Navigating Africa´s health financing in the post-aid era

¹Institute for Health Metrics and Evaluation, Department of Health, Metrics Sciences, School of Medicine, Seattle, Washington, United States

^&Corresponding author
Angela Esi Apeagyei, Institute for Health Metrics and Evaluation, Department of Health, Metrics Sciences, School of Medicine, Seattle, Washington, United States

Commentary    

Introduction: from stagnation to shock

For three decades, the prevailing global health financing architecture was defined by a steady, if sometimes erratic, flow of Development Assistance for Health (DAH). Development assistance for health is defined as the transfer of financial and in-kind resources through international development agencies from high-income countries to low-and middle-income countries with the primary intent to maintain or improve health [1]. However, a shift occurred in 2025. Cuts in development assistance, primarily bilateral health aid, have disrupted the traditional donor-recipient paradigm [2]. While the abruptness of the United States´ retreat has captured headlines, significant policy shifts in the United Kingdom, Germany, and France signal a broader, more permanent erosion of the traditional donor-recipient model [3-6]. This funding crisis offers a catalyst for transformation, requiring recipient nations to prioritize an outcome-driven health system - the domestic governance structures necessary to translate limited available resources into population health.

For the broad context, the current crisis was foreshadowed by a period of stagnation in the availability of aid. The COVID-19 pandemic precipitated a temporary, massive spike during which DAH reached unprecedented heights, totaling $82.2 billion in 2021, a 23.2% increase from the previous year [7]. However, the post-pandemic outlook is grim. As such, these changes have placed the African continent at a precarious crossroads. Since 2000, a total of $411.3 billion (2023 USD) has been provided as DAH to African countries. On average, DAH formed 15.2% of the total health spending in 2024 and 42.4% if one considers only the low-income countries on the continent (Figure 1). These percentages are the highest across continents, with the next (second) continent, Asia, having DAH only as 0.6% of total health spending in 2024 on average, and 31.8% when only low-income countries are considered [8]. The dependency is not just a matter of choice but of fiscal capacity. Many nations are trapped in a cycle where domestic tax bases are too narrow to cover basic primary care, fragile governance structures undermine development initiatives, and debt repayment remains a substantial portion of the national budgets, leaving little else for social spending.

The ambition of health sovereignty

In response to the retreat in aid, African leadership has signaled an intention to rebuild a global health financing architecture that is more country-driven and domestically resourced. This vision is an ambitious attempt to reclaim the health agenda. The logic is sound: true health security cannot be imported. It must be grown from within. However, the existing reality underscored by data is challenging. Not every nation is starting from the same baseline. While middle-income countries like Senegal, South Africa, or Kenya may have the institutional framework to absorb aid cuts through improved tax collection or insurance schemes, others like Sudan and Somalia face a challenging path forward. Political will, while essential, cannot conjure fiscal resources where they do not exist, especially in states currently grappling with high debt-to-GDP ratios and economic instability. Harnessing gains in efficiency presents an opportunity that could be seized.

Beyond arbitrary benchmarks

Globally, countries have been observed to have large differences in health-care inefficiency [9]. This means that countries with similar levels of spending often achieve vastly different health outcomes. For instance, some nations achieve better infant mortality rates with $100 per capita than others do with $300. This gap is caused by various factors: supply chain bottlenecks, infrastructure gaps, and administrative overhead, to name a few [10,11]. It suggests that traditional targets-where countries are encouraged to spend a fixed percentage of their budget on health-may be an insufficient peg to hold countries accountable; instead, the new architecture could tie spending to health outcomes.

