Summary

This chapter considers health care financing in the African context, particularly the role that financing mechanisms can play in addressing public-private mix inequities. Sub-Saharan Africa has the worst health status indicators of any region in the world. Given many African countries' low level of national income, high poverty levels and low social development, the African experience is a graphic illustration of the social determinants of health. Health services, nevertheless, have a role to play in promoting health improvements, yet the health systems in most African countries are ill-equipped to contribute as they could.

The current health system context in Africa is briefly considered, and then contrasted with the key characteristics of equitable health systems based on a review of evidence from other low-income and middle-income countries. It is argued that a complete reversal of the public-private mix in health care financing and provision is required in African health systems to promote equity. Various ways of potentially achieving this, particularly through health care financing mechanisms, are considered.

A key conclusion of this analysis is that fragmentation in health care financing and provision must be reduced in order for cross-subsidies in income and risk to be achieved. Out-of-pocket payments must be minimized, as they do not permit any cross-subsidies, and linkages between individual voluntary insurance schemes, such as through a risk-equalization mechanism, should be considered. However, the route to equitable health systems lies particularly in increased tax funding and mandatory health insurance.