Transition from dependence to self-reliance: financing and governing health systems in Africa

¹Resilient Health Systems, Washington, USA, ²Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA, ³Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Program, Nairobi, Kenya, ⁴Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom, ⁵Liberty University, Lynchburg, USA, ⁶Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, ⁷Ghana National Health Insurance Agency on Free Primary Health Care and Strategic Purchasing, Accra, Ghana

^&Corresponding author
Olusoji Adeyi, Resilient Health Systems, Washington, USA

Commentary    

Introduction

Upheavals and declines are contemporary features of Development Assistance for Health (DAH) in many African countries. For those countries, the cuts in DAH have put considerable stress on the financing, governance, and operations of their health systems. This is especially so in the procurement and supply management of commodities for DAH-dependent disease control programs, which were largely controlled by bilateral financiers, health management information systems that were fragmented between government systems and parallel systems established by external partners, and the DAH-dependent governance and architecture of health systems.

For historical context, as published elsewhere [1] between 2000 and 2020, spending on health increased in Africa from US$53 per capita to US$118 per capita (in real 2022 USD). The 20 countries receiving the most DAH per capita are mostly middle income countries, including South Africa (an upper middle income country), 11 lower middle income countries, (Cameroon, Côte d´Ivoire, Democratic Republic of the Congo, Egypt, Ghana, Kenya, Nigeria, Senegal, Zambia, Zimbabwe, and Tanzania) and eight low income countries (Burkina Faso, Ethiopia, Malawi, Mali, Mozambique, Rwanda, South Sudan, and Uganda). The extent of DAH dependence varied widely across countries.

Two broad themes have emerged in the wake of DAH cuts by the United States Government (USG) and several other governments of high-income countries. The first theme combines a purported indispensability of DAH with apocalyptic warnings of doom for health in many Low- and Middle-Income Countries (LMICs) that hitherto depended on DAH for essential health services. For example, dire proclamations by former USAID officials [2] and others [3] in the media were followed by quantitative claims that, unless the abrupt funding cuts at the defunct USAID were reversed, extraordinary numbers of avoidable deaths could occur by 2030. The latter example was the report of a retrospective impact evaluation integrated with forecasting analysis, with the assertion that “unless the abrupt funding cuts announced and implemented in the first half of 2025 are reversed, a staggering number of avoidable deaths could occur by 2030” [4]. Other scholars have queried the framing and epistemological premise of such claims, stressing that using aggregated data to show how many lives USAID purportedly saved assumes that USAID is needed to avoid those deaths. They point to the relevance of domestic and regional response capacity to reverse longstanding systems of conditional charity and dependence on DAH [5].

In the second theme, leaders of African countries, policy makers, scientists, and many others have framed the DAH upheavals as a wake-up call for African countries to assert their sovereignty in health systems, free themselves from chronic dependence on DAH [6], and take responsibility for their own health services [7,8]. The recently launched Accra Reset, a Head-of-State-anchored initiative to rebuild global development cooperation around practical sovereignty, asserts “that Country-led development, bolstered by regional alliances, can unlock massive and equitable prosperity worldwide-if the practice of development is liberated from small cohorts of specialists into the mainstream of social change at all levels" [9]. It has discernible political ancestry in Kwame Nkrumah´s vision of African self-determination [10] and Julius Nyerere´s “Arusha Declaration” on the policy of self-reliance in Tanzania [11].

The recent literature on self-reliance in African health systems includes themes of sovereignty, independence, and self-empowerment [12-14]. Self-reliance in health systems is a multidimensional construct encompassing financing autonomy, operational capability, digital and data sovereignty, and resilient supply chains for essential diagnostics, medicines, and vaccines based on African manufacturing capacity. Amidst the upheavals and declarations, African LMICs now face a practical challenge: how to transition their health systems from chronic dependence on DAH to self-reliance in financing and governance. Despite the complexity of the challenge, viable transitions depend on recognizing the ongoing crisis of legitimacy and deploying levers of public policy to execute two concurrent transitions.

