Africa’s Health Sovereignty Beyond Aid: Adaptive Leadership, Prevention, and Governance for Resilient Systems
Idea in Brief
As the global aid landscape shifts toward more conditional, politically driven engagement, African nations face a defining choice: continue depending on external funding or go beyond aid and reimagine their health systems for sovereignty. This paper calls for a bold reset—led by African governments—to build resilient, self-financed, and people-centred systems no longer tethered to volatile donor priorities. Several countries already offer promising models. Rwanda’s community-based insurance now covers over 85% of its population, supported by government subsidies and community health worker cooperatives. Ethiopia and Ghana have also scaled domestic financing efforts, demonstrating that homegrown solutions can work—and scale.
Yet deep challenges persist. Africa spends under US$100 per capita on health—less than 5% of what high-income countries allocate—even as non-communicable diseases surge, maternal mortality remains high, and prevention is underfunded. The result is an “inefficient equilibrium”: systems that appear stable but fail to deliver expected outcomes. To break this cycle, the paper introduces Health Systems 2.0, a practical framework grounded in systems thinking, adaptive leadership, and human-centred design.
Three strategic shifts are essential. First, leadership must move beyond technical fixes to adaptive leadership—capable of mobilizing people, enabling learning, and building trust. Rwanda’s trajectory shows how policy can align with frontline realities. Second, prevention must be placed at the centre of system design. Ethiopia’s Health Extension Program, Ondo State’s Abiye initiative, and Kenya’s COVID-era community response demonstrate the power of prevention-led models to deliver impact. Third, governance must be reframed as a lever for domestic resource mobilisation. Ghana’s health insurance and Kenya’s community scorecard initiatives show that trust grows when services respond to people’s needs and voices.
This paper argues that Africa’s health future lies beyond aid, not as aspiration, but as strategy. Adaptive leadership, prevention-centered delivery, and governance premised on transparency and trust are not optional—they are the core levers for the journey to self-reliance. Anchored in Health Systems 2.0 thinking, this approach places African leadership, insight, and lived experiences at the center of reform. By designing systems around the realities of people’s lives, Africa can build health systems rooted in resilience, dignity, and self-determination.
Download a copy of the article Beyond Aid – How Africa Can Reimagine Its Health Systems for Sovereignty here
I. INTRODUCTION
The era when Africa could rely on foreign aid for its health priorities is passing—signaling a defining opportunity for African nations to reimagine their health systems. Development assistance is shifting from broad solidarity to more conditional and politically aligned engagement. This shift—exemplified by current Trump administration policies that are reshaping foreign aid around U.S. political and strategic interests and echoed by broader cuts across traditional donor countries—confronts African nations with a hard choice: build greater self-reliance or remain vulnerable to the unpredictability of external funding. Yet this urgency also offers hope: an opportunity for Africa to assert leadership and agency over its own health agenda.
Several African countries are already advancing health sovereignty through smart financing and governance reforms—driven by presidents, health and finance ministers, governors, and development partners.
Rwanda’s community-based health insurance now covers over 85% of the population, anchored in national subsidies and community health worker cooperatives. Ethiopia has expanded its community-based insurance through a government-led Health Extension Program. Ghana’s model—partly funded through a national health insurance levy—has reduced out-of-pocket spending via dedicated domestic taxes. These examples, explored further in the article, show that Africa can sustainably finance and govern its health systems beyond aid.
Africa must now reimagine its health systems through a new, context-specific framework. Health Systems 2.0—anchored in systems thinking, adaptive leadership, and human-centered design—is proposed as that model. An illustrative version is included in the annex to support leaders in shaping resilient, self-financed, and people-centred systems.
II. The Financing Gap
Africa currently spends an average of under US$100 per capita on health—far below the US$249 per capita benchmark for basic service coverage, and less than 5% of what high-income countries invest (WHO, 2024). For years, donor funding helped bridge part of this gap. But that cushion is shrinking. Donor fatigue, shifting geopolitical priorities, and evolving funding criteria—however well-intentioned—have made continued reliance on external financing increasingly precarious. This evolving reality—reflected in the Trump administration’s foreign aid reforms—is forcing a strategic reckoning. Overdependence on donor flows can delay essential domestic reforms, obscure inefficiencies, and leave governments exposed when global priorities shift.
