Africa without foreign aid for health: Free at last?

Recent decisions on global health financing by the second Trump Administration exemplify hubris and geopolitical vandalism. The approach has caused needlessly abrupt dislocations and avoidable suffering among employees of USAID, the President’s Emergency Plan for AIDS relief (PEPFAR), and the President’s Malaria Initiative (PMI), with knock-on effects on their ecosystem of contractors, implementing agents, and beneficiaries at country level. Yet, these actions by the US government might have the unintended consequence of prompting low and middle-income countries to liberate themselves from their long-running dependence on external financiers. 

There are already signs of an awakening in African countries’ perspectives on development assistance for health. In Ghana, for example, the President has directed the Finance Minister to urgently bridge the funding gap arising from the suspension of USAID financing. In Nigeria, the legislature has approved an additional USD 200 million for the health sector as part of its 2025 spending plan to offset the shortfall from US funding cuts. Much of the additional financing will be used to purchase vaccines and treatments for epidemic diseases. Likewise, civil society organizations in South Africa are pushing for President Ramaphosa to “step up” in the wake of the US government’s cancelation of all aid to the country.

All things considered, health aid as practiced by US-funded agencies and the likes of Gavi and the Global Fund have been a strategic failure. In 2024, Justice Nonvignon and I posited that low and middle-income countries would be well served by a clear and determined transition out of foreign health assistance, with a sunset for the global health financing institutions. We noted that those institutions were established with no end date. That construct implicitly promised and encouraged expectations of indefinite financing for potentially limitless demand. The donors have been willing accomplices of African leaders who wax poetic about self-reliance while deriving a large part of their current health expenditure from foreign aid. 

We proposed, on the one hand, that countries set explicit transition dates for exiting development assistance for essential health services and allocate their own domestic resources to fill mission-critical gaps. At the same time, we argued that donors should embark on a transition to a sunset date — we suggested 2030 — such that they gradually and predictably phase out the global health institutions. That call was noted by the recent Lancet Commission report on “Global health 2050: the path to halving premature death by mid-century.” Elsewhere, former Chief Administrative Secretary of the Kenyan Ministry of Health Mercy Mwangangi articulated the problem this way: “As long as there’s no sunset clause, as long as there’s no forced transition plans and more forced graduation plans, the Ministry of Finance will not move.” 

However, neither the financiers of global health institutions nor the countries have changed their practices. The perils of dependence, which resulted from a pernicious tango between these global health institutions and recipient countries, are now crystal clear.

With the US government’s abrupt exit from global health funding, our proposals take on a new urgency. US funding of USAID, PMI, and PEPFAR is unlikely to be compensated by other donors, including Europe. Countries previously receiving health aid from the United States now have a golden opportunity to do, under duress, what they should have done during relatively calm periods.

Requiem for failed practices

The publicized reactions to cuts in US funding for global health have taken various forms, ranging from panic, outrage, and horror to implicit pleas for keeping the status quo. A former USAID Administrator now utters platitudes, after previously testifying to the US Congress that, in Africa, people did not “know what watches and clocks are” — and were thus unsuitable for antiretroviral treatment programs. The WHO is looking for appeasement, in an approach reminiscent of Neville Chamberlain. 

These reactions are understandable, even predictable. Coming from global health leaders and policy wonks, those reactions would make sense if the goal were to restore the status quo. But they are inappropriate, even foolish, if the goal is for countries that habitually received funds from the United States to end their dependence on foreign aid, which has left them strategically vulnerable to the whims and caprices of external deciders. 

Presumptions that things were right at USAID should be discarded. The wisdom of Thomas Paine is relevant to the misguided romanticization of USAID and its like: “A long habit of not thinking a thing wrong, gives it a superficial appearance of being right, and raises at first a formidable outcry in defense of custom. But the tumult soon subsides. Time makes more converts than reason.”

Let us imagine an extra-terrestrial creature witnessing the furor that followed moves by the US government to withdraw from WHO and end, or severely curtail, funding by the likes of USAID, PMI, and PEPFAR. That alien initially might suppose that indispensable, intellectually honest, and morally unassailable forces for good were being eliminated. That is not the case, and it is past time for candor in these matters.  

We must acknowledge that the same ruthlessness and impunity that the US government is currently inflicting on USAID and PMI has long been practiced by those very agencies, even when doing so contravened empirical evidence and harmed health services in developing countries. One striking example is the Affordable Facilities Medicine for Malaria (AMFm), which was discontinued three years after it began — despite the success of its first phase in eight African countries. USAID and PMI opposed the initiative — to whose core financing USG/USAID/PMI had refused to contribute — because its successful business model threatened their approach, whose funding was mostly captured by contractors in the United States. Despite published evidence from the independent evaluation of the initiative, USAID and PMI, through the US delegation to the Global Fund, bullied the Global Fund to end the AMFm in 2012. The US delegation made known at the time that unless the malaria initiative was terminated, US support to the Global Fund would be suspended. This was widely known among policymakers in global health institutions, financiers of malaria control programs, and the Global Fund. As founding director of the AMFm, I witnessed the ruinous effects of power imbalances and impunity in global health. 

