The Shock Was Not the Problem
USA’s change to funding health initiatives and questions of sovereignty and sustainability?
The withdrawal of USAID funding in 2025 was abrupt and, for many communities across Africa, the consequences were immediate and severe. Children in Uganda went without antiretroviral refills. South Africa’s HIV data architecture, built under American oversight, did not last beyond the architects’ last coffee in the departure lounge. The analysis by many, including The Economist.com Africa’s fragile health systems, reflects the nature of the international community’s focus on the grand curative or response mechanisms tied to established, corporate, suppliers, Big Pharma noted severally in different pieces.
But the honest question, the one too few in the development community are willing to ask publicly, is:
- Why, after sixty plus years of development assistance, hundreds of billions of dollars and countless experts flown in, were health systems across the continent still so structurally dependent on external ownership?
The USAID shock did not create the vulnerability but, rather, exposed it.
The evidence consistently points in one direction:
- The dependency was not an accident of scale or complexity but a predictable consequence of how the aid system was designed to operate.
The Structural Logic of Dependency
The aid-industrial complex, UN agencies, funds and programmes, large INGOs and their extensive sub-contracting networks, has operated according to an accountability logic consistently accountable to the donor as the customer. The recipient government is a delivery mechanism if fortunate to be fully involved in strategy into plans and accountability frameworks. The people in the community, whose health is at stake is the end point of a supply chain, neither controls nor, in most cases, meaningfully influences what is being delivered. This inversion has been playing out for decades in health as in education, water provision and wider food security and livelihoods projects. Jobs in public health systems pay less than aid sector equivalents. Career development, professional recognition and access to international networks flow through external organisations. Talent migrates from state, public, health systems into the international aid economy; not because African health professionals lack commitment to their communities, but because the incentive architecture has consistently pointed this to be the economically sensible approach when wider social protection is weak.
The result is what we have observed, been part of and railed against across multiple settings: parallel systems with parallel data architectures, parallel supply chains, parallel service delivery structures and parallel marketing processes. Perhaps parallel is too polite.
During the emergence of SARS-CoV-2 into Covid-19, the UN marketing machine was openly derogatory toward the capacity of African governments to manage the pandemic. The same is true now for Ebola, no matter the fact this is nothing new to health personnel, systems and structures across the continent where Ebola has appeared before. Capacity has not been built because African governments could not develop these capacities, but because donor timelines, procurement rules and accountability frameworks made it operationally easier to build around them through international organisations set up to market and sell into these donors.
When the external partner exits, the parallel system regularly exits too. State health systems have been progressively hollowed out as talk of public-private partnerships results in crony capitalism and, for the majority, unaffordable curative services with little or no promotive and preventive work reaching out beyond the tried and tested markets.
There is a further political economy at work as linkages to personalities in political positions support the people in position more than the institutionalisation of a locally accountable system reinforcing good governance. Some international organisations have had little institutional incentive to hand over operations to government counterparts because doing so would trigger reductions in their own funding. The UN agencies and large INGOs remain in conspicuously good health despite the USAID cuts. They are not villains, it is a fact of the neoliberal capitalist market dynamics many would content as they are products of incentive structures rewarding perpetuation over transition in the aid and development industry. The measure of their organisational success has been survival and growth, not exit with people’s wellbeing at levels comparable with at least global averages.
Durable solutions require local ownership not just in principle, but in institutional architecture with accountable government as a critical and non-negotiable element. This is a lesson the development sector has repeatedly acknowledged and repeatedly failed to act on.
The Politics of Health Priority
There is a further distortion embedded in how African health has been framed and funded. Politicians cut ribbons at hospitals and donors fund antiretroviral programmes with measurable beneficiary numbers. Both respond to the logic of visibility and accountability to their own constituencies. But the most powerful determinants of population health are not curative, they are promotive and preventive: clean water and sanitation, proper grey water disposal, eliminating mosquito breeding sites, maternal health services as part of enabling women to realise their rights, immunisation campaigns, nutrition education embedded in community systems and fitting to primary production (Something the USA started in Uganda just before Covid-19 seeking to develop the basis for value constellations and local governance legitimacy).
These generate no ribbon-cutting moments, nobody convenes a high-level side event at the UN General Assembly to celebrate the consistent emptying of stagnant water in a peri-urban settlement. The gains are incremental and distributed with political rewards being thin at state and international level (Until the long term delivers measurable wellbeing improvements; if wellbeing is being measured and assessed).
In our work across East Africa, the communities making the most durable gains have invariably been those where investment in this promotive and preventive infrastructure preceded or accompanied investment in curative services. The sequencing matters alongside the balance of investment, and current funding architecture systematically distorts both. HIV/AIDS has attracted extraordinary resources not only because of its severity, but because it generated measurable statistics, identifiable beneficiaries and powerful international advocacy coalitions. Dirty water was not so relatable despite the burden of maternal mortality, malnutrition and water-borne diseases collectively accounting for far more preventable deaths across the continent, why has this attracted proportionally less? Harder to address at distance? Harder to count and articulate impact? The sheer scale requiring integrated programming not benefiting big pharma?
- True health sovereignty means restoring this balance and investing in the conditions determining health and not only in the services responding to its absence.
The Root Variable: Poverty in All Its Forms
No open forthright discussion of African health can avoid the central variable. Poverty remains the greatest threat to health and wellbeing across the continent—not poverty as a background condition, but poverty in all its dimensions: economic, social, environmental, legal rights being delivered, and relational aspects between key stakeholders with power and influence. Poverty in knowledge is also fuelling the next generation of ill-health among the burgeoning middle classes and urban poor as ultra-processed foods gain market share with commensurate surges in non-communicable diseases linked to diet.
