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Stepping up domestic financing for health: ending the epidemics of HIV, TB and malaria by 2030

After years of outstanding progress toward sending the epidemics of HIV, TB and malaria by 2030, new threats such as stalled funding and the current COVID 19 pandemic have taken a heavy toll on societies and economies are likely to jeopardize the gains made thus far.

African countries are now facing the concurrent challenge of a high burden of communicable diseases, responding to and mitigating a pandemic, and at the same time experiencing economic shocks. The International Monetary Fund and the World Bank estimate that total African Gross Domestic Product will contract by 3.6% in 2020 . This gloomy economic outlook will most likely impact the impetus which has been spearheaded by the African Union Commission to close the funding gap for health and achieve Universal Health Coverage (UHC). Mobilizing resources for health has been on the agenda of African leaders for the past two decades aiming to allocate at least 15% of their annual budget for health (Abuja Declaration), a target which many countries are failing to meet. To accelerate the path towards UHC and reinvigorate the translation of commitments for health into measurable actions, the Africa Leadership Meeting (ALM) was launched in February 2019 by H.E. President Paul Kagame of Rwanda during his tenure as Chairperson of the African Union.


Despite the significant progress in improving health outcomes in the continent, it is worrisome that more than half of Africa’s population currently lack access to essential health services, and millions die every year from commonly preventable diseases including HIV, TB and Malaria. The lack of sufficient resources for health which is a consequence of insufficient domestic investment in health care, as well as of the dwindling of donor funding, exacerbated by inefficiencies in budget allocations for programs and weak governance has been impeding the progress towards meeting the 2030 Sustainable Development health goals of ending epidemics and achieving UHC for all. There is a general consensus that domestic resource mobilization is moving too slowly to be able to provide access to essential health services to the continent’s growing population constrained to pay out -of -pocket for health care.  The high and rising levels of out-of-pocket expenditure represent a substantial strain on households and is major cause for the impoverishment of millions of Africans. 

In this trying time where countries are confronted with a pandemic which has unveiled the costs of weak health systems, policy makers are expected to make difficult economic decisions. To stir the dialogue on domestic health financing, the continent through the ALM initiative and with the support of the global health community is rethinking on new and non-traditional ways to seek funding for health and improve value-for-money of spending. Actions put forward at the recently concluded AU Africa Leadership Meeting (ALM) of Ministers of Finance and Ministers of Health on ‘’Sustaining Africa’s Health Gains in the Face of COVID-19’’ include building more effective tax systems, calling on  ministries of health to focus spending on the most efficient programs and on  ministries of finance to reallocate funds towards the health sector without overlooking all determinants of health as to ensure that health spending does not fall in the midst of a global pandemic. Additional investment in building a stronger primary health care system to ensure that those in need in urban and rural communities alike access and use essential services, as well as leveraging on innovative tools and technologies to improve the productivity, resilience and sustainability of health systems, were some of the issues mentioned and agreed upon by the policy makers.

Similarly, African constituencies of the Global Fund expressing their views and positions in the Global Fund post-2022 strategy development process, pin-pointed Domestic Resource Mobilization (DRM) for health as one of the standalone areas of action for the continent. They have, in this regard, identified policy coordination particularly between ministries of finance and health,sustaining multisectoral financing-synergies for HIV/TB/Malaria and their Human Rights and social enablers,financial protection through pooled funding/ national health insurance schemes, innovative financing mechanisms such as private sector engagement and improving transparency, accountability and efficiency in resource utilization as critical action points towards ending HIV, TB and Malaria by 2030. In light of the Global Fund’s experience in facilitating national health finance dialogues in some African countries, the constituencies have expressed the need to strengthen and roll out this and other type of technical support for DRM in the Global Fund post-2022 interventions. In order to increase public revenue and consequently spending on health, strengthening the Macro economic agenda by adopting sound monitory and fiscal policies including effective debt management agenda was also recommended by the constituencies.


Finally, in this quest to increase public revenue and accelerate domestic health financing for health, it is noteworthy that the global economic slowdown due to Covid-19 is affecting the revenues in many countries, which are financing their growing expenditures through increased borrowing. As stated by Dr Tewodros Adhanom, Director General of WHO, in the aforementioned ALM of Ministers of Finance and Ministers of Health: ‘’The nature of this debt crisis calls for a global response, and I call on the international community and international financial institutions to consider measures, such as debt relief or restructuring, to enable poorer countries to ease the adjustment of their public finances so that health and other social spending can be sustained’’.

Fassika Alemayehu



1. Prospects for Public Spending on Health in Africa, A background paper for African Ministers of Finance and Health, Tom Hart, Antoine Lacroix, Federica Margini, Shakira Mustapha and SherillynRaga ; September 2020