In that callous display of hegemony, USAID and PMI regarded as expendable a program that saved lives. They ignored the published preferences of African managers of malaria programs, who concluded that “AMFm has proven itself and should be expanded to include more countries and adapted as needed to the changing malaria landscape and country specific context.” Since then, American taxpayers’ money has been wasted on over-hyped but largely ineffectual projects and grants funded by USAID and PMI, and through the Global Fund — none of which was subjected to rigorous evaluation as was the AMFm. 

Eleven years later, in its 2023 World Malaria Report, WHO concluded that “Global malaria progress has stalled in recent years, and a ‘business as usual’ approach will take countries and their development partners further off course.” That euphemism was an admission of wasted money, years, — and lives, mostly African — over more than one decade, for which there is zero accountability by USAID, PMI, and the Global Fund. Instead, the razzamatazz of replenishment continues. 

The perils and alternatives to perennial reliance on health aid have been published elsewhere in detail. For 2022, WHO reported that in low-income countries, foreign assistance for health per capita exceeded domestic public spending on health. In lower-middle income countries, it was less than domestic public spending. But those averages mask inter-country variations in the extent of reliance on health aid. This is especially the case in Africa, where pernicious forms of aid for health cause quantitative and qualitative substitutions of externally determined preferences for locally formulated policy and practice. 

Roads less travelled

At the global and regional levels, it is essential to reorient financing from legacy approaches to strategic cooperation in areas with added value across national boundaries. The pressing needs include pandemic preparedness, disease outbreak detection and response systems; publicly funded research and development whose results are freely available to all, without constraints imposed by legacy regimes of intellectual property rights at the World Trade Organization; development of mission-critical institutions like centers for disease control, pharmaceutical regulation agencies, centers for health technology assessment, and referral laboratory networks; and an end-to-end ecosystem, including manufacturing of diagnostics, medicines, and vaccines in Africa, as part of a global common goods approach. Investments in these areas would shape a safer world for all.

For African countries to consciously transition away from their dependence on health aid, strategic prudence requires attention to four determinants of success: 

•    Political fortitude at regional and country levels: Decades of dependence have entrenched norms, practices, and beliefs of African inability to self-manage. This narrative, which is encountered in both African institutions and international agencies, perpetuates rent seeking in global health. African political leaders who seek to chart a new course could encounter mixed reactions from their own citizens who are used to expecting solutions from outside their countries. They are sure to encounter varying degrees of resistance — and intentional sabotage — from international actors who might seek to preserve their status as benevolent saviors of Africans. Success requires unflinching resolve to leave dependence behind.

•    Internal rigor and transparency: It is essential that African governments seeking to exit health aid do so on foundations of technical rigor and transparency. The sources and uses of funds should be made public. This approach would increase their chances of success and, to some extent, protect them from unfounded charges of biting off more than they can chew.

•    Explicit compacts with the citizenry:  Given the finite tenure of elected politicians, risks of policy discontinuity are real. Incumbents who initiate bold policy changes to exit health aid would be prudent to communicate the rationale, benefits, and risks with the citizenry. The burden of proof would then be on any incoming government that wishes to go back to dependence on external financing for essential health services.

•    Accept external technical assistance on the recipient countries’ terms alone:  Much of “Technical Assistance,” such as provided by USAID and others like it, is ineffectual or outright harmful. Yet, there is an underlying narrative of benevolence. Years ago, this author observed a discussion in Washington DC, entitled “Can they get along without us?” The presumption was that those African low and middle-income countries could not have viable health services without begging donors from the Global North. Now is the time to consider the flipside: can the providers of technical assistance get along without African countries?

There is a cross-cutting need to learn while implementing, with a willingness to recalibrate approaches as new information becomes available. Such combination of political decisiveness and operational humility would serve well those African countries that decide to chart their own paths.

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Olusoji Adeyi is President of Resilient Health Systems in Washington DC and Senior Associate at the Johns Hopkins Bloomberg School of Public Health. He authored the critically acclaimed book, Global Health in Practice: Investing Amidst Pandemics, Denial of Evidence, and Neo-dependency. He has served as Director of the Health, Nutrition, and Population Global Practice at the World Bank, and was founding Director of the Affordable Medicines Facility for Malaria at the Global Fund. Views expressed in this op-ed are the author’s alone and should not be attributed to any institution with which he is affiliated.