Health in Africa–not African health–is
in deep crisis, writes Dr Jean Kaseya
Health in Africa needs multiple and varied sources of funding. Some health institutions are in decay. Patients need diagnostics, drugs, and vaccines, which the continent does not produce optimally. When they import the products, administrative issues often delay distribution. An insufficient health workforce is a reality. Debt servicing and dependence on imported medical measures are a big headache. Africa is not short of outbreaks. These can happen anytime, anywhere.
Public health events rising from 152 in 2022 to 213 in 2024 highlight the vulnerability of African nations to health threats. These needs are evident, but they don’t translate into Africa’s poverty. Africa is rich, which means that with careful planning, appropriate mechanisms, and execution, the shortage of funding can be history.
During the annual Conference on Public Health in Africa (CPHIA) 2025 in Durban, South Africa, I highlighted that, five years after the COVID-19 pandemic, Africa is still unprepared for another major pandemic. We have this worrying state of affairs. Some countries lack National Public Health Institutes to conduct disease surveillance, outbreak response, public health research, and workforce development. In some countries, managing data is tough. They also lack laboratories and face issues with surveillance and coordination. Transporting samples during outbreaks is another challenge. When an outbreak occurs, we as a continent still scramble to put in place ad hoc committees that vanish as soon as the crisis passes. We depend heavily on imports for diagnostics, vaccines, and medicines, and when there is an outbreak, my first question is: where do we find vaccines, medicines, and diagnostics?
Of course, it’s not all gloom and doom; for instance, in my home country, the Democratic Republic of Congo, which gets outbreaks every week, ad hoc committees established to deal with individual outbreaks have been replaced with institutes. This has meant better, quicker responses, benefiting from “institutional memory”.
These quantifiable challenges and successes are happening against the backdrop of broader changes in the global health financing landscape. Analysts project that official development assistance for health in Africa will decline by nearly 70% from US$80 billion in 2021 to about US$24 billion in 2025, impacting health programmes on the continent. HIV and AIDS, tuberculosis, malaria, and emergency preparedness and response are not spared. Already, decades of progress made in disease control in Africa are in jeopardy.
Based on Africa CDC estimates, two to four million annual deaths will add to the current health-related deaths on the continent due to changes in the health financing landscape. The risk we face is another unforeseen pandemic or an outbreak in Africa. The staggering thought of Africa witnessing a reversal of two decades of achievement in various areas of public health is unnerving. Panicking should be the least of our worries.
Though it is an open secret that Africa receives the bulk of its health system funding externally, it seems this fact has always been taken for granted. There are several ways Africa’s health can be served and saved, while saving the continent from a future pandemic bloodbath.
During the African Union 38th Summit in Addis Ababa, Ethiopia, African Presidents, including President Paul Kagame of Rwanda, the champion of Africa CDC on domestic financing, William Ruto of Kenya, and Cyril Ramaphosa of South Africa, pledged their support to ensure Africa can generate more domestic resources for health. Duma Boko, Botswana’s President, cautioned against Africa’s complacency over the years, which has put the continent in vulnerable situations and left it at the mercy of external powers due to its reliance on aid from the developed world.
Efforts to transition from this culture so that any future effective change is not dependent on or triggered by a crisis led to meet with 45 African health ministers in Addis Ababa in February 2025. We assessed our progress. Only Rwanda and Botswana are meeting the 2001 Abuja Declaration, committing African Union member states to allocate at least 15% of their annual budgets to health. In examining why, we are not fulfilling that commitment, only 16 countries out of 55 in Africa revealed that they do not have a National Health Financing Plan. Clearly, without a national financing plan, they cannot effectively advocate for more funding from their government or secure appropriate funding from the private sector and other sources. We need to enhance domestic financing, but that must be aligned with the national health financing plan.
To our external partners, help us with a transitional plan. Without it, we are hamstrung from moving towards innovative financing to have more funding for the continental health. We need $2 billion per year to support outright responses in Africa.
Blended finance is also on the table. African ministers and African heads of state, supported by the World Bank and several partners, are backing these plans. A closer alignment of external resources would benefit us greatly. We desire to speak with our partners so that they can invest wisely and leverage on domestic resources. We also need innovative financing mechanisms. This is where our diaspora comes in. We know they are already contributing around $95 billion in remittances. We can capture some of these funds for the health sector.
Additionally, some domestic taxes can be harnessed for our cause. It is a major success story for Africa that remains to be written. But again, we need concessional funds that can unlock and de-risk investment from the private sector, particularly in local manufacturing of vaccines, diagnostics and therapeutics.
The implications of America first for Africa
All these suggestions come at a time when the United States is reframing its role under the “America First” Global Health Strategy. Unveiled on 18 September 2025, the US government is repositioning global health as a mechanism to advance American safety, prosperity, and influence. The US State Department says global health programmes have become “inefficient and wasteful and created a culture of dependency among recipient countries”. The US global health investments have played a historic role on Africa through initiatives, such as PEPFAR, and broader health assistance, saving more than 26 million lives, millions of new HIV infections prevented, and progress has been achieved against malaria and tuberculosis.
