The African Union Commission convened global and regional health leaders, National Heads of States and Governments in Addis Ababa on the 9th February 2019 for the African Leadership Meeting (ALM)- Investing in Health.

A crucial outcome of the meeting was the “Addis Ababa Commitment toward Shared Responsibility and Global Solidarity for Increased Health Financing Declaration”. The Declaration, otherwise known as the ALM Declaration, is an initiative geared towards increasing domestic resources for health and reorienting health systems in Africa.

  • Overview
  • Milestones
  • Key Facts & Figures
  • Key Messages


The endorsement of the ALM Declaration by Heads of State and Government of African Union (AU) Member States serves as recognition for the need to improve the health financing status quo in Africa, by investing increased domestic funds for health in a more effective and efficient way.

The Declaration specifically calls for Increased Domestic Resource Mobilization for Health; and in tackling existing inefficiencies in health budgets towards financing more effective and efficient health systems. The declaration also calls for better collaboration between multi-sectoral actors - regionally and globally - to strengthen existing health systems in AU Member States. It further invites the private sector to explore and seize existing opportunities for investing in the health sector.

High-impact, multi-sector partnerships will go a long way in strengthening the concrete asks of the ALM Declaration which include:

  1. Increase domestic investment in health and for Heads of State to review country performance annually – against the benchmarks of the Africa Scorecard on Domestic Financing for Health.
  2. Convene AU Ministers of Finance and Health every two years to discuss implementation of these health financing reforms and to review progress against benchmarks.
  3. Complement the Scorecard with a domestic health financing ‘Tracker’ that will guide health financing reforms and track country progress in implementing these ‘enablers’ of progress.
  4. Establish Regional Health Financing Hubs in each of Africa’s five regions (based in RECs) to facilitate peer-to-peer learning by providing practical & technical expertise to support countries to implement these reforms and to coordinate alignment of partner efforts to Africa’s priorities.
  5. Better engage the private sector, create conducive investment climates and increase Member State stewardship of private sector support so that such efforts strengthen public health systems and expand access to health services.
  6. Increase the coherence of investment in health by better aligning development partner and private sector efforts to the priorities of the continent.
  7. Improve public financial management (PFM) capacity to help improve tax collection and/or increase the proportion of tax revenue collected as a percentage of GDP, through equitable and efficient general taxation and improved revenue collection, and strengthen the capacities of Ministries of Finance and tax revenue authorities to achieve this.
  8. Digitise the Africa Scorecard on Domestic Financing for Health so that the data used to review performance is more widely disseminated.
  9. Enhance national health financing systems, including exploring options to reduce fragmentation, explore national health insurance (where appropriate), strengthen procurement and purchasing and improve prevention, cost-effectiveness and efficiency.
  10. Improve effectiveness: Reorient health spending and health systems to target the diseases that have the greatest impact on mortality and human capital development with the mix of interventions that will deliver the greatest impact in combatting them.

The ALM Declaration also appoints H.E. President Kagame as AU Leader for Domestic Health Financing and charges the AU Commission with leading implementation of these interlinked components of the ALM Agenda and with coordinating the alignment of partners to Africa’s priorities.


The Africa Scorecard on Domestic Financing for Health measures progress by AU Member States against global and continental benchmarks on health financing and public finance management. In short, it measures performance against outcomes.

The health financing progress Tracker will complement the Scorecard by bridging the gap between desired outcomes [the Scorecard] and the steps countries will need to take to get there. The final Tracker will fulfil two functions:

  1. Part 1: An aggregated 1-page progress report (10-15 indicators, all 55 Member States).
  2. Part 2: Implementation manual / modules of key actions that sets out tools, collated guidance, best practices and practical actions across health financing and PFM modules where joint MoF & MoH interventions will realise the best return on country efforts.

The Tracker is being developed for use by senior technical officials within Ministries of Finance (MoF) and Health (MoH) as well as by the Hubs – who will provide support to country efforts.  Coordinated by the AU, it is being developed in adherence to the Paris, Accra, Busan principles for effective development assistance: country-led, build on what exists, leverage the wealth of country experiences and existing tools & data, and seek to reduce the reporting burden.


The ALM Declaration calls for the establishment of Regional Health Financing Hubs in each of Africa’s five regions. The Hubs are intended to become regional communities of practice based within Regional Economic Communities (RECs). Hubs will provide the technical and practical expertise to support REC Member States to implement the reforms set out in the Tracker as well as to coordinate the alignment of development partner efforts to Africa’s priorities.

The first Hub will be piloted in the East African Community (EAC) during 2021. To this end, following an assessment mission of the AU Commission in February 2020, the EAC has convened an Expert Working Group (EWG) of EAC Member States and key partners to consider the hubs and establish the EAC pilot.

