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Submission of evidence to the International Development Committee’s Inquiry into Extreme Poverty & the SDGs

May 2022

 

The context

Health, education, and poverty (or wealth) are inter-related. There is a direct correlation between health, the cost of healthcare, and persistent poverty: in Africa and around the world.

Every year, 100 million people are driven into poverty through out-of-pocket health spending. Across the African region, 15 million people – more than half a million people in Kenya alone – have been pushed into poverty because of having to pay for health services at the point of care (Barasa et al, 2017). A further 97 million people in Africa incurred catastrophic payments which put them at a higher risk of falling into poverty (AHAIC Commission Report on the State of UHC, 2021).

Against this backdrop, the COVID-19 pandemic has stalled and in fact reversed the progress being made towards achieving the global goal of ending poverty in all its forms. According to the UN Economic Commission for Africa’s Economic Report on Africa (ERA) 2021, released on 15th May 2022, “the disruptions caused by the COVID-19 pandemic pushed an estimated 55 million Africans into extreme poverty in 2020 and reversed more than two decades of progress in poverty reduction on the continent”.

For a majority of people living in lower- and middle-income countries, the economic damage resulting from COVID-19 could long outlast the pandemic itself, leaving permanent scars like increased levels of malnutrition, heightened susceptibility to diseases, and missed schooling. Consequences related to income loss, food security (in the context of a global food crisis that is particularly acute in the Horn of Africa), and the ability to access and purchase basic necessities like medication have already been evident across the African continent.

Beyond the immediate impact on household incomes, evidence from high frequency surveys is pointing to a longer-run impact of the pandemic on inequality and social mobility. Those who lost income due to the pandemic have been almost twice as likely to run down assets or savings, leaving them less able to cope with continued or recurrent income losses. They have also been 57% more likely to go a full day without eating, which carries serious long-term consequences for cognitive and physical development when experienced among children.

Low vaccination coverage means that Africa is still battling COVID-19 while other parts of the world are moving on to a “post-pandemic” era. Coupled with limited access to treatment and testing, vaccine inequity means that many households and families in low-income countries in Africa will remain heavily burdened by the pandemic, exacerbating their inability to recover and improve on their livelihoods. The recurrence of the same obstacles to treatment that existed during the roll-out of treatments for AIDS are an imminent reality for many people in Africa.

Our work at Amref Health Africa ensures that families do not have to decide between seeking vital healthcare and meeting essential household needs. We are advocating for an increase in investments that reduce the point-of-care financial burden for families living in poverty. This will not only reduce poverty resulting from healthcare: it will also increase health-seeking behaviour among communities, which in turn improves health outcomes.

The case for Universal Health Coverage (UHC)

In its 2020 – 2021 Results Report, released in May 2022 ahead of the 75th World Health Assembly, the World Health Organization (WHO) notes that, over the past two decades, “92 countries have experienced little change or worsening trends in financial protection”.

Universal Health Coverage (UHC) is an important proposition that examines the three key dimensions of healthcare provision: 1) access to services, 2) ensuring that these services are of sufficient quality, and 3) financial protection. In the words of Amref Health Africa’s Group CEO Dr Githinji Gitahi, speaking to the International Development Committee on 26th April, UHC is “a shock absorber for families”, as well as “a creator of wealth for communities”.

When expanding coverage, countries should strive to reduce barriers for low-income groups, rural populations, and other relevant groups to the extent that they are disadvantaged in terms of service coverage or health. This is especially important for high-priority services.

UHC is an important part of the health discourse in Africa. Governments across the continent have shown leadership with a wave of reforms that encompass the three dimensions of UHC highlighted above. With 50 out of 54 countries in the region establishing a UHC policy, or including UHC as part of their health policy goals, this provides a robust framework to outline key investments. Additionally, 20 out of the 54 countries in the year 2020 had UHC prioritised at the Presidential and/or Cabinet level as part of their development agenda.

To zoom in on one example, Kenya has recently enacted reforms that transform the National Health Insurance Fund into a vehicle for UHC by enacting legislative reforms that allow for more effective purchasing of services, and, under the leadership of the President, reducing or eliminating out-of-pocket payments for 1,000,000 low socio-economic households across the country by paying premiums for these households. This will allow the members of these households to seek services that are included in the package of services without payment at the point of care.

The WHO’s Thirteenth General Programme of Work sets out the ambition of “one billion more people benefitting from Universal Health Coverage” by 2023. However, the WHO’s 2020 – 2021 Results Report shows that the world is not on track to meet that ambition. The report notes that, although progress is being made, “Current estimates suggest that without course correction, we will fall short by 730 million people of reaching 1 billion more people with UHC in 2023. WHO pulse surveys on the impact of the COVID-19 pandemic reported that 94% of countries experienced disruption to essential health services, which increases the shortfall to 840 million.”

 

The impact of changes to UK Aid

Cuts to the UK’s Official Development Assistance budget had a direct impact on Amref Health Africa and the communities we serve in 2021.

Family planning work in Kenya, health worker training in South Sudan, support for people living with disabilities, efforts to end female genital mutilation or cutting (FGM/C) at a regional level: all saw their funding reduced or cut off entirely. Our teams have adjusted their activities and sought alternative sources of funding to plug the gaps: but in every case, the cuts have limited the support we can provide to communities living in challenging circumstances.

In terms of the work Amref implements, the impact of the cuts is perhaps most immediately obvious in South Sudan, which is home to one of the world’s most fragile health systems. A whole host of health services in South Sudan are reliant on international funding: any reduction in the latter is catastrophic as, in the words of Amref South Sudan’s Country Director, Morrish Ojok, “there is no back-up plan”. Ojok drew a direct link between the cuts to health programmes and access to / uptake of the COVID-19 vaccination in South Sudan.

 

Looking beyond our own programmes, the cuts have had a direct negative impact on the health workforce development in African countries such as Uganda, Zambia, Ethiopia, Somaliland/Somalia, Tanzania, Ghana, and Sierra Leone. The training programmes supported by the UK (through THET) have closed.

The UK Government’s newly-released Strategy for International Development contains a welcome recognition of the role of “patient, long-term policy expertise and evidence” in tackling structural challenges. Speaking to the IDC on 26th April, Dr Githinji Gitahi underlined the importance of “predictable multi-year funding” that both creates sustainable change and generates evidence to inform future programming. However, such a commitment would seem to be undermined by brutal cuts made with little or no warning, and no consultation.

It is reassuring to read that strengthening health systems will remain at “the core” of the UK’s approach in the long term. Health systems strengthening – including investment in the global health workforce – will play a vital part in COVID-19 recovery as well as in preventing the next pandemic. We look forward to more detail about what this commitment will look like in practice, particularly when it comes to resource allocation: the Strategy as published contains almost no detail on spending commitments. This is something we urgently need to see.

The Strategy speaks of “stripping back excessive bureaucracy associated with delivering aid, giving our Ambassadors and High Commissioners greater authority and making it quicker to get programmes delivering on the ground”. The voice of communities – and the need to shift towards locally-led development that gives in-country partners more power – is, however, almost entirely absent.

 

Our recommendations for the UK Government