Africa Urged to Rethink Health Financing as Donor Support Falls Away — and the Bill Grows
A stark warning has gone out from health ministers, development economists, and international partners gathered at the World Health Summit’s inaugural Africa regional meeting: the continent can no longer afford to rely on external development assistance to fund its health systems, and the transition away from that model must begin now — before the safety net disappears entirely.
The warning comes against a backdrop of accelerating aid withdrawals. The United States — historically the largest bilateral health donor to sub-Saharan Africa — has dramatically curtailed its PEPFAR and broader global health programming under the current administration’s revised foreign assistance priorities. Several European donors have similarly tightened budgets. Meanwhile, multilateral lenders like the IMF and World Bank have delayed disbursements to several African governments amid debt sustainability concerns and governance conditionalities.
The result is a widening gap. African countries collectively face a health financing shortfall estimated at over $50 billion annually, according to WHO Africa regional data published this month. That gap is not abstract — it translates into shuttered clinics, drug stockouts, laid-off community health workers, and ultimately, preventable deaths.
## The Dependency Problem
Africa’s health sector has long been structurally underfunded by domestic budgets. For decades, the gap was filled by external donors — a model that brought real progress. Childhood immunization rates rose dramatically. HIV/AIDS treatment reached millions. Malaria control programs expanded. None of this happened spontaneously; donor money made it possible.
But the model has always had a flaw embedded within its success: it created systems that could not sustain themselves without outside support. Health ministries in numerous countries now face a paradox — they have built infrastructure and launched programs that communities depend on, but they lack both the domestic revenue and the domestic capacity to maintain them if donor funds dry up.
“The moment has come to have an honest conversation,” said Dr. Fatima Adeyemi, a Nigerian health economist and one of the presenters at the summit. “We cannot keep building on a foundation of someone else’s money. When that money goes away — and it is going away — the system collapses unless we fix this now.”
## Afreximbank Steps Into the Breach
In a notable development, the African Export-Import Bank (Afreximbank) announced a $4 billion emergency health financing facility aimed at countries facing the most acute delays from traditional multilateral lenders. Kenya — which has seen both IMF and World Bank budget support frozen pending ongoing fiscal reviews — is among the first identified recipients.
The facility, structured as a combination of grants and low-interest bridging loans, is designed to prevent a total collapse of essential health services while governments work through their longer-term fiscal adjustments. It is an unusual role for an institution primarily focused on trade finance, but Afreximbank’s president, Professor Benedict Oramah, framed it as a necessary evolution.
“Africa’s health security is non-negotiable,” Oramah said in a press statement. “When traditional mechanisms fail, African institutions must step in. That is what Afreximbank is doing.”
## Domestic Resource Mobilization: The Only Sustainable Path
Beyond emergency measures, the summit’s central recommendation was clear: African governments must prioritize domestic resource mobilization for health. This means increasing budget allocations to health ministries, improving the efficiency of existing health spending, and exploring innovative financing mechanisms — from levies on mobile money transfers to diaspora bonds and climate-linked health bonds.
Several countries have made progress. Rwanda’s ring-fenced community health insurance scheme has become a model. Ghana’s National Health Insurance Scheme, despite ongoing sustainability questions, has reduced out-of-pocket spending dramatically. Kenya’s shift toward results-based financing in some counties has shown promise.
But these are exceptions, not the rule. Across the continent, health spending as a share of total government expenditure remains below the 15% target agreed in the Abuja Declaration of 2001 — a target that most countries signed onto but few have met.
## The Geopolitical Dimension
What makes the current crisis different from previous aid slowdowns is the geopolitical context. Donor fatigue is real, but it is also selective. Countries that have maintained strong alignment with Western donor priorities have in many cases retained aid flows longer than those that have not. This creates perverse incentives — and reinforces the case that Africa cannot afford to have its health security depend on geopolitical relationships that are entirely outside its control.
The summit’s final communiqué called for the establishment of an African Health Financing Mechanism — a continent-wide fund that would pool resources, reduce dependency on external donors, and give African governments collective ownership over health security priorities.
Whether such a mechanism can be established and funded at scale before the current aid cliff causes irreversible damage is the urgent question that no one at the summit was able to answer with certainty. What is certain is that the clock is ticking — and the people who will suffer first are the most vulnerable.