  • Tracker builds on the Scorecard by bridging the gap between ‘the What’ and ‘the How’. It provides practical guidance to enable countries to prioritise areas of need while curating development partner tools and expertise through which to seek additional support.
  • Hubs will facilitate peer-to-peer learning and the sharing of lessons, tools and experts; will provide the technical and practical expertise to support countries as they implement the reforms directed by the Tracker and will coordinate country efforts at a regional level.
  • Biennial AU Minister of Finance (MoF) and Minister of Health (MoH) meetings provide occasion for ministers to talk through the practical details of whether and how countries are making progress and how to adjust.


The 2001 Abuja Declaration was a historic milestone for Africa. The AU Member States met and pledged to set a target of allocating at least 15% of their annual budget to improve the health sector. Over the years, health expenditure in Africa has increased significantly, but domestically financed government spending has stalled.

According to the 2019 Africa Scorecard on Domestic Financing for Health: only two AU Member States dedicate 15% of the government budget to health; five dedicate 12%; twelve dedicate 10%; twenty dedicate 8% of GDP on health; and 29 spend less than 7%.  Moreover, out-of-pocket spending on health exceeds 20% in 41 AU Member States.

Development partner spending on health constitutes more than 50% of total health spending in three AU Member States; more than 40% of total health spending in 10 Member States; 25% in 20 Member States; and 10% in 17 Member States.

This must change. The future of Africa depends on its people. To make progress on the path of sustainability requires that Member States make substantial incremental increases in domestic investment in health every year. The Declaration, if implemented with sustained political commitment and accountable leadership will deliver Africa to the desired change.

July 11-12, 2019

The Pan African Parliament Summit: Brazzaville, Republic of Congo

Parliamentarians in attendance signed a communiqué where they pledged to support the ALM Declaration through various ways, importantly, by passing policies aiming at increasing domestic health financing and enhancing accountability during implementation of the Declaration;

July 29 - 2 August, 2019

Third Ordinary Session of the Specialized Technical Committee on Health, Population and Drug Control (STC-HPDC 2019): Cairo, Arab Republic of Egypt

The Department tabled several suggestions to Ministers of Health from African Union (AU) Member States regarding domestication of the ALM Declaration and respective implementation mechanisms and strategies. Following in-depth discussion, they endorsed establishment of: Regional health financing hubs; A domestic health financing tracker; An Accountability Framework; and Technical Working Groups. They also endorsed digitization of the Africa Scorecard on Domestic Financing for Health and the tracker;

August 2019

The Commission sent out letters to AU Member States calling upon their commitment towards health financing with specific reference to participating in the Replenishment Cycles and Conference in Lyon. 24 AU Member States responded to this call and leading to a cumulative pledge of US$ 75.2 million from Africa. This, in fact, is a 90% increase in Africa’s pledges from the 2017-2019 Replenishment cycle, which is a commendable indication of growing commitment from our leaders to improving health financing in Africa;

November 12, 2019

ALM Declaration Technical Working Group Meeting Kigali, Republic of Rwanda

The Department organised and executed the first ALM TWG. The conceptual frameworks guiding formation of the tracker, the regional health financing hubs and accountability framework were presented to the vast pool of health financing experts across both public and private sectors present at the meeting. The experts offered their recommendations which were used to improve the concept notes. They were also briefed on the outcome of the July STC-HPDC 2019 regarding the same.

November 13 – 14, 2019

AIDS Watch Africa (AWA) Experts Consultative Meeting: Kigali, Republic of Rwanda

Health experts from AU Member States working in the field of AIDS, TB and malaria were convened to prepare a report with key advocacy, resource mobilisation and accountability issues posed by the three diseases for the consideration of the AWA Heads of State and Government Action Committee.

The progress of implementation of the ALM Declaration was presented to the experts who were well-pleased with the initiative and pledged their support. The meeting was attended by health experts from 21 AU Member States, AUDA-NEPAD, 4 Regional Economic Communities (RECs) and 24 partner organisations.

November 15 2019

African Union - Regional Economic Communities (RECs) Coordination Meeting: Kigali, Republic of Rwanda

A working meeting with representatives from RECs was conducted to discuss hosting the regional health financing hubs within RECs. Representatives from Southern African Development Community (SADC), West African Health Organisation (WAHO), the East African Community (EAC), and Intergovernmental Authority on Development (IGAD) presented on their ongoing efforts towards strengthening health financing in Africa. The information was used to determine the RECs assessment mission schedule for 2020.

January – February 2020

The formation of the main ALM technical working group (TWG) and subcommittees took place. The members will shape and lead the strategic direction in which implementation of the ALM Declaration heads.

