In August 2026, health and finance officials from 16 African countries met in Mauritius for the first in-person meeting of CABRI's Network of African Health and Finance Officials. The meeting covered two issues in which the members had previously expressed interest: navigating health aid cuts and strengthening ministry of finance-ministry of health coordination. This blog covers the first priority; a companion blog covers the latter. 

Development assistance for health fell 21% in 2025, from $50 billion to $39 billion: a fifteen-year low, and less than half its 2021 peak. The shock has landed on health systems that were already exposed. In low-income countries, aid made up 32% of current health spending in 2023 and exceeded domestic public spending on health, while health's share of government budgets has been stuck below 6% since 2010.

This is not a problem the health sector can solve alone. On the first day of the three-day meeting, officials shared how they are responding across ministries of finance and health. Four themes stood out.

A structural shift, not a temporary shock

While there are various fora bringing together African ministers of finance and health, technocrats rarely meet with their cross-country counterparts to reflect on how their work is affected by and can feed directly into what is happening on the international stage. One objective of the first day was to increase technocrats’ awareness of how the global health financing architecture is evolving. 

Participants heard that the nature of global health financing is changing, not just the quantum. Funding is becoming more conditional on outputs and outcomes, co-financing policies are becoming the norm, and many donors are increasingly seeing aid almost exclusively as a foreign policy tool. 

More funders are using co-financing policies.  The Global Fund, Gavi and US bilateral agreements all treat co-financing as central to transition, with higher requirements tied to specific programmes and budget lines and stronger enforcement. In the 31 countries that have signed new US health agreements, funding is projected to fall by around 44% between the 2021–25 and 2026–30 periods. Co-financing commitments could reach 22–38% of government health expenditure by 2030 in Cameroon, Kenya and Uganda, and well over half in Nigeria. Where several donors' graduation dates cluster in the same budget years, countries risk a fiscal cliff.

The practical message for finance and health ministries was to cost co-financing obligations across the whole sector, test them against the fiscal space available for health, and build them into medium-term expenditure frameworks rather than meeting them programme by programme. 

Alignment: the same word, different views

One of the most candid exchanges concerned donor alignment. Countries often say donors are not aligning with national priorities; donors often say they are. So where is the disconnect?

Burkina Faso's presentation offered a useful answer. Donors’ funding priorities contained in a national health plan does not guarantee alignment, because funding may still sit off-budget, run through parallel systems or follow its own indicators and timelines. Real alignment shows up in measurable things: the share of aid recorded in the budget, spent and reported through national systems, and directed to underfunded national priorities. 

The Lusaka Agenda's new alignment indicators follow the same logic. They track donor funding through each stage of the budget cycle, moving beyond a simple on-budget versus off-budget distinction.

Countries described how they are asserting leadership. Zambia is building towards "one plan, one budget, one report" through its National Health Compact, which identifies a $3.8 billion financing need through 2030. Burkina Faso signed 24 financing agreements in 2025 to reduce its reliance on any single funder (challenges of fragmentation were not probed). As one participant put it, external financing should move from "doing for" countries to "building with" them.

Transition as institutional reform

Country responses across the region have been uneven. An IMF survey of 28 country teams found that only about 30% of lost aid is expected to be replaced through reprioritisation, around 30% is judged no longer needed, and roughly 40% is left unfunded.

Yet the Network heard of determined responses. Ethiopia, which lost more than 5,000 US-funded health worker contracts, directed government staff to take over critical functions within days. It raised its federal health budget by 43% in a single year and created a new levy on 17 revenue streams. Nigeria increased its domestic health allocation by around $200 million within a month. Its federal health budget share has risen from 3.5% in 2023 to 6% in 2026. Sierra Leone combined emergency reallocations and sped up implementation of its social health insurance scheme, under oversight from the Office of the President. Burkina Faso reports that health has received between 11.7% and 14.5% of the state budget between 2020 and 2027, alongside a restructuring of public health spending rather than a mechanical substitution for lost aid.

The common thread was that transition is not about replacing aid dollar for dollar. Zambia's officials put it most clearly: the key capability is making explicit choices about what to protect, what to integrate, what to redesign and what can no longer be sustained in its previous form. 

Procurement featured strongly too. Speakers stressed that a health financing transition will only succeed if procurement systems and capabilities transition at the same pace, and that budgets must account for total landed costs and supply risks, not just unit prices. 

What countries want to learn from each other

The questions officials put to one another were revealing. How did Nigeria secure its increase so quickly, and how was it negotiated with the finance ministry? Why did South Africa take the alternative approach, carefully costing the gap before allocating additional resources? How did Zambia bring donor-funded community health workers onto government stipends? Has social health insurance helped absorb the shock? How can primary health facilities retain and spend the revenue they collect? How can countries make better use of regional pooled procurement, which could cut procurement costs by around 30%?

Ethiopia's advice to peers was to build domestic financing analysis, including undertaking health accounts, fiscal space analysis and costing priority packages, before a crisis hits. Ethiopia already had those habits in place, so its decision-makers had better oversight of financing requirements and were not starting from zero.

Why a network matters now

The Network is demand-driven, with a focal point from both the health and finance ministry in each country. This is important because the aid transition can only be managed as a single government process. For development partners, the participants' message was consistent: offer longer and more predictable transitions, channel more funding through country systems, harmonise co-financing definitions, and invest in the data and institutions countries need to lead.

In the words of Burkina Faso's Finance Ministry, the aid cut "is not merely a financial risk: it is also an opportunity to accelerate the building of a health financing system that is more predictable, better aligned with national priorities, and progressively less vulnerable to external shocks." The Network intends to help countries seize that opportunity, together.