The brutal honesty is that only about 40% of resources have reached frontline services, while too much has been absorbed by overhead and management. Out of $100, that the US is sending to countries, only $40 is reaching the delivery level which means we have $60 out of 100 disappearing somewhere. For Africa, this is a wake-up call to prepare for a new model.
The proposed shift towards bilateral agreements with five clear principles, full protection of frontline services, commodities and health workers continuing to be funded in the transition period integration of systems, moving from old donor-driven programs to national systems for supply chains has opportunities and risks. It could help build resilience, self-reliance, reliant health systems aligned with national and continental strategies. But, on one hand it could fragment the collective voice on bilateral negotiations and shift reverence towards external partners when countries are not coordinated.
The new vision will be mostly to have a bilateral agreement, because they want the voice for the US to be loud at country level and regional level while responding to Africa’s requests of more country-owned health system while supporting their own agenda, that is, making America safer, stronger, and more prosperous. For now, 16 African countries are targeted. The selected countries will get a six-month bridging finance.
Remember, not all African countries are fully ready for the changes, for more than 20 years, some didn’t have opportunity to build a procurement system, or supply chain management system, these changes will enable them to build sustainable local capacity, shape alignment with the national health strategy. The bottom line is not all African countries will benefit from these changes. Africa’s response could shape the future of global health collaboration. This is where the Lusaka Agenda comes in.
The Lusaka Agenda
When it comes to health, funding will forever be an issue, but that does not mean, all the time we need to depend on extending a begging bowl. A roadmap for transforming Global Health Initiatives (GHIs) to strengthen health systems in Africa and advance universal health coverage, Lusaka Agenda stands to plug the gap.
After an inclusive 14-month process of consultation and deliberation with multi-stakeholders reflecting on how GHIs can more effectively and efficiently complement domestic financing to maximise health impacts in support of country-led priorities and trajectories to universal health coverage (UHC), the Lusaka Agenda was born in December 2023.
The agenda outlines five shifts for GHI and health ecosystem evolution, focusing on national ownership, equitable and coherent implementation, sustainable domestic financing, strengthening primary healthcare, and coordinating research and development.
The African Union Commission assigned Africa CDC to host the Lusaka Agenda secretariat to strengthen and sustainably finance Africa’s health systems, and Africa CDC has since developed an accountability framework. We’re thoughtfully wondering why African countries aren’t committing to the 15% Abuja agreement.
The agenda is a call to action to transition from dependency to self-reliance, ensuring health systems in Africa are sustainably financed and people-centred. We foresee a scenario where we will pool funding for Africa by aligning global health funding with national priorities, improving efficiency, and promoting more sustainable domestic financing through increased accountability and transparency. We want to see African countries taking the lead in setting the health agenda and managing investments, moving away from fragmented, donor-led programmes.
Already, some African countries, including the Central African Republic, DRC, Nigeria, Tanzania, Ethiopia, Ghana, Malawi, Mozambique, Senegal, and South Sudan, are moving ahead with the implementation of the Lusaka Agenda based on their country context. We are hopeful that this political commitment, endorsed by African Heads of State to achieve health equity and strengthen primary healthcare across the continent, will yield commendable results.
A new way forward
As we re-examine old ideas, solidify those already endorsed and welcome new ones, we take comfort in the fact that the Africa CDC’s baby, the African Epidemic Fund, a new pool of finance to assist countries in preparation and response to disease threats on the continent, is already operating as a trust fund. The fund is already receiving funds from member states and partners.
But as winds of financial generosity blow both hot and cold, we also need a new strategy as Africa CDC to guide us. The New Public Health Order endorsed by African Heads of State in 2022 guided us as an institution after COVID-19 to strengthen institutions. It was the guiding torch to rebuild the workforce, manufacturing, domestic financing, and partnerships for health security. We now face declining donor funding and ongoing health emergencies. So, we need a stronger vision for the continent. Member states must have that financial muscle and the right policies to make long-term investments in laboratories, surveillance, and rapid response capacity.
Recommendation from the September 2025 meeting of its Committee of Heads of State and Government says the adoption of a new way forward to realise and transition the commitments of the New Public Health Order to a more resonant, transformative, and evolving vision.
This new strategic transition, named Africa’s Health Security and Sovereignty (AHSS), reflects the growing recognition that achieving universal health coverage, pandemic preparedness, and sustainable development cannot be realised without health sovereignty—the ability of African nations to finance, produce, and govern their own health systems and countermeasures.
As African Union Member States lead us, we hold a comparative advantage over many external entities. We have also matured over the years. The designation of the Public Health Agency of Africa with political, strategic, and technical capacities has empowered us to lead the continental health agenda and shape global health reform.
We are embracing Africa’s Health Security and Sovereignty plan as a game changer. An unacceptable proportion of out-of-pocket health expenditure for people in Africa must be checked, we need a firm and workable response to decreasing official development assistance, and ignoring the impacts of the climate crisis and recurrent disease outbreaks would be fatal.
Dr Jean Kaseya is the Director General of the African Union’s Africa Centres for Disease Control and Prevention, based in Addis Ababa, Ethiopia.
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