Despite spending billions on health every year, many African health systems remain underfunded and heavily dependent on external assistance. Then, African leaders adopted the Abuja Declaration, which pledged to allocate at least 15% of their national budgets to health care.
Yet, as fiscal spaces tighten and debt burdens grow, a new consensus is emerging: the problem isn’t just a lack of funds but a crisis of governance.
In recent years, experts have increasingly argued that the deeper issue is accountability and the way health is positioned within national economic policy.
Following a Health Financing Workshop convened in December 2025, a coalition of leading African health financing experts, economists, and policy advisers released a roadmap to move ‘From Commitments to Action,’ outlining practical pathways to strengthening health financing across Africa. It identified four areas where political and policy action can make a measurable difference: reframing health as an economic investment, strengthening accountability for public spending, expanding financing mechanisms that already work in African countries, and generating credible, locally owned evidence for policy decisions.
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AllAfrica’s Melody Chironda spoke with Dr Ebere Okereke, a leading public health expert, about why the future of African health now rests with Finance Ministers, not just doctors.
For years, the conversation around African healthcare has centred on a “financing gap.” Your position statement argues that this framing is actually misleading. If the primary hurdle isn’t just a lack of funds, what is the “binding constraint” currently stalling progress?
The financing gap is real, but it is not the whole story, and in some settings it is not even the main story. The more binding constraint is how available resources are prioritised, governed, executed, and verified.
Across many countries, health is still not treated as a core economic function. It is treated as a social sector cost and therefore loses ground in budget negotiations. At the same time, budget execution is often weak, funds are fragmented, procurement inefficiencies erode value, and financing decisions are not tied closely enough to service delivery realities. That is why the issue is not just how much money is mobilised. It is whether financing decisions are governed well enough to produce results. Better governance, credible costing, transparent verification, and clear political ownership can improve performance even inside current fiscal ceilings.
You recommend that health be reframed as an economic investment rather than a social cost. In a practical sense, how should a Minister of Health change their pitch to a Minister of Finance during budget season to ensure health isn’t the first sector cut during a fiscal squeeze?
The pitch has to move from health sector language to economic language. Too often, Ministries of Health present budgets in terms of inputs, staff, facilities, and commodities. Finance ministries are asking different questions. What is the productivity impact? What fiscal risks are being reduced? What costs will rise later if this is not funded now?
So the health case has to be framed in terms of labour productivity, financial protection, resilience, and cost avoidance. Underinvestment in primary care, prevention, and basic system readiness does not save money; it shifts cost downstream into more expensive crisis response, more household impoverishment, and greater economic disruption. Once health is framed as part of economic policy, rather than as a discretionary social line, it becomes harder to cut and easier to defend.
The 2001 Abuja Declaration is often cited but rarely met. Your paper calls for “credibility through delivery, not declarations.” Should we stop using the 15% target as the primary success metric, and if so, what should replace it?
The Abuja Declaration mattered, and still matters politically, but a headline spending target on its own is a weak test of progress. Africa does not mainly have a commitment problem. It has a delivery problem.
What matters is whether countries are financing a defined package of essential services, protecting households from catastrophic spending, and turning allocations into functioning systems. Political commitments still matter, but they need to be matched by credible costing, standardised definitions, public reporting on execution, and routine verification. The point is simple. Credibility does not come from declarations. It comes from what gets funded, what gets delivered, and what can be verified.
The statement highlights successful models like Ghana’s Health Insurance Levy. However, earmarked funds are often raided by treasuries or eroded by inflation. What specific governance guardrails are needed to ensure health taxes actually reach the clinics they are intended for?
Earmarked funds work only when governance is designed in from the start. Without that, they become politically attractive on paper and unreliable in practice.
The guardrails are clear. There needs to be a clear legal basis for the levy and its permitted uses, transparent reporting from collection to expenditure, and independent audit and oversight. Parliament, audit institutions, and civil society all have a role in making diversion harder and scrutiny routine. The other issue that gets neglected is inflation. If these instruments are not protected against erosion over time, their purchasing power falls and the policy loses credibility. So the lesson is not just to create health taxes. It is to protect them from leakage, opacity, and erosion.
External aid is flattening and debt servicing is crowding out social spending. How can African governments transition to domestic-led financing without triggering a collapse in services for diseases like TB or malaria that have relied on donor support?
The transition cannot be abrupt. If external funding falls faster than domestic systems can absorb, service disruption is inevitable. That is the risk.
The answer is managed integration, not sudden substitution. Donor-supported programmes need to be progressively aligned with national budgeting, supply chains, procurement, and service delivery platforms so they strengthen the broader system rather than continuing as parallel structures. In addition, countries can expand domestic tools such as health taxes, insurance pooling, and other ring-fenced mechanisms, but with realistic sequencing and strong governance. The aim is not to walk away from an external partnership. It is to move towards a financing architecture in which national systems set the direction and external support reinforces that direction.
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We also need to place this discussion in the wider fiscal reality that many African governments face. Better health financing decisions matter, but so do debt servicing pressures, limited fiscal space, and poor access to affordable financing. That bigger picture matters because health financing does not exist in a vacuum. When governments are fiscally squeezed, even well-made health arguments struggle. So the health financing agenda has to sit within a broader push for fairer financing conditions and more fiscal room for African countries to invest in health and other priorities.
Parallel donor-funded supply chains have sometimes stifled local markets. How can African countries better integrate their private sectors and local manufacturers into national health financing strategies?
Parallel donor systems may solve short-term delivery problems, but they can also weaken the long-term development of domestic markets, private providers, and local manufacturing capacity. That is one of the least discussed costs of fragmentation.
A better approach is to bring procurement, supply chains, and service delivery back into national systems while creating a predictable space for domestic firms and private providers to participate. That means transparent procurement rules, more reliable financing flows, and policies that support regional manufacturing and local supply networks. It also means using private-sector data and service delivery capacity in national planning. If countries want resilient systems, they need financing strategies that build domestic capability, not ones that keep bypassing it.