Covid-19 caused a significant twofold shock on the African continent, with a dramatic impact on both economic and health systems. The pandemic demonstrated to the world and to the region the deep inequities in access to health services and life-saving medicines – illustrated most graphically by inequitable access to vaccines – and reflects the power imbalances in global health that need to be urgently addressed. 

To support governments across Africa on their paths to recovery and building back better, Sweden has entered a partnership with the Clinton Health Access Initiative (CHAI). Sweden will fund R540-million worth of technical assistance to strengthen and finance healthcare systems that can withstand future shocks like Covid-19 and ensure equitable access to quality primary care and sexual and reproductive health services.

The challenge is formidable. As of 15 June 2022, the World Health Organization (WHO) in Africa has reported over eight million confirmed Covid-19 cases and over 172,000 deaths – likely a significant underestimate. At the same time, the International Monetary Fund reports that Covid-19 has led to the first recession in the African region in decades and worsened debt vulnerability, with a 3.2% gross domestic product (GDP) contraction in 2020.

Equally worrying, in 90% of 105 countries surveyed by the WHO, the pandemic severely disrupted access to many essential health services that were not directly related to Covid-19, particularly sexual and reproductive health services such as skilled birth attended deliveries and uptake of contraceptives. This disruption was worse among low-income countries, compared to middle- and upper-income countries.

The response to Covid-19 has been varied but one key lesson is clear – countries with stronger primary healthcare systems were able to respond faster and more effectively to the pandemic and lessen the disruption of supply and demand for essential health services including sexual and reproductive health.

This is why the CHAI-Sweden partnership will work to strengthen primary healthcare, with a focus on sexual and reproductive health. For Sweden, health equity is a cornerstone of both domestic and international cooperation policy, as sexual and reproductive health and rights (SRHR) are a pillar of its feminist foreign policy.

So, what do we need to do collaboratively?

First, we must increase the resources available for health and we must use the resources available more efficiently and more fairly. A recent report found the African region has 16% of the world’s population and accounts for 23% of the global disease burden, but its health expenditure is 1% that of total global health expenditure. 

On average, R1,200 is spent per person per annum on health across the region. In South Africa this figure is much higher, on average R9,300 per person. But this average hides a major inequity. Half of the total health spending in South Africa only benefits the 17% of the population that can afford private health insurance and services. Such discrepancies fuel inequities in access to health services as well as health outcomes – for example, in the Free State, maternal deaths are almost three times higher than those in Western Cape.

Investing in sexual and reproductive health is not expensive. A comprehensive package of services that ensures access to contraceptives to prevent unintended pregnancies, maternal deaths, and HIV-acquisition is estimated to cost R150 per person per year. These interventions are also cost-effective, with a nine to one return on the money we invest because of their broad impact.

Improving sexual and reproductive health services prevents human tragedy and saves money for the health system. Add to this the social and economic benefits of a mother of two who does not die during her third pregnancy.

We must put people at the centre of care, and we must ensure we first reach the most vulnerable and poor who have been left behind. Each year more than 220,000 women in Africa die from complications related to pregnancy. Again, this number hides inequities: it is teenage girls, rural and poor women without access to contraceptives, termination of pregnancy, safe delivery services or skilled health workers who bear the brunt.

If every woman and girl had access to quality and comprehensive sexual and reproductive health services, most of these deaths would be prevented. That is why we need to ensure primary healthcare systems deliver an essential package of sexual and reproductive health services close to where people live. Well-trained and incentivised health workers, including community health workers, are required in sufficient numbers.

We need to build and strengthen health system capacity and accountability. According to the U4 Anti-Corruption Resource Centre, an estimated $500-billion in public health spending is lost globally to corruption every year. Addressing this challenge is critical to increase the money available for health and to ensure that translates to improved health for people, economic development and social inclusion.

To achieve this, we must build strong partnerships with communities and ensure that women, adolescents, children, and marginalised groups understand what services they have a right to and at what quality. This will enable them to meaningfully engage with governments and health service providers, to voice their needs, and help drive efficiency, equity, and progress towards sexual and reproductive health and rights from the bottom up.

There is significant momentum within the African Union to never allow the disruptions and inequities in access to care in the region that happened during this pandemic to reoccur. Sweden and CHAI are committed to work in partnership with governments and regional organisations to strengthen health systems, with a focus on primary healthcare to mitigate the impact of future health outbreaks and ensure sexual and reproductive health and rights for all. DM

His Excellency Håkan Juholt is Swedish Ambassador to South Africa. Professor Yogan Pillay is CHAI South Africa Country Director and Senior Director, UHC. Dr Anders Nordström is Sweden’s Global health Ambassador. Mikaela Hildebrand is Deputy Head of Sweden’s Regional SRHR team.