Households unable to afford adequate food of the right nutritional value are households at risk. Communities without safe water are communities at disease risk. Women who cannot exercise reproductive rights, lacking decision-making power in the household, access to resources and protection from violence, are women at elevated health risk. None of these are principally health-system problems; they are problems of political and economic intent; or lack thereof. Of asset distribution, of voice and agency.
This is why we are deeply sceptical of approaches to health sovereignty focused narrowly on health systems financing where control and accountability stay with external institutional actors. Basic service delivery is inseparable from governance considerations. Sustainable health sovereignty cannot be separated from the broader agenda of local economic development, from decent work, from community asset ownership and from the reduction of structural inequality.
A Different Model: Digital, Community-Vested, Locally Owned and Resourced
The alternative model is not theoretical as it is being built by local organisations and practitioners, largely without fanfare, frequently without the support of the established international architecture. Mobiklinic in Uganda, there are plenty of other people and organisations, is a digital health platform designed not as a donor-funded pilot, but as a blueprint for integrated infrastructure for national health systems, owned and operated by local entities, capable of evolving, surviving and thriving without any external partner. This is what real health technology transfer looks like.
Alongside this, place the framework of asset-based community development (ABCD), an approach linked to local economic development (LED) beginning not with deficits to be remedied by external intervention, but with the capabilities, social capital and institutional assets communities already possess. It is a rigorous methodology for mobilising local resources in ways building community agency rather than dependency.
Inside these two frameworks, further facilitating digital health outreach and engagement, consider competence-based skills development delivered through blended learning approaches able to reach aspiring and already engaged health workers. Capacity development is not training alone; it is structures, systems, people and the management of all three to deliver evolution where possible and the step changes required to get us away from what remain largely extractive practices engaged by the international community. These approaches share a common logic: they invest in people and institutions with a direct and durable vested interest in their own communities. Vested interest, properly channelled through accountable institutional structures, is not a risk to be managed. It is the most reliable sustainability mechanism available to us.
The Measure of Success
A critical question fudged in numerous evaluations is this: Do the systems continue to function effectively after the external partner has left? Not can they survive with reduced support? Not have we built a local NGO to replace the international one? We need governance and management structures and systems, staffed by local professionals, governed by community-accountable structures and financed through domestic and genuinely catalytic resources, taking full responsibility for the outcomes they were established to achieve. This standard implies specific, concrete changes in how development partners, bilateral donors, multilaterals, foundations and impact investors must orient their engagement:
- Resources are not synonymous with money. Ignorance is to be addressed with open-source knowledge alongside learning capabilities allowing innate talent and intelligence to be developed inside communities.
Good governance is reinforced by basic services being part of locally inclusive economic systems fitting into wider socially responsible infrastructure development. Economic empowerment reinforces social responsibilities and brings government systems back to politics for the people by the people.
- Invest in the economic and social determinants of health. Water, nutrition, noting urbanisation, with critical work on women’s rights and decision-making power a priority. Decent work and inclusive local economies are the real foundations of population wellbeing. Do not be afraid to block corporates seeking to manufacture foodstuffs with ultra processed foods satiating immediate wants and creating problems inside a generation far more costly than building on local primary production. Healthy food and water in, healthy people part of a society climate resilient
- Resourcing systems and accountable institutions, not projects. The current project-cycle model is structurally incompatible with building health sovereignty. Multi-year institutional financing, fit to wider resource development, noting skills, structures, systems to support promotive and preventive health aligning with governance systems.
- Be serious about cash-based programming. Market dynamics and people’s individual rights are critical ingredients and must be measured alongside the input of money if this is to change the trajectory of growing inequality compounding inequity. Engage local actors who bring local market engagement to change the dynamics of cash-based programming.
Build beyond the rhetoric and use of terms such as social protection to develop integrated systems measuring wellbeing outcomes.
- Require exit strategies from the outset. Every programme should be designed around a credible transition to local, defined, ownership with way markers against which transition is assessed and built. The closure of an organisation is a sign of success in delivering its mandate as it develops good governance through local accountability and inclusion in economic development for decent work.
- Reward what works at scale over time. The incremental gains of promotive and preventive health, the practiced, resolute, accumulation of institutional capacity, the gradual extension of community agency are harder to count but they are more consequential.
- Support local innovators directly. Fit this to how cash-based programming makes further step changes in how funds are sponsoring localisation fitting to skills and enabling infrastructure building. This means stopping routing resources through international intermediaries who extract margin and impose frameworks designed for other contexts and other eras.
The Opportunity in the Rupture
The rupture caused by USAID close out has done one thing decades of incremental advocacy from inside the system could not do: it has made dependency visible, undeniable and, hopefully, a political priority in a way creating genuine space for structural change. African governments, African civil society and African innovators do not need to be told they are capable of managing their own health systems. The question has always been whether the international community would make the political and financial choices necessary to enable this to happen when the conversations remain largely with industrial insiders defending their mature business models.
The organisations and approaches described are operational, being built now by practitioners who understand what has not worked, why it has not worked and how to go forward. The task for the development community is to make the choice to back them beyond sustaining what the Boston Box calls cash cows.
To direct resources toward locally owned and accountable systems measuring wellbeing outcomes and empowering, creating confidence facilitating the basis for good governance.
Donors to hold themselves to the standard of exit rather than perpetuation as the Gates Foundation is setting itself.
To accept genuine health sovereignty, once achieved, will make their current roles require fundamental rethinking.
This is not a threat. It is the inflection point now requiring informed decisions from stakeholders beyond the aid industry’s global actors
.