Closing the Gap: Financing Primary Health Care in Africa

A young mother living in a rural area of a low-income country struggles to access basic health services for herself and her children. Her country’s high rate of HIV and AIDS has drawn the attention of international donors who have channeled resources into critical investments to bring the latest advancements in HIV detection and treatment to a newly built clinic nearby. Fortunately for her, she and her children don’t have HIV. However, what are her options for postpartum care for herself, and for monitoring her children’s nutrition, growth, and routine immunizations as well as her hypertension?

What she and many of her neighbors need is affordable access to essential health care, which could be available should the health authorities adopt primary health care (PHC) as the mainstay of their health sector strategy. Defined by the World Health Organization as  “focusing on people’s needs as early as possible along the continuum from health promotion to treatment, rehabilitation and palliative care,” PHC is considered an essential component of achieving universal health coverage (UHC), but requires sustained investments.

Although there are few assessments of what low- and middle-income countries (LMICs) need to implement basic elements of PHC, there is a huge financing gap for UHC, estimated to reach $371 billion or $58 per person annually by 2030. Countries are struggling to finance the health of their populations amid a myriad of challenges, including high debt servicing and other fiscal pressures compounded by shifts in demographics and disease burdens. For example, with 2024 gross domestic product (GDP) estimated to be about $2.8 billion and average health expenditure 5 percent of GDP, Africa has the lowest health spending across the globe. A projected growth in GDP over the next two and half decades is not expected to lead to growth in public health spending if current trends remain the same.

At the same time, donor financing is declining and estimated to reduce further over the next two and half decades in response to changing donor priorities. We believe that African countries need to act decisively and explore other ways to mobilize more of their own resources to finance PHC as part of honoring political commitments to achieve UHC by 2030. There is an urgent need to revisit domestic financing of PHC with the aim of sustainably increasing it, while also ensuring that investments are efficient and promote equitable access.

This blog highlights three key ideas to help Africa make progress along these lines. These insights emerged from a virtual event on financing PHC, co-hosted by Management Sciences for Health and the Center for Global Development (you can watch a recording of the event here). 

Elevate the discussion

Conversations about financing for PHC need to happen at the highest levels of government and involve multiple stakeholders. Often, ministers of health understand the importance of PHC, but their ministry doesn’t control the purse strings. Regular interministerial engagement with the ministry of finance and members of parliament, mainly those on ways and means, finance, and budget committees can establish the importance of PHC well in advance of the budget process. We believe that it is possible for governments to give more attention to PHC on the back of strong political will, with the offices of the head of state coordinating interministerial engagements to champion PHC. Through evidence-informed priority setting, demonstrating the return on PHC investment, and making the case for PHC as an asset for achieving other goals such as advancements in economic development and education, the agenda for PHC can be promoted to ensure increasing domestic resource allocation. Also, governments should explore innovative ways to increase revenue. The role of technology through automation, progressive tax policies, and stronger tax administration can enhance tax-GDP ratios and improve the overall fiscal space to cope with competing priorities. PHC requires concerted action led by strong political will.

Two examples of high-level prioritization are worth noting. In Liberia, the Ebola crisis of 2014 demonstrated the importance of a strong health system that can respond to a crisis. The experience informed high-level support and coordination between ministries of finance and health, under the auspices of the head of state, to prioritize building a national public health institute so that when the COVID-19 crisis hit, they were better prepared. For context, there were more than 4,500 deaths due to Ebola in 2014, but less than 300 COVID-19-related deaths in 2020 due to some level of priority spending in public health during Ebola. Political will at the highest level is vital to prioritizing a country’s PHC spending. Response to the COVID-19 pandemic saw a high-level involvement of and coordination by heads of state, whose offices coordinated multisectoral planning and action in many African countries. Such prioritization led to other forms of domestic financing, for example introduction of the COVID-19 levy in Ghana. We call for this high-level prioritization not only as an ad-hoc measure to deal with pandemics, but to place PHC and UHC on the political agenda.

Rally behind country priorities

While countries need to prioritize PHC despite the fiscal constraints, they also need to prioritize within PHC interventions that are effective, efficient, and equitable, given the limited financing. We believe that prioritization within PHC should be driven by countries based on their needs and other relevant contextual factors through people-centered care, in ways that strengthen country health systems to holistically address the roots of inequities in an integrated way, not through siloed, disease-focused interventions. Countries need to institutionalize evidence-informed priority setting measures such as health technology assessment to demonstrate where investment will have the most impact in terms of value for money. If countries can establish their own priorities, and if donor funding can be directed more intentionally through a coordinated pooled fund, then the countries can decide how best to allocate that funding. We acknowledge the challenges with such an approach (including questions about country capacity to manage these), but believe that those challenges are not insurmountable, and do not override the benefits.

Align donor and country spending

When advocates call for increased PHC spending, it is important to acknowledge what countries are already investing. This level of ownership empowers countries to determine and lead their own agenda. Countries, not donors, should drive their priorities, with donors filling the gap if there’s a shortfall. Rather than focusing on disease-specific, selected interventions, donor spending should strategically align to both domestic financing and country leadership to support system-level interventions that can strengthen the countries as a whole to implement the different interventions they need. Countries should not continue to cede leadership in determining their priority health needs as well as financing basic health care to donors and global health initiatives.

Thailand provides a case study of a country that has done a combination of all these approaches and made great strides in improving access to care and reducing out-of-pocket spending. Through a series of reforms which began in the 1970s and 1980s, they began enhancing the accessibility of primary care in rural areas, by redistributing funds from urban centers to build new rural health facilities, and incentivizing doctors to move and practice in rural areas. They also introduced the use of community health volunteers to provide basic care and to promote hygiene and general health. Then, in 2002, they decisively introduced a universal health coverage scheme using progressive general taxation, which graded society so that you have more, you pay more, and the healthier would pay to cover for the sick. And today Thailand is a shining example of how people have access to health care they can afford and need. 

Prioritizing PHC challenges us to see people, like the young mother and her children mentioned above, and not just diseases. Most importantly, those who have the ability to make decisions to invest need to have a clear understanding of what primary health care is and how it leads us to universal health coverage.   

Click here to watch the authors discuss these topics in depth in a recent webinar hosted by MSH and the Center for Global Development. This blog was also cross-posted by MSH.