African countries face the greatest burden of disease in the world; while the population in low- and middle-income countries in Africa account for 11% of the world’s population, these countries account for 27% of global disability-adjusted life years (DALYs). Figure 1 shows that African countries have a far greater burden from communicable diseases, maternal and perinatal conditions and nutritional deficiencies (accounting for 76% of DALYs in Africa) than the global average (45% of global DALYs). The leading contributors to this burden of disease in Africa are:

• respiratory infections (accounting for 13.2% of total DALYs in Africa);
• perinatal conditions (12.3% of DALYs);
• HIV/AIDS (11.7% of DALYs);
• diarrhoeal diseases (10% of DALYs);
• malaria (9.6% of DALYs).

Despite this massive burden of disease, African countries have limited financial, human and other resources to provide health services to meet these health needs.  Of particular concern is the heavy reliance on out-of-pocket (OOP) payments to fund health services in many African countries.
 
Figure 2 shows that OOP payments account for nearly 90% of health care expenditure in extreme cases, and exceed 30% in most African countries.  Thus, the burden of funding health care is borne quite directly by individual households, who have very limited financial protection against the costs of using health services.

In recent years, there have been growing calls for countries to move towards universal coverage in their health systems. While there are a number of definitions of universal coverage, all definitions have two core elements in common:

• Providing financial protection for all from the costs of health care; and
• Enabling access to needed health care for all.

Universal coverage was firmly placed on the global policy agenda when the 2005 World Health Assembly adopted a resolution calling on member states to pursue universal coverage. A major focus of this resolution was to reduce the reliance on out-of-pocket payments and to promote pre-payment health care financing mechanisms (such as tax and health insurance).
 
This emphasis was related to the growing evidence of the catastrophic effects of out-of-pocket payments, particularly that large numbers of households were being pushed into poverty as a result of paying for health care on an out-of-pocket basis.  For example, nearly 400,000 people were impoverished in Ghana in 2005/06 as a result of paying for health care. This evidence highlighted the urgency of providing financial protection through pursuing pre-payment funding mechanisms.  While considerable attention has been devoted to the financial protection component of universal coverage, it is also recognised that one needs to go further than creating entitlements to services funded through pre-payment mechanisms to ensuring that the population is able to access these services when needed.

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