Authors: Charlotte Muheki, Moreen Mwenda, David Olpengs
Global health financing is undergoing a significant transformation. After decades of substantial external aid, key donors, including the United States, France, Germany, and the United Kingdom, are reducing their investments in African health systems. However, within this apparent crisis lies a powerful opportunity to rethink health systems as self-sustaining, resilient, and responsive to the population’s needs.
The Magnitude of the Challenge
The extent of donor dependency in African health systems is staggering. In Kenya, USG funding freezes have resulted in a $217 million annual shortfall in HIV programme financing. Tanzania receives approximately 22% of its total health expenditure from external sources, with HIV programmes dependent on donor funding for over 70% of their budgets.[1]In Malawi, external funding accounts for 68% of the total health expenditure.[2] Across sub-Saharan Africa, approximately 60% of community health worker (CHW) program funding comes from external sources, primarily from disease-specific and vertically designed programmes.[3],[4]
These figures represent more than financial gaps, they reveal structural dependencies that have shaped how health systems function. Vertical disease programs, parallel supply chains, duplicative monitoring systems, and specialised health workforces have evolved to capitalise on donor priorities. When donors exit, it has most often resulted in the inability to sustain the gains achieved and the risk of health and economic shocks due to high poverty rates and limited domestic financing. But what if transition planning could go beyond simply filling financial gaps, and instead catalyse optimization of Primary Health Care (PHC) systems to work sustainably within optimised domestic resources?
Beyond Traditional Transition Planning
Conventional transition approaches typically focus on maintaining existing service delivery models within reduced funding, a defensive approach that often results in service cuts, lower quality of care, and increased out-of-pocket expenditures for vulnerable populations. Traditional transition planning asks, “How can we maintain and sustain existing systems with less money?”. The more transformative question is: how can we design systems that function optimally within domestic resource constraints?
A systems-thinking approach that preservation is paramount, as it goes beyond merely maintaining the status quo to fundamentally reimagining how PHC systems can operate effectively within optimized available resources. The technical innovation lies in connecting transition planning directly to PHC reengineering across the health systems strengthening building blocks.
What successful Countries are doing differently
Building a resilient health workforce
Perhaps no area demonstrates the need for rethinking more clearly than human resources for health. Donor transitions can potentially lead to staff layoffs, salary cuts, reduced training and learning, and decreased motivation and incentives. In Uganda, during PEPFAR transitions, the loss of field outreach allowances for facility personnel and ‘community linkage facilitators’ resulted in reduced community outreach activities, which depressed demand for facility-based HIV testing services.[5]
A proven solution to maintaining and strengthening health services during transitions is investing in integrated Community Health Worker (CHW) programmes. CHWs are cost-effective when properly trained and supported; their deployment at the community level is scalable, and they fill critical service gaps, particularly in underserved areas. When Rwanda realigned its community health worker programme from disease-specific workers to integrated CHWs, it achieved a 36% reduction in training costs while expanding the scope of services delivered at the community level.[6]
Since 1994, Brazil has scaled up multidisciplinary Family Health Teams (FHTs) under the Family Health Strategy. Each FHT typically comprises one physician, one nurse, one nursing assistant, and up to 12 community health agents (CHWs), who collectively serve a shadow population of up to 4,000 people within a defined catchment area. CHWs play a pivotal role in community outreach, home visits and health education, helping bridge social and geographic barriers.[7] CHWs, when embedded within national health strategies, play a crucial role in mitigating this shortage due to their effectiveness (when properly trained and supported) and the feasibility of their deployment.
Revolutionising Supply Chain Architecture
A 2022 study of six African countries found that HIV, TB, malaria, immunisation, and essential medicines programmes operated an average of 4.7 separate supply chains per country, each with its own funding, information systems, and distribution networks. Research shows that integrated supply chains can reduce stockouts by up to 30% and lower operational costs by 15–20% through economies of scale.[8] Integrating health supply chains ensures that medicines and essential health products are managed more efficiently within a unified, government-led system. When Ethiopia integrated its previously vertical supply chains for HIV, TB, malaria, and essential medicines, it achieved a 26% reduction in logistics costs. The technical question isn’t simply how to maintain multiple supply chains with less funding, but how to fundamentally optimize supply systems for greater efficiency.
