Resourcing Resilience in African Health Systems

From Jollof Wars to a System Under Siege

The conversation opens light-heartedly with a “jollof rice war” between Ghana, Nigeria, Liberia, and a neutral referee from Kenya. Beneath the humor lies a theme that runs through the session: regional competition is real, but solidarity and shared purpose are essential. As moderator Raj Panjabi notes, Africans must “preserve our visas to all three countries”—and to each other’s systems—if they are to navigate the storm ahead.

The storm is serious. Over the past 25 years:

• Preventable maternal deaths have fallen by over 30%.
• Preventable newborn deaths have declined by more than 40%.
• Deaths from HIV, TB, and malaria have dropped by over 60%.

Those gains, built by governments, communities, NGOs, and partners, are now under threat. Recent political decisions have led to:

• Sharp pullbacks in U.S. global health funding, disrupting billions of dollars in delivery.
• Additional cuts from the U.K., France, and Germany, compounding an already fragile post‑COVID environment.

Many countries were already struggling: mortality declines in malaria had stalled before COVID, and the pandemic further exposed African health systems’ vulnerability—from inequitable access to vaccines to limited capacity to deploy them quickly.

Nigeria’s Shock and Response: Owning the Responsibility

Kelechi Ohiri, Director General and CEO of Nigeria’s National Health Insurance Authority, situates the current crisis within a set of overlapping transitions:

• Epidemiologic transition: Noncommunicable diseases have grown from one-sixth to about one-third of the country’s disease burden, creating a “dual burden” alongside infectious diseases.
• Development assistance transition: Multilaterals such as Gavi and the Global Fund are requiring higher co‑financing from governments.
• Demographic transition: A youth bulge and rapid population growth are straining service delivery and job markets.
• Macroeconomic headwinds: Currency devaluations, high inflation, and stalled growth have eroded fiscal space.

Against this backdrop, U.S. and other donor cuts landed as a genuine shock. Nigeria has long been one of the largest recipients of U.S. health assistance, with tens of millions of dollars annually for malaria alone, plus HIV and maternal and child health.

Immediate Mitigation: Filling the Gap

Nigeria’s initial response was practical:

• Mobilizing $200 million approved by the National Assembly to fill the gap created by donor exits.
• Absorbing approximately 11,000 full-time and 12,000 voluntary donor-funded health workers into government payroll.
• Searching systematically for efficiency: streamlining supply chains, integrating previously vertical services, and reducing the cost per service delivered.

The goal is not just to survive this shock but to lay the foundation for what Ohiri calls “sustainable health financing.”

Rebuilding on New Terms: Insurance and Integration

Central to Nigeria’s strategy is rethinking how priority services are financed and delivered. One flagship move is to integrate HIV, TB, and malaria services into the national health insurance benefit package, rather than treating them as donor-funded verticals.

In partnership with the Global Fund, Nigeria is piloting this approach with a view to making these services part of the minimum benefit package—pooling risk and resources to lower the actual cost of care while expanding access.

Resourcing What Cannot Be Taken Away: Community Health Systems

Angela, who works with the Financing Alliance for Health and the Africa Frontline First initiative, reframes resilience as an investment in structures that persist even when external funding disappears:

As donor-funded staff contracts end and supply chains are disrupted, many facilities are struggling with surges in demand and reduced capacity. In this vacuum, community health workers (CHWs) have again become critical shock absorbers.

Community Health Workers as the First Line of Defense

Across the continent, governments are increasingly aligning systems with Africa’s burden of largely preventable disease. That means:

• Building a strong delivery platform at household and community level.
• Training, paying, and supporting CHWs to provide preventive and basic curative services, reducing unnecessary facility visits.
• Leveraging this platform in crises—from Ebola in West Africa to COVID-19—where CHWs consistently emerge as the “first line of defense.”

In the current funding shock, CHWs are again absorbing pressure by preventing illness, triaging cases, and maintaining continuity of care when facility-based services falter.

Building the Financial and Policy Architecture

Financing Alliance for Health and Africa Frontline First work with governments to:

• Secure and expand domestic budget lines for CHWs and primary health care.
• Ensure the policy environment enables CHWs to deliver an appropriate package of services, in line with community needs and national priorities.
• Strengthen procurement and supply chains so that supplies reach not only facilities but households.

The crisis, Angela argues, is forcing a pivot from a narrow focus on official development assistance to a more diversified portfolio: domestic budgets, debt swaps and guarantees, remittances, pension funds, and catalytic philanthropy that unlocks larger pools of multilateral and domestic capital.

The Innovation and Accountability Gap: A Bottom-Up View

Bright Simons, a Ghanaian technologist and policy thinker, brings a dual perspective as a supply-chain innovator and activist. His core critique: global health has failed to live up to its own rhetoric on country ownership and local innovation.

