Experts advise on how country can build sustainable systems
When U.S. President Donald Trump on March 06 announced aid suspension to South Africa over a disagreement, it was a vindication for the country. South African President Cyril Ramaphosa confidently made the point to Trump in a response that except for PEPFAR aid, which constitutes 17 percent of South Africa's HIV/Aids program, there was no other significant funding provided by the United States.
The South African parliament also gave an additional US$1.5 billion to the health sector following the aid cuts. The extra money was for salaries of roughly 9,300 medical personnel in clinics and hospitals and about 800 newly qualified doctors.
The South African situation is in contrast to what countries like Uganda and Kenya are going through following Trump ending U.S. funding to the U.S. Agency for International Development (USAID).
Kenya is said to have laid off 40,000 workers because they were all dependent on USAID.
Uganda, on a lower scale, laid off 2000 medical workers according to the president of the Uganda Medical Association. The Ministry of Health in Uganda urged workers to volunteer to the chagrin of a large section of the public.
Following Trump's disbanding of USAID, global health experts are urging countries to adopt bold new reforms and approaches to build sustainable and self-reliant health systems. They argue that countries should transition to ownership of their health systems through deliberate investments and funding.
In a paper published in March titled 'After USAID: what now for aid and Africa?', three global health experts: Dr Christine Kyobutungi, Dr. Ebere Okereke and Seye Abimbola say African governments and health practitioners have an "unprecedented opportunity" to question aid models of health service delivery.
"They must question aid models that lack sustained impact, do not strengthen-or worse undermine--health systems, do not improve population health, or create dependency."
The paper makes a clarion call to reframe aid and centre local health needs. It states, "Discrete HIV care clinics run through donor funded projects, for example, do not deal with other health conditions and create inefficiencies in the healthcare system through duplication of procurement, data and reporting mechanisms."
The researchers argue that domestic financing of the healthcare system will ensure that African countries cater to the needs of their populations rather than donors.
"African governments must insist on partnerships on their own terms and along with civil society in Africa, must control what gets funded and reject processes that undermine the whole system."
Dr Kyobutungi is the Executive Director of African Population Health Research Centre, an Africa-led research organisation in Nairobi; Dr Ebere is an epidemiologist and consultant on communicable disease control; and Abimbola is a researcher at the University of Sydney.
The trio advise governments to redeploy highly trained staff who have been rendered jobless to parallel programs to build robust data systems that track everyone's health as the foundation for universal health coverage.
The experts say there must be re-evaluation of all existing or new donor initiatives. "Donors should invest in underlying healthcare systems to make vertical programs, targeting specific populations, redundant. Programs need careful design, close evaluation and constant modification in response to lessons from implementation."
In their paper, they argue that local research institutions often rendered invisible by larger international organisations, need investment given their unique capacity to identify local problems, priorities and solutions.
Nelson Karanja, a behavioural change communication expert who worked on USAID programmes in African countries expressed similar ideas in an article on Medium.
"South Africa has the largest HIV epidemic in the world, yet its government now funds about 80% of its HIV/AIDS programs domestically, including purchasing the vast majority of antiretroviral drugs for over 5 million citizens," wrote Nelson Karanja, a behavioural change communication expert in an article on Medium. Karanja has worked on USAID programmes in African countries.
"Out of roughly 272,000 health workers providing HIV care in South Africa, over 94% are funded by the South African government, not donors. This remarkable level of domestic financing did not happen overnight -- it resulted from years of steady investment and planning, driven by a recognition that donor support (e.g. PEPFAR) would plateau or decline as South Africa's economy grew," Karanja added.
There has been a lot of talk about the Abuja Declaration, a treaty that was signed by several African countries in 2001 at a summit in Abuja, Nigeria. The summit was devoted to addressing the challenges of HIV/AIDS, Tuberculosis and other infectious diseases.
The declaration was a pledge by African countries to spend at least 15% of the annual budget on the improvement of the health sector. However, 24 years later, only Nigeria and Rwanda have fulfilled this pledge.
"Even low-income countries can navigate transitions with careful planning. Rwanda, for instance, has leveraged strong governance and innovative financing to increase its health budget share to meet the Abuja Declaration target of 15% of government expenditure on health, easing its dependence on aid," Karanja writes on Rwanda's transition to local ownership of its health systems.
He adds, "Several countries have developed formal "transition plans" in collaboration with donors: these plans map out how key programs (e.g. immunizations or malaria control) will be gradually handed over to national funding and management over a period of years, rather than cut off abruptly.
Karanja stressed that The Global Fund's transition framework and Gavi's graduation process are examples of "structured approaches where benchmarks (like income level and disease burden) trigger a phased donor exit coupled with technical support for the government to assume responsibility."
