In this blog series, we will examine the state of debt and its impact on the right to health in four countries – Malawi, Burundi, Zambia, and Uganda

The implication of debt on human rights is becoming an increasingly significant concern – especially in the Eastern and Southern Africa region. Many countries in the region are either already in a debt crisis or approaching debt distress. This is not a new phenomenon for the region, as 15 of the 25 countries in East and Southern Africa were part of the Heavily Indebted Poor Countries initiative. The COVID-19 pandemic exacerbated the ability of many countries to both service debt and meet the increasing health needs of their citizens.  Research shows that some governments in the region chose to borrow more funds to support at-risk groups and build health infrastructure to respond to the pandemic.

With the emergence of increased investment interest in the region from governments, corporates and individuals – particularly in the natural resource sector – public debt on the continent is now owned by an array of different lenders in addition to the traditional multi-lateral development institutions. This makes it more challenging for creditors to reach consensus on debt restructuring or cancellation.

So why is debt a problem?  It is not necessarily the size of the ratio of debt to GDP that represents the risk to a country’s fiscal sustainability. Rather, one needs to consider what tax revenues, savings, and reserve levels a country has. This indicates whether a government can fund a call on the debt and maintain confidence from creditors. Secondly, where there is limited maneuverability in a country’s budget to address spending needs and crises- as is the case with many African countries – the pace of growth of debt interest costs and repayments, in comparison to other budget items like health and education, becomes critical.

During the pandemic, at least 29 African countries faced this tough choice and were pushed to join the Debt Service Suspension Initiative (DSSI) offered by the Group of 20 (G20). The DSSI was designed specifically to provide countries like Zambia, Malawi, and Uganda additional flexibility in their budgets to provide for health, social and economic needs in response to the COVID-19 crisis. In reality, however, the DSSI faced criticism on the lack of participation by corporate and individual creditors, and that it was only a temporary break from interest and repayments – providing no solution for long-term debt obligations and the worsening economic context of countries.

An obligation to guarantee the right to health

Covid-19 had a marked impact on the provision of health services in African countries, with the perfect storm of declining tax revenues, increasing debt repayments, and rising expenditure demands. In particular, the focus on COVID-19 has often been at the expense of other health concerns, such as sexual reproductive health, malaria, tuberculosis, and HIV. Lockdown protocols also likely further exacerbated the disparities in health equity between rural and urban areas. This is against a historical backdrop of existing health services often failing to meet the universal human rights standards of availability, accessibility, acceptability, and quality. The UN Committee on Economic, Social and Cultural Rights has stated that states are obliged to respect, fulfill, and protect the right to health. This right is guaranteed under various international and regional treaties that African states have ratified, including Article 12 of the International Covenant on Social, Economic and Cultural Rights, which obliges states to ensure the highest attainable standard of physical and mental health. Implementation of these obligations, however, has been hindered by budgetary constraints, alleged corruption, and a lack of political will to prioritize health, even in countries like Malawi, Zambia, Uganda, and Burundi that have ratified these agreements. While State parties are obligated to provide adequate, affordable, and accessible health services, with the Abuja Declaration requiring the allocation of 15% of the budget to health, very few African countries have ever met this 15% commitment, spending much more of their revenue on debt servicing, especially in recent years. In cases where countries have been able to meet the spending requirement, a closer look at their books may indicate that the focus is not necessarily on primary healthcare.

Next in the blog series

In this blog series, we will examine the state of debt and its impact on the right to health in four countries – Malawi, Burundi, Zambia, and Uganda. We will analyze the challenges faced by these countries in meeting their obligations in terms of the right to health, particularly in the context of debt, and provide recommendations on better ways to address debt while still meeting their health obligations. By doing so, we hope to shed light on the urgent need to prioritize health equity in African countries and ensure the universal realization of the right to health for all.