ROUND TABLE DISCUSSION
Department of Economics, University of Zambia, Lusaka, Zambia
At some level, I am in agreement with the opinions expressed by Ooms and Van Damme. There is virtually no dispute that, currently, total health expenditure in Africa falls far below what is required to address the health challenges facing the vast majority of the continent's population. It is also likely that this situation will continue for a long time to come. Thus, Ooms and Van Damme are right in observing that more international donor aid is needed urgently to enable African health systems to meet their health goals. I also concede that some of the proposals made by Kirigia and Diarra-Nama may not make a big impact on resource availability in many African countries in the short term. Therefore, I agree that African countries should not wean themselves from donor aid in the short term.
However, I have just a few points of disagreement with Ooms and van Damme. First, strictly speaking, there is no technical reason why a country with an income of US$ 366 per capita cannot increase its domestic health spending from US$ 20 to US$ 34. Several countries in Africa would possibly increase their per capita total health spending to US$ 34 and still have a total health expenditure-to-GDP ratio below 10%. It is the value of forgone alternative benefits (as perceived through either collective decision making or unilateral decisions of political authority) that puts a limit on how much a society can spend on health, not some health expenditure-GDP ratio technical limit.
Further, general lessons of experience from parts of east and south-east Asia and Latin America show that, as countries experience substantial broad-based economic and social progress, greater health funding becomes feasible. Such a situation requires time, but has been realized in these countries within about 20 to 40 years. Furthermore, one could argue that achieving independence from donor aid does not mean that external aid should not contribute anything at all to financing health care in Africa. Even rapidly growing economies like China are still recipients of aid from donors such as the Global Fund to Fight AIDS, Tuberculosis and Malaria.
With regard to corruption, if, as has been demonstrated by a number of public health expenditure tracking surveys in Sierra Leone, Uganda and Zambia, a large proportion of disbursed resources do not reach the intended service facilities, there will always be a perceived need for more money because population health indicators would remain dismal. This then might suggest that countries would perceive a funding gap (to be filled by an appeal to donor aid) even if countries were spending US$ 34 per capita of their own resources. As indicated in the WHO Statistical Information System,1 Zambia's total health expenditure per capita in 2005 was US$ 36. It cannot be ignored that productivity of health spending is also important. Overall, it is my belief that it would take a long time to reduce the high dependency on donor aid. But Africa's strategic vision should be to progressively increase domestic resource mobilization.
Competing interests: None declared.
1. WHO Statistical Information System. Geneva: WHO; 2008. Available from: http://www.who.int/whosis/en/index.html [accessed on 30 September 2008] .