The cost of not knowing: evidence gaps and Africa´s Universal Health Coverage financing journey

¹West Africa Monetary Agency (WAMA), Freetown, Sierra Leone

^&Corresponding author
Boima Sekou Kamara, West Africa Monetary Agency (WAMA), Freetown, Sierra Leone

Commentary    

In global health, we often speak of the financing gap. We speak far less of the evidence gap. In my experience, they are the same problem wearing different clothes: the flip side of the same coin. This commentary argues that the persistent underperformance of health financing in Africa is not only a matter of insufficient resources, but also a consequence of insufficient, poorly framed, and ill-timed evidence, and calls for the kind of rigorous, policy-relevant African scholarship that AJHESP was created to produce.

There are very few people in African public life who have sat at the budget negotiation table as both the official requesting health funds and the economic official deciding how much to release. I am one of them. Before the Ebola crisis, I served as Deputy Governor of the Central Bank of Liberia, responsible for monetary policy and fiscal oversight in one of the continent´s most fragile economies. I subsequently served twice as Minister of Finance and Development Planning, first during the final years of President Ellen Johnson Sirleaf´s administration, and again in 2024 under President Joseph N. Boakai, Sr. Between June 2023 and February 2024, I served as Senior Health Financing Advisor at the Africa Centres for Disease Control and Prevention. I now lead the West Africa Monetary Agency (WAMA), working daily on the macrofiscal frameworks governing ECOWAS member states as the region moves toward monetary convergence.

Each of these roles has given me a different lens on the same problem: African governments are making consequential health financing decisions in conditions of genuine analytical poverty. Not because the will to use evidence is absent. But because the evidence, in the form that ministers, central bank governors, and related officials can actually apply to the decisions they face, either does not exist, arrives too late, or is not framed in a way that a minister of finance would appreciate and use. That gap has a cost, measured in lives lost, in fiscal collapses, and in health systems rebuilt on foundations whose sustainability was never properly analysed.

When Ebola arrived in Liberia in 2014, it did not find a robust health system [1]. It found a fragile system being rebuilt after civil war, largely on the foundations of external financing, donor-driven priorities, and a domestic resource base that was structurally insufficient to sustain what had been constructed. The international response was generous and rapid, but handicapped. Decisions about resource allocation, facility support, and supply chain restructuring were made with little reliable cost data, no functional health expenditure tracking, and no modelling of what post-crisis fiscal sustainability would require. The absence of an evidence-based framework to inform decision-making and prioritisation compounded the country´s resource allocation problems. Critically, Ebola did not create these weaknesses - it only exposed pre-existing systemic fractures. The absence of health financing frameworks grounded in domestic realities was a structural feature: health systems dependent on external technical assistance and calibrated to donor reporting requirements were unhinged from the national fiscal architecture that ultimately determines what survives when emergency funding ends.

When I returned to the Ministry of Finance and Development Planning in 2024, several of those gaps persisted, compounded by the lack of earmarking in the national budget for critical areas, including public and mental health. Cost data for primary health care remained fragmented. Fiscal projections from empirical modelling were unavailable. The actuarial basis for any serious expansion of community health coverage was thin. These are not exotic analytical requirements. They are the basic inputs to decisions. And their absence imposes costs not on researchers or ministries, but on the Liberians who depend on the system those decisions seek to shape.

Let me be direct about something the health research community rarely acknowledges openly. When a minister of health enters a budget negotiation with the minister of finance, the quality and format of the evidence they carry matters enormously, not in the abstract sense of “evidence-based policy,” but in the specific, quantitative, political-economy-legible sense that a finance official can act on. In my experience on both sides of that conversation, health ministries across Africa consistently arrive with high-level political commitments, the Abuja Declaration [2], the Sustainable Development Goals, and maternal mortality targets. While these are crucial, they rarely provide the granular, domestically grounded, fiscally framed analysis that persuades an economist. What is the marginal cost of each additional percentage point of primary health care coverage in this specific country context? What is the fiscal return, in terms of economic growth, reduced catastrophic health expenditure, and productivity recovery, of expanding health insurance enrolment by a specific increment? What is the projected debt service impact of a concessional health sector loan over a fifteen-year horizon under the country´s current debt sustainability architecture [3]? These questions confronted policymakers in Mexico´s Seguro Popular reform debates and in Thailand´s UHC transition; they are not uniquely African, but the absence of African-produced answers to them is.

These are the questions that move finance ministers and economic advisors, and the answers are usually either unavailable or unclear. While the research community has studied the failure of Abuja Declaration commitments for 25 years [4], it has not produced tangible recommendations on how to ensure that the next budget negotiations in Monrovia, Conakry, or Cotonou would realistically improve health investments, not yet, or at least not to the level that it should.

I want to raise a dimension of health financing that the research community has largely not explored, and that my current role places at the centre of my daily work: the relationship between regional economic and monetary integration and domestic fiscal space for health in West Africa. ECOWAS member states are engaged in a consequential process of monetary union. The macroeconomic convergence criteria that accompany this process - including the ratio of budget deficit to GDP, central bank financing of the budget deficit, and an annual inflation average of 5% directly constrain the domestic fiscal space available to member countries for health investment, and by extension for regional public goods for health such as cross-border surveillance and disease control [5]. Each country navigating structural adjustment toward these convergence criteria is simultaneously being asked to increase domestic health spending. For fragile economies such as Liberia, Guinea, Sierra Leone, and The Gambia, the design of regional fiscal architecture has direct implications for the room to invest in health [6].

The choice of convergence criteria, the speed of fiscal harmonization, the treatment of social sector spending within regional fiscal frameworks: these are health financing questions as much as monetary integration questions. They are being decided right now, in forums where health economists are not present, and to which they have contributed almost no analytical work. The bridge between regional monetary integration and health financing has yet to be built. It needs to be. African Journal of Health Economics, Systems and Policy is, to my knowledge, the platform best positioned to publish the work that would build it.

The African Journal of Health Economics, Systems and Policy represents a direct institutional response to the evidence gaps this commentary has described. Evidence gaps in UHC financing are not neutral: they redistribute risk downward, to patients enrolled in systems whose fiscal sustainability has not been modelled, to health workers whose salaries depend on unpredictable funding flows, and to governments held accountable for outcomes they lacked the tools to anticipate [7,8]. When African researchers publish rigorous, policy-relevant health economics and financing analysis in AJHESP, they are not producing papers for academic promotion; they are taking ownership of the African health narrative and building the analytical infrastructure on which current and future decision-makers will rely [9,10]. Three specific contributions would signal, in the journal´s first volumes, that this agenda is real: first, country-level analyses of Abuja Declaration compliance grounded in political economy frameworks, explaining not just whether targets were met but why budgets moved or failed to move; second, actuarial modelling of national health insurance expansion in ECOWAS fragile states, providing the fiscal sustainability evidence that ministries of finance need before they can commit; and third, a dedicated analytical series on the health fiscal space implications of regional monetary convergence criteria, connecting the monetary integration literature to the health financing field for the first time. The problem is not that African decision-makers do not want evidence. The problem is that the infrastructure to produce, validate, and deliver it on time has been missing. AJHESP is part of the answer. I know what that gap costs. Most African finance ministers do.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All the authors have read and approved the final version of this manuscript.

References