Financing Africa’s Health Security and Sovereignty requires Governments and their citizens to work together

Africa is the biggest financier of its own health care — but in the most painful way possible. In 2022, 77% of Africa’s health expenditure was domestic and 23% was external. Out-of-pocket (OOP) spending accounted for about 64 % of domestic health expenditure. This creates a troubling paradox. On the one hand, Africa is less dependent on aid and is funding more of its health needs domestically. On the other, this “self-financing” is being carried largely by households at the point of care, exposing millions of families to catastrophic health expenditures and pushing many into poverty each year. Financing health this way is neither equitable nor sustainable, and it undermines the very notion of health security and sovereignty.

The question, therefore, is not whether Africa has the potential to finance its health. The evidence shows that it does. The real question is whether Africa can harness this potential without households continuing to bear the brunt of the cost of illness. Doing so will require bold change — not necessarily grand new strategies, but consistent, politically difficult reforms that require governments and their citizens to work together effectively. We examine three strategies through which Africa can finance its health security and sovereignty and demonstrate how Governments and citizens can collaborate. They are 1) Converting OOP payments to prepayments 2) Harnessing remittances as external private inflows that can finance health and 3) Addressing social determinants of health (SDH).

 Convert out-of-pocket payments into prepayments

Why do people wait until they are sick to pay for health care? Part of the answer lies in poor health-seeking behaviour, but there may be a more structural issue: low confidence in public services. People are reluctant to prepay when medicines are unavailable, facilities are understaffed, or funds fail to reach the front line. Therefore, converting OOP spending into prepayments whether through taxes for national health service type of health systems or insurance payments for social or private insurance systems demands Governments and citizens to collaborate. Africa’s prepayment base remains small. Only a fraction of Africans pay direct taxes, there is high informality, estimated at over 80% of employment in many countries. In national health insurance systems, coverage remains limited: while countries such as Rwanda and Ghana have expanded coverage to over half their populations, many others remain below 20% coverage, leaving most people exposed to user fees.

Here, governments have a fundamental responsibility.  They must engage citizens effectively and understand the contextual factors that lead to these low prepayment levels and develop Government-citizen agreements to jointly address those issues. As for the part that is known already, low confidence in public service delivery, Governments must show commitment to public service reform whose primary outcome is improved citizen satisfactions with services. Such reform should have public financial management (PFM) reform at the core. PFM reforms such as making the budget credible, i.e. revenue forecasts are realistic and what is voted in the national budget is funded, and in a timely fashion, the whole budget cycle is transparent to citizens and citizens are more involved in health service delivery will likely improve health care quality and access and ultimately the satisfaction of citizens. Because Government health budgets in Africa are mostly spent on personal emoluments (55%) and medicines and medical supplies (25%), PFM reform targeting these two areas will be critical for improved citizen satisfaction. Digitalising payroll management and improving methods for training health workers, in-service, may improve their availability by 16%. Pooled procurement of medicines and medical supplies, for example, may improve medicines availability by cutting the prices of medicines by about 33%.

Citizens, in turn, must be prepared to contribute through taxes or insurance prepayments while the Government embarks on public service reform, the two parties need to work in tandem. This process could be facilitated by the Government using appropriate incentive structures. If citizens were meaningfully engaged in the design of public service delivery reforms, it will be easier for them to do their part and for Government to enforce the social contract.

Harness remittances as private external financing for health

Africa received over US$100 billion in remittances in 2024, more than three times the volume of official development assistance and this is not all, because other flows use informal channels. These resources could be used to fund local pharmaceutical manufacturing, build health centres, scale up digital health for primary health care and indeed other flagship health projects, through diaspora bonds. Or citizens abroad could pay solidarity health insurance contributions or contribute to earmarked health instruments. Governments therefore must proactively engage their diaspora not as a revenue source of last resort, but as long-term partners in national development. Developing an incentive framework for diaspora engagement could be a critical action, anchored in a shared commitment to nation-building, selflessness, and a long-term national vision. Governments should also ensure macro-fiscal stability, build strong institutions that guarantee transparent and effective use of funds.

On the other hand, citizens living abroad can play a broader role by moving beyond remittance transfers towards active collaboration with their governments in advancing national development. At the least, they should cooperate with their government, on the basis of the incentive framework, by channelling their remittances through formal channels to enable better Government planning and predictability and fulfilling their obligations.

Finance health by addressing its social determinants

Finally, financing health is not only about raising more money, it is about using resources more effectively. The evidence shows that some countries with lower total health expenditure per capita achieve better health outcomes such as higher life expectancy than higher-spending peers, largely because they invest in interventions to address social determinants of health such as education, water and sanitation, nutrition, housing, and safer environments. Health outcomes are shaped as much by policies outside the health sector as within it. This underscores the importance of intersectoral co-financing. Governments must therefore rethink the traditional, Ministry/Department/Agency, siloed, budgeting approach and consider co-financing interventions across sectors in order to maximise health outcomes and reduce long-term health costs. Governments can adopt  sector-neutral ceiling allocation in order to focus on key results that the whole of Government must achieve. Pragmatically, a proportion of the Government budget could be allocated to indispensable operational costs, but a sizable percentage dedicated to the whole of Government approach.

Citizens have a bigger role to play in addressing SDH though engaging in promotive and preventive activities that reduce avoidable costs of care. Government can also design a framework that incentivises citizens to do their part. In some cases, favourable citizens’ behaviour might be facilitated by Government policies on issues such as the built environment.

To sum up, Africa’s health security and sovereignty will not be achieved through government action alone, nor can it be built on external support that is increasingly uncertain. It requires a renewed social contract in which governments lead with credibility, transparency, and reform, and citizens contribute through trust, participation, and shared responsibility. This is not about shifting burdens, but about building ownership.