  • The main TWG is chaired by Dr Benjamin Djoudalbaye , the Head of Policy, Health Diplomacy and Communication at Africa CDC. This group convened for its inaugural meeting on 8 April 2020.
  • The subcommitees are as follows: Tracker subcommittee (Chaired by Dr Lamboly Kumboneki, representing the SADC Secretariat); Hubs subcommittee (Chaired by Dr Michael Katende, representing the EAC Secretariat); Communications & Advocacy subcommittee (Chaired by Julien Mahoro, representing the Government of Rwanda); and Private Sector Engagement subcommittee (Chaired by Chimwemwe Chamdimba, representing the AUDA (formerly) NEPAD)

February 10, 2020

African Union Summit: Addis Ababa, Ethiopia

His Excellency Paul Kagame, President of the Republic of Rwanda and AU Leader for domestic health financing briefed the AU Assembly on the progress of implementation of the ALM Declaration. His report was complemented by briefing from His Excellency Cyril Ramaphosa, the President of the Republic of South Africa and Chairperson of the African Union (AU) and AIDS Watch Africa (AWA) about the progress attained by AWA in 2019.

February 20, 2020

Regional Economic Communities (RECs) Assessment Mission: Arusha, Tanzania

The Commission conducted its first RECs assessment mission in February to evaluate the capacity of the East Africa Community to host a regional health financing hub.

How much does government spend on health? (2016 data)

#1. Only 9 member states meet the benchmark of spending at least $86.30 per capita on health.
Indeed, of the 55 member states, only 16 (29%) spend even half of the benchmark. (Data not available for 4 member states).

#2. 26 of 55 member states (47%) increased their per capita USD investment in health (#1)
between 2015 and 2016. 25 member states decreased their investment year-on-year. (Data not available for 4 member states).

#3. Only 1 member state meets the benchmark of spending at least 5% of GDP on health.
50 member states (91%) spend less than the 5% of GDP benchmark. Indeed, only 5 member states spend at least 4%, only 9 member states spend at least 3%, and only 19 member states spend at least 2% of GDP on health. (Data not available for 4 member states).

#4. 26 member states increased the percentage (%) of GDP spent on health (#3)
between 2015 and 2016. 25 decreased their investment year-on-year. (Data not available for 4 member states).

#5. 2 member states dedicate 15% of the government budget to health. 49 member states (89%) do not meet the benchmark.
Indeed, only 5 member states spend at least 12%, only 12 member states spend at least 10%, and only 20 member states spend at least 8% of GDP on health. 29 member states spend less than half of the 15% benchmark. (Data not available for 4 member states).

#6. 32 member states (58%) increased the percentage of the government budget invested in health (#5) between 2015 and 2016.
14 member states decreased their investment as a percentage of the government budget year-on-year. 5 member states maintained funding levels. (Data not available for 4 member states).  

Download the brief here.

View scorecard here.
Health is a key aspect of human and economic development in Africa.
  • Recognizing this, countries are increasing investment in actions and reforms to strengthen health systems and thus improve health outcomes.
  • The health system consists of all organisations, people and actions whose primary intent is to promote, restore, or maintain health.
  • The primary goal of a health system is to improve health — both overall health and health equity — and to do so in ways that are responsive, financially fair, and make the best, or most efficient, use of available resources.
Ensuring Sustainable Financing for Health is a cornerstone for building stronger health systems.
  • Reducing financial barriers to access depends on coordinated intervention on regulation of user fee schemes, scaling-up health equity fund (HEF) arrangements in a sustainable manner and expansion of as an intermediate measure before an effective implementation of compulsory health insurance.
  • We also need to ensure alignment of public funding with the priorities of the health sector.
  • Unfortunately, global resources are limited, so we must make the best use of available resources even as we continue to generate additional resources for health.
  • Innovative resource mobilization instruments and prioritization of government spending on health will bridge the funding gap to a great extent.
Better collaboration towards establishing resilient and sustainable health systems that nurtures preventive care and health for all remains a critical issue.
  • External funds also remain critical and more is being done to ensure their effective use through improved predictability alignment with national priorities and mechanisms.
  • Different international development partners need to collaborate toward establishing resilient and sustainable health systems that nurtures preventive care and health for all.
Every human being has the right to health and governments have the responsibility of ensuring access to those things that safeguard health.
  • Because health is central to sustainable development, inadequate funding for health impacts not just health, but other aspects of social and economic development as well.
  • The poorest and most vulnerable people in society are often most dependent on the public health system, and are therefore most likely to be affected by how public resources are allocated.
  • Governments show their commitment to health largely by allocating public funds to health-related activities and initiatives.
  • Governments have an obligation to govern in the best interests of their citizens, ensuring that health budget formulation begins at the community level.
Gathering and presenting evidence in support of key arguments and positions will be critical for success.
  • Even if a government allocates funds to disadvantaged groups, weak financial management – and a lack of political ‘voice’ on the part of those groups – can mean that money does not always reach them.
  • Efficient accountability mechanisms will ensure that resources are being spent as they were intended to be.
Attainment of sustainable health financing in Africa is within reach.
  • However, it will require sustained political leadership and a clear strategic vision.
  • The path to attain healthy and well-nourished citizens - as mandated by the African Union Agenda 2063 - is through accountable leadership, joint effort, and dedication to protecting Africa against the impoverishing effect of catastrophic health payments.