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Africa: Paying for Health Care for All – Fiscal Consent Across Africa

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Africa: Paying for Health Care for All – Fiscal Consent Across Africa


Public support for higher taxes depends on whether the state can deliver.

Key findings

  • Across 38 African countries, seven in 10 respondents (70%) “agree” or “strongly agree” that government should ensure access to adequate health care for all citizens even if this requires higher taxes. Support ranges from 45% in Mauritius to 89% in Gabon.
  • Health-care insecurity is widespread: Almost three-quarters (74%) of respondents say they worry “somewhat” or “a lot” that they or someone in their family will be unable to obtain or afford needed medical care.
  • Support for tax-financed health care for all is higher among citizens who rate health- service delivery more positively, rising from 68% among those who say government is handling basic health services “very badly” to 74% among those who say it is doing “very well.”
  • Support for tax-financed health care also rises with trust in the Ministry of Health or public health agency, from 67% among respondents who do not trust the institution “at all” to 73% among those who trust it “a lot.”
  • Regression results show that worry about affording medical care, positive evaluations of government performance on basic health services, and trust in the Ministry of Health or public health agency are associated with greater odds of supporting tax- financed health care.
  • Perceived corruption among tax officials is associated with lower odds of support, suggesting that fiscal consent is linked not only to confidence in the health system but also to confidence in tax administration.
  • Lived poverty is counterintuitive: Once other factors are taken into account, greater levels of lived poverty are associated with lower odds of support, though this may reflect concern about higher taxes rather than opposition to health care for all.
  • Among respondents who had contact with a public clinic or hospital during the previous year, those who found it difficult to obtain medical care and those who encountered a lack of medicines or supplies are more likely to support tax-financed health care. However, respondents who say they went without needed medical care because it was too expensive are less likely to support the proposal, suggesting that direct cost burdens may make additional taxation less acceptable.


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Universal health coverage (UHC) is a central objective of contemporary development policy in Africa. It seeks to ensure access to essential health services while limiting the financial burden on households. Achieving this objective, however, requires sustainable financing arrangements. In many African countries, this involves navigating fiscal constraints and determining whether, and under what conditions, citizens are willing to support taxation as a means of financing broader and more equitable access to health care (Kutzin, 2013; World Health Organization, 2025a, b).

This paper asks: Who supports tax-financed health care for all1 in Africa, and how is this support associated with their material circumstances, previous experience with public health services, and perceptions of governance? Using Afrobarometer Round 10 survey data from 38 African countries, we examine support for the proposition that government should ensure adequate health care for all, even if doing so requires higher taxes. The analysis explores how support for tax-financed health care is associated with respondents’ level of lived poverty, difficulty in obtaining medical care, evaluations of government delivery of health services, trust in the health ministry, and perceptions of corruption, among other factors. These measures capture related but analytically distinct dimensions of the fiscal bargain: citizens’ need for publicly financed health care, their assessment of the state’s capacity to deliver it, and their confidence that additional public revenue will be used effectively and fairly. The empirical setting is therefore particularly valuable because it measures support for health care for all under an explicit fiscal trade-off. This distinction is central to fiscal-contract and tax-morale theories, which suggest that willingness to pay taxes depends not only on demand for public services, but also on expected public returns, institutional legitimacy, and perceived fairness (Levi, 1988; Torgler, 2007; Prichard, 2015; Isbell, 2022).

The paper examines this trade-off through the concept of fiscal consent. By fiscal consent, we mean citizens’ willingness to accept taxation because they regard its purpose as legitimate and believe that the state can transform public revenue into public benefit.

Existing studies largely examine public support for government-provided health care, health financing, and taxation separately. Much less attention has been paid to whether citizens support health care for all citizens when it is explicitly financed through higher taxes. This paper addresses this gap by examining the conditions under which citizens accept this fiscal trade-off between health care for all and increased taxes. It connects research on UHC financing (Lagarde & Palmer, 2011; Kutzin, 2013) with research on attitudes toward taxation and state capacity (Besley & Persson, 2014; Prichard, 2015), tax morale (Torgler, 2007; OECD, 2019), and service delivery, trust, and legitimacy in Africa (Sacks & Levi, 2010; Bratton & Gyimah-Boadi, 2016; Krönke, Mattes, & Naidoo, 2022).

We find that support for tax-financed health care for all is associated with both need and credibility. Across 38 African countries, citizens who worry about affording medical care are more likely to support tax-financed health care for all, a finding that is consistent with research on financial protection and the effects of out-of-pocket payments on access to care (Lagarde & Palmer, 2011; Kutzin, 2013; World Health Organization, 2025b). At the same time, support for tax-financed health care is stronger among citizens who think their government has performed well on delivering basic health services as well as among those who say they trust the Ministry of Health or public health agency. Conversely, we find that perceived corruption among tax officials weakens support for tax-financed health care. This finding aligns with related research connecting corruption to weaker institutional trust and tax morale in Africa (Lavallée, Razafindrakoto, & Roubaud, 2008; Jahnke, 2017; Kouamé, 2021). The relationship with lived poverty is counterintuitive: Poorer citizens may stand to gain more from health care for all, but the results suggest that they may also be less willing to support tax-financed health care.