‘How did we get here?’ — African health experts on ending aid dependence

  Throughout the halls of the conference center in Kigali, Rwanda, last week, there was a resounding sentiment that the African continent needs to quickly snap into gear around reforming health care financing. This was coupled with frustrations that African countries are even in this current predicament — a precarious dependence on donors for many critical elements of health care for the continent’s population, such as malaria, tuberculosis, and HIV medicines. Health experts gathered for the Africa Health Agenda International Conference amid a seismic, unexpected shift in the foreign aid sector after the Trump administration gutted the U.S. Agency for International Development. The U.S. spent some $12 billion on global health funding — most of which was disbursed in sub-Saharan Africa. The United Kingdom also recently announced plans to slash aid spending — shifting billions of pounds from international development to support a larger military. The Netherlands and Germany also announced cuts last year. The carpet has been pulled out from beneath the feet of the continent’s population, said Dr. Samukeliso Dube, executive director at FP2030. “The funding architecture as we know it for global health has just changed.” But there were unexpected tones of optimism that the continent could be at a crossroads moment where it could change the existing paradigm towards reimagined health systems that are more integrated, with genuine ownership by African governments, and are buoyed by more sustainable financing. This would all be done in the name of ensuring that in the long run, the continent’s population is never in this position again. “Even though the future looks dark, progress is possible,” said Dr. Magda Robalo, president and co-founder of the Institute for Global Health and Development in Guinea-Bissau. “The power to change this is in our hands and the moment is now.” Paying the piper The verdict is out: The Trump administration canceled 5,200 programs, which includes many global health programs — with about 1,000 programs remaining. Now, it's time to assess the damage. For example, Ghana’s government said USAID’s departure left a $156 million gap, and in South Africa, the U.S. President’s Emergency Plan for AIDS Relief, or PEPFAR, funds about 17% of HIV/AIDs programming. “Many African countries have placed the health of their citizens in the hands of donors — deliberately or not deliberately — expecting that the stream of funding which has powered health systems may continue for a long time,” Dube said. In response, some citizens are asking governments why they let other countries fund their health care for so long, said Serah Makka, executive director for Africa at the ONE Campaign. “They’ve said: Someone shouldn’t wake up one morning and say, ‘Ah, I’m done with this’ — and then over here we are scampering,” she said. “It stimulated a bit of a bruised pride, like: ‘How did we get here?’” And while these donor-driven programs have saved many lives, they’ve also been weighed down with baggage. Many donor programs were vertical — focusing on a single disease as opposed to a horizontal approach that builds up health systems. But this moment could be an opportunity to push for more integration — because there’s a lot of redundancies in the way things are done, said Ngozi Erondu, technical director at the Global Institute for Disease Elimination. “Now, we're forced to streamline,” she said. And U.S. funding comes with conditions. On his first day in office, U.S. President Donald Trump ordered the end to programming around diversity, equity, and inclusion, or DEI — which included scrubbing the internet of certain words and canceling entire programs. Dube said that in those early days when the threat of U.S. funding cuts was starting to emerge, “people were removing words like sexual and reproductive health from their programs.” “They were removing gender; they were removing family planning; people … were removing women from the future of what they were going to do,” Dube said. African governments need to lead the way and redefine priorities — shifting away from donor-led priorities, experts at the conference said. “He who pays the piper determines the tune,” said Dr. Mary-Ann Etiebet, president and chief executive of Vital Strategies. Experts said that instead of hoping other donors fill in gaps, policies on the continent should change and leaders should be creative in finding ways to secure sustainable funding. “Many of our countries now are more than 60 years — and I think when one is 60 years, you feed yourself,” said Boniface Mbuthia, acting technical director of health financing at Amref Health Africa. “We are not young anymore.” Sourcing from within There’s been a rallying cry for over two decades for African governments to increase domestic spending on health care to at least 15% of their annual budgets, a commitment known as the Abuja Declaration. Some countries have struggled to consistently meet this target, and many others have never