How funding influences the sustainability of health systems: Data-driven insights from Africa

Amine Aissaoui, PhD

Senior consultant economic affairs, market access, and pricing, HEOR

How funding influences the sustainability of health systems: Data-driven insights from Africa

18 August 2021 | 6min

Quick Takes

  • Data suggests a strong relationship between economic strength and healthcare system sustainability

  • Strategies to improve the cost-effectiveness of healthcare include practices and tools that promote collaboration, transparency, and adding value to patients

  • Data-driven and research-based best-practices should serve as inspiration and a basis for healthcare reforms

Improving health systems in Africa, properly armed with data

There are stark differences across the African continent when it comes to the delivery, access, and quality of healthcare. Countries with relatively good access to services do not necessarily lead the way in the quality of health services provided.1 There are unique challenges that continue to plague African healthcare systems that need to be addressed, but first, they must be understood.

For instance, technology can help to leapfrog some of the systemic issues that Africa has, however, how do we know which innovations are working without data? How is it possible to prioritize the weakest, the poorest, and the most vulnerable in society without data? 

We have no choice, we should absolutely collaborate together in order to enhance our healthcare systems.1

Saber Boutayeb, Professor of Medical Oncology, University of Rabat, Morocco.

The realization of this need to collect quality data to develop the insights to help drive and inform action and policy, led to the launch of the Africa Sustainability Index in March 2021. 

The index provides a unique overview of the current status of 18 health systems across the continent.2 The Index is made up of 76 different measures split across six categories called Vital Signs. The measures were identified by experts from health systems, international organizations, think tanks and academia from across Africa. 

Africa Sustainability Index: The 6 vital signs 

  • Access: Equitable access to and coverage of healthcare to those who need it
  • Financing: Funding levels that are adequate and sustainable
  • Innovation: Advancement, access and application of novel technology
  • Quality: Offering uninterrupted quality-assured services
  • Health status: The overall health of a population 
  • Wider factors: Factors outside of the healthcare system that impact outcomes

Africa Sustainability Index: The 6 vital signs 

Economic strength is a key indicator of overall sustainability of health systems in Africa

Initial insights into the index score patterns suggest a definite relationship between economic strength and healthcare system sustainability. Most countries performing well in the “Financing” vital sign do well in the index overall. 

Economic strength is a key indicator of overall sustainability of health systems in Africa

To understand more about the Financing vital sign and how it influences the sustainability of healthcare systems, we sat down with Amine Aissaoui, expert in health economics, to understand more about the Finance vital sign and what it means for the sustainability of health systems across African countries, now and into the future.  

Strategies to help make healthcare affordable 

HT:  11 out of 18 African countries have scores ranging between 40 and 50 for the Financing vital sign. What are the main challenges affecting the Financing vital sign in this close-scoring group and how can they be overcome?    

Amine Aissaoui: I believe that the main challenges affecting the Financing vital sign for this group of countries are expenditure and health insurance coverage, or the affordability of care.

There are several strategies that can be implemented to help overcome these challenges and help improve the cost-effectiveness of care. 

  1. New management tools (e.g. IT tools) that allow for data-driven and transparent management decisions. 
  2. A health technology assessment (HTA) approach which includes:
    • Clear guidelines for disease treatment and reimbursement costs based on factors such as disease severity and prioritization (e.g.the implementation of diagnostic-related group (DRG) codes) 
    • Ability to economically evaluate the cost-effectiveness of treatments and services provided
    • Guidance on the quality of diagnostic tests
  3. Tax reform to help develop sources of financing and extend health insurance coverage (e.g. increasing tax on cigarettes)

As an economist, I don’t think the focus should be on reducing the costs of care, but we need to ensure that the money spent has a benefit and is of value for the patient. It is a shift towards value-based healthcare (VBHC). 

HT:  You mentioned that an HTA approach is important in the transition towards VBHC. As someone who has a lot of experience working with the health systems of Tunisia and Algeria, could you comment on their status of implementing HTA? 

Amine Aissaoui: HTA implementation in Tunisia and Algeria is still in its early stages. Previously, the healthcare expenditure budget was voted upon and split by hospital, without taking into account the efficiency of each hospital or for what disease the money will be spent on. 

It is encouraging that both countries have now realized the importance of HTA and have developed strategies to implement it in their healthcare systems. However, it is too early to know the impact. 

HT: What sources of information or best practice examples were used in designing and implementing an HTA approach in these countries?

Amine Aissaoui: Multiple sources are available and were taken to develop an HTA approach. Steps taken in Tunisia (ahead of Algeria in their implementation of HTA) included: 

  1. Literature review 
  2. Working closely with international HTA organizations as well as the World Health Organization


Key areas of investment for sustainability  

HT: If you were a leader of a healthcare system, what areas would you invest in, or focus your resources towards, in order to promote sustainability?

Amine Aissaoui: My focus would be to establish a framework that takes into account the following:

1 Collaboration between stakeholders: Multiple stakeholders, including healthcare professionals (both clinicians and non clinicians) managers, patients, industry partners, scientists, IT and digital health experts, health economists and health law experts, statisticians and governments/policy makers are just some of the people who make up the healthcare community. This multi-stakeholder environment means that there is not only a need but an expectation for a collaboration model in Africa. Shared interests among stakeholders need to be developed in defining different policies, strategies, and objectives. Where healthcare systems are dysfunctional or struggling to achieve sustainability, collaboration can address such challenges and improve the quality of care
2 Health IT system: Well-functioning health systems need to utilize data at all levels, from the provider, to local and national-level decision makers, in order to make evidence-based and needed adjustments to improve the quality of care provided. Historically, health systems in Africa have not been able to unlock the enormous value of digital resources and the COVID-19 pandemic has highlighted the lack of digital readiness. Governments can start the journey to digitization by identifying gaps in current digital systems, if indeed there are any at all, and then defining a strategy for end-to-end systems strengthening. This can allow the Department of Health and the Department of Finance to better plan and make decisions based on real world evidence that can ultimately result in savings and sustainability. For example, digital/health IT can help African countries to implement payments based on diagnosis-related groups (DRGs), which is an efficient tool for inpatient care management.
3 HTA approach: Sustainable financing demands evidence-based processes for effective resource allocation, and catalyzing knowledge-sharing opportunities among countries facing similar challenges. Using a Health Technology Assessment (HTA) approach can give countries the opportunity to assess the cost benefit of a treatment and diagnostic and issue clear guidelines on its use.

Amine Aissaoui, PhD specializes in economics and policy applied to healthcare. As an associate researcher, he teaches Health Economics and industrial organization of pharmaceutical markets at Paris Dauphine University and in the Faculty of Pharmacy of Marseille. He also advises several public institutions in issues dealing with pharmaceutical policy and economics. At the same time, Amine Aissaoui has worked for many consulting firms specializing in health economics.


  1. F. Hoffmann-La Roche Ltd. (2021). Video available from  [Accessed July 2021]
  2. F. Hoffmann-La Roche Ltd. (2021). Index available from [Accessed July 2021]