Our health system remains chronically underfunded. Year after year, the health sector receives less than 4% of the national annual budget. This figure starkly contrasts with the minimum 15% target set by the Abuja Declaration—a commitment our government also signed along with other African countries, two decades ago.
Countries like Rwanda and Uganda dedicated 24% of total government budgets to health. This fiscal year, Ethiopia allocated only 3.7 % of the federal budget to health reflecting continued default on the Abuja Declaration and a profound under-prioritization of public health.
To deliver essential health services, WHO’s minimum threshold is $86 per person. That means the government should, at very minimum, aim to spend $86 per person annually. This amount represents the minimum amount of money required to provide essential health services including primary care, maternal and child health, infection control, infrastructure development, and fair pay for health workforces.
If it’s to cover advanced care like specialized surgeries, ICU care, etc., the minimum required amount goes higher. Let’s see the five year average of per person health expenditure of these countries: the US spent $13,038 per person for health, South Africa—$875, Kenya—$95, Ethiopia spends only $27 per person on health. This is one of the lowest per capita health expenditure in the world—falling far from WHO’s minimum recommendation.
Likewise, our national health expenditure accounts for less than 3.5% of our GDP, another telling sign that health is not priority in our country. The global average in this regard is 9.5%. Sub-Saharan Africa average is 5.6%. WHO recommends at least %5 of GDP to ensure progress towards universal health coverage. Ethiopia’s low health expenditure relative to GDP reflects that health is undervalued as both a fundamental human right and an economic catalyst.
Having this low domestic investment, vital programs such as HIV, TB, and malaria continue largely because of foreign donor support. With the same token, other critical programs like childhood vaccinations, malnutrition treatment, maternal and neonatal care depend on the funds from development partners or donors. This heavy reliance on external funding for these critical health programs simply reflects that our health system is unreliable, fragile, and unsustainable.
From the above paragraphs, we can see that the health is not treated as a priority in our country. It’s undervalued edging near complete collapse. In clear words, the low government spending in the sector is the culprit of the unfolding crisis—from underpayment of health workforce to heavy dependence on donors for critical services.
I am firmly convinced that the core problem of our health sector is financial — it is a crisis of health care financing. Five other pillars of health systems like leadership, workforce, service, medicines, and information can better be ameliorated if the funding (the finance) is corrected. Without serious and systemic investment, no health reform can truly succeed.
There was a time — about six years ago — when I strongly believed that leadership quality was the main issue. I openly criticized the appointment of health leaders based on political loyalty rather than competence. But that concern has evolved.
Today, many of our health institutions are led by highly educated, at least professionally capable leaders. We have a gynecologist running the sector, a gold medalist state minister, professors at the helm of regional health bureaus, and even a neurosurgeon heading a directorate. Nowadays, from federal institutions down to primary hospitals, there’s a good progress on who is leading health institutions.
It is no longer accurate to say our health system is led by some party loyalist cadres with no professional background. If anything is the challenge now in this regard (leadership), it’s their lack of courage or will to demand change from the top.
In clear words, what’s lacking from our top health leaders is not expertise, it’s courage and commitment to challenge top politicians so that the status quo changes and our sector gets better finance it deserves.
Until we treat health financing as a national priority, we will remain dependent on donors, vulnerable to diseases and poverty, and unable to meet even the most basic needs of our best caregivers. When I tried to see the trend, the political will and commitment, the economic policy framework of the country—what I mentioned above as a crisis will be a tip of the iceberg. The worst is yet to unfold under macroeconomic reform dubbed home-grown economic reforms (HGER 2.0).
The macroeconomic reform that is announced last July by the government is a classic copy of neoliberals market-oriented economic agenda. The only difference you see in it is that our government refrained from using the same terms as neoliberals.
One of the macroeconomic reform is fiscal austerity measures (fiscal policy reforms)— it’s an act of increasing government revenues and reducing government spending by tightly managing public funding and subsidy system.
Under this fiscal policy, the government is expected to reduce its public spending by cutting the budget from health, education, and social security. It will save money for itself by cutting subsidies e.g. on oil (fuel). This means that the little percentage of annual budget for the health sector is expected to be reduced or at least it’s not going to show rise to the level the sector is demanding. This would worsen the the health sector crisis.
Cutting subsidies, for example on fuel, will hike the price, further increasing the cost of transportation—thereby of other basic necessities— worsening the anxiety of the health workforce, who are struggling with the pittance it earns from the public sector.
Another notable component of macroeconomic reform program policy is market-based foreign exchange rate. This was followed by immediate currency devaluation—resulting in the birr losing more than 50% of its value against the dollar. For example, this pulled GPs salary from 170 dollars to 85 dollars in a few months period.
Now, the exchange rate is floating, the purchasing power of the salary we receive in the birr will keep on falling month after month. Simply because the US dollar is a global reserve currency and a hard currency whose values continue to appreciate against weaker currency like birr. Under such a market-based foreign exchange rate, a fixed salary in birr continues to be a pittance.
Even if they are not mentioned in the name on the macroeconomic reform program policy statement—privatization, foreign direct investment, trade liberalization, and deregulation—are all underway and to some extent they are visible.
Well, In such economic system (model), health is just treated as a market commodity, not public good. Health professionals are considered as costs to be managed, not as an asset to the country. What matters is the monetary income you generate through your services, not the generous service you offered.
In macroeconomic reform inspired by neoliberalism, the government’s appetite on provision of equitable and quality health services would be minimal. Health service will become a market issue. the rich will pay to get premium care at best private health facilities. The poor will queue in the overcrowded, underfunded and understaffed health services to get minimal care with unaffordable prescriptions.
Five or so years from now, we will see Chinese or Indian Hospitals with their imported staff and technology operating in Addis where our riches pay them in dollar or renminbi—not even in birr. The competition in private sector will be fierce. I fear to mention that the private health sector will flourish like well-watered garden, while the public sector withers. The professionals who shift to private sector will make good income, those who prefer to stay in public sector likely suffer with low pay and unwelcoming work conditions.
Today, I’m not in a position of asking our professionals— to put on struggle to improve the rotten public health system as I have been doing for years—I gave up years ago. I lost brilliant friends whose lives were cut short by this good-for-nothing and improvident system. If you truly believe in your slogan—we have been saving lives, now it’s time to save our own—here are my final statements for you:
“When classic neoliberal policies are repackaged as Home-Grown Economic Reforms, our chronically underfunded public health sector has little to no prospect of improvement (zero future hope).
For our health professionals, the future offers three choices:
~ To remain in the public health system wallowing in poverty and professional frustration.
~ To shift to the private health sector or NGOs or join other businesses in pursuit of financial stability and may be for potential capital accumulation.
~ To migrate abroad in search of better pay, and working conditions.
Decide wisely. It’s your time to decide! Break a leg!
This article is written by Dr. Nuredin Luke and originally published on a Facebook page called Hakim
