Africa’s health systems face a financing challenge that cannot be addressed by health ministries alone. The UN Economic Commission for Africa (ECA) is calling for multi-year agreements between finance and health ministries, arguing that annual budget negotiations have left health reforms without sufficiently predictable funding.
In brief
- The ECA says African governments finance less than 41% of total health expenditure on average.
- The proposed fiscal compact would replace annual negotiations with more predictable multi-year health funding arrangements.
- Under the proposal, finance ministries would protect allocations while health ministries would set measurable efficiency and results targets.
- The ECA has put Africa’s annual health-financing gap at up to $66 billion.
In its proposal, reported by Birr Metrics, the ECA says African governments finance less than 41% of total health expenditure on average. It also says external assistance has historically accounted for more than 30% of health spending, while debt-service demands and tighter fiscal conditions are narrowing governments’ room to increase allocations.
The issue is therefore not simply the size of health budgets. It is whether policy commitments can be converted into funded programmes that endure beyond a single budget cycle.
Why the ECA wants multi-year health funding agreements
The proposed fiscal compact would replace annual negotiations with arrangements intended to make health financing more predictable. Under the framework described by the ECA, finance ministries would commit to protected and foreseeable allocations, while health ministries would provide measurable targets for efficiency and results.
That division reflects a practical tension in public finance. Health authorities need resources to plan services and programmes over time, while finance authorities need evidence that spending can be monitored and assessed. The ECA has also called for stronger links between health and budget data so that governments can track expenditure and outcomes more effectively.
The proposal has not been presented as an adopted policy across African governments, nor as a guarantee of higher health spending. Its significance lies in the attempt to put health financing within the routine fiscal decisions that determine whether reforms receive the resources needed for implementation.
A wider squeeze on domestic budgets and external support
The ECA’s call comes amid pressure from several directions. Governments face competing demands for public investment, higher debt-service requirements and limited concessional financing. When public resources are constrained, the consequences can also fall more heavily on households, especially where people pay directly for care.
At a separate ECA-linked conference, speakers said that more than 40% of Africa’s health-care funding came from donor aid, according to Global Issues.Org’s report on the meeting. The figure illustrates the continuing importance of external funding, although estimates depend on the period and measure used. The same report said the ECA estimates an annual health-financing gap of up to $66 billion.
That gap should not be read as proof that one funding source can solve the problem. The ECA has pointed to fiscal integration, better expenditure assessment and financing mechanisms tailored to countries’ debt and cash positions. Those are choices that require coordination across government, not only new commitments from health agencies or development partners.
The regional context has become more difficult as global health assistance faces uncertainty. During the World Health Assembly, African countries called for increased support to strengthen health systems after cuts to World Health Organization regional-office budgets. Health Policy Watch reported on those calls, including the joint statement made on behalf of the 47 countries in the WHO Africa region.
Linking health outcomes to fiscal decisions
A multi-year compact would place a clearer expectation on both sides of government. Predictable allocations could help health ministries plan beyond the next annual budget. In return, measurable objectives could give finance ministries a basis for judging whether resources are being used as intended.
This approach does not remove the importance of international support, and it does not suggest that every country faces the same fiscal conditions. It does, however, focus attention on the connection between health policy and the budget process. That connection will matter as governments weigh public-health needs alongside debt, infrastructure, education and other spending priorities.
Health financing also belongs in the wider discussion of public finances. Africa’s economic outlook for 2026 and beyond provides further context for the fiscal pressures shaping policy choices across the continent.
For the ECA, the central argument is that a health strategy without an accompanying budget line remains incomplete. The proposed compact is an effort to make financing, accountability and health outcomes part of the same government conversation.
Featured image. Source: Pexels. Credit: Werner Pfennig. License: Pexels License.
