Will Africa’s New Scorecard Promote Universal Health Coverage?

By Sharifah Sekalala

They say, ‘that what gets measured gets done!’1 On 26 August 2016 all 54 African leaders agreed to create a scorecard on Domestic Financing for Health. This scorecard will collate and publish data from all African countries on domestic health spending; the transparency and comparison with other African states is expected to encourage increases in health expenditure. The World Bank, Global Fund to fight AIDS, tuberculosis and malaria, and the Government of Japan have committed $24 billion to support this program over the next three to five years.

If implemented successfully, this measure could go a long way in supporting universal health coverage (UHC) in Africa. UHC is defined by the WHO to mean that all people receive the health services they need without suffering financial hardship when paying for them. The full spectrum of essential, quality health services should be covered, including health promotion, prevention and treatment, rehabilitation, and palliative care. UHC is needed throughout Africa where out-of-pocket payments have increased from US $15 per capita in 1995 to US $38 in 2014, causing 11 million people to fall into poverty. Achieving UHC is a Sustainable Development Goal target (SDG 3.8) as well as being critical for the achievement of SDG1 on eradicating poverty.   

Previous agreements, including the Paris Declaration in 2005, the Accra Agenda for Action in 2008, and the Busan Partnership in 2011, raised concerns about insufficient domestic funding for health. In 2014, African countries spent about US $126 billion on domestic funding for health. However, this was far short of their targets under the Abuja Declaration of 15% of government spending, which only four of the 54 countries met. To achieve better health outcomes, African countries need to increase financing, improve service delivery, target vulnerable and excluded populations, and mobilise critical sectors and political leadership.

All 54 African countries have agreed to monitor strategic indicators and report annually to the African Commission, which will use this data to provide a comparative analysis of health spending.

Countries will update National Health Accounts annually and will upgrade their systems to comply with WHO regulations, enabling WHO to validate the data. The scorecard will show health financing performance over time, health financing expenditure derived from government, donors and households, and amount of tax collected as a percentage of GDP which is spent on health.

Comparative systems like this have three major problems. Firstly, there is a danger that scorecards focus on total numbers without publishing underlying details. For instance, a country may opt to increase domestic health expenditure on expensive private hospitals or paying for ministers to travel abroad for medical treatment. Such use of health funding would not promote universal access to health care.

Secondly, many African countries already struggle with multiple reporting burdens to donors. Health ministries are overstretched trying to find data for different programs and UN treaty reporting obligations. They lack the human resources and would struggle to report on yet another scheme. Is the funding allocated by donors sufficient to address these resource constraints in African countries?

Thirdly, African countries do not have a good track record on increasing their health funding commitments, and much of the data collated in the scorecard is already available elsewhere, so will this endeavour make any difference?

Optimists would refer to the evidence that human rights reporting to the UN has resulted in improved human rights compliance. The same may well hold true of the scorecard. Benchmarking systems such as the scorecard can promote good practice and enable countries with similar historic, social, and economic contexts to learn from each other.

Greater transparency provides civil society organisations and opposition parties with data to hold governments to account for their right to health and UHC obligations. The scorecard system will simplify data so that cross country comparisons are easily conducted and the results can again be used to put pressure on governments to continually improve – to progressively realize the right to health.

These achievements depend on African countries taking their reporting obligations seriously. Whether this scorecard works in practice, only time will tell!

Sharifah Sekalala, PhD, is an Assistant Professor in the School of Law at the University of Warwick (UK). Her research focuses on the role of law in responding to global health problems. Email: Sharifah.Sekalala@warwick.ac.uk


  1. Lord Kelvin, May 3, 1883, lecture on “Electrical Units of Measurement” (Popular Lectures, Vol. 1, page 73)