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Five ways to get more health for your money – Priorities for TICAD (Tokyo International Conference on African Development 28-30 August)

27th August 2019

Official handover ceremony for medical equipment procured under the Japanese Grant Aid for Economic and Social Development in the city of Kafue, Zambia. (February 2019)

The Seventh Tokyo International Conference on African Development (TICAD) opens tomorrow and health is high on the agenda. In the lead up Crown Agents Chair Marie Staunton CBE reflects on five interventions that governments and donors should seriously consider to help resources go further. 

In 2018 Japan reported an average life expectancy of 85.77 years, the highest figure it has recorded to date. It places the nation second behind Monaco which boasts an average life expectancy of 89.33 years. In Japan it’s believed that health is the foundation of a nation’s prosperity and as a member of the G7 it commands the world’s third largest economy. These achievements can be attributed in large part to its well-designed public health system which has enabled it to achieve Universal Health Coverage for the past 50 years.

Japan leveraged it’s G7 presidency in 2016 to push UHC as a top policy priority. And at the recent Osaka G20 summit Prime Minister Abe reaffirmed Japan’s commitment to strengthening the health sector in Africa. Nearly 20 years on from the 2001 Abuja Declaration, where African governments committed to spend 15% of GDP on health, just two out of 54 states have successfully met the target and the continent continues to report some the worst health outcomes globally.

The Tokyo International Conference on African Development (28-30 August) opens tomorrow and health is high on the agenda. At the triennial meeting organised by the Japanese government in collaboration with the African Union, UNDP and the World Bank, Japan will share its deep understanding of how to develop a healthcare system when infrastructure, supply chain and funding is scarce. Following the Second World War Japan’s public health delivery systems lay in ruins, but with careful planning and spending wisely it had set up universal healthcare by the 1950s.

Today parallels can be drawn with the experience of many African states. The shadow of the debt burden and weak economic growth mean that Africa’s health budgets are under strain, but there are a key set of systems reforms, which although overlooked can make a real difference.

More and better health care can be delivered by optimising funds that have already been made available for health – be those domestic or international. Crown Agents has been running supply chains in Africa for a number of years and was established in Japan 50 years ago. In our long running history of tried and tested experience, we’ve identified a set of interventions that governments and donors should be seriously considering to help resources go further.

Crown Agents Japan Project Manager Hidemi Sano with a doctor at a Zambian hospital and staff.

1. Open contracting
Good governance and sound systems of procurement and supply of medicines are key to enabling countries to attain UHC. In 2015 the Ukrainian government used international organisations to break open a corrupt supply chain which had caused scarcity of essential medical supplies and skyrocketing prices for drugs. When the government invited Crown Agents to intervene in its failing health procurement system there were just five local suppliers. The Ministry of Health now has over 100 international suppliers and costs have drastically fallen. In the four years since Crown Agents’ intervention, $80 million in savings have been secured for the health budget. In human terms these efficiencies and taxpayer gains translate into a 20% drop in heart attack across nearly half the country, since every individual who needs a stent fitted can now access treatment on demand. Heart disease is the leading cause of death in Ukraine and previously stents were in short supply and being procured at twice the cost.

2. Get value for money
Globally an estimated $455 billion of the $7.35 trillion spent on healthcare is lost due to fraud and corruption. In over 10 years of partnership with the Ghanaian Ministry of Finance, Crown Agents has identified over $1 billion worth of savings of public funds by providing independent third-party verification services. By digging into the detail of large-scale projects before scarce public resources are committed, value for money is rigorously assessed – circumventing any potential waste and corruption. Audits tracking VfM can accelerate expansion of UHC by ensuring that capital expenditure on high profile infrastructure like hospitals is not disproportionate – thereby enabling savings which can be redirected towards urgently needed primary healthcare which WHO stipulates as the cornerstone for achieving UHC.

3. Streamline stock management via strategic planning and preparation
Transparent and efficient supply chains help to reinforce and promote resilient health systems in peace time and during humanitarian emergencies. The Ebola epidemic spiralling in DRC has killed over 1,800 people since it began a year ago, making it the second largest outbreak in history. During the Sierra Leone Ebola crisis in 2014, currently still the largest in history, we streamlined our response to become more efficient, cost-effective and agile by minimising the number of suppliers and distributors for personal protective equipment, setting up an in-country warehouse so that Ebola treatment centres could be kitted out faster in line with changing needs, and investing in good data systems which eliminated wastage as we could keep track of all supplies across the chain.

4. Staff retention during crisis and in rural areas
WHO states that the most cost-effective way to achieve UHC in the long term is to educate and train more health workers. In the midst of economic crisis and Zimbabwe’s largest cholera outbreak in 2008, the donor-funded Human Resources for Health Retention Scheme (HRHRS) was launched to mitigate the decline in health service delivery by increasing staff turnout through payment of a retention allowance in foreign currency. Due to the crisis and limited resources public health centres were severely under strain adversely impacting working conditions for health workers. The implementation of HRHRS has seen attendance rates shoot up and the number of institutions recording zero vacancies in some categories has risen from 20% to 99.98%. Distribution of health professionals across urban and rural areas has equalised and doctor/nurse patient ratios have become more sustainable. All health workers are paid on time and as per submitted schedules, and the number of nurses applying to train as midwives has increased. Crown Agents was contracted as the managing agent for the programme and designed the scheme. HRHRS won British Expertise’s Development Project of the Year Award in 2011.

5. Effective performance-based financing
Our data shows that payments to health centres based on performance contributes significantly to the quality and quantity of services delivered, which fosters expansion of primary health care and widening of UHC. In Zimbabwe the Unicef supported Results-Based Financing for Health Programme has delivered significantly positive outcomes in antenatal, neonatal, maternal and child health. On Unicef’s behalf Crown Agents implements robust data management and verification processes at 834 facilities across the country. Good data enables centres to increase their earnings based on quality of services and community uptake. Subsidies received are then reinvested into building capacity and improving the health infrastructure and stepping up the quality of patient care. Effective data management also contributes to better long-term national health planning and serves as a transparent mechanism of accountability showing donors how and where their funds have been spent, with results.

Learn more about our work on health or for more information contact Director of Health Stefan Lawson at