To secure long-term resilience, African nations must embrace a new financing posture—one that strategically blends catalytic donor support with robust domestic resource mobilisation. This shift must be anchored in adaptive leadership, stronger governance, and prevention-focused investment. Done well, this shift will reduce vulnerability to external shocks and will build the foundation for smarter fiscal policy, local innovation, and lasting national ownership of health priorities.
III. An Evolving Burden – and a Clash With Old Models
The public health landscape on the continent has shifted. While infectious diseases remain a significant threat, non-communicable diseases (NCDs) such as hypertension, diabetes, and cancers are rapidly rising. Most African health systems, originally built for acute care, are poorly equipped for the sustained demands and escalating costs of chronic illness. Dr. Githinji Gitahi warns starkly: “Africa has a big risk of collapse of health systems in the next few years because of NCDs […] 50% of all admissions in a typical African hospital are NCDs, yet 80% of NCD care is paid out of pocket. And governments don’t have money to actually take care of NCDs” (Lay, 2025).
The sustainable solution is prevention, early screening, and resilient primary healthcare—strategies that break the persistent cycle of low coverage and high disease burden known as the “inefficient equilibrium.” Central to Health Systems 2.0 thinking, this inefficient equilibrium describes systems that seem stable superficially yet fail to deliver meaningful health outcomes due to underlying flaws in design or leadership.
IV. Three Essential Shifts Africa Must Make
a) Why Adaptive Leadership, Not Just Technical Expertise, Matters
Africa’s most persistent health challenges—rising rates of non-communicable diseases, high maternal mortality, and chronically underfunded frontline preventive and treatment services—are not simple technical problems. They are adaptive challenges: complex, systemic issues that demand leadership to mobilize diverse stakeholders, build trust, and drive behavioural and institutional transformation.
Adaptive leadership, as defined by Heifetz and colleagues, involves distinguishing between technical problems—those that can be solved with existing knowledge and tools—and adaptive challenges, which require deeper structural shifts, often without clear precedents. Addressing the latter demands leadership that fosters learning, experimentation, and iteration—distributing problem-solving across systems and cultivating shared ownership of change (Heifetz, Grashow and Linsky, 2009).
Rwanda offers a compelling example of adaptive leadership. Today, its community-based health insurance covers over 80% of the population—largely funded through government subsidies and contributions by communities. Anchored in sustained national commitment, inclusive policy design, and locally embedded accountability, Rwanda expanded this model while integrating HIV investments into primary care and scaling access to other essential services. Between 2000 and 2012, under-five mortality declined by more than 60%, maternal mortality dropped from 910 to 340 per 100,000 live births, and childhood immunisation coverage reached 97% (Binagwaho et al., 2014).
A nationally representative survey further found that the insurance scheme reduced annual per capita out-of-pocket spending by approximately US$12—an 83% drop from baseline—and significantly lowered catastrophic health expenditures, accelerating progress toward universal coverage (Woldemichael, Gurara and Shimeles, 2019). These gains were not achieved through technical fixes alone, but through adaptive leadership that aligned policy with community realities, embedded iterative learning, and cultivated shared ownership of health. Citizens increasingly came to view health insurance not as charity, but as a shared national and household investment. Rwanda’s experience affirms that adaptive leadership is foundational to building resilient, people-centred health systems.
b) Put Community-Led Prevention at the Centre of Health Systems
Prevention remains one of the smartest, most cost-effective ways to improve population health and reduce long-term health system costs. Community-based approaches—especially those rooted in trusted, locally embedded health workers—are central to making prevention real and scalable.
