A chance for universal healthcare in sub-Saharan Africa

May 13, 2020


COVID-19 has done more than throw economies, livelihoods and societies into chaos, it has also given us more than a pause for thought on how our societies are constructed. The fundamentals of governance, development, inequality and economics are all being  reconsidered. We have seen some remarkable policy shifts in the last few months, none more so than what appears to be a recasting of the financial and social contract between citizen and state. The International Labour Organization, has identified 742 different social protection measures enacted by 144 countries since February 1st, from special grants to unemployment benefits, income and job protection to food and nutrition, pensions to healthcare.

A key question we’re asking right now is whether these measures are here to stay, and if so in what form? And do they represent a revolution in the citizen-state contract or a mere momentary pause in the usual?

For the UN and UNDP, it’s clear that this cannot be momentary; the United Nations framework for socio-economic response to the outbreak makes it clear that we cannot go back to business as usual when it comes to the world’s unsustainable wealth inequality, our destructive relationship with the environment, and of course the world’s incredibly uneven standards of healthcare, to name just a few.

Building resilience to pandemics

Health obviously occupies our attention right now, and although healthcare is but the frontline of COVID’s exposure of country and family vulnerability, it is critical to any notion of building resilience to pandemics. If an outbreak can devastate the jobs, livelihoods and economics of advanced nations, then what will be the outcome in less developed regions of the world, such as sub-Saharan Africa, where healthcare of all types is some of the poorest in the world?

Some 408.6 million people in sub-Saharan Africa don’t have healthcare, with Somalia and Chad at the highest point with 58 percent and 51 percent, while South Africa is the most covered with just 13 percent without access. Country wealth obviously plays its part in health care, so it should not be surprising that low-income countries account for nine of the top 10 of the weakest. And while the volume of people without universal care is dominated with a relatively few countries the issue is critical in almost all countries – 34 of 46 countries have 30 percent or more of their population without universal coverage.

The concept would provide a basic healthcare across two simple tiers of cost and service, and supported by a very significant investment in health advice and guidance as a mitigation to both the more mundane of health conditions all the way through to major disease outbreaks. A massive investment in telemedicine, itself an increasingly innovative tool for many aspects of healthcare, would be at the centre of the project, building on the enormous growth of mobile phone use across the continent, with premium payments, claims, health advice and impact measurement digital and mobile based.

The cost

Naturally such an initiative does come with a cost, which we’ve very provisionally priced at US$15.2 billion a year. And we’ve complemented that with an outline that suggests US$7.3 billion of that should be covered through premium subsidy, while US$225 would be required to build the technical assistance to make the initiative work across the continent.

Perhaps unsurprisingly, the caveats come thick and fast. Is the data robust enough for such an initiative, and does it represent real need? Would governments support such a measure and would they or institutions such as the multilateral development banks commit premium subsidy. Do mobile networks extend to the most vulnerable countries and communities? Are we in danger of confusing need with demand, and if so, should be worried given the scale of the issue? And even if some of this initiative can be delivered through telemedicine, some health infrastructure will be needed physically for patient visits, and we already know how poor that infrastructure and capacity can be.

Can the region with the highest proportion of low-income countries afford US$15.5 billion a year for healthcare insurance?

The data suggests that the region can’t afford not to make such an investment. According to the World Health Organization nearly 630 million years of healthy life were lost in a single year due to diseases alone in sub-Saharan Africa, a loss of more than US$2.4 trillion from the region’s gross domestic product. Suddenly US$15.5 billion seems a rather prudent expenditure.

Stripping health vulnerabilities

But the economic costs and benefits of such an initiative are only part of the story. It is in our view that an initiative of this scale would revolutionize resilience across the continent at the lowest point of societies pyramid, stripping away health vulnerability from millions of those in need, and while doing so, spurring the financial inclusion of millions, transforming insurance markets, and stimulating  health infrastructure investment. Investments in the technical assistance for data and analysis, institutional development, financial literacy and advocacy, training and education and digital technology that would be required to deliver on this initiative, would be at such a scale, regionally, as to drive transformation.

But perhaps more important than all of this, is that our firm belief that such an initiative would activate entrepreneurism on a remarkable scale, with millions of people thinking big for perhaps the first time, knowing that a critical part of their life and the lives of their family, their healthcare, is covered.

At UNDP we realize it would take a monumental effort and this moonshot may be beyond our reach, but even as we explore the potential, and work through the caveats, we firmly believe that this moment, as terrible as it is, permits us all to think of development, vulnerability and risk, and policy and programming in a way that would have been impossible just months earlier.