Advancing health financing and Universal Health Coverage in Africa: The role of civil society

A crucial meeting occurred in Nairobi, Kenya, on 26 – 27 March 2024, bringing together civil society organizations (CSOs) from across Africa for the Joint Learning Agenda (JLA) on Health Financing and Universal Health Coverage (UHC). The JLA program is led by two regional organizations, WACI Health and Impact Santé Afrique (ISA), with support from global health initiatives (GHIs) such as Gavi, Global Financing Facility (GFF), Global Fund, The Partnership for Maternal, Newborn & Child Health and UHC 2030. This event marked a significant milestone in the two-year program aimed at bolstering CSOs’ capacity to advocate for and ensure accountability in health financing for UHC throughout the region. The gathering of CSO representatives and the above-mentioned organizations and partners provided a platform to evaluate progress, exchange knowledge, and address challenges, further solidifying civil society’s role in advancing health financing and UHC in Africa.

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Challenges in domestic health financing in Africa

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In Africa, macroeconomic challenges, shifting disease burdens, and heavy reliance on external funding highlight the urgent need to strengthen domestic health financing. Despite targets set in the 2001 Abuja Declaration urging governments to allocate 15% of annual budgets to healthcare, many African nations still lack sufficient resources. In 2021, only Cabo Verde and South Africa managed to surpass the 15% Abuja target. This shortfall hampers efforts to combat diseases, risking lives and exacerbating poverty due to high healthcare costs.

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While overall health spending has increased, the proportion funded domestically has not kept pace. This limits the adaptability of national health systems to address pandemics and emerging health threats, perpetuating preventable illnesses. Recognizing health’s pivotal role, the African Union reaffirmed its commitment to prioritize domestic health investments in the 2019 Africa Leadership Meeting (ALM) declaration, saving lives, alleviating financial distress, and driving economic growth.

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CSOs are crucial in advocating for increased health financing and hold their governments accountable for their commitment or access to quality and affordable care. They shape policies, monitor implementation, and promote evidence-based recommendations aligned with Sustainable Development Goals (SDGs). Despite challenges like coordination duplication and poor policy implementation, CSOs intensify advocacy efforts, including initiatives like JLA, to address these obstacles.

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Empowering civil society for health financing advocacy in Africa

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The JLA program promotes multi-stakeholder collaboration to strengthen civil society’s role in advocating for equitable health financing and UHC in Sub-Saharan Africa. The program, involving 20 participating countries (Figure 1), emphasizes supporting CSO engagement in health financing, cultivating a cadre of trainers capable of delivering capacity-building initiatives on health financing, UHC, and budget advocacy at the grassroots level. Divided into two phases, the program focuses on learning and support, bolstering the capacity of CSOs in advocacy and accountability and offering customized capacity building, technical assistance, mentoring, and grants to assist in implementing strategies and initiatives.

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Figure 1: The 20 countries participating in the JLA program in Sub-Saharan Africa

Key highlights of the JLA program

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Since its launch in 2020, JLA program, 40 trainers from Africa have undergone comprehensive training, creating a robust pool of technical experts capable of supporting local, national, and regional advocacy efforts. The program has organized in-country training sessions, equipping approximately 400 representatives from CSOs with valuable insights into the health financing landscape and budget-making processes. What sets this training program apart is its South-led approach, yielding tailored, practical, and creative solutions for successful implementation at the country level. Moreover, the program has significantly strengthened the institutional capacity of ISA and WACI Health, fostering collaborative partnerships and a multi-sectoral approach to advocacy.

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The achievements of the JLA program

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The JLA initiative convened multiple GHIs, including Gavi, GFF, and the Global Fund, to emphasize the importance of advocating for domestic resource mobilization. In discussing the importance of collaboration among GHIs, Shu-Shu Tekle-Haimanot, a senior manager for health financing advocacy at The Global Fund, emphasized the power of collective action, stating, “In a public health space with diverse agendas, it’s heartening to see GHIs unite for a common goal: empowering communities and civil societies. This event in Nairobi shows the power of collective action and the belief that CSOs can make a meaningful difference by holding governments accountable for effective health governance, financing, and service delivery.”

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The meeting participants were briefed on the findings of the JLA program evaluation, which revealed a significant transformation in civil society’s role in health financing. The program has been instrumental in shaping policies, promoting evidence-based decision-making, and strengthening advocacy movements. CSOs engaged in the JLA have influenced national policies, leading to concrete legislative outcomes such as the development of a Single National Insurance Bill in Tanzania and active engagement in discussions surrounding the National Health Insurance Bill in Uganda. Moreover, they have utilized evidence and budget analysis to drive progress in countries like Niger and Ghana. Additionally, CSOs’ representation in key committees has risen notably in JLA countries like Togo. In Togo specifically, CSO representatives actively contribute to coordination meetings of the inter-agency committee chaired by the Minister of Health, illustrating the expanding representation of civil society in influential decision-making bodies. CSOs are now more actively engaged in shaping health financing discussions at the national level, notably in places such as Mozambique, Kenya, and Malawi.

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Successes, commitments, and challenges in Malawi’s health financing landscape

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Maziko Matemba, the Executive Director of the Health and Rights Education Programme (HREP), discussed Malawi’s health financing progress, challenges, and commitments under the JLA program. Malawi has significantly increased its health budget from 300 billion Kwacha to 700 billion Kwacha since 2019, doubling health sector spending. This rise, coupled with increased allocations from 9.4% to 12%, reflects a strong investment in healthcare. Health outcomes have improved, with reduced maternal and child mortality rates and expanded coverage of key health indicators like HIV, TB, and malaria as well as indicators of Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition (RMNCAH).

