{"id":987794405,"date":"2026-09-18T09:24:13","date_gmt":"2026-09-18T08:24:13","guid":{"rendered":"https:\/\/p4h.world\/?p=987794405"},"modified":"2026-09-18T11:42:12","modified_gmt":"2026-09-18T10:42:12","slug":"from-billions-to-balance-sheets-where-will-the-money-for-health-actually-not-come-from-part-2a","status":"publish","type":"post","link":"https:\/\/p4h.world\/en\/from-billions-to-balance-sheets-where-will-the-money-for-health-actually-not-come-from-part-2a\/","title":{"rendered":"From billions to balance sheets: where will the money for health actually (not) come from – Part 2A"},"content":{"rendered":"

[et_pb_section fb_built=”1″ admin_label=”!! PLEASE DO NOT EDIT !!!” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][et_pb_row use_custom_gutter=”on” gutter_width=”1″ admin_label=”!!! PLEASE DO NOT EDIT !!!” _builder_version=”4.20.4″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][et_pb_text admin_label=”TEXT – SUMMARY” _builder_version=”4.21.0″ _module_preset=”default” custom_margin=”||20px||false|false” global_colors_info=”{}”]<\/p>\n

At the scale universal health coverage (UHC) needs, where is the money and how can it be mobilised and directed to the right investment?<\/strong><\/p>\n

[\/et_pb_text][et_pb_text admin_label=”TEXT – BLOCK 10 – Series” _builder_version=”4.21.0″ _module_preset=”default” text_font_size=”15px” background_color=”#e8e7e2″ custom_margin=”||30px||false|false” custom_padding=”20px|25px|20px|25px|false|false” global_colors_info=”{}”]<\/p>\n

This blog post launches Part 2 of the P4H series on financing health systems in the age of the aid retreat. Part 2 comprises three blog posts \u2013 2A, 2B, and 2C \u2013 and builds on Part 1 of the series, Designing Blended Finance: The Do\u2019s and Don\u2019ts for aspiring Health-System Fund Architects<\/a><\/span>,<\/em> which explored key considerations for designing blended finance approaches for health systems.<\/p>\n

[\/et_pb_text][et_pb_text admin_label=”TEXT – BLOCK 3 – blocco 1″ _builder_version=”4.21.0″ _module_preset=”default” custom_padding=”||1em||false|false” global_colors_info=”{}”]<\/p>\n

Though our focus here is the volume of financing, the quality<\/em> of money matters as much as the quantity: the wrong kind can distort priorities, entrench fee-for-service and out-of-pocket spending among the poorest, and divert scarce grant funding to the wrong causes. Simply \u201cfilling the gap\u201d can do more harm than good.<\/p>\n

[\/et_pb_text][ba_gradient_heading title=”SO WHERE IS THE MONEY NOT COMING FROM (IN THE SHORT TERM)?” html_tag=”h3″ primary_color=”#455A64″ secondary_color=”#455A64″ admin_label=”TO BE EDITED – HEADING (50-60 characters)” _builder_version=”4.21.0″ _module_preset=”default” title_font=”||||||||” title_font_size=”32px” title_line_height=”1em” custom_margin=”10px|0px|10px|0px|false|false” custom_padding=”0px|0px|0px|0px|false|false” global_colors_info=”{}”][\/ba_gradient_heading][ba_gradient_heading title=”ODA, philanthropy and the broader structural agenda” html_tag=”h3″ primary_color=”#455A64″ secondary_color=”#455A64″ admin_label=”TO BE EDITED – HEADING (50-60 characters)” _builder_version=”4.21.0″ _module_preset=”default” title_font=”||||||||” title_font_size=”32px” title_line_height=”1em” custom_margin=”10px|0px|10px|0px|false|false” custom_padding=”0px|0px|0px|0px|false|false” global_colors_info=”{}”][\/ba_gradient_heading][et_pb_text admin_label=”TEXT – BLOCK 4 ” _builder_version=”4.21.0″ _module_preset=”default” custom_padding=”||1em||false|false” global_colors_info=”{}”]<\/p>\n

The structural agenda, domestic and international, is incredibly important: domestic tax capacity<\/a> as well as the international tax regime<\/a> discussions under the United Nations (UN); debt restructuring<\/a>, the cost of capital and biased credit ratings<\/a>; legacy terms of trade<\/a> and currency markets reform are all critical for sustained domestic public investment in health and human capital in all countries. Such shifts can however be slow and require political will and global solidarity currently in short supply and this piece will not be addressing them.<\/p>\n

[\/et_pb_text][et_pb_text admin_label=”TEXT – BLOCK 5 – When it comes to traditional” _builder_version=”4.21.0″ _module_preset=”default” custom_padding=”||1em||false|false” global_colors_info=”{}”]<\/p>\n

When it comes to traditional (and easier) sources, the news is sobering. Official development assistance<\/a> is in steep decline, with no sign that new donors will fill the G7\u2019s retreat whilst philanthropy<\/a>, whilst important, cannot plausibly close a hole of this size<\/a>. The post-Addis private sector \u201cbillions to trillions<\/a>\u201d agenda has simply not materialised.<\/p>\n

[\/et_pb_text][ba_gradient_heading title=”Africa\u2019s institutional capital” html_tag=”h3″ primary_color=”#455A64″ secondary_color=”#455A64″ admin_label=”TO BE EDITED – HEADING (50-60 characters)” _builder_version=”4.21.0″ _module_preset=”default” title_font=”||||||||” title_font_size=”32px” title_line_height=”1em” custom_margin=”10px|0px|10px|0px|false|false” custom_padding=”0px|0px|0px|0px|false|false” global_colors_info=”{}”][\/ba_gradient_heading][et_pb_text admin_label=”TEXT – BLOCK 6 – Africa\u2019s much-cited domestic” _builder_version=”4.21.0″ _module_preset=”default” custom_padding=”||1em||false|false” hover_enabled=”0″ global_colors_info=”{}” sticky_enabled=”0″]<\/p>\n

