ADDIS ABABA, Ethiopia, 24 August 2026 — Speaking today at a ministerial dialogue held on the margins of the 76th WHO Regional Committee for Africa RC76, Aboubakri Diaw, Chief of Staff of the United Nations Economic Commission for Africa (ECA) and project lead for ECA's Sustainable Financing Imitative launched in March 2026, called for a fundamental reset in how African governments and their finance ministries fund health systems, warning that the continent’s challenge is not a shortage of reforms but a shortage of financed reforms.
“We have a fundamental fiscal problem that is tied to the health-sector problem,” Diaw told ministers and senior officials gathered for the dialogue. “Many countries on this continent now spend more on servicing debt than on public health.”
As indicated by Mr. Diaw, health is a central pillar of Africa’s socioeconomic transformation. Strategic investment in health systems contributes directly to human capital development, productivity, and inclusive growth. Yet Africa’s health financing model remains structurally fragile: governments finance less than 41 per cent of total health expenditure on average, and unpredictable donor funding pushes households toward out-of-pocket payments that drive more than 150 million people into poverty every year.
Furthermore, rising debt distress and declining concessional flows are further compressing already limited fiscal space, a configuration ECA has described as unsustainable given the continent’s demographic expansion, epidemiological transition, and climate vulnerability.
“We know ODA has fallen and is still falling,” Diaw said. “External aid covered more than 30 per cent of health expenditure; in some 13 countries the ECA has looked at, households pay more for health than their own governments do. That is the fiscal space we are asking health to grow.”
Diaw described this as a paradox at the heart of African health financing, stating, “Africa does not have a reform deficit. It has a sustainable financed-reform deficit.
Health financing strategies sit on shelves. Insurance schemes are legislated but struggling to be capitalised. Benefit packages are defined but not costed into medium-term expenditure frameworks. A reform without a budget line does not constitute a policy.”
He argued that the way forward is a multi-year fiscal compact between ministries of finance and ministries of health, replacing the “annual, adversarial budget negotiation” with an arrangement in which finance commits to predictable, protected allocations and health commits to measurable efficiency and results.
“A compact is only as strong as the evidence behind it,” Diaw noted, pointing to the need for real-time, interoperable health and budget data, and what he called “a digital twin of the health budget,” so that finance can verify results and health can defend its allocation.
Diaw was direct about the cost of inaction on efficiency. “We estimate that thirty to forty per cent of health spending is lost to inefficiency,” he said. “Efficiency is the currency that buys fiscal space. No minister of finance can expand an envelope that leaks.”
He outlined how ECA is supporting member States to close this gap: quantifying financing gaps through a shared data and intelligence platform, running fiscal-space and public-expenditure diagnostics, and structuring instruments, from health taxes to debt conversions and blended finance vehicles — that turn strategies into financed strategies.
“Universal coverage, in this logic, is the outcome of fiscal reform, not its substitute,” he said.
While acknowledging broad consensus around the idea of “health as investment,” Diaw said finance ministers need more than a slogan to act. “To act, that minister must see four things: a quantified, credible gap and pipeline; returns expressed in their language, i.e productivity, human capital, revenue; efficiency gains demonstrated and banked first; and instruments that fit their actual debt and cash position,” he said.
“When we put an investment-grade proposition on the table, ministers of finance move. Our collective task, and the work that ECA is doing, is to build and lay that table.”
About “Transforming Health Financing in Africa”
The remarks were delivered against the backdrop of ECA’s initiative, “Transforming Health Financing in Africa,” which proposes a systemic architecture built on seven interlinked outcomes: fiscal embedding, innovative financing instruments, digital governance, primary health care modernization, regional public goods, institutional capacity, and narrative transformation. The initiative will run over five years, from 2026 to 2030.
About ECA
The United Nations Economic Commission for Africa (ECA) is one of the UN’s five regional commissions, mandated to promote the economic and social development of its member States, foster intra-regional integration, and promote international cooperation for Africa’s development.
Issued by:
Communications Section
Economic Commission for Africa
PO Box 3001
Addis Ababa
Ethiopia
Tel: +251 11 551 5826
E-mail: eca-info@un.org