A new compact for global health: rebalancing power between African governments and donors

The health financing crisis precipitated by the closure of USAID has thrown into sharp relief the vulnerabilities of health systems that rely heavily on external support. While such crises are acute, they expose deeper, longstanding issues: volatility in funding, fragmentation of aid, and a persistent misalignment between donor priorities and national needs. These problems are not new. For years, countries have struggled to plan and consistently deliver essential health services while dealing with unpredictable donors and short-term funding cycles, often forced to fit domestic priorities around external preferences.

The proliferation of multilateral initiatives, each with their own mandates and requirements, has exacerbated complexity, at times overwhelming ministries and diluting the effectiveness of both domestic and external investments. The result is a system that too often undermines country ownership and leaves essential health services exposed to political and economic shocks in donor countries.

There is growing recognition of the need for a new kind of partnership—a New Compact—between countries and their development partners. This is not a prescriptive blueprint, but an opportunity to reshape the relationship around three core principles:

• Country-led, evidence-informed priority setting: National governments must lead in defining, budgeting, and monitoring essential health services. Technical support when needed, should support countries to identify which health services are most essential and cost-effective for their populations. This empowers countries to set the agenda and ensures that both domestic and external resources are directed where they can have the greatest impact.
• Domestic-first financing: Countries should commit to funding the highest-priority services from their own budgets. This approach builds a stable foundation for health systems and strengthens accountability to citizens.
• Consolidated, supplementary aid: Donors and multilateral initiatives would align their support to expand the package of services beyond what domestic budgets can cover, reducing fragmentation and focusing on areas where aid can add the most value. There is also a significant opportunity for these initiatives to refocus on common goods—such as pooled procurement facilities, market shaping for new technologies, and support for cross-border health security—while evolving their approach to financing country-level services.

This isn’t about donors stepping back but about stepping into a more supportive and strategic role. By shifting the focus of aid from core service provision to expanding and strengthening national systems, donors can help build resilience and sustainability for the long term.

Leadership and new narratives for global health

For this shift to succeed, leadership from within Africa will be essential. The African Union, supported by the Africa Centres for Disease Control and Prevention, is well placed to champion a new approach, providing political momentum, technical guidance, and a platform for collective action. Regional coordination can help ensure that reforms are shaped by African priorities and realities, not just external agendas.

But a shift in power also requires a shift in narrative. For too long, the story has been one of donor-driven “lives saved” and external expertise. As the sector moves towards country-led approaches, the narrative must also evolve—celebrating national leadership, system resilience, and shared responsibility for both domestic and global public goods. These are the true markers of long-term progress and genuine country ownership, and they call for new ways of measuring and communicating success.

The current aid cuts are not anomalies to be fixed, but instead symptoms of a model that has reached its limits. A New Compact, rooted in country leadership, shared responsibility, and a renewed narrative, offers a practical and political pathway to a more resilient, equitable, and effective system. The time for change is now, with African institutions leading the way and partners aligning behind a vision that puts a long-term vision for effective and sustainable health systems at the centre.

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Nadia Yakhelef is Head of the Health Economics and Financing Programme at the Africa Centers for Disease Control and Prevention, based in Addis Ababa.
Tom Drake is a Senior Policy Analyst at the Center for Global Development in London.