Beyond aid: insights on Africa´s path to health systems sovereignty

¹Amref Health Africa, Nairobi, Kenya

^&Corresponding author
Ndirangu Wanjuki, Amref Health Africa, Nairobi, Kenya

Perspective    

The era when Africa could rely on foreign aid for its health priorities is passing, signaling a defining opportunity for African nations to reinvent their health systems. Development assistance is shifting from broad solidarity to more conditional and politically aligned engagement. This evolving reality, reflected in recent shifts in U.S.A. foreign aid priorities and echoed by broader changes across traditional donor countries, is forcing a strategic reckoning for Africa: build greater self-reliance or remain vulnerable to the unpredictability of external funding. Yet this urgency also offers hope: an opportunity for Africa to assert leadership and agency over its own health agenda.

Several African countries are already advancing health sovereignty through smart financing and governance reforms, driven by presidents, health and finance ministers, governors, and development partners. Rwanda´s community-based health insurance now covers over 85% of the population, supported by national subsidies and anchored in community health worker cooperatives. Ethiopia has expanded its community-based insurance through a government-led health extension program, demonstrating how locally embedded systems can scale access. Ghana´s model, funded in part through a national health insurance levy, has reduced out-of-pocket spending via dedicated domestic taxes. And in South Africa, health taxes on products like tobacco and alcohol are being used not only to curb harmful consumption but also to raise domestic resources for health. These examples, explored further in the paper, demonstrate that sustainable progress is possible when African countries pair context-driven reforms with innovative financing tailored to their own realities. Africa must now reinvent its health systems through a new, context-specific framework. Health Systems 2.0, anchored in systems thinking, adaptive leadership, and human-centered design, is proposed as that model. An illustrative version is included in the annex to support leaders in shaping resilient, self-financed, and people-centred systems.

The financing gap: Africa spends an average of US$116 per capita on health, far below the US$249 per capita benchmark for basic service coverage, and less than 5% of what high-income countries invest [1]. For years, donor funding helped bridge part of this gap. But that cushion is shrinking. Donor fatigue, shifting geopolitical priorities, and evolving funding criteria, however well-intentioned, have made continued reliance on external financing increasingly precarious. This evolving reality, reflected in the Trump administration´s foreign aid reforms, is forcing a strategic reckoning. Overdependence on donor flows can delay essential domestic reforms, obscure inefficiencies, and leave governments exposed when global priorities shift. To secure long-term resilience, African nations must embrace a new financing posture, one that strategically blends catalytic donor support with robust domestic resource mobilisation. This shift must be anchored in adaptive leadership, stronger governance, prevention-focused investment, and innovative financing. Strategically and regionally executed, this shift will reduce vulnerability to external shocks and build the foundation for smarter fiscal policy, local innovation, and lasting national ownership of health priorities.

An evolving burden and a clash with old models: the public health landscape has shifted on the continent, contrary to epidemiological transition expectations, with infectious diseases remaining a significant threat and non-communicable diseases such as hypertension, diabetes, and cancers on the rapid rise. Most African health systems, originally built for acute care, are poorly equipped for the sustained demands and escalating costs of chronic illness. Dr. Githinji Gitahi warns starkly: “Africa has a big risk of collapse of health systems in the next few years because of NCDs [……] 50% of all admissions in a typical African hospital are NCDs, yet 80% of NCD care is paid out of pocket. And governments don´t have money to actually take care of NCDs” [2] . The sustainable solution is prevention, early screening, and resilient primary healthcare strategies that break the persistent cycle of low coverage and high disease burden known as the "inefficient equilibrium". Central to Health Systems 2.0 thinking, this inefficient equilibrium describes systems that seem stable superficially yet fail to deliver meaningful health outcomes due to underlying flaws in design or leadership.

Four essential shifts Africa must make

a) Why adaptive leadership, not just technical expertise, matters: Africa´s most persistent health challenges, rising rates of non-communicable diseases, high maternal mortality, and chronically underfunded frontline preventive and treatment services, are not simple technical problems. They are adaptive challenges: complex, systemic issues that demand leadership to mobilize diverse stakeholders, build trust, and drive behavioural and institutional transformation. Adaptive leadership, as defined by Heifetz and colleagues, involves distinguishing between technical problems and adaptive challenges. The former can be solved with existing knowledge and tools, while the latter requires deeper structural shifts, often without clear precedents. Addressing adaptive challenges demands leadership that fosters learning, experimentation, and iteration, distributing problem-solving across systems and cultivating shared ownership of change [3].

Rwanda offers a compelling example of adaptive leadership. Today, its community-based health insurance covers over 80% of the population, largely funded through government subsidies and contributions by communities. Anchored in sustained national commitment, inclusive policy design, and locally embedded accountability, Rwanda expanded this model while integrating HIV investments into primary care and scaling access to other essential services. Between 2000 and 2012, under-five mortality declined by more than 60%, maternal mortality dropped from 910 to 340 per 100,000 live births, and childhood immunisation coverage reached 97% [4]. A nationally representative survey further found that the insurance scheme reduced annual per capita out-of-pocket spending by approximately US$12, an 83% drop from baseline, and significantly lowered catastrophic health expenditures, accelerating progress toward universal coverage [5].

