Press Release No. 21/1997

Cost Sharing on Social Sectors in Sub-Saharan Africa - Social Services Should be Given Priority in Public Expenditure Allocation

Addis Ababa, 18 June 1997: "If the level of quality of social services on this continent remain at their current levels, human resources development, which is the foundation of poverty reduction, will be negligible".

The warning was given by K.Y. Amoako, UN Under Secretary General and Executive Secretary of the Economic Commission for Africa (ECA) Wednesday at the beginning of a three-day forum on cost-sharing in the social sectors in sub-Saharan Africa.

The record on the provision of social services and the fight against poverty, he added in his opening statement, has lagged behind the record of other regions:

• Life expectancy has remained stable for May years and, if present trends continue, AIDS will bring it even lower.
• Nearly one third of the current population of the region, or 125 million people will not survive to age 40. In East Asia, the corresponding figure is less than one tenth.
• The average adult illiteracy rate, at 42 percent, is more than three times higher than the rate in East Asia and the Pacific region.
• Nearly half of the population in sub-Saharan Africa does not have access to health services compared to a little more than 20 percent in South Asia.

Attending the forum is an array of Ministers and experts from 20 African countries -- in addition to the World Bank, Swedish International Development Agency (SIDA), USAID, Netherlands, Overseas Development Agency (ODA, UK) and Germany.

Chairing the forum, Dr. Adam Ibrahim, Minister of Health of the Federal Republic of Ethiopia, pointed out that "cost sharing raised highly emotive political economic and social concerns", making the task of decision-makers particularly difficult but unavoidable.

"Otherwise," he added, the decision will be taken for us by the market without adequate protection for the poor, particularly children".

Lead specialist in Human Development of the World Bank's Africa Region, Avril D. Adams, recalled that while cost-sharing had been a key standing feature of the African policy landscape dating from the colonial era, it had become apparent by the mid-1980s that governments did not have the financial resources and were unlikely to ever have, to pursue successfully a policy of free universal services for all.

"No industrial country has provided so much of the health and education services free to users with so much central administration as the countries of Sub-Saharan Africa", he noted.

Cost sharing raises some complex issues for the forum. On the one hand, it can mobilize additional resources to extend and improve the quality of the social services, encourage community participation and optimum delivery of services; and enhance accountability and thus upgrade efficiency. On the other, evidence has emerged according to the UNICEF Representative in Ethiopia, P.R.N. Tuluhungwa that user charges can impact negatively on access to basic social services thereby leading to serious equity losses.

"In the past, too many mistakes have been repeated in too many countries that have resulted in too high a cost for children", he warned. "I wish to emphasize the need to approach social policy from a rights perspective".

The forum is one of the activities of the United Nations Special Initiative (SIA), launched in 1996 against a background of United Nations commitment to Africa sustained through the World Conference on Education for all, the United Nations Conference on Population and Development and the World Summit on Social development, among others.

The SIA was designed to identify and develop a set of concrete programmes that give practical and coordinated expression to the commitment made to Africa in the context of these conferences.

Out of the 13 programme clusters, education and health together account for the two largest clusters of programmes. The World Bank, UNICEF and the World Health Organization (WHO) lead the UN family in these two areas.

"Regrettably, the policy debate on public financing of these services have given too much emphasis to raising revenues through user services", Mr. Amoako noted. He highlighted the fact that too little attention has been given to how cost sharing can "contribute to efficiency, equity, and sustainability of national systems of social service delivery".

The ECA Executive Secretary underscored that the level of investments necessary to meet the social sector needs of Africa are far in excess of what the public sector alone can provide.

"Success in achieving human resource development will depend on improving efficiency in the allocation and utilization of public funds" as well as involving communities and the private sector in the cost sharing of social sector delivery", he said.

The World Bank did not address cost-sharing as a financing strategy for the social sectors until 1987 when it began issuing a series of policy statements, on this topic calling for:

• targeting of public spending on basic education and health care;
• option of user fees at the tertiary level as part of a broader package of reforms to improve the equity and efficiency of health and education service delivery;
• protection of access for the poor to education and health services through targeted subsidies and fees exemptions.

"The World Bank has now joined others in the development community in asking whether or not these messages are being heard or translated into effective policies on the ground", Mr. Adams observed.

While aware of the lack of simple answers for these policy issues Mr. Tuluhungwa of UNICEF pointed out that the Untied Nations Convention on the Rights of the Child -- "which in just 8 years has been ratified by no less than 191 countries making it the most widely accepted human rights treaty in history" -- should bear on discussions on cost-sharing in the social sectors at the forum.

Beginning with an overview of issues, the forum will continue to examine country experience from Malawi, Chad, Uganda and SIDA, and then summarize elements of consensus and emerging principles. That should lead to the development of guidelines for cost-effective cost sharing at the close of the forum.