In most countries, key stakeholders recommend that the government and donors increase efficiency in procurement processes by eliminating bureaucratic hurdles that introduce avenues for mismanagement of available resources and investing in capacity building for local vaccine production. The key question is not how to preserve parallel supply chains with less funding but how to optimize them for maximum efficiency under national leadership.
Recalibrating Laboratory Networks
In many African countries, laboratory systems have been particularly dependent on donor support, with sophisticated testing platforms often concentrated in centralised facilities. Apart from vertical programs (e.g. HIV, tuberculosis), national tiered laboratory networks generally remain grossly underfunded with mild to critical dysfunctions in the underlying laboratory systems. The proposed approach challenges the conventional tiered laboratory pyramid model by proposing more decentralised testing networks that leverage point-of-care technologies at the primary care level.
When Zimbabwe restructured its laboratory network for early infant diagnosis of HIV, it cut turnaround times from 30 days to 3 days while lowering overall system costs. Strategic government investment ensures that laboratories at all levels, from national reference labs to peripheral and point-of-care facilities, follow standardized practices, thereby strengthening the overall health system.
Cultivating Adaptive Leadership Capacity
Studies have shown that a lack of leadership in both the country and existing donors results in delays in program continuation, gaps in health financing and technical capacity, as well as changes or disruptions in health service delivery in the post-transition period. Research from Harvard’s Global Health Delivery Project found that technical solutions for health financing transitions failed in 67% of cases due to inadequate capacity for change management. Notably, a lack of precise planning and communication from the donor side was shown to influence the sustainability of programming negatively.
When Botswana established a transition leadership team three years before planned PEPFAR funding reductions, it achieved a seamless transition, maintaining over 95% of services while reducing coordination costs by 43%. Political commitment, domestic ownership of health programming, legislative and policy support, and multi-stakeholder coordination all facilitate the development of sustainable health systems.
Conclusion
The journey from donor dependency to domestic sustainability isn’t just about finding new money, it is about reimagining how systems are structured, delivered, and governed. This paradigm shift holds the potential for African health systems to emerge stronger, more resilient, and more self-determining than before.
Global experience demonstrates that successful transitions rely on strong leadership, early planning, and strategic investments in a country’s financial, technical, and logistical capabilities. Without these foundations, countries often face stockouts of medicines, workforce shortages, service disruptions, and setbacks in population health outcomes. Transitions, if done right, can be powerful catalysts for innovation, enabling African health systems to emerge more self-reliant, resilient, and better equipped to meet the health needs of their people.
[1] https://data.worldbank.org/indicator/SH.XPD.EHEX.PP.CD?locations=TZ
[2] https://data.worldbank.org/indicator/SH.XPD.EHEX.PP.CD?locations=MW
[3] https://doi.org/10.1186/s12961-021-00751-9
[4] https://www.unicef.org/media/156841/file/UNICEF_CHW%20Advocacy_ENGLISH.pdf
[5] Zubin Cyrus Shroff, et.al., Managing transitions from external assistance: cross-national learning about sustaining effective coverage, Health Policy and Planning, Volume 39, Issue Supplement_1, January 2024, Pages i50–i64, https://doi.org/10.1093/heapol/czad101
[6] Community Health Program Investment Case in Rwanda, https://www.unicef.org/rwanda/media/3786/file/2021-CHP-Investment-Case.pdf
[7] OECD. Primary Health Care in Brazil [Internet]. OECD; 2021 [cited 2025 Jun 4]. (OECD Reviews of Health Systems). Available from: https://www.oecd.org/en/publications/primary-health-care-in-brazil_120e170e-en.html
[8] The Shift to Integrated Supply Chains in Global Health – Pamela Steele Associates https://www.pamsteele.org/blog-articles/the-shift-to-integrated-supply-chains-in-global-health/