Out-of-pocket health payments in Africa have become one of the greatest barriers to equitable healthcare access. For millions of households, the cost of seeking treatment can mean the difference between recovery and financial hardship. In this article, William Menson, Director for Health Financing for Africa examines why these payments function as a hidden tax on the poorest families and what governments can do to reduce their impact.
Names have been changed for confidentiality.
Africa does not only have a health financing gap. It has a hidden tax problem.
We call them “out-of-pocket payments”, as if they are ordinary consumer choices. But a payment demanded from a woman in labour, a father with a child on oxygen, or a patient waiting for discharge is not ordinary spending. It is a charge collected at the moment of fear, when people are least informed, least powerful and least able to negotiate.
In political terms, out-of-pocket payment is Africa’s most regressive health tax: unpredictable, unpooled, unaudited and imposed most heavily on those least able to pay.
In Lagos, let us call her Chiamaka. A Guardian Nigeria investigation observed a nursing mother asking for her baby to be discharged after being told that the drug bill alone had reached ₦17,000 in the first week. Not the full hospital bill. Just drugs. In Kenya, an ICIJ investigation documented families turning to churches, relatives, friends and coworkers to meet crushing hospital debts. In one case, coworkers voted to surrender part of their monthly pay to help a colleague after a road accident. One finger cannot lift a stone, but no community should have to become an emergency health financing scheme.
In Sierra Leone, let us call her Aminata. In a country where maternal and newborn care is officially meant to be free, a Human Rights Watch investigation documented women delaying care because they feared hospital costs. One woman with eclampsia almost died after her husband, a fisherman, reportedly asked her to wait until he could get fish and raise money for the hospital. In northern Ghana, let us call her Abiba. She gave birth under a free maternal care policy, but a study of rural northern Ghana found that more than one-third of women still incurred potentially catastrophic payments during childbirth; many used savings, and some sold assets.
In Lubumbashi and Cotonou, the story becomes harsher still. At Sendwe Hospital in the Democratic Republic of Congo, a peer-reviewed study found that more than half of women eligible for discharge from the maternity ward were detained because they could not settle bills. In Benin, Amnesty International reported that four women and their babies were kept in hospital after childbirth because of unpaid fees. At that point, out-of-pocket payment stops looking like financing. It begins to look like punishment.
The forms differ by country: informal fees inside a free-care promise, gaps in insurance benefits, medicine stock-outs, hospital deposits, exhausted insurance ceilings, debt, detention, family fundraising. Different doors, same house.
This is not an argument that African governments have done nothing. Ghana’s National Health Insurance Scheme and free maternal health policy mattered. Sierra Leone’s Free Health Care Initiative was a serious political commitment. Rwanda’s community-based health insurance shows what determined pooling can achieve: a 2025 AHOP/WHO brief reports coverage above 90%, out-of-pocket expenditure falling from 26.6% in 2000 to 10.4% in 2020, and health-care use rising substantially. Rwanda still faces co-payment, quality and coverage challenges, but it proves the central point: when risk is pooled, households are less exposed.
The difficulty is that Africa must now do this in a harsher world. Aid is falling. The OECD projects a 9-17% drop in official development assistance in 2025, after a 9% fall in 2024, with sub-Saharan Africa likely to be disproportionately affected. The IMF warns that the current aid shock is unprecedented in scale, speed and uncertainty. Debt is also eating the room: the World Bank notes that external public debt service as a share of revenue has doubled, from 9% in 2017 to 18% in 2025.
These pressures are real. But they cannot become an excuse to balance health systems on the backs of sick families.
The data are already damning. According to WHO Africa, reported by Africa Renewal, out-of-pocket payments burdened more than 200 million people in the WHO African Region and pushed more than 150 million into or deeper into poverty in 2019. Africa CDC estimates that out-of-pocket payments account for about 35% of total health expenditure across Africa, rising to 40-60% in many low- and lower-middle-income countries.
African leaders should make reducing out-of-pocket payments a cabinet-level measure of health financing reform. Protect essential medicines, diagnostics, emergency care, maternal and child health from point-of-care charges. Pay facilities predictably so “free” care is not financed through back-door fees. Track informal payments. Ban hospital detention for medical debt. Learn from countries that have pooled risk better and adapt those lessons without pretending any model is perfect.
Above all, stop calling this private spending. A mother asking to discharge her sick baby because the drug bill has become unbearable and is not exercising consumer choice. She is absorbing a public failure.
The axe forgets, but the tree remembers. Budgets may forget these hospital bills once they are paid. Families remember them for years, however, and African leaders should remember them too.
Dr. William Nii Ayitey Menson is Director of Health Financing for Africa at The ONE Campaign (ONE). ONE drives the investments needed to create economic opportunities and healthier lives in Africa.
