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With an African running the WHO, it’s time for the continent to get hands on

Africa is home to many disease outbreaks yet is ill-prepared to deal with them. UNMEER/Martine Perret

New World Health Organisation (WHO) Director-General Dr Tedros Ghebreyesus has already drawn up a list of things to do.

The former Ethiopian Health Minister wants the organisation to work with governments to build their national capacity for universal health coverage through strong and resilient health systems. Secondly, he wants to strengthen the WHO’s response to threats such as disease outbreaks. And finally he wants to see the WHO harmonise emergency responses across partners while bolstering frontline defences at national and local levels.

The priorities make sense because the African continent is notorious for being ill-prepared to deal with disease outbreaks, yet it’s home to many emerging and re-emerging diseases such as Ebola, Yellow Fever, meningitis and Lassa Fever.

African leaders have a role to play in helping the new Director-General achieve these objectives. And the best way for them to contribute is by dusting off the 2001 Abuja Declaration in which AU member states resolved to increase their health budgets to at least 15% of the state’s annual budget.

Over the last 16 years governments have indeed improved their spending on health. For example, Rwanda currently spends 22.3% and Togo 15.4% of their annual budgets on health. Nigeria spends 6.7% and Uganda 10.2%. South Africa’s health expenditure is 14% of its general expenditure.

But most countries still have a long way to go to ensure that allocations to health are consistent and that the money is spent in ways that bolster the chances of Ghebreyesus meeting the objectives he’s mapped out for the WHO.

No clear consensus

Countries signed the declaration because they believed that special efforts and increased funding were needed to prevent and control epidemics and improve the general health of its citizens. But 16 years later there’s still no clarity on who has fulfilled the 15% pledge. Different assessments have come up with different results.

For example, in 2010 the African Union Commission tallied each country’s progress, finding that only six of the 55 member states had met the 15% benchmark. These were Botswana, Burkina Faso, Malawi, Niger, Rwanda and Zambia.

But a more comprehensive report by the WHO in the same year found that only one African country – Tanzania – had reached the target although 26 had increased their spending on health. The report also showed that 11 countries had actually reduced spending on health and nine had neither a noticeable negative or positive trend.

In another report in 2011, UNAIDS put the number of African countries who had met the target at nine: Ethiopia, Lesotho, Liberia, Madagascar, Malawi, Rwanda, Swaziland and Togo.

What seems to be generally accepted – and confirmed by the WHO’s 2016 assessment – is that since the turn of the century most African governments have increased the proportion of total public expenditure allocated to health.

The average level of per capita public spending on health nearly doubled from about US$70 in the early 2000s to more than US$160 in 2014

There’s no clear agreement on what the per capita spend should be. Between 1995 and 2014, the per capita expenditure on health across the world rose from US$461 to US$1060. Countries in the European Union spend up to US$3612 per capita while North America spends US$ 8990.

Challenges ahead

Health financing faces several challenges which can reverse gains made on the continent over the last 16 years. These include governments deciding to reduce spending on health, the wrong allocation of funds, unpredictable and the inconsistent funding as well as bad financial management.

Research shows that out of every US$100 that governments’ budget, only US$16 is allocated to health. And less than US$4 goes to the correct health services.

In many instances, there are weak links between health and public financial management. This leads to under spending, which is a serious impediment for health care workers to access the allocated funds.

These challenges have several knock-on effects. They compromise government’s capacity to sustain long-term progress, they hamper effective planning and undermine efforts to provide the same service throughout a country.

The reality is that each African country must provide adequate domestic resources to create environments where health workers can get the job done. This would need leaders on the continent to use these resources in an accountable and transparent way with less dependence on external aid and global support.

This is because donor funding presents its own set of challenges. External aid makes up 24% of the health spend of governments on the continent. But funding can be unpredictable and subject to the interest of the donor which may not tally with pressing health problems faced by countries. On top of this donor funds can get sucked into the vortex of corruption and misapplication of domestic funds unless there are proper frameworks for accountability and transparency.

The bottom line is that extra spending by African governments needs to be channelled to the three areas outlined by the Director-General. Without this, his ambitious plans for improving health care on the continent won’t be realised.

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