Ethiopia’s Health Extension Program (HEP), launched in 2003, shows how government-led, community-based models can drive measurable population health gains and accelerate progress toward universal health coverage. As part of broader reforms, HEP deployed more than 42,000 trained health workers to rural communities, expanding access to essential services. It contributed to increased uptake of maternal and child health interventions, improved sanitation, and stronger disease prevention practices—supporting a 67% reduction in under-five mortality and a 71% decline in maternal mortality between 1990 and 2015 (Assefa et al., 2019). Nigeria’s Ondo State offers another compelling example. The Abiye Safe Motherhood Programme—fully funded by the state and free of cost to clients—was associated with a 70% drop in maternal mortality, from 708 to 208 deaths per 100,000 live births between 2010 and 2014.
This success stemmed from the removal of financial barriers, expanded access to skilled care, and a community-based tracking system that followed pregnant women from conception to delivery (Mimiko, 2017, p.11). Kenya provides further evidence: during the COVID-19 pandemic, community health workers reached over 2.5 million household members across 27 counties within weeks, helping sustain essential health services (Amref Health Africa, 2020). These examples show that deliberate, systems-level investment in trusted, prevention-first strategies can deliver meaningful population health gains—and move countries beyond the inefficiencies of reactive, hospital-centric models.
In a reimagined Health System 2.0, prevention must be intentionally placed at the centre of service delivery—not treated as a peripheral add-on, but embraced as a core function. Governments should commit at least 10% of national health budgets to prevention, prioritizing scalable approaches that shift care upstream, ease hospital burdens, and deliver measurable health and economic gains. Countries that invest in prevention not only save more lives, but also build stronger, more fiscally resilient health systems.
c) Strengthen Governance to Unlock Domestic Financing
Africa’s path from aid dependence to resilient health systems hinges on a renewed social contract—anchored in public trust, equity and inclusivity, transparency, and accountability. Promising pathways are already emerging: Ghana’s VAT-backed National Health Insurance Levy, Rwanda’s community health worker cooperatives, and Ethiopia’s locally managed community-based insurance schemes reflect early models of locally anchored health financing. Ghana’s National Health Insurance Scheme (NHIS)—funded through dedicated domestic taxes and citizen contributions—remains a promising model, despite equity challenges. Recent analysis shows that NHIS coverage expanded to approximately 54% of the population by 2021, improving access to essential services. Yet catastrophic health expenditure continues to rise, particularly for hospital care and medical supplies, with rural, northern, and low-income households most affected (Akazili et al., 2025). These patterns highlight the need to strengthen governance through an equity lens—ensuring that reforms protect the most vulnerable as they expand coverage.
Trust in health systems is earned—not assumed. In Kenya, Amref Health Africa has used community scorecards—through the Community Systems Strengthening approach, supported by the Global Fund—to ensure that community voices shape national health decisions. These tools have strengthened accountability and responsiveness in HIV, TB, and malaria programs by aligning services with lived community experience (Global Fund, 2022). This is Precision Population Health in practice: listening not just to data, but to people—in context.
Strong governance sets off a reinforcing cycle: transparency builds trust, trust unlocks resources, and those resources sustain resilient, locally funded health systems (Figure 1).
V. Conclusion & Call To Action
“Beyond aid” is Africa’s call to reclaim agency over its health future. Declarations alone will not suffice; governments must visibly prioritise health, actively invest in prevention, and nurture adaptive leadership at every level. Finance ministers must recognise health expenditure as strategic investment, and health ministers must decisively shift their focus from managing illness to promoting wellbeing.
Africa stands at a pivotal crossroads. Today’s choices will shape health outcomes for generations. By embedding adaptive leadership, expanding community-led prevention, and strengthening governance to unlock domestic financing, Africa can build resilient, self-financed, and people-centred health systems. This approach—anchored in systems thinking, adaptive leadership, and human-centred design—is the foundation of Health Systems 2.0, as illustrated in Annex 1, driving lasting impact and dignity for Africa’s people.
Dr. Meshack Ndirangu Wanjuki is a health systems strategist and Country Director of Amref Health Africa in Kenya. He champions adaptive leadership, health sovereignty, and resilient, people-centred health systems for Africa.
References
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