The crisis of legitimacy

The credibility and perceived legitimacy of health systems are driven by citizens´ expectations and engagement on the one hand, and governments´ responsiveness to their populations´ health service needs on the other hand [15,16]. Challenges may arise when citizens whose expectations are unmet demand better performance from their governments. The root causes of underperformance of African health systems and their dependence on DAH have been explored elsewhere [17]. Regardless of the roles played by external actors in the current health system upheavals, any African government that cannot ensure basic health services for its population faces a domestic crisis of legitimacy.

Levers of public policy

Governments are constrained by finite resources in the short term and conflicting demands from interest groups. Policy makers depend upon solutions that emerge from multiple bargaining and transactions among those interest groups. But what levers can they deploy to execute those solutions? In the framework in Figure 1, four levers revolve around the two drivers identified above: legislation and policy; regulations and institutions; financing, specifically shifting from passive allocation to strategic purchasing that links funding to health outcomes and equity, while providing clear incentives for efficient domestic resource mobilization and allocation; and learning, monitoring, and evaluation. These are the principal levers that governments can use to initiate, enable, or enforce systemic change in the health system.

In this framework, although DAH is only one part of revenue generation in financing, its ramifications are profound because DAH often results in substitutions of external financing for domestic financing [18]. It is often the most important source of funding for essential health services, including preventive and promotive components, vital diagnostics, vaccines, and medicines for the most common infectious diseases. Furthermore, the quantitative substitution, in turn, is often associated with qualitative substitutions of external financiers´ preferences and practices for country-initiated, country-designed, and country- managed health systems and services [1]. Within this conceptual framework, health supply chains should be recognized as core determinants of service continuity and sustainability. This consideration includes the full set of procurement and supply management processes-forecasting, procurement, warehousing, distribution, logistics management information systems, and quality assurance-that translate financial and governance inputs into service-ready commodities. It also highlights the importance of functional and structural integration across vertical programs to reduce fragmentation, improve efficiency, and strengthen resilience as external funding declines.

Dimensions of the transition to self-reliance

We posit that the transition to self-reliance in financing and governing health systems has two dimensions. The first is quantitative, and garners the most attention because it is essentially about money: domestic revenues to finance essential health services, the costs of those services, and, since LMICs are so resource-constrained, the vexing gap between revenues and costs. In practical terms, every government should analyse and project its health system revenues and financial costs for the short and medium terms, publish them in the public domain, and specify which set of basic services it will ensure for its population. This highlights a crucial political reality: there is peril in defining and committing to the delivery of the most basic services to the population. This is because it requires revisiting utopian promises of “free” access to every health service for everyone, which is an impossible but politically useful social balm, especially when couched in terms of “rights” or constitutional guarantees. Navigating this complexity requires tempering idealistic aspirations with the realism of finite, and in many countries, highly constrained resources. It means moving from implicit priority setting to explicit priority setting, with the latter making it possible for the population to finally hold the government accountable if the basic services are not delivered. The scope of services covered can be expanded as economies grow and health budgets increase. This approach puts governments under public scrutiny, which is good for the population.

The qualitative dimension is about changes in how the health system is organized, managed, and incentivized to achieve the country´s policy goals. Here, governments can deploy the levers of legislation and policy, institutions, and learning to ensure that revenues generated are deployed for maximum impact. With variations across countries, the opportunity here is for governments and their institutions to take responsibility, demonstrate initiative, and exercise capabilities that have withered because essential functions were either unwittingly abdicated or deliberately outsourced to external financiers and their contractors. These may include, for example, implementing laws and policies that existed on paper but were dormant or passing new legislation. Opportunities abound for functional integration of hitherto separate programs to achieve efficiency gains (such as those for malaria, HIV, tuberculosis, maternal health, child health, and family planning), and for efficiency gains in cross-cutting functions like laboratory services, procurement and supply management, and health management information systems. Beyond these, there is merit in exploring the structural integration or merger of separate and often externally funded departments or agencies for HIV/AIDS, tuberculosis, and malaria. Such structural integration could eliminate or minimize wasteful spending on administration, supervisory trips, workshops, parallel reporting, and repetitive consultations with external partners.