reached it. “Is it time for us to torpedo the whole thing and start again? The question I have is: Why has it not worked?” Makka asked. But it’s also not simple — many African governments are burdened with high levels of debt and raising taxes can lead to political suicide. But still, experts in Kigali said it’s crucial for governments to raise tax revenue. This can include taxes on unhealthy products like tobacco and alcohol, Etiebet said. But these raises must be coupled with public education campaigns to ensure people accept increases. “We forget about actually supporting a full conversation with the public about why we are doing this,” she said. For example, Ghana has a 2.5% tax across all goods and services earmarked to national health insurance. There must also be public confidence that money paid in taxes is actually funneled to health care — and technologies like blockchain can assist in following the money from source to end, Etiebet said. “Without the public feeling like my taxes actually will translate into better health care, it's like pulling teeth to get them to actually be willing to pay,” ONE’s Makka said. “The accountability part has to be part of this conversation.” And a lot of that falls to weeding out corruption and other illicit financial flows, experts said. Kenya, for example, is estimated to lose 2 billion shillings (around $15.5 million) per day to corruption. Not providing citizens with health care should have a political cost: A politician risks being voted out, experts said. “We need to get there,” Makka said. “That’s the North Star.” And with limited resources, governments should prioritize preventing disease as opposed to treatment — because it’s more cost-effective. This includes a focus on areas such as clean water, sanitation, immunization, and nutrition. But prevention isn’t always an easy sell. “A minister of health will tell you: ‘Look, I have people who are dying. Don’t talk to me about prevention, because I need to be able to treat my people now,’” Etiebet said. Cross-governmental collaboration is also key, such as coordination among multiple ministries, experts said. If a minister of health doesn’t have an adequate budget, maybe the ministry of education, transportation, water, agriculture or lands can provide supportive resources. “There's an opportunity to really push on domestic resource mobilization so that African governments can actually determine how those resources are spent,” Etiebet said. Dig the well There’s also a lot of untapped potential in remittances from diaspora flowing to the continent, experts at the conference said. But there’s a need for some sort of architecture around consolidating and channeling it. For example, Makka said, the African Development Bank could create a health fund that the diaspora invest in and receive a return on investment. And there’s more that can be done with private sector involvement in areas such as insurance coverage, experts said. “If we are going to attract investment, there must be certain things that we will do that will give the investors confidence,” said Amref’s Mbuthia. “To ensure our government systems are transparent.” Experts also emphasized the importance of regional bodies, such as the Africa Centres for Disease Control and Prevention, to guide reforms. In the wake of the COVID-19 pandemic, there’s been a concerted effort to increase the manufacturing of pharmaceutical products on the continent. There are also efforts to harmonize regulations through the African Medicines Agency so those products can ultimately be sold somewhat seamlessly across borders. The continental free trade area is also working on facilitating payments across borders despite multiple currencies. There’s also power in reducing prices of medical products through pooled procurement which creates larger markets and increased negotiating power, experts said. And there’s work to be done in changing the global financial architecture, which isn’t working for many African countries, experts said. For example, the international tax treaty system was formed in 1920 before many African countries became independent. There are efforts to change the sway multinational companies have in African countries. They have a lot more negotiating power, Makka said, adding that global south countries have been working to change this by shifting power to the United Nations as opposed to the Organisation for Economic Co-operation and Development. “Oftentimes, African countries, in a bid to attract foreign direct investment, give it off for free,” Makka said. “There must be a balance between attracting and giving it all away.” And if debt for climate swaps are possible, debt for health swaps should be as well, Etiebet said. The road is long but conference speakers said there’s a lot of resolve on the continent to turn these visions into reality. Racey Muchilwa, head of sub-Saharan Africa at Novartis, said it’s important to dig the well before the water comes. “We are in that moment where we've not dug the well and the water is coming,” she said. “But it's never too late.”