Vivianne Ihekweazu (Lead Writer)
The development of the health sector in Nigeria is widely regarded as primarily a health financing challenge, that is how does a society allocate its limited resources to achieve the best possible outcomes in health and health care?
Consider the story of Grace, who runs a small food stall in Onitsha market. She lives with high blood pressure, a condition that requires regular monitoring and medication. However, with the high cost of medical care, she often delays care, only visiting a clinic when symptoms become severe. She receives suboptimal and expensive care. Grace adds to Nigeria’s terrible health indices. Sadly, her story is not unique. Across Africa, millions face similar challenges, not because services do not exist, but because they remain out of financial reach.
At the recently concluded 78th World Health Assembly, this challenge was in the spotlight during a well-attended high-level side event titled “The Future of Domestic Financing for Health is Now: Africa’s Pathway to Sustainable Health Systems.” The event was organised by Nigeria’s Ministry of Health and Social Welfare and co-hosted with the Ministries of Health from Ethiopia, Senegal, and South Africa, along with the African Union Commission, AUDA-NEPAD, SADC, EAC, the Afro Champions Initiative, and the Global Fund. It brought together African health and finance leaders to explore how countries are responding in real time to the challenge of declining donor support.
As global aid declines, there is growing recognition that governments world-wide have to pay more attention to sustainable health financing. This was highlighted by the unanimous adoption of a resolution on Strengthening Health Financing Globally, sponsored by Nigeria. The resolution urged countries to boost domestic resource mobilisation, cut down out-of-pocket spending, and invest more in primary healthcare.
Dr. Kelechi Ohiri, Director General of Nigeria’s National Health Insurance Authority (NHIA), has led Nigeria’s efforts in getting this resolution passed. In his welcome remarks Dr Ohiri asserted that “sustainable health financing is not just an economic imperative, it is also a moral one and speaks to our collective responsibility to ensure that no one is left behind in accessing quality and affordable health care.”
Nigeria’s resolution signals a Shift
“Nigeria has taken a decisive step,” said Dr. Iziaq Adekunle Salako, Nigeria’s Minister of State for Health and Social Welfare. “With over 70% of health spending in our country still funded out-of-pocket, this resolution demonstrates our resolve to frontally address this challenge.”
Nigeria’s resolution builds on a long trajectory of commitments, starting from the Abuja Declaration which urged African countries to allocate 15% of their budgets to health. But it also acknowledges today’s stark realities, public health budgets are squeezed by debt repayments, and overseas development assistance (ODA) is under severe threat.
What countries are doing in response
The side event served as an opportunity for African health leaders to share how they are pivoting from aid dependency, under pressure.
In Ethiopia, Dr. Mulukem Argaw Haile explained that the Ministry of Health immediately initiated high-level discussions with the Ministry of Finance. One strategy Ethiopia is implementing is turning to non-traditional donors, as well as philanthropic contributions and private institutions. He also explained that they were strengthening existing financing schemes, such as adapting their community-based insurance schemes to increase their resource mobilisation potential.
Zimbabwe is demonstrating how health taxes can become a lifeline. According to Hon. Prof. Mthuli Ncube, Zimbabwe’s Minister of Finance and Economic Development, they introduced taxes on sugar, alcohol, fast food, and then ring fencing them for health infrastructure and cancer care. “We have made significant efforts to address the gap, and currently, we are capable of funding it.”
In Ghana, Deputy Minister of Finance Hon. Thomas Nyarko Ampem highlighted the vast untapped tax base. They have a VAT gap of over 70% and a corporate income tax gap of 80%. He stated that they were not asking our citizens to pay more, they are asking more citizens to pay. “We do not need to introduce new taxes in Ghana to overburden the already few Ghanaians who are being good citizens and are paying taxes.”
Senegal and Mozambique similarly showcased adaptive approaches, ranging from expanding risk-pooling mechanisms and health insurance coverage to creating sovereign health funds and eliminating tax loopholes.
Image credit: Nigeria Health Watch
Lessons in domestic innovation
There is a clear sense of urgency, but the focus must be on what needs to be done. “We need to move from budgeting for survival to planning for sovereignty,” said H.E. Amma Twum-Amoah, the new African Union Commissioner for Health, Humanitarian Affairs and Social Development. Her rallying call was clear “This moment calls not for withdrawal, but for recalibration and shift from dependency to balanced partnership.”
Dr. Donald Kaberuka, AU High Representative and former President of the African Development Bank, warned of “analysis paralysis.” “There is no point lamenting about it” The US has made a choice.”
He asserted that we must recognise that aid was always meant to be phased out. What matters is what we do about it now.
A measured transition: The global fund’s perspective
“It is not a light switch and different countries across the continent are in very different states of readiness,” Peter Sands, Executive Director of the Global Fund stated. Countries have differing abilities to absorb full financing responsibility, depending on their disease burden, income levels and how developed their health systems are. He cautioned that mishandling this transition could reverse hard-won gains and cost lives.
Instead, he called for a pragmatic partnership model. “We very much see ourselves as a partner and enabler, aligning behind the plans laid out by the leaders of countries.” He mentioned that the organisation’s aim is to eventually step back, but not before countries are ready.
Turning commitments into action
The adoption of the health financing resolution demonstrates strong political will and leadership; however, the harder work lies ahead. As the resolution notes, domestic resource mobilisation must be the primary strategy, supported by pooled funding, strengthened public financial management, and prioritised health benefit packages.
The path forward also requires integration. As UNAIDS Executive Director Winnie Byanyima noted, “HIV services must come back into the mainstream health system. That means governments must integrate community health services and fund them sustainably.”
So, what now?
African countries and their partners must come together around five key priorities:
- Commit to the Abuja Declaration — Governments must move from aspiration to action, ensuring 15% of national budgets are allocated to health.
- Strengthen domestic tax collection — Expand health taxes on sugar, tobacco, and alcohol, while improving budget execution and reducing leakages.
- Invest in primary health care — Allocate at least an additional 1% of GDP to primary care, as recommended by the UN resolution.
- Institutionalise accountability — Strengthen tracking of domestic and external financing using national health accounts and digital tools.
Align aid with national priorities — Development partners must support government-led strategies, not parallel systems, and remain engaged during transition phases.