnerable populations and, ultimately, increased life expectancies. Still, both ministers acknowledged that much more progress is needed if their countries are going to achieve the SDGs and emphasized the importance of maintaining momentum that has been built in recent years.
Japan’s Vice Minister for International Affairs Yoshiki Takeuchi offered welcome remarks on behalf of the Japanese government. He referenced Japan’s commitment to supporting countries around the world in achieving UHC, particularly while they are still at early stages of development, arguing that in addition to stronger health systems, sustainable finance mechanisms that draw on domestic resources are critical to the long-term maintenance of UHC.
Amira Elfadil Mohammed Elfadil, the AU commissioner for social affairs, provided an overview of progress that African countries have made so far toward meeting the commitments made at the ALM, citing the creation of regional hubs for DRM and new tools to track and accelerate progress, such as the Africa Scorecard on Domestic Financing for Health. She also discussed African countries’ contributions to the Global Fund replenishment, explaining that it is a way for Africans to take ownership over the solutions in their own communities and stressed the importance of political will in order to maintain progress that has been made on DRM and sustainable financing. Support for the ALM was reiterated by most of the speakers throughout the event, who cited the trend toward consolidation of leadership around DRM in Africa.
A panel discussion moderated by Mark Dybul, co-director of the Center for Global Health Practice and Impact at the Georgetown University Medical Center, brought together leaders from many of the major global health organizations to discuss the state of health financing and concrete steps for improving health financing in Africa. Ikuo Takizawa, deputy director general of the Human Development Department at the Japan International Cooperation Agency (JICA), highlighted the importance of careful coordination with strong country ownership among various partners in order to achieve UHC, a point that was echoed by many other speakers. As one of those partners, Global Fund Executive Director Peter Sands described the concrete ways that his organization contributes to DRM. He explained that the Global Fund, like Gavi and other global health financing mechanisms, integrates co-financing requirements into grant agreements and supports local governments’ ability to manage and allocate financing in cooperation with partners in each country. He called on all partners to be as supportive as possible of country-led responses to health challenges. Annette Dixon, vice president for human development of the World Bank discussed the role of International Development Association (IDA) loans in those partnerships, providing critical financial support for primary healthcare and health system strengthening and helping to build domestic capacity for financial management and efficient resource use in the world’s poorest countries through partnership with the Global Fund, Gavi, the Global Financing Facility (GFF), and bilateral donors. IDA and GFF are both explicitly designed in part to use their resources to leverage domestic financing for health.
One major theme of the discussion was equity, with Rosemary Mburu, of the UHC2030 Civil Society Engagement Group and executive director of WACI/Health for All in Africa, asserting that financing needs to be carefully designed to support the most vulnerable individuals and communities, many of whom still do not have access to health services. Ms. Dixon reminded the audience that even with increases in financing, the burden of health costs falls heavily on households, particularly those who are least able to afford it, and 100 million people have been pushed back into extreme poverty because of health costs, a number that will only continue to grow if financing stagnates in the face of rapid population growth in Africa. In order to address the equity challenge, Regional Director of the WHO Regional Office for Africa Matshidiso Moeti and others argued that, while insurance schemes can be important tools for taking more of the burden off of households, they need to be designed in a way that is appropriate to the economies in which they operate—particularly in settings with large informal sectors—and they need to be constantly reviewed and revised in order to be sustained over time. Ms. Dixon advocated a focus on strengthening social safety nets, requiring a whole-of-government approach going well beyond the health sector.
Another major theme was efficiency. While all of the speakers agreed that financing for health can be a good investment for countries’ economic development, they also cautioned that the allocation of funding needs to be carefully designed in order to be effective. Gavi CEO Seth Berkley estimated that about 20–40 percent of money in the health sector is wasted. He referred, for example, to a phenomenon in which increased funding for health ends up being used more for costly tertiary care at the expense of more cost-effective health prevention and promotion efforts. The panelists all agreed that an emphasis on primary healthcare is the most efficient and equitable way to allocate health sector investments. Dr. Moeti and Dr. Dybul stressed the importance of not losing momentum on primary healthcare even during pandemics that by their nature require time-bound concentrated financial and human resource investment. Mr. Sands also highlighted the importance of being realistic in how we engage the private sector, warning that it is an illusion to expect the private sector to be a major contributor of financial resources. Rather, we should focus on their major role in service delivery as well as their potential to help build capacity for more efficient management and accountability of health systems.
