African leaders opened the World Health Summit Regional Meeting at the United Nations complex in Nairobi this week with a unified declaration that two decades of dependence on foreign aid for health is over.

“The challenge that I see is that many of the leaders in our continent believe that it is somebody else’s responsibility. It should be the World Health Organization, USAID, I don’t know who,” Kenyan President William Ruto told the summit. 

“The sooner we realise that it is our responsibility to raise especially domestic resources to fund our health, the better for all of us.”  

The Nairobi meeting, the first co-organised by the World Health Organization (WHO) and the World Health Summit, has positioned itself as the continent’s first high-level response to the collapse of official development assistance (ODA) for health, which fell by an estimated $31.1 billion in 2025, according to the Africa Centres for Disease Control and Prevention (Africa CDC).

Over 2,000 delegates from more than 50 countries, including health and finance ministers from 17 nations, are convening in the Kenyan capital to coordinate a united African position ahead of next month’s World Health Assembly in Geneva.

“I don’t want to see this continent being dependent. And we are dependent because we want it,” Ruto said. “Africa is manufacturing a number of products today, from Egypt, from Kenya, from South Africa, from a number of countries, but we are not buying our own product.”

Africa carries more than 25% of the global disease burden but accounts for less than 3% of global health expenditure. The continent currently produces less than 2% of the medicines and vaccines it consumes, leaving its countries dependent on external supply chains for essential medical commodities.

“Who’s asking us not to buy our own product, who’s asking us not to register to the African Medicines Agency for the regulatory aspect?” Ruto asked. “It’s not Germany, it’s not Europe, it’s ourselves. We need to change our mindset.”

A break with the past

The urgency on display in Nairobi is driven by the most disruptive year for global health financing on record. For African governments, the pivot to self-reliance has become a fiscal necessity.

The dismantling of the United States Agency for International Development (USAID), followed by aid cuts by the United Kingdom, Germany, France and the Netherlands, drove a 23.1% drop in total ODA from OECD donors in 2025. This is the largest single-year contraction since records began. The US, Germany, UK, Japan and France accounted for 95.7% of the total decline.

The Boston University ImpactCounter estimates the US cuts have already led to more than 518,000 child and 263,000 adult deaths from preventable diseases such as HIV and tuberculosis. A further 14 million preventable deaths, including 4.5 million children, may occur by 2030 if USAID funding gaps are not filled, a major international study found.

Africa CDC estimates the combined cuts from the US, UK, Germany and other major donors will kill an additional two to four million Africans annually.

“The year 2025 marked the end of one era and the beginning of another,” Sulaiman Shahabuddin, President and Vice Chancellor of the Aga Khan University, told the opening plenary. “We are confronting a new reality, defined by funding constraints, the rise of technology and artificial intelligence, and a decisive shift towards local ownership.”

“Climate change, chronic diseases, lack of financial resources, the digital divide, inequity and others are [challenges] we will have to overcome,” Shahabuddin added.

What aid remains on the table increasingly comes with strings attached. Washington has begun rolling out bilateral “America First” global health agreements, with US President Donald Trump retaining the right to terminate any programme judged not to align with American interests.

Conditionalities include sharing pathogen samples and genomic data with US authorities, prioritising faith-based health providers to prevent services such as abortions, channelling funding away from non-governmental organisations, and, in the case of Zambia, granting access to critical minerals in exchange for health funding.

Lukoye Atwoli, Dean of the Aga Khan University Medical College East Africa and the summit’s international president, said this year’s gathering would mark a break with past meetings on African health.

“Historically, meetings about Africa and Africa’s health have been about lamentations. Have been about framing the problems. Have been about basically begging and saying that we have a problem and we need help,” Atwoli told delegates. “This meeting will be different.”

Reform body launched

On the sidelines of the summit, Africa CDC launched the African High-Level Ministerial Committee on Global Health Architecture Reform. 

The body brings together health and finance ministers from across the continent to coordinate African positions ahead of the World Health Assembly and broader UN reform processes. Convening both portfolios in the same room is a long-standing demand of global health advocates, who have struggled for decades to make the economic case for health investment to treasuries that hold the purse strings.

The committee, chaired by former Liberian president Ellen Johnson Sirleaf, will produce coordinated African position papers on health architecture reform and a 2026–2030 reform roadmap focused on five axes: governance, financial sovereignty, data sovereignty, local manufacturing, and pandemic preparedness.

“The old model is no longer fit for purpose. Africa cannot continue to be a passive recipient of global health decisions,” said Africa CDC Director General Dr Jean Kaseya. “We welcome our partners, but on a new basis: not as donors and recipients, but as equal partners aligned with Africa’s priorities.”

Aspiration meets evidence

The data on whether Africa can deliver on the vision laid out in Nairobi tell a more complicated story.