Africa\u2019s much-cited domestic institutional capital is reported at a little over US$2 trillion<\/a>\u00a0(pension ~$600bn, insurance ~$400bn, sovereign-wealth funds $164bn, reserves $530bn and public development banks $276bn).[1]<\/a><\/sup> Most of it is, however, effectively locked (see the Annex “Africa’s domestic capital pools” – XLSX<\/a>). Of the total, the four savings<\/em> pools (US$1.7 trillion in insurance, pension and sovereign wealth funds and in central bank reserves) are the only parts that can, in principle, be redirected (with the $276bn held by public development banks also discussed briefly below). In practice the realistic figure is smaller still: of that US$1.7 trillion, only the roughly US$1 trillion held in pension and insurance is genuinely long-term, investable savings \u2014 central-bank reserves are mandate-bound offshore and most sovereign-wealth assets are held abroad or effectively frozen \u2014 so it is this ~US$1 trillion, not the US$2 trillion headline, that is the real measure of potentially deployable domestic capital.<\/p>\n

[\/et_pb_text][et_pb_text admin_label=”TEXT – BLOCK 7 – Capital held by insurance” _builder_version=”4.21.0″ _module_preset=”default” custom_padding=”||1em||false|false” global_colors_info=”{}”]Capital held by insurance and pension funds is largely invested in domestic government securities (over 80% of Africa\u2019s institutional capital sits in government paper, by statute and regulatory incentive[2]<\/a><\/sup>) and is highly unlikely to be redirected towards domestic infrastructure. Pension funds (the continent\u2019s largest pool at ~$600bn, with ~90% concentrated in South Africa, Nigeria, Namibia and Botswana<\/a>) are the most-cited candidate, yet in every case the money is already committed. South Africa\u2019s, which make up the bulk, are tied up offshore and in listed equities under Regulation 28, with barely 1\u20132% in infrastructure<\/a>; Namibia\u2019s and Botswana\u2019s are similarly weighted offshore; and the genuinely domestic pools sit heavily in government securities \u2014 around 81% in Ghana, 65% in Nigeria and 48% in Kenya<\/a>.[3]<\/a><\/sup> Either way, little is free to flow to new infrastructure. Assuming a change of statute permitting such redirection was possible, it would also be risky as funds selling government securities to finance new development projects could disrupt the local government-securities market. The net effect would then be similar to the government simply issuing fresh securities and applying the proceeds to those projects itself. Such capital is, moreover, entirely in local currency, whereas a development project may need both local and hard currency. In short, tapping these funds is not a trivial task: as the Africa Finance Corporation (AFC) puts it<\/a>, external capital is increasingly complementary, rather than foundational, to Africa\u2019s development model.[\/et_pb_text][et_pb_text admin_label=”TEXT – BLOCK 8 – The public development banks” _builder_version=”4.21.0″ _module_preset=”default” custom_padding=”||1em||false|false” global_colors_info=”{}”]<\/p>\n

The public development banks, for their part, are already lending for development, but collectively remain modest in scale and are widely judged to be underutilised, constrained by fragmented mandates and weak alignment with national development plans.[4]<\/a><\/sup> Initiatives such as Finance in Common<\/a> are slowly gaining momentum in highlighting the potential of PDBs playing a central role in the international financial architecture.<\/p>\n

[\/et_pb_text][ba_gradient_heading title=”The potential for mobilisation” html_tag=”h3″ primary_color=”#455A64″ secondary_color=”#455A64″ admin_label=”TO BE EDITED – HEADING – The potential for mobilisation” _builder_version=”4.21.0″ _module_preset=”default” title_font=”||||||||” title_font_size=”32px” title_line_height=”1em” custom_margin=”10px|0px|10px|0px|false|false” custom_padding=”0px|0px|0px|0px|false|false” global_colors_info=”{}”][\/ba_gradient_heading][et_pb_text admin_label=”TEXT – BLOCK 9 – First, what is the potential headline” _builder_version=”4.21.0″ _module_preset=”default” custom_padding=”||1em||false|false” global_colors_info=”{}”]First, what is the potential headline figure? Once South Africa, which dominates the pools but is unlikely to send capital across borders, and the resource-rich North African economies, where the largest sovereign-wealth and reserve balances sit, are set aside, the institutional savings within reach of the lower-income sub-Saharan countries with the greatest need falls to roughly $250bn (see the Annex: pension and insurance less South Africa and North Africa – XLSX<\/a>), a small fraction of the \u201c$2 trillion\u201d headline.[\/et_pb_text][et_pb_text admin_label=”TEXT – BLOCK – The most frequently cited reform” _builder_version=”4.21.0″ _module_preset=”default” custom_padding=”||1em||false|false” global_colors_info=”{}”]The most frequently cited reform, raising the statutory ceilings on where pension funds may invest, would change little. In the largest markets those ceilings are already generous and sit largely unused: Nigeria permits up to 15% of assets in private equity and Ghana up to 25% in alternatives, yet actual allocations run far below the limit \u2014 just 0.58% in Ghana<\/a>.[\/et_pb_text][et_pb_text admin_label=”TEXT – BLOCK – A first real constraint is” _builder_version=”4.21.0″ _module_preset=”default” custom_padding=”||1em||false|false” global_colors_info=”{}”]<\/p>\n