Christopher Elias, president of the Global Development Program at the Bill & Melinda Gates Foundation, offered estimates of the scope of financing that is needed to have a positive impact on population health. One example that he gave was that US$300 per person spent on health seems to be the tipping point where most countries should be able to achieve the under-five mortality goal of no more than 12 deaths per 1,000 live births. But we need to have a better understanding of what inputs correlate with better outcomes on other health priorities, which requires better data collection and analysis. Strengthening DRM is a long-term process, and investments are needed in building capacity in individual countries for sustainable financing and effective use of limited resources. The above-mentioned score card, the Primary Health Care Performance Initiative, and the sustainable financing accelerator were cited as positive steps toward better measurement of progress, which then need to feed into processes for continuous system improvement. Ms. Mburu stressed the importance of engaging those at the community level in data collection, stressing that cross-sectoral partnerships to support data collection is critical in in many communities, given limits in the capacity of community-based organizations. Dr. Berkley provided the concrete example of community members and health workers contributing to the feedback loop using cell phones and other types of new technology to provide policymakers with vital information about trends on the ground.
Donald Kaberuka, board chair of the Global Fund and former president of the African Development Bank, picked up on several additional themes that emerged from the panel discussion. He cautioned countries not to siphon funds from other sectors that support health in the narrow interest of increasing health sector financing. He gave the example of water and sanitation programs as key drivers of health improvement, particularly in urban areas. He argued that taking money away from those projects will be counterproductive to achieving health goals, and their contributions to better health should be taken into account in discussions regarding health financing.
Ngozi Okonjo-Iweala, Gavi board chair and former Nigerian minister of finance, closed the session arguing that health is not only good politics but it is also good economics. But as other speakers throughout the event stressed, she reiterated that simply increasing spending on health will not automatically ensure better outcomes, and attention needs to be paid to what that money is spent on. She cautioned against assumptions that all health financing is spent on improving health, estimating that about 6 percent is lost to corruption. She suggested that, instead of the abbreviation DRM—for domestic resource mobilization—we should adopt the abbreviation EDRU—for efficient domestic resource use—as our primary goal.
Mr. Akio Okawara, President & CEO, Japan Center for International Exchange (JCIE)
H.E. Abdoulaye Diouf Sarr, Minister of Health and Social Action, Senegal H.E. Uzziel Ndagijimana, Minister of Finance and Economic Planning, Rwanda
Mr. Yoshiki Takeuchi, Vice Finance Minister for International Affairs
Report on African Leadership Meeting (ALM) and Updates
H.E. Mrs. Amira Elfadil Mohammed Elfadil, AU Commissioner for Social Affairs
Panel Discussion (alphabetical order)
Moderator: Amb. Mark Dybul, Co-Director, Center for Global Health and Quality, Georgetown University Medical Center Dr. Seth Berkley, CEO, Gavi, the Vaccine Alliance Dr. Annette Dixon, Vice President for Human Development, World Bank Group Dr. Christopher Elias, President of the Global Development Program, Bill & Melinda Gates Foundation Ms. Rosemary Mburu, Member, UHC2030 Civil Society Engagement Group (CSEM); Executive Director, WACI/Health for all in Africa, Kenya Dr. Matshidiso Moeti, Regional Director of the WHO Regional Office for Africa (AFRO)* Mr. Peter Sands, Executive Director, The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) Mr. Ikuo Takizawa, Deputy Director General, Human Development Department, Japan International Cooperation Agency (JICA)
H.E. Dr. Donald Kaberuka, Board Chair, the Global Fund; former President, African Development Bank (AfDB); former Minister of Finance, Rwanda H.E. Dr. Ngozi Okonjo-Iweala, Board Chair, Gavi, Vaccine Alliance; former Minister of Finance, Nigeria