Beyond aid: Rethinking Africa’s health financing

Progress made in Sub-Saharan Africa so far 

Sub-Saharan Africa bears a disproportionate share of the global disease burden including for HIV.  There were 39.9 million people living with HIV globally, with 25.9 million of those living in Sub-Saharan Africa in 2023,with the highest rates of incidence and prevalence in East and Southern Africa. The region has made major progress in its HIV response with the annual number of people acquiring HIV in East and Southern Africa falling by 59% between 2010 and 2023. Annual numbers of HIV infections in West and Central Africa fell by 46% between 2010 and 2023. 

Worrying shifts in foreign assistance for the HIV response 

Health financing has been key to ensuring a sustained and efficient HIV response. Financing has played a critical role in the gains made in the HIV response in the past two decades. It has helped low and middle income countries have the capacity to sustain the HIV response particularly scaling up effective prevention and treatment initiatives. However, with shifts in development priorities, there’s been a trend of reduction in  funding for the HIV response.      

Both international and domestic funding for the HIV response dropped by 5% from 2022 to 2023 and around 7.9% from 2020 to 2023. In 2023, 59% of all HIV funding was from domestic sources. Funding is still short of the US$ 29.3 billion needed for the HIV response in low and middle income countries. The recent decision by the United States’  to freeze all US foreign assistance for 90 days endangers the HIV response even further. Critical institutions such as PEPFAR - which provided HIV treatment to over 20 million people across the world in 2024 - have been affected by stop work orders.      

Africa’s reliance on external funding 

Africa’s heavy dependence on external funding is a threat to the gains made in the HIV response. This is particularly concerning for Sub-Saharan Africa, which majorly relies on external funding to finance health. As of 2021, half of Sub-Saharan countries relied on development assistance to finance more than a third of their health expenditures. Despite the high disease burden, Sub-Saharan Africa has the lowest spending on health globally. 

Health spending by African governments is significantly lower than any other region in the world with 92 USD per person being spent on health in 2021 – a fifth of the next lowest region North Africa and the Middle East (379 USD per person). In 2001, African Governments passed the landmark Abuja Declaration where they committed to allocating at least 15% of their national budgets on healthcare. As of 2021 (most recent data available), only South Africa has met that target. With the rapidly rising debt burden on the continent, national health spending in many African countries is projected to decrease. 

What does this mean for the HIV response?

Without sustained funding, the progress made in ending the HIV epidemic is at risk. Community-led data is already revealing the damaging effects of the freeze. There are serious challenges in HIV prevention and treatment services. Supplies of HIV testing kits, PEP, PrEP and ART have been disrupted and some outreach services for testing have been suspended. 

The U.S. waiver to resume life-saving humanitarian assistance has led to resumption of HIV treatment and prevention of vertical transmission services. However, vital parts of national HIV responses are ineligible particularly, HIV prevention and community-led interventions for key and affected populations. 

It is vital to direct more attention to advocating for increased domestic allocation for health funding. Therefore ensuring a stronger and more resilient health system. This includes community-led documenting of the effects of weak and underfunded health systems on the HIV response; and showing policymakers the damaging effects on public health.