Health has long been a complicated and tragic topic in Africa. By April 2001, Southern African Development Community (SADC) governments together with other African Union member states, had met in Abuja, Nigeria, and signed the Abuja Declaration on health in Africa. It was a historic moment as Africa pledged a new commitment to eliminating the health crises devastating the continent.
Each country that signed agreed to raising public health higher on the totem pole of its national priorities. Health matters were by this point, a difficult subject to ignore. Endless decades of one public health crisis after another had proven that socioeconomic and political development were continually being stunted by disease, incapacitation, and death. According to the World Health Organization (2011), one of the key features of the declaration was a binding pledge to allocate at least 15% of a country’s annual budget, by 2015, to improving the health sector.
Primary areas of interest for this African Union-led initiative included HIV/AIDS, tuberculosis and malaria. Plans were developed and tailored to each individual country and targets were created. These targets ranged from grassroots efforts to mobilize and partner with vulnerable groups such as those living with HIV/AIDS to the identification of possible resource mobilization avenues.
In 2011, a World Bank review monitored the progress made by the signatory countries. This report revealed that 10 years after the Abuja Declaration was made, only South Africa- out of the 16 SADC member states- had the potential to achieve the 15% target.
According to the World Bank’s World Development Indicators, during the period 2011‒2015, the SADC region’s total health expenditure as a percentage of gross domestic product (GDP) was around 6.4 percent. Still, there was some light at the end of the proverbial tunnel with 2015 empirical research suggesting that though most countries in Africa were still struggling to reach their 15% target, SADC countries had made progress in the area of public health investment.
Sadly, this light didn’t shine bright enough because by 2018, further research by the World Health Organization’s (WHO) Global Health Expenditure Database showed that all SADC member states were struggling to meet their 15% annual target. To date, none of the countries present in Abuja over 20 years ago have achieved the declaration’s goal.
In the policy document, ‘SADC and Abuja Declaration: Honoring the Pledge,’ author Jack Bwalya reviewed Zambia’s performance of the Abuja Declaration. According to Bwalya, Zambia’s reliance on external aid is accompanied by various austerity measures that have been introduced to reduce the national debt burden. This makes meeting the 15% target all the more challenging. Presently, the average annual allocation in the region is 5.3%.
Realistically, the Abuja Declaration does not fit into Zambia’s domestic resource mobilization on the basis that Zambia’s dependence on international aid is high. With a hybrid health financing system that incorporates public, private, and external financing, Zambia juggles a socioeconomic model that’s often crippled by a high percentage of external aid. As of 2016, for example, domestic government financing accounted for 38% while external financing contributed 43% to the total health expenditure.
A weak macro fiscal system also adds to the burden. In 2017, the state’s health budget expenditure on salaries alone constituted 70 % of the total budget. In the health sector, just like in many other sectors in the country, expenditure primarily goes to salaries.
To add to the country’s challenges, there are high corruption levels in tax administration. This corruption not only reduces tax revenue but also reduces tax morale because it affects people’s trust in the government. If people believe that taxes are too high, hence unfair, or that the tax system is corrupt or complicated, they’re likely to feel a moral justification to evade taxes.
On 12th August, 2021, a presidential election was held that resulted in the Patriotic Front losing to the United Party for National Development (UPND). Popularly hailed as the ‘New Dawn’ government, the UPND has since allocated K13.9 billion ($783. 6 million), representing 8% of the total 2022 budget to public health. This is a clear indication of Zambia’s determination to honor the Abuja Declaration. A counterargument however, is that an 8% budget allocation towards health will translate into a necessity for more external aid and that this will continue the vicious cycle that stunts and paralyses national growth and development. Which way the hammer swings will soon be seen.
Sources: • African Union (2001). Abuja Declaration on HIV/AIDS, Tuberculosis, and other Related Infectious Diseases. Abuja: Nigeria • Bwalya, J, (2021). Policy Brief. SADC and Abuja Declaration: Honoring the Pledge. Southern African Institute of International Affairs. • https://pmrczambia.com/wp-content/uploads/2019/07/Overview-of-Domestic-Resource-Mobilisation-Infographic.pdf • J Dieleman, M Schneider, A Haakenstad, L Singh, N Sadat, M Birger, A Reynolds et al., ‘Development Assistance for Health: Past Trends, Associations, and the Future of International Financial Flows for Health,’ The Lancet 387, no. 10037 (2016): 2536‒2544. • https://apps.who.int/nha/database/country_profile/Index/en • McIntyre D, A Obse, E Barasa & J Ataguba, ‘Challenges in Financing Universal Health Coverage in Sub-Saharan Africa,’ in Oxford Research Encyclopedia of Economics and Finance (London: Oxford University Press, 2018). • Policy Monitoring and Research Center. (2022). 2022 Budget- Education, Health, Social Protection, Water and Sanitation. https://pmrczambia.com/blog-2022-budget-education-health-social-protection-water-and-sanitations • World Health Organization. (2011). The Abuja Declaration: Ten Years On. World Health Organization: Geneva