Last week, the world's global health leaders gathered in Geneva, Switzerland, for the 78th World Health Assembly.The corridors buzzed with optimism and concern in equal measure, as participants navigated the increasingly volatile global health landscape, most notably destabilised by the United States' decision to cut funding for key domestic and global health institutions and programs responsible for safeguarding the health and wellbeing of millions. The United States' decision is the largest and most impactful, but reflective of a growing trend in cuts in funding for global health initiatives and development aid.
Through a show of global support, the World Health Organization (WHO), secured additional funding for its 2025-2028 budget and further commitments to guarantee more predictable funding from donor countries. In contrast, one truth loomed large: Africa's health systems remain dangerously under-funded -- and the current model of global health financing is no longer fit for purpose -- if it ever was.
The reality of Africa's health financing
Across the continent, health systems are fraying under the weight of chronic underinvestment. They are fragile, fragmented, and frighteningly underprepared for health emergencies. Decades of chronic underinvestment by domestic governments and weak accountability systems have left hospitals without basic supplies, health workers underpaid and overstretched, and data systems outdated.
This has been compounded by the existence of many donor-funded vertical programmes that often prioritise short-term wins over long-term resilience, ignoring national priorities, bypassing national systems and undermining governments' leadership. Not to be overlooked is the continuing reliance of the global north on skilled health workers from Africa and other regions of the globe to shore up their own under investment in developing their health workforce, contributing to a chronic brain drain.
Concurrently, countries were under perpetual dependency from external consultants and technical assistance to design, implement and evaluate programs, supported by a multitude of organisations established around global health initiatives.
The COVID-19 pandemic merely underscored these vulnerabilities: oxygen shortages, vaccine inequity, and supply chain breakdowns. And post pandemic, the response from the global health system, domestic and international, remains donor-driven, still too vertical, disease-oriented, and far too often out of sync with national priorities.
Africa accounts for 25% of the world's disease burden but only 1% of global health expenditure. We must confront the uncomfortable truth: overreliance on external assistance has not built resilient systems. It has created fragmentation, dependency, and short-termism. Donor agendas often shift faster than health system reforms can take root, leaving governments scrambling to plug the gaps.
Domestic priorities have played second fiddle to donor interests for far too long. This must be reversed. This is not to diminish the impact of global solidarity. Development assistance has saved millions of lives and remains essential. But charity is not a strategy, and good intentions alone will not deliver sustainable, equitable health systems for Africa. Donor funding must be complementary to support national health plans built on domestic investment in health.
What needs to change?
The time has come for a fundamental reset; one that puts African leadership at the center of its own health agenda. A new health governance and funding model must reflect Africa's realities and unlock the continent's potential. While more could be achieved with what is currently available if we consider allocative efficiencies, it must be acknowledged that significant increase in domestic health investments will require sustained economic growth and reforms of the international financial systems to end unfair debt servicing.
1. Reorganise national health sector governance:
The fragmentation created by global health initiatives resulted in multiple, parallel national coordination mechanisms along disease streams, disempowering and replacing previous health sector governance structures. As a result, the leadership of Ministries of Health was diluted, ownership dissipated, and national priorities substituted. It is urgent to reposition the leadership of national authorities through inclusive health sector coordination platforms, to enable country-owned and country-led health programmes, in line with national priorities.
2. Prioritise domestic resource mobilisation:
Despite tough fiscal environments and rising debt burdens, African governments must not deprioritize health but must be more deliberate in treating health as an investment, not an expense. We need bold but pragmatic targets for health spending, accompanied by strong accountability for how those resources are used. Doing more with less will require better data, smarter allocation, and unwavering political will. Governments should ensure better and broader tax collection, through incentives to reduce the size of the informal economy. And community engagement; ordinary African citizens must be part of the decisions made. Targets must be bold but achievable and grounded in local realities.
3. Embrace innovative and diversified financing:
African leaders must explore innovative financing strategies for greater, more diverse, and more sustainable funding. Debt restructuring / debt swaps can expand the fiscal space for health. Initiatives such as diaspora bonds and blended finance could attract private and philanthropic capital for long-term health investments. Enhanced, data-informed planning could improve the efficiency of fiscal spending and help governments better target and direct their resources.
4. Strengthening regional collaboration can maximise the value of collective action. From data sharing and pooled procurement to regional manufacturing and joint emergency responses, cooperation can reduce reliance on supply chain and help realise the value-add of the health ecosystem. The African Medicines Agency and regional pooled procurement mechanisms are steps in the right direction and should be supported.
5. Leverage digital health and data systems:
Digital tools -- from AI-powered diagnostics to mobile health platforms -- offer enormous potential to expand access and improve decision-making and resource allocation. Examples already exist. Rwanda's nationwide telemedicine platform, developed in partnership with digital health providers like Babyl connects patients to doctors via mobile phones, extending far beyond the reach of traditional health infrastructure, offering consultations, prescriptions, and follow-ups without requiring patients to travel long distances. In South Africa, mobile phone health apps and AI-powered diagnostic tools are being developed to support HIV care, tuberculosis detection, and maternal health.
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A defining moment
This is a critical juncture. Countries like Nigeria, Ghana, Botswana and Cabo Verde are showing what's possible through ambitious reform, partnership, and ownership. But progress cannot rest on a few pockets of excellence, it must become the norm.
We must reframe health as a foundational pillar of national development. Africa's future depends not on the generosity of others, but on its own capacity to build inclusive, accountable, and resilient systems that serve all its people.
Global partners still have a role to play -- but it must be one rooted in equity, mutual respect, and shared responsibility. The global health architecture must evolve -- from one that delivers aid to one that supports sovereignty and sustainability.
This is not just a call for governance and funding reform. It is a call for a new compact -- between African governments, their citizens, and the global community. The path forward must be defined by partnership, led with vision, and measured by impact that benefits all.
Dr. Ebere Okereke is an Associate fellow in Global Health at Chatham House, and Dr Magda Robalo is the President and Co-founder of Institute for Global Health and Development.