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Efforts to reduce the health sector financing gap from 50% to around 30% show a concerted push to address resource shortages. Commitments from the Malawian government, parliament, and development partners aim to strengthen health financing mechanisms and ensure equitable healthcare. These include incremental budget increases, subsidy system reforms, and enhanced public-private partnerships for infrastructure development. Despite progress, challenges remain, including divergent metrics, resource mobilization constraints for CSOs, and inconsistent messaging from partner initiatives. Addressing these challenges requires streamlined advocacy and implementation, along with sustained partner support.

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Lessons and achievement from CSO-led Immunization Budget Advocacy in Nigeria, Ghana, and Madagascar

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Shani Winterstein, Director at the Global Health Advocacy Incubator, discussed successful Immunization Budget Advocacy (IBA) campaigns in Nigeria, Ghana, and Madagascar. Key strategies included careful planning, understanding the political and legal landscape, and strategic media engagement. These campaigns focused on holding governments accountable, tracking spending, and creating sustainable funding models.

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In Ghana, engaging citizens and dialoguing with the Ministry of Finance, improved payment performance. In Nigeria, advocacy meetings with government officials led to increased budget allocations for immunization, while partnerships with international organizations helped meet co-financing obligations. Similarly, in Madagascar, ongoing dialogue with ministries and capacity-building for CSO partners led to honoring co-financing commitments.

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However, challenges remain, including changing attitudes towards local funding, maintaining public engagement, and coordinating between health and finance ministries. Solutions involve closer engagement with stakeholders, revisiting subsidy strategies, exploring new financing methods, and intensifying advocacy efforts.

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Parliamentarians leading health funding advocacy in Africa

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Honorable Daniel Molokele, a Member of Parliament from Zimbabwe, discussed a successful parliamentary initiative for health financing. Together with parliamentarians from nine African nations, they formed the Parliamentarians Taskforce on Domestic Resource Mobilization (DRM) for Health in Africa in July 2023. Their main goals are to increase healthcare funding, improve accountability, and enhance health policies.

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Their efforts have already yielded significant results, including drafting the Nairobi Declaration to enhance health funding across Africa. In various countries, they have organized workshops, engaged with the media, and advocated for better health funding policies. Their endeavors have led to the formation of health-focused parliamentary groups and increased civil society participation in healthcare funding initiatives.

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Despite challenges like political transitions and Africa’s debt burden, the taskforce proposes solutions like training for new parliamentarians, continued engagement by former members, and collaboration with other governmental entities. They also call for closer cooperation with CSOs and increased support from international organizations to keep healthcare funding a global priority.

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Empowering sub-national health financing advocacy in Kenya

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Reena Atuma from the Population Reference Bureau shared strides in improving healthcare funding at the local level in Kenya. With healthcare managed by 47 semi-independent counties, significant increases in health budget allocations have been noted, especially in coastal areas. CSOs have enhanced their budget advocacy skills through training, and legislation supporting facility improvement funds has been passed in coastal counties like Mombasa, Kilifi, and Taita Taveta. Political engagement has risen, with constructive dialogues between CSOs and Members of County Assembly. Moreover, budget transparency has improved, with Kwale County ranking third nationwide in a 2022 survey on county budget transparency.

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Despite these achievements, challenges remain, including limited funding leading to stagnant healthcare budgets and delays in accessing improvement funds due to bureaucratic hurdles. To tackle these challenges, it’s vital for CSOs to remain engaged in the budget process, foster collaboration between local and national levels, and advocate for increased transparency. Additionally, development partners can support by funding local CSOs, providing pertinent information, and encouraging private sector involvement in healthcare funding.

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Empowering communities: the International Budget Partnership’s approaches to health budget advocacy

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Sally Torbert from the International Budget Partnership (IBP) shared how they advocated for health budget allocations. IBP aims to increase public understanding and oversight of public funds globally. They prioritize grassroots movements and underserved communities in their advocacy efforts. In Nigeria, IBP collaborated with local organizations to form coalitions and identify issues in primary healthcare centers. Their advocacy efforts in Ogun State (Nigeria) led to increased budget allocations for local clinics and improved infrastructure across three states.

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However, challenges persist with health budget credibility, including discrepancies in approved budgets versus actual spending, and transparency gaps during implementation, especially in Nigeria and Kenya. IBP addresses these challenges through research on budget credibility, collaborating with CSOs and communities for real-time feedback, and conducting social audits to tackle issues like underspending, which in Kenya has led to increased resources for medical supplies.

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Conclusion

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Important lessons have been learned while implementing the JLA program: Firstly, it’s crucial to strengthen civil society organizing by building coalitions and coordinating strategically. This helps extend civil society engagement beyond JLA activities, creating networks at regional levels, as demonstrated by the creation of platforms for Francophone and Anglophone African countries under the JLA umbrella. Secondly, efficient program management is vital. Being flexible, ensuring financial stability, offering tailored support and facilitating knowledge sharing allow for quick responses to emerging issues and effective resource utilization to achieve program goals.

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By fostering collaboration between CSOs, governments, and international partners, the JLA program represents a promising approach to advancing health financing and UHC in Africa. Through collective action and shared commitment, stakeholders can work towards a future where equitable access to healthcare is a reality for all.