Avoiding relapses and pitfalls in transition

The geopolitical fraying of multilateral cooperation enables a new generation of approaches to DAH, of which the USG´s push for bilateral Memoranda of Understanding is a prime example [19,20]. The promise of short-term financial relief could lure countries into signing agreements that perpetuate dependence without rigorous transition plans that are grounded in domestic consultations and transparent policy consensus within each African country. In broad terms, African countries would be well served by the following considerations: national sovereignty and African solidarity to avoid “divide and conquer” by coercive or predatory external financiers; primacy of treaties and compacts formally approved by African countries through the African Union and WHO over bilateral side-deals with financiers; emphasis on transitioning to financial and organizational self-reliance within specified timelines; contractual obligations to procure quality-assured products manufactured in Africa; transparency and reciprocity in all bilateral agreements, especially regarding health data, biological samples, and potential intellectual property derived from such samples; requirements that there will be no grant financing agreement in which technical assistance, or the procurement and use of technologies and commodities, are tied to the nationals or firms originating from an external financier or donor country; no external financier, entity, or contractor should control or be the primary custodian of information on health programs being delivered in an African country; related data on disease burden, service delivery needs, service utilization, procurement, supply chains, and costs shall be housed on platforms determined and controlled by African country officials and institutions; no external financier should indirectly influence national priorities through formal or informal financing conditions; and avoidance of a veto power, whether implicit or explicit, by any external party in the health systems of any African country.

Similarly, it is prudent for countries to avoid pitfalls during the transition to self-reliance. The major pitfalls identified elsewhere include the following [21]: shifting the financial burden to out-of-pocket payments, over-reliance on contributory health insurance schemes that may exclude the most vulnerable, displacement of basic primary healthcare services, and abandoning community-based service delivery in favor of facility-centric models, undermining the integrity of people-centered health systems. There is an additional, cross-cutting risk: that countries, used to glitzy initiatives and declarations brokered and proclaimed in global fora, do not rise to a central challenge of transitioning to self-reliance: committing to the gritty and non-glamorous functions of local policy makers and institutions, to be done day after day, year after year, without fanfare. In this regard, learning from within and outside Africa could inform robust and durable approaches to health system transformation, including how others have navigated systemic complexities and political turbulence [22,23].

Conclusion     

Transitioning from dependence to self-reliance is essential. It is also filled with possibilities and perils. Faced with the stark realities of hard work required for self-reliance, it might be tempting to wish for the days of easy money from DAH. Chinua Achebe, in Anthills of the Savannah, shared cautionary wisdom worth heeding [24]: “charity, he thundered, is the opium of the privileged; from the good citizen who habitually drops ten kobo from his loose change and from a safe height above the bowl of the leper outside the supermarket; to the group of good citizens like yourselves who donate water so that some Lazarus in the slums can have a syringe boiled clean as a whistle for his jab and his sores dressed more hygienically than the rest of him; to the Band Aid stars that lit up so dramatically the dark Christmas skies of Ethiopia. While we do our good works, let us not forget that the real solution lies in a world in which charity will have become unnecessary.” We posit that nostalgia is not a viable strategy for African countries. That route would condemn African countries to a future of self-imposed dependence on the capricious kindness of strangers, akin to what Shakespeare's character Cassius invoked [25]: “men at some times are masters of their fates: the fault, dear Brutus, is not in our stars, but in ourselves, that we are underlings.” Sovereignty will be earned not by declaration alone but by action. By bringing political leadership and public accountability to bear upon the quantitative and qualitative dimensions of transition, African countries can move from chronic dependence to self-reliance in financing and governing their health systems.

Disclaimer: the authors wrote this paper in their personal capacities. Its contents should not be attributed to any institution with which they are associated.

Competing interests     

The author declares no competing interests.

Authors' contributions     

The authors have read and approved the final version of this manuscript.

Figure     

Figure 1: ecosystem of transition to self-reliance; source: resilient health systems

References