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Keynote Speech by Jean-Paul Adam, Minister of Health of the Republic of Seychelles at the Second WHO Africa Health Forum : ‘Domestic Financing for Sustainable Health Security in Africa’

By Jean-Paul Adam
on April 15, 2019

Distinguished panelists and participants, ladies and gentlemen,

We are delighted that this second African Health Forum is taking place here in Cabo Verde, an African Small Island Developing State.  As a Seychellois, I am from an island on the opposite side of our continent. The African sun rises over Seychelles, and sets over Cabo Verde!  Our languages are different- but our challenges and opportunities are the same.  When we look at you, we see ourselves.

African islands face a paradox.  We are often quick to achieve good results in health care outcomes. We are often the ones that are leaders in terms of GDP per capita.  But we also pay a premium price per capita when it comes to investing in our health systems and infrastructure because of lack of economies of scale.

We are also the most vulnerable to external shocks- whether they be environmental or economic.

The vulnerability of Africa’s islands is also situated within the overall vulnerability of our continent in relation to health security.  There are many factors that underpin health insecurity in Africa.  Most of us do not have mature public health systems and we lack the local built in institutional set up to respond quickly and effectively to crises. 

Our lack of sustained domestic resource mobilisation is also a fundamental challenge to building long term resilience. 

Every health minister knows that resources never suffice.  We are constantly battling to get more investment into critical areas. 

Seychelles’ experience has nonetheless shown that implementing universal health coverage, costly as it may be, is critical to ensuring health security.  Universal Health coverage has been built on the bedrock of a political commitment to ensure that every Seychellois has equitable access to appropriate health care for their needs, with no cost barriers to treatment that is appropriate.  In 1978, we decided that access to health care should be universal, and that Government would pay for it.  We have worked with donors and partners to start new programmes or build new infrastructure, but we have always started with the principle that we will pay for the running of our health system, and that we must never be dependent on an external partner for recurrent commitments.  We have gone as far as to inscribe the right to free primary health care in Article 29 of our Constitution.

Our universal access to care is built on a strong primary health system, where all citizens have easy access to health facilities within 20 minutes of their habitual residence.  It is anchored in our community programmes touching especially young children through their schools, and families through our community and regional health centres.  It has allowed us to achieve ANC coverage of over 97% and vaccination coverage of also above 97%.

We have achieved efficiencies in terms of our spending relative to results as per the WHO State of Health in Africa Report, which showed that while we have the strongest indicators in terms of results in most sectors, we are only 6th in relation to spending per head on health.  This is despite the fact that our costs for many procurement lines are higher than peers.

The message from our experience is simple- by committing Government to deliver on primary care, we build more resilience to external shocks. A joint publication by the Government of Seychelles with the World Bank recently in the Health Systems and Reform Journal, has demonstrated that sustained annual investments into a strong primary care system that is free to use brings optimum results relative to resources invested.

Despite this positive experience, we are more aware than ever that while we have bolstered our resilience through strong primary care, the ever increasing burden of non-communicable diseases further creates pressures that are difficult to contain, and lead to disproportionate resources going into expensive treatments in tertiary care. 

In addition to the rising burden of NCDs external shocks are also expected to continue to rise. 

One of the most critical factors that will impact African countries is the threat of climate change.  Most African countries are currently faced with an increase in vector borne diseases and this can be traced in many instances to disruptions in weather patterns, which increasingly can be linked to climate change.  In Seychelles, irregular rainfall patterns, and persistent rain at key junctures have led to a prolonged outbreak of dengue since 2015.  This contrasts with previous outbreaks which were clearly defined in relation to the rainy season. 

The experiences of many other African countries concur with this situation, and this will place an even heavier burden on financing for our health systems.  Finance and human resources that could otherwise be deployed on further improving prevention services, are being diverted into permanent mobilisations for outbreak management.

Small island countries such as Seychelles are also disproportionately affected by regional epidemics.  In 2017, we had to mobilise all our capacity to address the outbreak of plague in our neighbouring island of Madagascar.  If we had registered even one confirmed case, this would have been an incredible burden for our economy based on our reliance on tourism.  We were able to manage extensive contact tracing among our population based on the fact that one of citizens unfortunately died in Madagascar.  We are incredibly grateful to our partners in Madagascar and the Indian Ocean region, and WHO, who worked with us to address this threat effectively. 

It is important to note that these threats are very much international in nature, and not just an issue for Africa. 

We must also be ready deal with diseases that were previously on the wane, but which are reappearing thanks to falling vaccination rates, with measles outbreaks in Europe being the prime example.  In this era of global trade and movement, these risks will increase.  For countries such as Seychelles and Cape Verde, with our high dependence on European outbound tourism, we need to ensure that we are suitably prepared.  We are on the frontline in relation to dealing with these risks that would have been unimaginable even 10 years ago.

Africa’s challenge for health security is also a story of human resources.  Our continent is woefully underprepared to deal with the increased burden that of outbreaks, and their projected increase in frequency.  In Seychelles, our human resource is precious and is a cornerstone in delivering improved standards of health care.  Like all countries we are faced with inadequate trained personnel and we depend a lot on international cooperation to recruit health workers from overseas to work in our health system.  We are investing a lot in training our own nationals, and we always face a challenge to keep them in the face of what is effectively a global shortage of health professionals.  On top of this, we face an increased challenge to develop the numbers we need to address the ‘new normal’ imposed on us by climate change.

Ladies and gentlemen,

The factors I have outlined so far further underline our continent’s lack of health security.