Global Rhetoric vs. Local Reality

Since the Monterrey Financing for Development conference in 2002 and subsequent meetings in Paris, Accra, and Busan, one idea has been repeated: the primacy of the domestic—for innovation, experimentation, and accountability.

In practice, Simons argues, that promise has not been met:

• USAID set a goal to channel 25% of its funds through local actors. It never got close, peaking near 10% and dropping below that before the recent cuts.
• Local innovators often operate in parallel to donor-funded global initiatives they hear about only secondhand, despite working on identical problems.

Accountability Flows Up, Not Down

Using the Global Fund as an example, Simons notes:

• Local Fund Agents, typically Big Four accounting firms, act as de facto country offices but their reports are not public in Ghana, limiting domestic scrutiny.
• Country Coordinating Mechanisms (CCMs), designed to ensure “country ownership,” are often disconnected from domestic activists and innovators.
• When over 400 containers of Global Fund commodities arrived in Ghana in 2023, it took a full year to clear the final shipment due to tax-waiver disputes and weak political clout—an example of how governance, not dollars, can choke impact.

Small Pot, Bigger World

Simons places global health funding in perspective:

• Total global health spending is less than half what the world spends on chocolate each year.
• The cumulative funds raised by Gavi and the Global Fund since the early 2000s—under $100 billion—are only slightly more than what the world spends on Pokémon merchandise.
• By contrast, financial movements in the U.S. economy alone amount to roughly $4.5 trillion per day.

The issue is not that global health is “too big to fail,” but that it is too narrow to transform if it remains confined to a small, donor-dominated pot and a narrow set of actors.

Designing the Future: A Health System “Of Us, By Us, For Us”

The moderator asks each panelist to imagine an open canvas: What would a better global health system look like, and how can this crisis move us there?

Kelechi Ohiri: Reclaiming Agency and Equity

Ohiri begins with a critical question: In global health, who are the principals and who are the agents? Many global institutions, he notes, are accountable upward to funders, not downward to the communities they serve.

He proposes a democratic lens: just as democracy is “government of the people, by the people, for the people,” future African health systems must be:

• Of us: Priorities are set locally. Why, for example, is sickle cell disease not a global priority, despite its heavy burden in Africa?
• By us: Health workers, supply chains, and manufacturing are domestically controlled; governments do not outsource 23,000 health workers to a foreign agency.
• For us: Equity is explicit. National insurance schemes build in vulnerable groups, people with disabilities, the elderly, internally displaced people, and women at risk in childbirth.

In Nigeria, this principle is being operationalized through a Vulnerable Group Fund and through efforts to expand essential packages to include rehabilitation and services often neglected in medicalized systems.

Angela: Centering Communities and Politics, Not Just Policy

For Angela, genuine agency starts at the community level:

• CHWs and community members help define what services they need, where and how they want to receive them.
• Community voices are brought into policy processes to co‑design strategies and service packages.
• Budget transparency and public financial management reforms allow communities to see what has been allocated, what is being paid for, and whether it meets their needs.

Africa Frontline First seeks to change both sides of the equation:

• Globally, by helping institutions like the Global Fund fund in more integrated ways aligned to government priorities, and by using philanthropic capital (e.g., from the Skoll and J&J foundations) to unlock larger Global Fund commitments.
• Domestically, by supporting countries to increase their own investments—unlocking an additional $119 million in domestic resources so far for community health systems.

Angela also underscores a hard truth: health is political. Technical investment cases are necessary but insufficient; engaging ministries of finance, budget, and political leaders in the trade‑offs of resource allocation is indispensable.

Bright Simons: Power, “Soft Development,” and Unsticking Capital

Simons argues that rebuilding requires three shifts:

1. Broader definition of health and private-sector roles.
   Many of the gains in maternal and child mortality may be driven as much by nutrition and other social determinants as by clinical interventions. Yet when Africa “invites the private sector to the table,” it is often only pharmaceutical companies; actors in food, housing, and other sectors remain on the margins.
2. Investing in “soft development.”
   African governments systematically underfund continental institutions and integration efforts that look “non-essential” because they are not roads or hospitals:
   • The African Union needs roughly $600 million annually; only about $200 million comes from member states, with the rest from external partners.
   • The African Continental Free Trade Area (AfCFTA) Secretariat relies on external financing for most programmatic costs.

   Yet without such institutions, efforts like pooled procurement, regulatory harmonization (e.g., the African Medicines Agency), and regional industrial policy struggle to take off. The result: hard infrastructure investments fail to yield productivity gains, and debt burdens escalate.

