Achieving universal health coverage (UHC) has become a dominant policy preoccupation within the global health community. For Africa, progress towards UHC involves ambitious goals for expanding access to a range of effective health services, a substantial increase in health expenditure, and establishing a greater reliance on prepayment and pooling mechanisms to finance healthcare. According to one set of calculations, achieving UHC requires countries to spend at least $86 per capita in 2012 dollars on healthcare, and a minimum of 5% of Gross Domestic Product (GDP). Clearly, expanding the ‘fiscal space for health’ will be key to the success of UHC.
The global UHC movement is welcome and has helped to galvanise political will to tackle the problem of growing health inequities and the impoverishing effect of out-of-pocket health expenditures. It also helped refocus attention on the fragmented and inefficient architecture of domestic and international health financing, the unpredictability of foreign aid and the lack of regulation over the private health sector in low- and middle-income countries (LMICs). The concept of health insurance has become central to the promotion of UHC, in the belief that financial and risk pooling offers the best guarantee for cost-effective expenditure and protecting the most vulnerable from financial hardship. Public financing will need to play a critical role, and it has been argued that domestic taxation should be designed to both expand the fiscal space for health and pursue social justice objectives.
However, the promotion of UHC in Africa has been largely built on the optimism associated with the continent’s commodity boom and improved economic performance over the past decade. As the economic outlook for the continent deteriorates, optimism about the viability of ambitious UHC policies and targets is beginning to recede. This paper argues that if the continent is to remain committed to the concept of UHC, the associated policies and financial tenets need to incorporate the nature of Africa’s non-linear, fragile growth.