Yet this shift toward outcomes-based accountability must be carefully constructed to avoid an unintended consequence: that efficiency gains become a justification for constraining health budgets rather than expanding them. Public revenue can be expanded through tax reforms and natural resource mobilization, so a country´s level of economic development does not stipulate its public spending levels or the size of its health budget [12]. Ultimately, it is a political choice. If outcomes-based frameworks are applied without acknowledging this, national planners may invoke efficiency arguments to resist new investment - effectively capping budgets at levels that are already inadequate. This distinction is institutionally recognized in WHO's Health Financing Progress Matrix, which treats revenue adequacy and spending efficiency as separate but complementary dimensions of health financing performance [13]. Tying spending to outcomes should therefore serve as a floor for accountability, not a ceiling on ambition. The goal is to ensure that money spent achieves more and that the amount of money committed reflects what population health genuinely requires.

A framework for sustainability

As countries navigate this transition, they must look beyond the immediate disruption to understand how African nations can seize the opportunity this new landscape presents. While the pursuit of health sovereignty is a necessary evolution, its success depends on shifting focus from how much money is spent to how effectively that money translates into improved population health. By keeping the end goal upfront, countries can chart their unique best paths forward [14]. To chart this new course, the continent requires a framework that recognizes the diversity of its economic landscapes. Three pillars emerge to ensure the most vulnerable are not left behind. The first pillar, fiscal capacity, focuses on the structural mechanisms of revenue generation, specifically through tax reform and the expansion of insurance coverage. Its primary objective is to diversify the national economy's support for health, advancing toward a more stable, broad-based domestic resource pool. The second pillar, outcome-based targets, represents a shift in how success is measured within a health system. This pillar prioritizes tangible health metrics. For instance, the utilization of disability-adjusted life years (DALYs) to quantify impact or describe population health. By measuring the number of years lost to ill health, disability, or early death, policymakers can ensure that spending is directly correlated with the actual improvement of population health rather than just the movement of resources.

Finally, the strategic efficiency pillar addresses the how of health delivery through systematic optimization. Here, the focus is on identifying and analyzing the best performers, African countries that achieve superior health outcomes relative to their spending levels. By modeling the best practices of these high-efficiency outliers, other African nations can improve their own resource utilization. Notably, these three pillars are not parallel tracks but a mutually reinforcing system. Stronger fiscal capacity gives governments the revenue base to fund services at an adequate scale. Outcome-based targets ensure that expanded spending translates into measurable population health gains rather than institutional overhead. Strategic efficiency - learning from the continent's best performers - stretches each additional dollar of domestic investment further, in turn generating the visible returns that sustain political will for continued revenue mobilization.

Conclusion     

A new social contract

The aid cuts of 2025 were an unwelcome disruption for many across health systems in Africa, but they offer an opportunity to build a new and sustainable health system framework going forward. In addition to the three pillars proposed above - strengthening resource mobilization, tying spending to outcomes, and learning from the best performers on the continent - success requires acknowledging that the most aid-dependent nations require a tapered transition. A tapered transition would involve country-led time-bound schedules that are embedded within national health financing strategies that support the development of resilient, domestically funded health systems. Most critically, in practice, that transition timeline is formally differentiated by fragility status. In non-fragile contexts with functioning revenue systems and moderate aid dependence, a ten-to-fifteen-year transition path is plausible, with domestic financing expected to absorb most of the gap by mid-transition. On the other hand, fragile or conflict-affected states may need over twenty years to transition due to structurally limited tax capacity and health systems. In these contexts, multilateral development banks such as the African Development Bank and the World Bank could guarantee a financial floor to sustain essential services during institutional recovery. This distinction is essential to achieving long-term health system resilience and sustainability. Ultimately, health spending is merely a means. The end goal is a continent where a child´s survival is assured by the resilience of their national health system. The disruption in aid, which began in 2025, was challenging, but if managed correctly, it could lead to an African health architecture that is robust and sustainable. Through the lens of population health outcomes, the path to resilience becomes not just a fiscal necessity but a moral imperative.

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: development assistance for health as a share of total health spending in Africa by income group, 2024; DAH = development assistance for health; source: IHME Financing Global Health Development Assistance for Health database

References