Health financing reform in sub-Saharan Africa: major constraints, goals, and strategies.

Health financing reform became a critical element of public sector reform in sub-Saharan Africa during the past decade. Within the framework of health sector reform, this article reviews the major constraints, goals, and strategies for health financing reform in sub-Saharan Africa. It identifies shrinking budgetary resources, increasing demand for health services, and rising health care costs as the primary factors driving the sub-region's health financing reform agenda. In light of these constraints, the article defines the major goals and the strategies for health care financing reform employed by many sub-Saharan African countries. Key words: health reform, international health care, sub-Saharan Africa, African health care, developing countries.

**********

HEALTH CARE financing reform gained prominence in the agenda of policymakers and health planners worldwide during the past decade. The term "reform" refers to "a sustained process of fundamental change in policy and institutional arrangements guided by government, designed to improve the functioning and performance of the health sector, and ultimately the health status of the population." (1) The reasons and urgency for reform differ among countries; however, the trends and objectives are similar. (2) In developed countries, the desire to contain skyrocketing health care costs largely triggered the initiatives for reform. In developing countries, it was the shrinking public resources and increased demand for health care services that drove the health care financing reform agenda. In sub-Saharan Africa, discourse for health finance reform focused on how to improve the equity, sustainability, and effectiveness of health care services. Overall, sub-Saharan Africa's health care financing reform policies broadly involve "alternative arrangements for paying for, allocating, organizing, and managing health resources." (3)

This article reviews the major challenges, constraints, goals, and strategies for health care financing reform in sub-Saharan Africa. It begins with an assessment of the sub-region's health status and economic conditions by comparing sub-Saharan Africa's recent key social and economic indicators to other regions of the world. Social and economic indicators provide critical data about a country's or a region's overall health status and level of economic development. Next, the article reviews the major challenges and constraints of health care financing reform in sub-Saharan Africa. Finally, it defines the major goals of health care financing reform and evaluates specific health care financing strategies germane to health care reform policy in sub-Saharan Africa.

Key Social Indicators

Virtually every region in the world made significant progress in improving health conditions and health status in the past three decades. In sub-Saharan Africa, the improvements have been modest. International statistical data on economic, social, and health care improvement indicate that most countries in the sub-region lag behind major world health benchmarks, such as infant mortality, morbidity, malnutrition, maternal mortality, and the incidence of the spread of deadly diseases (e.g., AIDs).

Economic data for the past two decades show that up to 50 percent of the population in sub-Saharan Africa lived in absolute poverty. The rate of population growth compared unfavorably to the rest of the world (i.e., sub-Saharan Africa recorded the fastest rate of population growth in the world). The high population growth subdued government efforts to reduce poverty and maintain sustainable levels of economic growth. The sub-region's annual population growth rate averaged 2.7 percent during the 1990s, compared with 1.9 percent for Asia (China excluded), 1.8 percent in Latin America and the Caribbean, and less than 0.1 percent in Europe. (4) Its average infant mortality rate of 103 per 1,000 remained the highest in the world. In addition, the sub-region's average fertility rate of slightly over 6.0 exceeded the rest of the world's average of under 4.0 in the past quarter century.

International statistical data show that economic conditions remained fragile and vulnerable to internal and external shocks despite positive indications of economic progress during the 1990s. Sub-Saharan African countries registered the lowest availability of social services in the world. Expenditures on health care averaged below 5 percent of annual total budgets. Such unfavorable statistics entail that the incidence of disease and early deaths remained higher in sub-Saharan African countries compared to other regions of the world.

Major Challenges and Constraints

Health planners and policymakers in sub-Saharan Africa deal with various challenges and constraints that affect health care financing, the provision of health services, and health status. According to Kutzin, sub-Saharan African countries "face an array of health financing problems that leave their health systems far from achieving the objectives of good health status, equity, efficiency, acceptability, and sustainability." (5) Researchers have identified a variety of challenges and constraints that adversely affect the region's health care financing reform. The major challenges include how reformers can improve equity, access, health status, and overcome financial deficiencies in the health care sector.

Beyond the challenges, a myriad of constraints plagued heath care systems in sub-Saharan Africa. Senbet found the failure of government policies at the root of social and economic deterioration in the sub-region. (6) Ruger, Jamison, and Bloom cited low personal income, a large subsistence sector exempt from income taxation, and low administrative and tax collection capacity as major health financing constraints. (7) Kutzin noted the shortage of budgetary resources, inequities, and inefficiencies in distribution of limited resources, managerial incapacity of the health …