An opinion article by Dr. Olive Shisana, Hon Professor, and Mr. Elhadj As Sy.
Africa is entering a unique period in its history, one that requires more than a shift in donor models. It demands a new political order in global health, one that confronts how power is exercised and by whom. Global health has been treated primarily as a financing pain point rather than a health challenge: something to be addressed with more aid, more external support, and more donor-driven programs. However, as revealed during the Global Health Reform – Africa Regional Dialogue, Africa does not suffer from a financing deficit as much as from a political economy shortfall. Aid dependency is simply a symptom. The core problem is the continent’s limited agency in shaping the global rules, priorities, and governance structures that determine health outcomes.
This conclusion emerged consistently during consultations across all five regions of Africa. Participants were clear that Africa’s health future cannot be anchored in aid-dependent models that weaken sovereignty, fragment national priorities, and dilute the continent’s political influence. Reform, they argued, must begin with a shift in power, not merely a change in funding flows.
Africa already funds most of its health expenditure through domestic sources (government budgets, out-of-pocket payments, and private-sector investments), and external funding in some countries barely exceeds 20%. Nevertheless, despite this domestic effort, agenda-setting authority in global health remains largely concentrated outside the continent. Initiatives are often designed elsewhere, conditions are imposed with limited negotiation, and external actors continue to shape national health choices in ways that overshadow domestic priorities. African governments are left accountable for results without having commensurate influence over how global health is governed, financed, or delivered.
Worsening this imbalance is the long-term decline in development assistance. The OECD 2023 Development Co-operation Report confirms that global aid to low and middle-income countries has fallen in real terms for two years in a row, with further declines expected as donor governments tighten fiscal policy. In a world moving into a post-aid era, Africa must enter a post-dependency period. As the world moves into a post-aid era, Africa must chart its own path into a post-dependency future. Crucially, the continent’s growing emphasis on sovereignty and self‑reliance is not merely a reaction to declining aid budgets. For a region where 60% of the population is under 25, it reflects the urgency and impatience of a new generation of Africans demanding peace, equity, better health, and dignity in how decisions about their lives are made.
Throughout the Dialogue, participants stressed that Africa cannot shape global health reform without first consolidating its political voice. Fragmentation and, at times, redundancy across institutions, mandates, and regional blocs have diluted the continent’s negotiating power and hardened its periphery-bound role in global governance. There is an urgent need for greater continental coherence in decision-making, aligned mandates between regional and continental organizations, stronger political leadership on health as a strategic investment, and consistent African representations and positions in the world’s conversations. Participants pointed to examples from other sectors, such as trade and financial reform, where unified African positions have translated into greater global influence.
This political repositioning aligns with the spirit of the Accra Political Declaration on Africa’s Reset, which advocates for increased African autonomy in shaping the global economic order, reforming multilateral institutions, strengthening domestic governance systems, and integrating health into broader economic, climate, industrial, and digital transformation agendas. The Accra Reset reframes health not as an isolated technical sector, but as a driver of economic resilience, productivity, and continental integration, making global health reform inseparable from Africa’s wider political and economic renewal.
Moving “beyond aid” does not mean rejecting external support. Participants were clear that the issue is how external financing is structured and whose priorities it serves. External resources should reinforce African priorities, not substitute for them. This requires increasing predictable domestic and regional investment in health, developing shared financing arrangements that reduce duplication, and mobilizing public-private investment aligned with national strategies rather than pulling systems off course.
Integrating health financing with macroeconomic strategy, debt sustainability frameworks, and climate resilience plans is essential if health system reform is to endure. This approach echoes the work of the WHO Council on the Economics of Health for All, which argues that health should be treated as an investment in development rather than a cost. As many Dialogue participants warned, priorities that are not financed domestically eventually become priorities shaped externally.
Participants also called for a fundamental shift in how evidence, research, and innovation are defined and valued. Persistent challenges remain, including externally controlled data systems, chronic underinvestment in African research institutions, and the marginalization of indigenous knowledge and community insights. Yet Africa is home to some of the world’s fastest-growing public health and digital ecosystems. The rapid expansion of genomic surveillance networks during recent outbreaks, documented through the Africa CDC’s Pathogen Genomics Initiative, demonstrates what is possible when African systems are properly financed and coordinated. Reclaiming knowledge means ensuring that Africa leads in generating evidence, shaping research agendas, setting regulatory frameworks, and building innovation pipelines, moving from a passive consumer of external knowledge to an active global producer.
A similar imbalance persists in global representation. Despite being home to nearly 1.5 billion people and carrying roughly a quarter of the global disease burden, Africa remains underrepresented on the boards and advisory bodies that shape global health norms and investment decisions. Global legitimacy continues to be defined more by historical financial contributions than by population needs, scientific leadership, or moral authority. Calls by bodies such as the UN High-Level Panel on Global Health Crises to reform global health governance reflect a growing recognition that representation must better align with where health risks and impacts are greatest.
Many contributors emphasized that global health reform is not a technical exercise. It is fundamentally political. Achieving meaningful change requires continental solidarity, assertive leadership, institutional coherence, rebalanced partnerships, and a reimagined role for Africa in global governance. Africa’s unified engagement in recent global negotiations on pandemic preparedness and response has already demonstrated that when the continent speaks with one voice, it can influence global outcomes. The Kigali and Johannesburg dialogues build on this momentum, offering both the intellectual grounding and political direction for a new continental consensus.
Examples across the continent further challenge the notion that Africa lacks the capacity to lead. Rwanda’s investments in vaccine manufacturing, Senegal’s expansion of Institut Pasteur as a regional manufacturing hub, Kenya’s acceleration of digitally driven primary health care, and the growing number of countries implementing national e-health strategies represent a transition from dependence to resilience. These are not isolated successes, but signs of a broader convergence between political will, technical readiness, and continental ambition.
The vision emerging from the Dialogues isn’t about more aid but agency. We described a future where Africa’s health governance is fully embedded in economic, climate, industrial, and digital policy-making, domestic and regional financing is the backbone of system transformation, African-led research anchors global evidence, and continental institutions negotiate as equal partners on the world stage. The question is no longer whether Africa is prepared to lead. It is. The real question is whether the global community is ready to engage Africa not as a beneficiary or implementer, but as a co-author of the next chapter in global health.