These gains were not achieved through isolated technical fixes, but through adaptive leadership that aligned policy with community realities, embedded iterative learning, and cultivated shared ownership of health. Citizens increasingly came to view health insurance not as charity, but as a shared national and household investment. Rwanda´s experience affirms that adaptive leadership is foundational to building resilient, people-centred health systems.

b) Put community-led prevention at the centre of health systems: prevention remains one of the smartest, most cost-effective ways to improve population health and reduce long-term health system costs. Community-based approaches, especially those rooted in trusted, locally embedded health workers, are central to making prevention real and scalable. Ethiopia´s Health Extension Program (HEP), launched in 2003, shows how government-led, community-based models can drive measurable population health gains and accelerate progress toward universal health coverage. As part of broader reforms, HEP deployed more than 42,000 trained health workers to rural communities, expanding access to essential services. It contributed to increased uptake of maternal and child health interventions, improved sanitation, and stronger disease prevention practices, supporting a 67% reduction in under-five mortality and a 71% decline in maternal mortality between 1990 and 2015 [6]. Nigeria´s Ondo State offers another compelling example. The Abiye Safe Motherhood Programme, fully funded by the state and free of cost to clients, was associated with a 70% drop in maternal mortality, from 708 to 208 deaths per 100,000 live births between 2010 and 2014. This success stemmed from the removal of financial barriers, expanded access to skilled care, and a community-based tracking system that followed pregnant women from conception to delivery [7]. Kenya provides further evidence: during the COVID-19 pandemic, community health workers reached over 2.5 million household members across 27 counties within weeks, helping sustain essential health services [8]. These examples show that deliberate, systems-level investment in trusted, prevention-first strategies can deliver meaningful population health gains and move countries beyond the inefficiencies of reactive, hospital-centric models.

In a reimagined Health System 2.0, prevention must be intentionally placed at the centre of service delivery, not treated as a peripheral add-on, but embraced as a core function. Governments should commit at least 10% of national health budgets to prevention, prioritizing scalable approaches that shift care upstream, ease hospital burdens, and deliver measurable health and economic gains. Countries that invest in prevention not only save more lives but also build stronger, more fiscally resilient health systems.

c) Strengthen governance to unlock domestic financing: Africa´s path from aid dependence to resilient health systems hinges on a renewed social contract, anchored in public trust, equity and inclusivity, transparency, and accountability. Promising pathways are already emerging: Ghana´s VAT-backed National Health Insurance Levy, Rwanda´s community health worker cooperatives, and Ethiopia´s locally managed community-based insurance schemes reflect early models of locally anchored health financing. Ghana´s National Health Insurance Scheme (NHIS), funded through dedicated domestic taxes and citizen contributions, remains a promising model, despite equity challenges. Recent analysis shows that NHIS coverage expanded to approximately 54% of the population by 2021, improving access to essential services. Yet catastrophic health expenditure continues to rise, particularly for hospital care and medical supplies, with rural, northern, and low-income households most affected [9]. These patterns highlight the need to strengthen governance through an equity lens, ensuring that reforms protect the most vulnerable as they expand coverage.

Trust in health systems is earned, not assumed. In Kenya, Amref Health Africa has used community scorecards, through the community systems strengthening approach, supported by the Global Fund, to ensure that community voices shape national health decisions. These tools have strengthened accountability and responsiveness in HIV, TB, and malaria programs by aligning services with lived community experience [10]. This is precision population health in practice: listening not just to data, but to people, in context. Strong governance sets off a reinforcing cycle: transparency builds trust, trust unlocks resources, and those resources sustain resilient, locally funded health systems (Figure 1).

d) Deploy innovative health financing: given Africa´s constrained fiscal space, with average health spending at US$116.9 per capita in 2020, significantly below the global average of US$1,205.6, traditional domestic financing approaches alone will not close the gap [11].

Innovative financing mechanisms provide pragmatic solutions for sustainably increasing domestic investments in health. Kenya´s Facility Improvement Fund (FIF) is a compelling example. As highlighted in the WHO Health Financing Progress Matrix assessment, Kenya´s FIF Act (2023) empowers public health facilities to retain, manage, and transparently account for their own revenue. When fully operational, this model could significantly improve resource management, service quality, and overall health outcomes, particularly at the primary care level [12].

Additionally, health taxes, such as those successfully implemented in South Africa and Brazil, represent another proven strategy. These excise taxes on tobacco, alcohol, and sugar-sweetened beverages simultaneously raise critical revenue for health services and reduce the consumption of products that drive non-communicable diseases (NCDs). The World Bank underscores that well-structured health taxes can significantly lower the burden of NCDs while generating sustainable financing for health priorities [13]. However, raising additional funds alone is insufficient. Resources must be strategically allocated, transparently managed, and rigorously governed. Investments should prioritize preventive and primary healthcare services, ensuring every dollar delivers maximum health impact. Africa´s path to sustainable health financing depends not merely on innovative funding approaches, but also on accountable governance systems that earn public trust and tangibly improve population health.

Conclusion and call to action: "Beyond aid" is Africa's call to reclaim agency over its health future. Declarations alone will not suffice; governments must visibly prioritise health, actively invest in prevention, and nurture adaptive leadership at every level. Finance ministers must recognise health expenditure as a strategic investment, and health ministers must decisively shift their focus from managing illness to promoting wellbeing. Africa stands at a pivotal crossroads. The decisions made today will shape health outcomes for generations to come. By embracing adaptive leadership, advancing community-led prevention, strengthening governance to unlock domestic financing, and adopting innovative financing mechanisms, the continent can build resilient, self-financed, and people-centred health systems. This approach, rooted in systems thinking, adaptive leadership, and human-centred design, forms the foundation of Health Systems 2.0, illustrated in Figure 2, and offers a pathway to lasting impact and dignity for Africa´s people.

Competing interests     

The author declares no competing interest.

Authors' contributions     

The author read and approved the final version of this manuscript.

Figures     

Figure 1: the governance-transparency-trust-resource cycle for resilient health systems

Figure 2: health systems 2.0 framework founded on system design, human-centered design, and adaptive leadership

References