Can Low-Income SADC Countries Afford UHC? Evidence on Fiscal Space, OOP Burdens, and Donor Dependence

Abstract

Universal Health Coverage (UHC), defined as access to needed health services without financial hardship, remains difficult to finance in low-income Southern African Development Community (SADC) countries where fiscal space is constrained, out-of-pocket (OOP) payments are high, and donor dependence is substantial. This study evaluates the financial feasibility of achieving UHC in Zimbabwe, Malawi, Mozambique, Lesotho, and Tanzania over the period 2010–2024 using a mixed-methods comparative design. Quantitative analysis draws on WHO Global Health Expenditure data, World Bank World Development Indicators, National Health Accounts, and national budget documents to assess trends in government health spending, OOP payments, per capita expenditure, and external financing. Qualitative policy and institutional analysis examines revenue-raising capacity, risk pooling mechanisms, strategic purchasing, and governance constraints. Results indicate persistently low public health spending, generally around 1–2% of GDP, alongside high OOP burdens and substantial donor dependence, with Lesotho as a partial outlier. Scenario-based fiscal space assessment suggests that gains from economic growth, budget reprioritization, earmarked taxes, and efficiency improvements are insufficient to close financing gaps in the medium term, particularly under conditions of informality and recurring economic shocks. The study highlights the gap between theoretical affordability and practical feasibility.