Africa’s health systems are approaching a defining moment. For decades, progress in disease control, maternal and child health, and epidemic response was sustained by expanding development assistance and disease-specific global programmes. That model is now under strain. External health financing is declining, public debt levels are rising, populations are growing rapidly, and the continent’s disease profile is changing faster than its financing systems can adapt.
Yet the most consequential insight emerging from Africa’s latest health financing assessment is not simply that there is too little money. It is that Africa is losing too much of what it already has. The real constraint undermining health outcomes across the continent is inefficiency, fragmentation, and weak system governance, not absolute scarcity.
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This recognition is quietly reshaping how health is being positioned within Africa’s broader development agenda, from a social sector dependent on aid to a strategic pillar of economic resilience and sovereignty.
The scale of Africa’s challenge is stark. The continent carries approximately 22 per cent of the global burden of disease, yet accounts for around 1 per cent of global health expenditure. Average total health spending per capita stands at about US$85, and fewer than 40 per cent of African Union Member States meet the World Health Organisation’s recommended minimum of US$86 per person required to deliver an essential package of health services.
This structural imbalance is unfolding alongside significant demographic and epidemiological change. Africa’s population is projected to grow from 1.4 billion in 2025 to 2.5 billion by 2050, with rapid urbanisation and a persistently high dependency ratio. At the same time, the continent is experiencing a pronounced epidemiological transition. While communicable, maternal, neonatal, and nutritional conditions have declined as a share of the total disease burden, non-communicable diseases have grown by almost 95 per cent since 1990, now accounting for nearly two-fifths of the total burden, alongside rising injuries and recurrent outbreaks. Health systems largely financed and organised around vertical infectious-disease programmes are increasingly ill-suited to this complex, multi-burden reality.
For many African countries, the pressure is intensified by a sustained decline in development assistance for health. After peaking during the COVID-19 response at US$25.8 billion in 2021, donor financing fell sharply to US$19.9 billion in 2022 and further to around US$13 billion by 2025. Major reductions by traditional donors, particularly the United States and several European countries, have fundamentally altered the financing landscape. Projections indicate that development assistance will remain flat or decline further in real terms over the coming decades.
Compounding this shift is the graduation of several African countries from eligibility for concessional and disease-specific financing mechanisms. Graduation is often triggered by income thresholds rather than demonstrated fiscal or system readiness, leaving countries exposed to abrupt financing cliffs. Costs previously absorbed by donors, particularly for vaccines and essential commodities, are increasingly transferred to domestic budgets and households.
The social consequences are already visible. Out-of-pocket payments account for roughly 35 per cent of total health expenditure across Africa, rising to 40–60 per cent in many low- and lower-middle-income countries. This heavy reliance on household spending weakens risk pooling, reduces service utilisation, and pushes an estimated 15 million Africans into poverty every year.
Fragmentation: The Systemic Drain on Performance
While underfunding remains real, the most immediate and actionable constraint lies in how existing resources are used. African health systems operate at approximately 67 to 77 per cent efficiency, meaning that up to one-third of health spending is effectively lost to misallocation, duplication, weak procurement, poor payroll management, and fragmented planning and reporting structures.
In many countries, health financing is splintered across dozens of schemes and hundreds of implementing partners. National systems frequently manage parallel budgets, procurement channels, information systems, and service delivery platforms, often aligned more closely with external programme requirements than with national priorities. In one documented case, Malawi’s health sector operated with 191 financing sources and 261 implementing partners.
This fragmentation erodes accountability, inflates transaction costs, and prevents governments from exercising strategic purchasing power. Crucially, comparative analysis shows that countries spending similar amounts on health achieve markedly different outcomes. Systems anchored in pooled, publicly governed financing consistently deliver higher universal health coverage and better financial protection than fragmented, out-of-pocket-dominated models.
Reframing the Development Question: Efficiency as Fiscal Space
The emerging reform agenda represents a fundamental rethinking of health financing as a development issue. Rather than treating declining aid as a gap to be filled, the new approach treats efficiency as a primary source of domestic fiscal space.
Modelling demonstrates that coordinated reforms, integrated national planning, pooled procurement, strengthened public financial management, rationalised human resources, and integrated service delivery could generate approximately US$14 per capita in efficiency gains. In aggregate terms, this equates to around US$16 billion in 2026, rising to US$37 billion by 2050, without increasing taxes or public debt.
Key drivers of these gains include price reductions of 30–33 per cent through pooled procurement of medicines and health commodities; US$1.3–1.6 billion annually from integrated, people-centred service delivery models; up to US$6.8 billion per year unlocked through reforms to human resources for health, including better payroll management and skills mix; and strengthened public financial management and digital systems that reduce leakage and fraud.
Within five years, these measures alone could replace around half of current donor financing, reducing reliance on external aid to below 20 per cent of total health expenditure.
Health Sovereignty and the Broader Development Agenda
These reforms extend beyond the health sector. Financing reform is increasingly being linked to industrial policy, digital transformation, workforce development, and regional integration. Local manufacturing of vaccines, medicines, and diagnostics is framed not only as a health security imperative but as a driver of economic diversification and job creation. Pooled procurement is positioned as a tool for market shaping and price stability. Digital health systems are recognised as essential infrastructure for accountability, data sovereignty, and system governance.
Together, these elements underpin a broader vision of health sovereignty, defined not as isolation from global partnerships, but as the capacity to plan, finance, produce, and govern health systems sustainably and on Africa’s own terms.
A Choice That Can No Longer Be Deferred
The evidence leads to a clear conclusion. Africa’s health financing challenge is not simply about replacing lost donor funds. It is about whether countries can move decisively away from fragmented, aid-dependent models towards integrated, efficient, and domestically anchored systems.
The choice facing policymakers is no longer whether reform is desirable, but whether inaction is affordable. Incremental increases in spending will not be sufficient in a context of rapid population growth, shifting disease burdens, and constrained fiscal space. The next phase of Africa’s development will be shaped less by the volume of external assistance it receives and more by its ability to govern resources effectively, align health investments with broader development strategies, and translate efficiency into resilience.
