Expenditure on health is productive capital

The traditional view of healthcare no longer works as aid declines and national finances are squeezed. Instead, we must view health financing as productive capital, as virtually all other sectors depend on a healthy population functioning at peak capacity.

A frica approaches 2030 as Official Development Assistance is declining, debt is rising, and fiscal space is shrinking, while pressures mount.

The challenge is protecting hard-earned gains during fiscal contraction while accelerating progress towards the Sustainable Development Goals. Achieving speed and scale requires a broad political-economy approach. Health financing can no longer be treated as a technical issue confined to the health sector. It is a macroeconomic, sovereignty and accountability imperative.

For decades, domestic expenditure and external assistance saved millions from HIV, tuberculosis, malaria and vaccine-preventable diseases. But this model also produced fragmentation, parallel structures and dependence on donor priorities.

As Minister of Health and number two in Mali’s government, I had approximately $40 per person per year for health services. Yet I had little control over the financing provided by partners or how it was used. The systems were fragmented – not truly ours.

Many Ministers face the same reality: too little fiscal space, too many parallel programmes and limited control of national agendas. Declining ODA reveals more than a financing gap. It exposes a structural vulnerability: systems dependent on external decisions cannot be fully resilient or sovereign.

The conventional question – ‘How do we increase domestic health financing?’ – is insufficient. Finance Ministries balance health against debt, food insecurity, energy subsidies, employment, security and political stability. Calls for more health spending will fail unless they recognise this reality.

The priority must be health financing resilience: protecting essential services and gains; improving efficiency and reprioritising expenditure; establishing domestic co-financing pathways; and progressively expanding investment as fiscal space improves. This sequences Africa’s ambitions intelligently.

Families already finance too much healthcare from their pockets. High out-of-pocket expenditure is not merely a household burden; it signals a failure of pooling, protection and solidarity. It delays care, deepens inequality and can push families into poverty. Reform must reduce this burden, not transfer more costs to citizens.

The years to 2030 must become an emergency implementation window. Countries must determine which services cannot be interrupted, which externally financed programmes should enter national systems and which reforms offer the greatest returns. Success must be measured by continuity, equity and lower out-of-pocket expenditure – not only by money mobilised.

Health as productive capital

The future begins by changing how health is presented to political leaders and Finance Ministers. Health is not simply social expenditure; it is productive capital.

Health investment strengthens human capital, workforce productivity, economic resilience and national stability. Healthy children learn better. Healthy adults contribute more. Resilient systems

protect economies from epidemics and shocks.

We must also stop paying predominantly for sickness and start investing in prevention. Sanitation, clean water, primary healthcare and health education are essential economic investments. Prevention is not charity; it is common sense. It protects lives, reduces treatment costs and preserves scarce public resources.

We must speak the language of Finance Ministries. The question is not only what health costs, but what it produces – and what countries lose by failing to invest.

A national health plan should become a national investment compact, jointly owned by the Ministries of Health and Finance and linked to budgets, strategic purchasing, industrial policy and measurable outcomes.

It should define priorities, establish predictable government co-investment and align partners behind one country-led framework. Countries must become conveners of partnerships, not recipients of projects.

Every time we wait for aid, we delay our own development. Real power lies in what we choose to fund ourselves.

Domestic public finance must remain the foundation of equitable systems. Private capital cannot replace the state’s responsibility to guarantee essential services and universal access. But national budgets and traditional aid will not be sufficient alone.

Africa must connect public resources with private, institutional and development finance through blended finance, guarantees, health bonds, debt-for-health swaps, diaspora investment, public-private partnerships and, eventually, African health capital markets.

These instruments must finance investment-ready opportunities: primary healthcare infrastructure, digital systems, diagnostics, supply chains, pharmaceutical manufacturing, biotechnology and African-led research.

Public and concessional resources can absorb risk and protect equity. Development finance institutions can de-risk investment. Governments can create predictable demand through pooled procurement and long-term purchasing commitments.

Private capital can finance viable infrastructure, leaving public resources focused on essential services and populations markets cannot reach.

The objective is not to commercialise the right to health, but to use each form of capital according to its comparative advantage while safeguarding public leadership and social justice.

Africa’s dependence on imported medicines, vaccines and technologies is both a health vulnerability and an economic failure. Local production fails not mainly from insufficient factories, but because demand, financing, regulation, data, research and industrial capability remain disconnected.

Sustainable production requires an integrated African market, guaranteed demand, de-risked capital, manufacturing hubs, a strong African Medicines Agency and African-led research and innovation. Connecting financing, procurement, production, regulation and innovation will create scale, skilled employment and resilience.

Accountability and implementation

No financing model is sustainable without trust. Health financing requires accountability for commitments, allocation, implementation, results and every dollar invested. Data creates visibility, moving us from opacity to accountability. Governments and partners must show not only how much was spent, but whether resources improved access, outcomes and lives.

External financing should strengthen national institutions and use national systems. Partners should catalyse transition and co-investment, not remain perpetual landlords of African health programmes.

Africa has never lacked declarations or strategies. It now needs disciplined execution: turning commitments into results and investment into impact. The HIV response proved what political leadership, science, solidarity and community mobilisation can achieve. Africa today has stronger institutions, scientific excellence, community leadership, political experience and greater confidence in its capacity.

Our ambition must not simply be to finance more. It must be to decide more, allocate better, innovate more and lead more. The question is no longer how to fill the gap, but how to redesign our systems around resilience, sovereignty and accountability – with the speed and scale that 2030 demands .

Michel Sidibé is the AU Special Envoy for the African Medicines Agency (AMA he is a former Minister of Health and Social Affairs of Mali, and a former Executive Director of UNAIDS and UN Under-Secretary-General

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