Last month, a high level ministerial forum was convened by the African Centre for Disease Control (CDC) on the margins of the 36th Ordinary Session of the African Union Assembly. The meeting had notable Heads of State and Ministers of Health from several African countries. This was a bold show of commitment and support not only for the African CDC, but also for driving the new Africa Public Health Order.

Africa’s new Public Health Order, a roadmap to sustainable health outcomes and health security, was launched in September 2022 by the Africa CDC and is defined by five pillars; strong African public health institutions, expanded manufacturing of vaccines, diagnostics, and therapeutics, investment in public health workforce and leadership programs, increased domestic investment in health and, respectful action-oriented partnerships.

On the surface, this bold agenda sets out a transformative vision for driving forward global health security and improving health outcomes on the continent. Bold as it may be in its vision, it is action that will make the difference and, to date, many African institutions have fallen short. Something must change to drive this dream forward.

Resilient health systems require political action and goodwill. In his solidarity message at the Summit last month, Cyril Ramaphosa, South Africa’s President, raised two pertinent issues, the limited historic investment by African governments in health and a dearth of leadership to drive progress on the continent. He said, “Inequities in access to quality health services […] is a blight on the conscience of the African continent […] In the end, the onus remains on the member states to advance the agenda to equitable health care for all and to achieve universal health coverage.”

Data from the World Health Organization’s World Health expenditure database gives a damning scorecard of most Sub-Saharan African (SSA) countries’ domestic government health expenditure and universal health coverage, with an average ranging from three and eight percent of the national budget spend, compared with the target 15 percent outlined in the Abuja declaration. Domestic government expenditure averages between 21 percent and 56 percent in most SSA countries and out of pocket expenditure on health by individuals, averages as high as 59 per cent in countries like Chad. These figures are unacceptably high and unsustainable. Compounding this issue, most countries sit below 50 percent in terms of universal health coverage. When faced with the facts, President Ramaphosa’s indictment of African governments reneging the investment in health to external partners hits even closer to home.

Hearing the Heads of State reaffirm their commitment to implementing the new Public Health Order is refreshing and gives cause for optimism, but these bold declarations are at risk of remaining only rhetoric if we do not think through innovative financing models that are rooted in our realities as a continent, including huge public debt, global economic downturn and governments’ focus on post-pandemic economic recovery, all of which constrict fiscal space for health.

So, what could innovative health financing look like?

National health insurance schemes have the capacity to provide the most equitable option for expanding access to quality health services. Only four out of 26 countries in SSA have national health insurance coverage above 20 percent – Rwanda (78.7 percent), Ghana (58 percent), Gabon (40.8 percent) and Burundi (22 percent).

Dr Rose Oronje, a health development expert with the African Institute for Development Policy, recently argued that the most obvious innovative financing could include tax-based health financing systems that expand and earmark tax revenue for healthcare from government tax revenues of tobacco, alcohol, sugary soft drinks, gambling, etc.,​ as well as from profitable, commercial sectors, such as the mobile phone, banking and petroleum sectors and luxury goods and services.

Another opportunity for increased health financing is to explore domestic resource mobilisation approaches. In Nigeria, to improve domestic financing in the country, Malaria Consortium’s Support to the National Malaria Programme in Nigeria 2 (SuNMaP 2) programme developed a domestic resource mobilisation (DRM) approach that sought to utilise all available resources and data towards improving the funding of the malaria programme at the national and state levels.

By late 2020, SuNMaP 2’s adapted DRM approach had resulted in an improvement in budgetary allocation in two of the programme states. This included increases in budgetary allocation and release for malaria programming in Katsina and Lagos — a significant improvement compared to previous years. This success was rooted in ensuring the effective implementation and strengthening of coordination platforms; continuous adaptation of strategies and capacity-development interventions to strengthen budgeting systems and processes; strengthening systems and processes for improved performance monitoring; further clarifying role ambiguities within the DRM approach; and encouraging continuous stakeholder engagement and participation.

The second pillar of the Public Health Order is centered on investment in public health workforce and leadership programmes. Importantly, investing and supporting public health institutions in Africa, like the African CDC, is vital in shaping continental and national policies. So too, is the pathway for strengthening heath leadership on the continent and programmes such as the Africa Ministerial Executive Leadership Programme, will be critical.

While the political commitment and support of African leaders to the new Public Health Order is commendable and much welcomed, it is bold, unified, political action that is needed. Without this action, transformational change at a scale where quality healthcare is accessible to every individual, no matter their location or financial circumstances will remain rhetoric and not reality. The collective response to the COVID-19 pandemic demonstrated that African governments can do this effectively and we must use this success to propel us forwards, channelling consistent commitments and, most crucially, investment, to deliver strengthened public health institutions across the member states and strengthened health systems across the continent.

Reagan Wamajji is Malaria Consortium’s Policy & Advocacy Manager