WE ALSO COMMIT OURSELVES to take all necessary measures to ensure that the needed resources are made available from all sources and that they are efficiently and effectively delivered. In addition, WE PLEDGE to set a target of allocating at least 15% of our annual budget to the improvement of the health sector – Abuja Declaration 2001
In April 2001, the heads of state of African Union countries met and pledged to set a target of allocating at least 15% of their annual budget to improve the health sector. Yet almost decade later, not only have just a handful of African nations allocated the pledged amount of money to their healthcare systems, but Africa still has the worst health outcomes in the world (figure 1). The poor and vulnerable still have limited access to healthcare, the insurance and coverage schemes that do exist usually miss out those in the informal sector who make up a sizable portion of the African workforce. Despite some marked improvements since 2001 too many Africans are still falling victim to diseases that could be prevented, too many Africans are being made bankrupt paying medical bills for friends and family and far too many Africans are going without the care they need lowering their quality of life.
Figure 1 source: Angus S. Deaton and Robert Tortora, People in Sub-Saharan Africa Rate Their Health And Health Care Among The Lowest In The World 2015, Health Affairs
If we are to think of development as being people centred, then the health of the people is crucial. Quality of life (not to mention length of life) improves significantly when everyone has access to quality healthcare at an affordable cost (which is the WHO’s definition of universal healthcare[1]). If Africa is serious about development we must get serious about healthcare, and the best way to do that is through pursuing universal healthcare. Many will say this isn’t possible, it is too expensive, or African countries simply do not have the resources, however both Botswana and Rwanda show that not only can universal healthcare be done in Africa, but there is more than one way to do it. Thus, the question African policy makers should be pursuing is what do we have to do create quality, affordable healthcare with access for all.
Lessons from Botswana and Rwanda
Rwanda and Botswana have slightly different ways of implementing universal healthcare. Botswana operates a fully public system where the governments owns over 95% of healthcare facilities. The system is built around the delivery of primary healthcare which is available through an extensive network consisting of;
- 844 mobile stops and 338 health posts which deliver primary preventative care to all it is citizens;
- 272 clinics (101 of which have beds) which provide outpatient and general inpatient care;
- and finally, there are the district hospitals and the two referral hospitals which provide long term and complex care and procedures.[2]
Almost all services are free except people between the ages of 5 and 65 pay 5 pula (‘USD’ or ‘$’ 0.50) for general check-ups.
Rwanda pursues universal health through a mandatory health insurance system called Mutuelles de Sante. The scheme is community based, residents of a particular area pay about ‘USD’ or ‘$’ 6 into a community insurance pool, richer citizens are charged higher premiums and for those who can pay a 10% service fee is paid for each visit to a health centre or hospital. Like Botswana Rwanda’s system is decentralised and built around providing primary care through;
- 34 health post which do outreach activities such as immunisations, antenatal care and family planning;
- 18 dispensaries and 442 health centres which provide preventative and primary care, out and inpatient services and maternity care;
- 48 district hospitals which provide inpatient and outpatient care and 4 referral hospitals which provide specialised complex care.[3]
In both countries over 90% of the population have access to affordable healthcare whose quality has seen significant improvement over the last decade.
Botswana and Rwanda hold valuable lessons for policy makers on the continent. The first and most important being that universal healthcare is possible. Secondly multiple funding models are available and there is no reason that you cannot mix match payment, insurance and tax revenue to pay for it. Third, to be effective, primary and preventative health must be at the centre of the system. Primary healthcare focuses on people and their communities, by providing preventative and early continuous care and education, treatment of illnesses before they become life threatening and the early identification of serious health issues that require specialist treatment. Fourth you need appropriate infrastructure, specifically clinics, dispensaries and health posts/centres that are situated in communities around the country and are just as important as big hospitals. If you only invest in big hospitals they will end up being crowded with patients who could have been more effectively treated in facilities in their own communities. Investing in community health centres and facilities ensures that everyone has access to healthcare close to home and that large hospitals can take care of those who need the most help. Finally, we need to invest in people, and this strikes me as part of the solution to an existing problem. Africa has far too many young men and women who are educated but unemployed, to me this presents an untapped pool of administrators, doctors, nurses, pharmacists and clinical technicians who would be needed staff a universal health care system.
Health as development
Universal healthcare in Africa is achievable but only if our governments begin to think of healthcare as just as important to development as roads, power, jobs and education. Fundamentally healthier people are happier people. Universal healthcare will significantly improve the quality of life for hundreds of millions of people, it would take away the spectre of going broke because you, or a relative got sick and it could provide millions of meaningful jobs for young men and women who would jump at the prospect.
In 1948 Great Britain was broke and had just come out of two devastating world wars in the space of three decades, yet it was in that year that they launched the National Health Service which was and still is based on 3 principles; ‘That it meet the needs of everyone, that it be free at the point of delivery, and that it be based on clinical need, not ability to pay.’[4] Today, the NHS is the institution that the British are most proud of. Today, like Britain in 1948, Africa is not rich and faces a myriad of challenges, but we can and should dream big, that all Africans should all have access to quality affordable universal healthcare. If development in Africa is to mean anything surely it must mean that Africans can live full and healthy lives, it is time to bring the Abuja declaration to life.
[1] http://www.who.int/health_financing/universal_coverage_definition/en/
[2] http://www.gov.bw/en/Ministries–Authorities/Ministries/MinistryofHealth-MOH/About-MOH/About-MOH/
[3] http://www.hrhconsortium.moh.gov.rw/about-rwanda/health-system/
[4] https://www.nhs.uk/nhsengland/thenhs/about/pages/nhscoreprinciples.aspx