But there are a number of areas where there are opportunities to dramatically alter the course of the narrative. 

First and foremost we must address the fact that as a continent, and as individual countries, we are under-investing in health.  This was evident from the report which was presented to us on the first day of our deliberations in Cabo Verde. And of course the challenge is always how do you mobilise resources to invest in health when those resources are limited in the first place? There is no one size fits all approach. 

But from Seychelles’ experience, what has worked is to prioritise the simple low cost investments in primary care first.  The first priority has been to invest in access to primary care, programmes to support communities and extensive vaccination programmes.  When we started offering free access to health care in 1978, we had very limited capacity.  But we made sure what we had was accessible to all. 

This led to savings in other areas, and productivity gains across the economy.  It was also an enabler for the development of our tourism industry which is our biggest contributor to GDP.  In 2019, our earnings from tourism allow us to invest in health care, but in 1978, we would not be able to develop tourism the way we have if we had not invested in health care. 

Another key factor is to recognise the co-investments required to improve the social determinants for health.  Some of our biggest health gains have been achieved by improved sanitation, for example through our sustained programme for the elimination of pit latrines.  We have also linked our health system with our education system- the majority of vaccinations are carried out in our schools for example- while we also build health education programmes into our curricula.  We are currently championing a health promoting schools concept.

These investments in primary care do not on their own provide health security, but they are building blocks to reinforce resilience and sustainability in health systems.

Secondly, we need to reinforce the specific preparedness of our individual countries to address potential crises. 

In Seychelles, we have realized, based on recent events, that we need to further reinforce our capacity.  Our countries are more interconnected than ever, and an outbreak will strain our resources more than ever before.

This is where the importance of building national capacity to fully implement the International Health Regulations (IHR) is essential. Seychelles has recently undergone an assessment with the support of WHO and we are prioritising the means to address identified gaps.

The reality is, that no country in the world can be prepared for every eventuality.  But it is essential to have prepared systems and responses in place.  And what we are seeing in Seychelles, that while we may never fully have the capacity to meet the deal preparedness standards- our reach to our communities means that we are able to touch target populations quickly and efficiently. 

We appreciate immensely the support of WHO to continue to build this capacity.

Thirdly, it is important to recognise that we can reinforce our collective health security through regional capacity building.  By building common reporting and mobilisation standards among regional neighbours surveillance can be enhanced and consequently improve early warning systems.

Seychelles has a very positive experience of this through our regional SEGA One Health disease surveillance programme covering the islands of the Indian Ocean under the auspices of the Indian Ocean Commission.  Through this programme, we have built capacity in our respective countries for the monitoring and reporting on communicable diseases, to facilitate quick and effective responses.  This has been critical in ensuring a positive regional response to mosquito borne diseases in the region such as dengue and chikungunya as well as other communicable diseases.  By reinforcing the communication and adherence to WHO best practices at regional level we can reinforce our collective security positively, and often for less cost. 

A fourth consideration for the way forward must of course address opportunities for cost savings in health systems to reinforce health security.  Many countries face challenges in terms of procurement, whether it be in terms of cost, or reliability of accessing essential medicines.  This has been a particular concern for African Small island Developing States, and this is why we are working on an initiative to address this in partnership with WHO.  We are also looking forward to the SADC initiative on pooled procurement.  The key issues for smaller countries is to be able to take advantage of economies of scale to procure more efficiently.  Timely access to affordable medicines are a key concern for all our countries however, and this is one mechanism that can help us achieve more predictability which ultimately boosts resilience and preparedness.

This leads us to also consider ways in which we can make our health systems more climate smart, and hence more resilient.  The WHO Director General has led an initiative to reinforce climate resilience particularly in small island states, and this will aim to make health systems more adaptable to the challenges of increased burden of vector borne diseases, as well as for example building more renewable energy into the design and operation of health centres. 

By re-looking at our health systems in the context of climate change we can reduce future costs and also ensure appropriate preparedness.

The fifth and final consideration for the way forward is mobilising additional finance for African health systems. I will repeat again, that there is never enough investment into the health sector.  Sustained investment over time brings rewards that are felt even outside of the health sector.  But it is necessary to continuously identify new sources of finance.

In Seychelles, we currently have a system which is funded directly from taxation.  We provide access free of charge.  But one effect of this, is that while our spending as a percentage of the budget is routinely above 10%, our spending as a percentage of GDP is below 4%.  There is thus scope for us to mobilise additional resources to meet the expected future needs.  Different options are being explored including a possible national insurance system.  This will be necessary also as the pressures and needs of tertiary care will continue to increase. 

In Seychelles we also operate a principle of high taxation on alcohol and cigarettes which both have a deterrent effect on consumption while also raising revenues.  As of next month we will also be introducing a tax on sugar sweetened beverages, which is also designed to mute consumption. 

It is worth repeating again also that there is no exact formula for resource mobilisation as every country has to manage its own domestic considerations.  No country can lecture on this subject.  But we are free to learn from each other’s experiences. 

From our experience, the key factors which must be underlined in relation to domestic financing for sustainable health security are predictability and efficiency.   You need to know where the money is coming from, and you need to measure the impact it has when it is being spent.

As we consider the investments needed to achieve the sustainable development goals, we realise that the investment required is massive.  But by also looking at the price we are paying for inadequate health care, we must focus on the opportunity before us. 

By recurrently investing in primary care capacity, we build long term resilience.

Can we prepare for every eventuality?  Evidently not.

But by treating Universal Health Coverage as an imperative, we will set ourselves on a course towards health security.

Thank you.

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