At Wemos, we believe more in systems change than in addressing single-targeted issues to effectively enhance health equity. Therefore, we were delighted that the Belgian development agency Enabel – who focuses on (among others) health systems strengthening – invited us to speak at the ‘International conference on social health protection’ in Niamey, Niger (10-13 May). We shared our thoughts on sustainable financing for health and social protection with representatives from ten African countries, bi- and multilateral institutions, academic institutions and civil society actors.
After more than two years of exclusively attending webinars and online conferences, it was exciting to be in Niamey: hearing country representatives from Ministries of Health talk about their experience, meeting people from civil society organisations in the region and getting to know about their work, and learning more about Enabel’s vision on social health protection and strengthening health systems – which is not a given in the development partners’ community. We applaud such a systemic approach and their close collaboration with governments and civil society.
What is social health protection?
Social health protection is the set of collective foresight and assistance mechanisms that enable individuals or households to cope with the financial consequences of illness and to have access to quality care. It reduces the financial barriers as far as possible and allows health service users to obtain treatment as soon as possible without fear of falling into poverty.
Solidarity, redistribution of resources and equity
If designed with a focus on equity and Universal Health Coverage, social health protection can contribute to social stability, social justice, and a strong social contract between citizens and the state.
The speakers and participants at the conference strongly agreed that the basis of social health protection schemes are solidarity and redistribution of resources, and that equity should be a fundamental criterion when deciding on how to shape it. Moreover, for social health protection to work in an equitable way, governments need to subsidise the costs, so people do not have to pay at the point of service or that, at least, the contribution is low and fixed. For that, however, they need to mobilise resources.
As noted by Dr Anya Blanche (World Health Organization (WHO) representative in Niger), despite the efforts made in recent years, progress towards Universal Health Coverage is still slow. According to the figures she presented, 35 out of 47 countries in the WHO African region spend less than the minimum of USD 112 per person per year required to ensure access to essential health services.
Sustainable financing for health and social protection
In our presentation, we reiterated Dr Blanche’s message, showing the current health expenditure in the countries who participated at the conference. As the orange bars in the graph indicate, this is way below the international benchmark of USD 112 . The yellow bars show an important observation: even if countries would prioritise health more and allocate 5% of their gross domestic product (GDP) to it, still, the per capita spending would remain well under USD 112.
Three ways to enlarge fiscal space for health and social protection
So how can countries enlarge their fiscal space for health and social protection, without compromising other sectors? To answer this question, we presented three suggestions while making a case for governments and civil society organisations to fight for more resources for social health protection. Our suggestions are based on a key publication by UN Women and the International Labour Organization (ILO) – the handbook on Fiscal Space for Social Protection – which details alternative avenues of fiscal space expansion that have the potential to fill the financing gaps.
1) Eliminate illicit financial flows
Social health protection is a matter of equity and justice. This includes tax justice. The level of global tax injustice is immense. According to UNCTAD and the Tax Justice Networks, USD 483 billion is lost annually due to illicit financial flows, out of which USD 89 billion from Africa. This equals 3.7% of Africa’s GDP: enough to fill half the financing gap for attaining the SDGs in the region!
As pointed out by our audience, much is of course also lost through inefficiency and wastage of existing resources at country level. Nevertheless, the enormous global losses highlight the need for both national and global level advocacy for tax justice.
2) More external resources
When talking about redistribution of resources for social health protection, we can project this to the global redistribution of wealth and global solidarity. Even though domestic resources for health are extremely important, external resources cannot be ignored as they still represent a significant share of countries’ total health expenditure. However, the amount of external aid is not as great as it could and should be. Only five countries of the Organization for Economic Cooperation and Development (OECD) meet the international target of allocating 0.7% of their gross national income (GNI) to development assistance (Figure 2). The difference between potential and actual international aid is huge: USD 541 billion of potential aid, compared to USD 179 billion of actual aid.
3) Better external resources
Just more money is not enough; we need ‘better money’. There are many global commitments on better coordination of external resources for health. For example, the WHO Global Action Plan for Healthy Living and Well-Being for All. Alignment of aid and global health initiatives like the Global Fund, Gavi and the Global Financing Facility, can also bring significant gains. We presented some examples to improve quality of aid, based on previous work on this topic (i.e. on alignment of global health initiatives):
- Creating predictable donor funding, pledged in advance of the fiscal year, so governments can plan accordingly;
- Rethinking attribution: donors can move away from the need to link their contributions to an individual outcome, and instead coordinate towards health systems strengthening;
- Staying critical of private investment in health, such as private health insurances and public-private partnerships in health.
Social health protection schemes are a viable option, but systems approach remains essential
After four intense days of discussions and sharing valuable country experiences, it was clear that large-scale social health protection schemes are a viable option for the region, including the informal sector. There may not be a universal solution for all countries, but the value of strengthening health systems and social protection systems overall was generally acknowledged. To realise this, political will, social participation, and technical and financial support are necessary. And, very importantly, a systemic approach. If Covid-19 confirmed something during the last years, it’s that pandemics thrive on inequality and that countries need to implement strategies that strengthen their health systems and social protection systems.
Civil society can also play a significant role by advocating more fiscal space for health and social protection. As the audience pointed out during our Q&A session, this advocacy goal is not restricted to the health sector but should expand to actors like the Ministry of Finance. Cross-sectoral advocacy at national and global level in tandem is necessary to operationalise the vision of equitable social health protection for all.
Inspiring exchanges and insights
It was very inspiring to attend the ‘International conference on social health protection’, organised by the Ministry of Public Health, Population and Social Affairs of Niger, the Belgian Embassy, the development agency Enabel in Niger, WHO, ILO, and the Belgian health sector platform Be-cause health.
We definitely learned a lot from all the experience, expertise and different insights that were present in the same room. It was a wonderful opportunity for us to be in a space where everybody embraced the joint vision for equitable health financing and strong health systems that are accessible to everyone, leaving no one behind.
 The WHO and others have questioned the usefulness of these international targets and benchmarks. We agree that 1) even with less money, progress can still be made towards UHC by spending better, and 2) the estimated shortfall of resources should not be used as an argument to advocate for more private funding as the important solution. As highlighted and substantiated by the WHO, we agree that public funding is essential for UHC. Nevertheless, these benchmarks serve for inter-country comparisons and do show us that resources fall short by a very large margin.”
To know more about how development actors support private health financing and thus jeopardise universal and equitable access, read our inventory study ‘Improving healthcare, but for whom?’, in which we analyse the work of the International Financing Corporation (the private sector’s arm of the World Bank) in health.