A Centre for Global Development (CGD) audit of 442 government actions across all 54 African countries found a continental reaction to the historic aid cuts split in radically uneven ways, a story of inequality within Africa as much as between Africa and its donors.

The countries that moved fastest are those with the deepest pockets and most diversified economies, including Nigeria, Ghana and Ethiopia. Lower-income, debt-burdened countries, many of which were the largest per-capita recipients of foreign assistance, have largely absorbed the loss in silence.

“Governments with limited fiscal space and weaker administrative capacity have less room to cushion abrupt external shocks,” the analysis found. “What is slightly surprising is that they were not only doing little about the aid cuts, they are also saying little about them.”

Global Health Leaders Urge Fewer Agencies Amid Funding Crisis

A separate CGD study published in February examined the budget statements of 18 sub-Saharan African countries: among the world’s poorest, most heavily aid-dependent and exposed to the cuts. It found that only two, Tanzania and Sierra Leone, proposed new revenue measures to replace lost financing in their 2025 budgets. None reprioritised spending from other sectors to protect health.

“With few exceptions, governments neither raised new revenues nor reallocated spending to compensate for lost external financing,” the analysis concluded.

The burden of adjustment, it found, has instead fallen on the services patients receive, from disrupted HIV and tuberculosis treatment to delays in vaccination campaigns and the closure of clinics that depended on donor financing.

“Health is not a cost, it is an investment,” Ruto said. “And it is important for us to invest.”

Cascading crises

The continent’s ability to absorb the aid shock and finance the pivot to support its own health systems is constrained by an unending sequence of external crises over the past decade that continue to batter government budgets, layered on top of the escalating climate crisis.

The COVID-19 pandemic, during which wealthy nations hoarded vaccines, exposed Africa’s reliance on a foreign supply chain that produces 99% of the vaccines and 90% of the medical supplies it consumes. Pandemic response cost African governments an additional $154 billion in 2020 and 2021, according to the African Development Bank, pushing sub-Saharan public debt up by 8 percentage points of GDP in a single year.

Russia’s invasion of Ukraine drove an inflationary spike that ballooned debt-service costs across the region, a pressure that has now snowballed into the global economic crisis triggered by the US-Israeli war on Iran, to which African economies are uniquely vulnerable.  

The closure of the Strait of Hormuz, a chokepoint for a fifth of the world’s oil and a third of its liquefied natural gas, is driving up fuel and fertiliser costs and deepening food insecurity across the continent.

The resulting inflation, weaker currencies and tighter global financial conditions across Africa are inflating debt-servicing bills and forcing governments to divert money that could otherwise help absorb the aid shock.

Climate change is compounding the pressure on every front. African countries are losing between 2% and 5% of GDP to climate extremes, the World Meteorological Organization estimates, with some governments diverting up to 9% of national budgets to respond.

Health systems will bear a growing share of that cost. The World Bank estimates climate change could drive at least $21 trillion in excess health costs in low- and middle-income countries by 2050, with sub-Saharan Africa among the regions hit hardest.

“What was considered reliable for decades is turning out to be fragile,” said Birgit Pickel, Director-General for Global Health at Germany’s Federal Ministry for Economic Cooperation and Development. “Cracks are appearing in the international order. Cracks that, in some cases, are already leading to its collapse.”

Fiscal squeeze limits options 

The cumulative damage has left African governments with little room to manoeuvre. Thirty-two African nations now spend more servicing external debt than funding healthcare.

The continent paid almost $90 billion in external debt service in 2024 alone, with African governments now spending an average of 17% of state revenue on debt servicing, according to leading estimates.

The IMF warned last week that more than a third of African countries are at high risk of, or already in, debt distress, with rising interest bills “crowding out essential development spending, healthcare above all.”

“Official funding will probably shrink, at least internationally. Domestic funding will hopefully move up,” Pickel said. “But there are innovative instruments out there to also meet urgent funding needs in the health sector, especially for heavily indebted countries.”

Pickel proposed debt-for-health swaps, an instrument under which creditor nations cancel debt in exchange for redirected health spending, as a route to fiscal space for highly indebted countries.

Germany issued €100 million in such swaps last year, channelled to the Global Fund. The figure is substantial as a signal, but negligible against the scale of the African external debt service crisis.

The IMF’s Africa Director, Abebe Selassie, told the Fund’s Spring Meetings in Washington this month that the 2025 foreign aid contraction marks a structural break – and the money is unlikely to come back.

“Past aid shocks were largely cyclical; donors cut back and then returned. What we are seeing now appears more structural,” Selassie said. “And it is falling hardest on the region’s most vulnerable countries: fragile states and low-income economies that depend on aid not as a supplement, but as a critical source of budget financing, healthcare, and food assistance.”

The summit runs through Wednesday, with the African Union expected to publish a position paper on global health architecture reform at its close.

Image Credits: ONE Data.