From aid dependence to resilient health systems in Africa

Africa must take action to build resilience, self-reliance, and self-determination for its health future

Dr. Meshack Ndirangu Wanjuki, Country Director – Amref Health Africa in Kenya

The volte-face in foreign aid at the start of 2025 was shocking in its execution, but not unexpected as the focus shifts from broad solidarity to more conditional, politically-aligned engagement. Or, as the UK’s Minister for International Development said, “partnership, not paternalism.”

Africa has an average continent-wide health investment of just $116 per person, far below the US$249 benchmark needed for basic service coverage, and just a fraction of what high-income countries invest. External donor funding was a bridge over part of that gap, but now that is crumbling.

Africa’s disease landscape is rapidly evolving. Infectious diseases remain a threat, but non-communicable diseases (NCDs) like hypertension, diabetes, and cancers are rising sharply. NCDs accounted for 37% of deaths in sub-Saharan Africa in 2019, up from 24% in 2000. By 2030, NCDs are projected to become the leading cause of death in the region. The current health system is ill-prepared for this scenario.

Africa now needs a Health Systems 2.0—anchored in systems thinking, adaptive leadership, prevention-focussed investment, and human-centred design—to build robust, resilient, and responsive health systems.

The Four Essential Shifts Africa Must Make

Adaptive Leadership Over Technical Expertise

The toughest health challenges for Africa are both technical and adaptive. They demand deeper structural shifts made through leadership that mobilises stakeholders, drives institutional transformation, and fosters a culture of learning.

Rwanda’s experience with community-based health insurance exemplifies this. Technical fixes were key. But the transformation came through adaptive leadership that aligned policy with community realities, embedded iterative learning, and cultivated citizens’ perception of health as a shared national and household investment.

Through this approach, Rwanda achieved over 80% health insurance coverage, 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 decreased from 910 to 340 per 100,000 live births, and childhood immunisation coverage reached 97%. A survey further revealed 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.

Prioritise Community-Led Prevention at the Centre of Health Systems

Community-based prevention approaches must be central for healthier populations, to save more lives, and build stronger health systems. Ethiopia’s Health Extension Programme (HEP) 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 from 1990-2015.

Governments should allocate at least 10% of health budgets to scalable, prevention-first approaches that shift care upstream, ease hospital burdens, and deliver measurable health and economic gains.

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. 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. 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. Strong governance sets off a reinforcing cycle: transparency builds trust, trust unlocks resources, and those resources sustain resilient, locally funded health systems.

Deploy Innovative Health Financing

Governments must deploy innovative financing mechanisms to sustainably increase domestic investments in health, such as health taxes on tobacco, alcohol and sugary beverages.

Kenya’s Facility Improvement Fund (FIF) is another 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.

However, raising additional funds alone is insufficient. Resources must be strategically allocated, transparently managed, and rigorously governed. Investments should prioritise preventive and primary healthcare services, ensuring every dollar delivers maximum health impact.

Beyond aid

Governments must visibly prioritise health, actively invest in prevention, and nurture adaptive leadership at every level. Finance ministers must recognise health expenditure as strategic investment, and health ministers must decisively shift their focus from managing illness to promoting wellbeing.

Today’s choices will shape health outcomes for generations. By embedding adaptive leadership, expanding community-led prevention, and strengthening governance to unlock domestic financing, and adopting innovative financing mechanisms, the continent can build resilient, self-financed, and people-centred health systems.