Healthcare expenditures have never been high and medical costs are expected to continue to rise. This increase can be attributed in part to an aging population and medical innovation. It is therefore more important than ever, to critically assess financial investments in health care and measure the importance of ‘inputs’, such as human resources and the infrastructure in the health system.

4.1 Health financing

The part of the public expenditure allocated to health reflects the priority given to the health sector. In 2019, the African Region is ranked fifth out of six WHO regions with 5.3% of its GDP spent on health. The average expenditure in sub-Saharan Africa tripled from 27 to 90 dollars between 2002 and 2011, then began to decline around 2014–2016.

The African continent has made progress in improving some health indicators, but this progress needs to be sustained. In fact, Health equity, value for money, and access to health services for all are all issues that still need to be addressed. It is not about spending more, but about spending more equitably. Weak budget execution and the reduction of resources available for health result in high expenditures and an inequitable health system that ensures access only to those who can pay.

4.2 Health governance

In 2020, at least 33 countries in the WHO African Region had an updated health strategic plan with a monitoring and evaluation framework that defines the objectives, associated indicators as well as baselines and targets to be achieved per period. They also indicated the review periods of the plans, although many countries are not systematically conducting this exercise. In addition, the successful reorientation of health systems towards PHC depends on the recognition of the role of health facilities in this process. It is important at all levels of the health pyramid to equip the actors with “soft skills” to bring the health system to produce the expected results. Moreover, the detailed analysis of several other strategies developed for specific health problems generally suffer from a lack of strategic alignment in monitoring and evaluation with the national health strategy. In effect, parallel data collection systems are created which weaken the national system and in either case fail to produce quality information for decision making.

4.3 Health information

In almost half of sub-Saharan African countries, the legal time to register a birth is more than one month while the legal time to register a death varies from 24 hours to one year. To improve health and reduce deaths and disabilities around the world and particularly in the African Region, it is essential to regularly collect and analyze high-quality data on deaths and causes of death, as well as on disability. These aspects, which are nevertheless the “blood” of public health, still faces many difficulties. In addition, several countries in the Region are using/piloting various patient data collection solutions and very few report on the percentage of facilities using patient records/unique patient ID numbers. There is need for countries to setup consolidated architecture to address data security as well as interoperability issues, only 2.77% of countries have their digital health ecosystem fully interoperable. In fact, 76% of countries has developed their digital strategy plan while just 14.7% digital health projects have been implemented.

4.4 Service delivery

Service delivery is the part of a health system where patients receive the treatment and supplies, they are entitled to. The services can vary greatly depending on the location (urban or rural), whether the patient is an outpatient or an inpatient, the patient's pathology, and the patient's financial capacity or socio-cultural background. This reality runs against the goal of universal health coverage, the attainment of which is further compromised by inequalities caused by several challenges such as the COVID–19 crisis, conflicts and other disasters. One direct consequence is poor quality of care, which accounts for more than 15% of deaths each year in low- and middle-income countries, compare with 60% that are attributable to care conditions, and the remainder death due to non-use of the health system. A WHO cross-sectional survey on service delivery in ten countries shows that, the public sector leads the health facilities, followed by the private sector and finally, traditional practitioners. In urban areas, the private sector accounts for most services (55.9%) and, in peri-urban areas, traditional and spiritual healers account for 67.1% of services for health reasons. In Africa, outpatient care is still very hospital-centric and inaccessible for many. Outpatient services need to be strengthened and decentralized (including the resources) to bring services closer to their users, but also to ensure affordability.

4.5 Health workforce

Reaching the level of performance necessary to achieve UHC and the SDGs might be compromised as long as qualified workforce is insufficient or mismanaged. In 2018, thirty-one countries (79%) had an accreditation body for training institutions. Even though resources are being put into training health personnel, Africa had the lowest density of doctors (2.9 per 1 000 population) compared to others WHO regions in 2020. Only 28% of the countries were above the regional average for doctors, excluding specialists (mostly higher incomes countries). The continent is facing a brain drain of locally-trained doctors to the Western regions. The same shortage is observed for nurses and midwives: Africa has 12.9 nurses per 10 000 inhabitants whereas Europe or America is at more than 80. So far, only four countries (Seychelles, Namibia, Mauritius, and South Africa) had reached or exceeded the SDG density target of 4.45 doctors per 1 000 population.

4.6 Health infrastructure

The density of the population goes together with the density of health services. Although there is currently no official standard for inpatient bed density per total population, the global average for inpatient bed density is 27 per 10 000, while the average for the African region is 10 beds per 10 000 population. The Service Availability and Readiness Assessment Survey (SARA) suggests benchmarks of 18 and 39 inpatient beds per 10 000 population in low- and high-income countries, respectively. The availability of intensive care unit beds in public, private, general, and specialized hospitals that are regularly maintained and staffed by qualified and readily available personnel is more difficult to estimate for all the countries in the African Region. This makes it difficult to determine the readiness to respond to a crisis or critical situation such as the COVID–19 pandemic.

4.7 Health products

WHO still estimates that more than half of the population of the African Region does not have full access to essential drugs. For most countries, production scores for essential drugs remain low. With regards to stocks of essential products, many countries in sub-Saharan Africa are accustomed to shortages of medicines in hospitals and pharmacies. The readiness score of countries for health products for countries with available data is very low. An analysis conducted by WHO during the COVID–19 pandemic showed that African Region had an average readiness score of 33% for COVID–19 vaccine deployment, which is below the baseline set at 80%. Innovative methods are necessary to improve supply chains, drug demand and ordering, communication between facilities and districts, and forecasting of future needs.