He said that research shows transitions succeed when there is strong government ownership, upfront investment in local capacity, and bridge funding to avoid service gaps.
"Countries that have built up robust health systems -- with solid supply chains, data systems, and financing mechanisms -- are more likely to smoothly absorb programs without resurgence of disease," he wrote.
Centering local needs
Dr. Prosper Ahimbisibwe, co-founder and co-CEO of MSCAN Uganda, a medical start up that provides antenatal ultrasound scans to pregnant mothers in rural areas, says when USAID closed shop his company was hit with massive funding cuts that were critical in their work when USAID closed shop.
But he says they are exploring new funding models.
"We are re-strategising to foundations and public health support from Europe and Asia to drive our social impact," he told The Independent in an email.
He has some advice for the government of Uganda on mitigating donor exits. "The Ministry of Health should quickly be given a significant supplementary budget to cover the emergent gaps followed by aggressive lobbying to raise its share of the national pie from meagre 6.5% to the 15% as envisioned by the Abuja Declaration so we move to full ownership and coverage of the public healthcare sector as for any serious country."
Dr Ahimbisibwe says the government equally needs to be proactive on matters of financing so as not to roll back progress on fighting HIV/AIDS.
"The Ministry of Health can work out a credit facility and partnership with local manufacturers of ARVS like Cipla-Quality Chemicals to make sure HIV-positive patients don't miss their medicines so that we may not lose the gains we have made in the fight against AIDS."
He adds that the thinking on healthcare needs to change from that of another key sector to that of a foundation of a healthy nation even to the level of national security. "Investment in health should be viewed as an economic strategy for the prosperity of the nation starting with a healthy productive population to facilitate economic activity," he told The Independent.
An expert who worked on USAID health communication campaigns but preferred to remain anonymous says there are three things the government can do to cushion the blow of funding cuts. "Prioritise disease prevention across the board; this can cut OPD (outpatient department) attendance by over 50%; invest in health promotion and disease prevention. Avail significant resources for the health sector (both money and human." He adds, "Emphasize integration of services."
Researchers at Duke Global Health Institute, Duke University in the U.S. made the same point about the danger of relying on a few donors. "A study of the donor landscape in Kenya found that just four donors--the United States, the Global Fund, the United Kingdom, and Gavi--contributed nearly 90% of all external health aid. In this situation, any large change by one donor will affect resources available to Kenya's health sector," said Ipchita Bharali, Gavin Yamey, and Osondu Ogbuoji, in a commentary on navigating U.S. global health aid cuts.
They added, "In financial year 2020-21, PEPFAR financed 60% of all Kenya's HIV programs. In the last two decades, PEPFAR invested around $8 billion in HIV programs in Kenya, providing antiretroviral (ARV) treatment to 1.3 million people and saving millions of lives."
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Kenya's predicament is no different to that of Uganda where the single-donor syndrome is manifesting in stark terms. For decades, Uganda's health sector has survived on support from the U.S.
Of the 1.4m Ugandans living with HIV, 700,000 were receiving lifelong ARV therapy through the PEPFAR. In the last year, Uganda received about $710m from USAID of which a substantial portion was for health sector support.
Ruth Aceng, the Minister of Health, while appearing before parliament to present the ministerial policy statement for the 2025/2026 Health budget told legislators that Uganda lost Shs604 billion in funding when the US government suspended foreign assistance.
Of the kitty, Shs243bn was for HIV/AIDS prevention and the rest was divided among programmes like malaria control, TB treatment, paying salaries, health information systems and healthcare waste management. The minister's statement shows how difficult it is for Uganda to cut its umbilical cord from donors.
The current donor cuts have created moments to pause and reflect for the health sector but the Covid19 pandemic was an even greater lesson for African medics and health care professionals. The pandemic meant that poor African countries like Uganda had to chart their own course through therapeutics and prevention measures before vaccinations came on board.
But the crisis also proved that African scientists had the capacity to do research and ably advise their governments in designing effective public health responses. An example is the Covidex drug that was invented by Prof. Patrick Ogwang in 2021 that proved vital in the fight against Covid19.
From the Ministry of Health to National Drug Authority to National Medical Stores; the three institutions at the heart of the public health sector, there is a realisation of the different state of play. In this new dispensation in the last three months, the ministry has battled an Ebola outbreak, a surge in the m-pox virus and dealing with an imminent public health crisis while severely under-resourced.
"NMS has not been affected by the USAID exit, as we already have in stock sufficient ARVs for this FY," said Sheila Nduhukire, NMS spokesperson responding to questions about the organisation's mitigation plans. "The government has promised to bridge any existing gap created by USAID for the next financial year."