3. Unsticking existing capital.
   Within multilateral development banks, a large share of committed funds never reach implementation. Simons estimates that as little as 35% of committed resources are disbursed in practice, due to unmet conditions and weak domestic execution capacity. Strengthening governance and implementation could triple effective financing for health without raising a single new dollar.

Equity, Mental Health, and the Climate–Health Nexus

Audience questions push the panel to address who benefits—and who is left behind—as systems are reimagined.

Ensuring the Most Marginalized Are Not Sacrificed

Recent aid cuts in some donor countries have disproportionately hit programs for women, people with disabilities, and other marginalized groups. Ohiri’s response is straightforward: equity cannot be left to “trickle down.”

In Nigeria, this means:

• Explicitly identifying vulnerability categories (internally displaced persons, people living with disabilities, the elderly, women facing maternal risk).
• Creating a Vulnerable Group Fund within the insurance architecture.
• Expanding benefit packages to include services such as physical therapy and rehabilitation, which are critical for people with disabilities but often excluded from narrow, curative benefit designs.

Mental Health and Climate Anxiety

Another question highlights rising eco‑anxiety and climate-related mental health issues among African youth and elders. Angela responds by calling for a more holistic framing of health:

• Talking about well-being, not just disease.
• Designing multi-sectoral responses that engage health, education, environment, and social services.
• Integrating mental health into essential health benefits and primary-care packages, rather than treating it as an add-on.

She draws a parallel with nutrition: if nutrition were a shared responsibility of health, agriculture, and education—not siloed in one ministry—countries would see more robust, better funded interventions. The same logic should apply to mental health and climate resilience.

Extractive Industries, Green Minerals, and Health Financing

A participant asks whether longstanding extractive industries and hidden offshore wealth might be levers for financing health and development.

Simons cautions that while legacy extractives (oil, gold, minerals) have often delivered limited benefits to African populations, the emerging green minerals economy offers a chance to do better—if managed differently.

However, no single country controls all inputs. Ghana has lithium; Togo has phosphates; the cheapest power may be elsewhere. Realizing the health and economic benefits of green minerals therefore requires:

• Integrated regional value chains, enabled by AfCFTA and stronger continental institutions.
• More sophisticated political and fiscal governance to capture and direct resource rents toward health, education, and infrastructure.
• Stronger domestic and international mechanisms to address illicit financial flows and tax havens.

Without this, Africa risks repeating the mistakes of past extractive booms—with limited fiscal gains and persistent underinvestment in human development.

What This Community Can Do: Calls to Action

The session closes with a challenge to the audience of social entrepreneurs, policy makers, philanthropists, and private-sector leaders. Drawing on a Liberian proverb—“No condition is permanent”—Panjabi asks: how should we respond to this moment?

1. Engage in Politics, Not Just Policy

Ohiri urges practitioners and entrepreneurs to recognize that resource allocation is inherently political:

Julio Frenk’s distinction between “politics” and “politicking” is helpful: health actors need not engage in partisan maneuvering, but they must participate in debates over priorities, budgets, and trade‑offs. That includes:

• Contributing evidence and narratives that resonate with finance ministries and legislators.
• Joining or building coalitions that advocate for primary health care, community systems, and equity.
• Supporting diaspora initiatives, such as Nigeria’s forthcoming diaspora health insurance program and physician networks returning with both capital and expertise.

2. Stop Othering the Problem: Everyone Has a Role

Angela emphasizes that this crisis affects everyone, not just “countries over there”:

She highlights three forms of contribution:

• Time: serving as advisors or sounding boards for frontline enterprises and ministries navigating transition.
• Talent: co‑creating investment vehicles, governance reforms, and data systems with local partners.
• Treasure: deploying flexible, unrestricted capital to help proven but subscale initiatives grow and to unlock larger pools of multilateral and domestic finance.

3. Devolve Power, Not Just Resources

Simons’ final message is blunt:

For external partners, that means:

• Bringing domestic innovators, activists, and community representatives into the design and governance of global initiatives.
• Making accountability mechanisms (such as Global Fund local fund agent reports) more transparent to domestic stakeholders.
• Supporting Africa’s own institutions—parliamentary bodies, AfCFTA, the African Medicines Agency—through predictable funding and technical partnership, not just project grants.

For African governments and civil society, it requires:

• Strengthening internal cohesion and integration, including practical steps like implementing small airline ticket levies to fully finance the African Union.
• Investing in “soft development”: leadership programs, regulatory harmonization, and cross-border coalitions that are easy to cut but essential for long-term transformation.
• Championing Africa’s demographic and talent advantage, from nurses and doctors to scientists building homegrown biotech ventures.

Watch the Full Discussion

To hear the complete conversation and nuances in the panelists’ own words, watch the full session below.