The sudden suspension of American aid, notably via the United States Agency for International Development (USAID), has sent shockwaves through many African countries. This decision, whose consequences are particularly serious in the fight against HIV, malaria, tuberculosis, reproductive health and child health, highlights the structural fragility of African healthcare systems. For decades, these systems have been largely supported by external funding, creating a situation of dependency that is now proving to be a tangible danger. Faced with this crisis, Africa finds itself at a decisive turning point: either it continues on the path of dependence, hoping for further international aid, or it seizes the opportunity to thoroughly restructure its health sector and build sustainable health sovereignty.   This article takes a two-pronged approach to exploring this issue. First, a narrative dive into a dream I had will highlight the concrete effects of this suspension of aid, illustrating the realities experienced by healthcare professionals and vulnerable populations. This scenario will help us to grasp the urgency and scale of the challenges posed by this new situation. Secondly, an in-depth analysis will draw out the main lessons of this crisis, highlighting the opportunities it offers for rethinking the financing and organization of the African health sector.   The harmattan season and the awakening of the lions   I had a dream. A troubling dream, burning with realism, where Africa stood at an uncertain crossroads. The warm harmattan wind blew with unusual harshness across the savannah. This was no mere seasonal breeze, but an allegory of change, challenge and renewal. And in this dream, destinies intertwined: that of a destitute doctor, a desperate mother, a child battling fever and a continent seeking to emancipate itself from a deadly dependency.   The harmattan was blowing with unusual harshness across the savannah. The dry, dust-laden wind rushed through the winding alleys of the Koroma hamlet, raising ochre clouds that settled in an impalpable veil over the terracotta huts. In the small clinic, Doctor Amadou wiped his sweaty forehead and gazed helplessly at the half-empty shelves of his pharmacy. The pungent smell of disinfectants and fading remedies wafted through the air, but their efficacy would soon no longer suffice. Since the abrupt announcement of the suspension of American aid, stocks of medicines had been melting like raindrops on a dry land.   In this region, where life was often based on a fragile balance, the sudden disappearance of treatments for malaria, antiretrovirals and vaccines posed a mortal threat. Amadou knew this better than anyone: he had already had to send patients away, explaining that there was nothing left to administer. And that morning, when a young mother, Mariama, crossed the threshold of the clinic, carrying her fever-burning son against her chest, he felt his heart clench. Ibrahim, barely three years old, was suffering from a severe attack of malaria. In the past, a single pill would have been enough to turn the tide. Today, all that remained was hope and prayer.   A few hundred kilometers away, in the big city of Bamako, the corridors of the Ministry of Health echoed with the worried discussions of experts and politicians. Reports flashed across the desks, each figure testifying to the scale of the impending crisis. One question was on everyone's lips: how to deal with this health catastrophe, the result of a dependency that has been nurtured for too long?   But in the midst of this storm, a glimmer of audacity was beginning to emerge. In the most visionary circles, the idea of a historic turnaround was germinating. What if, instead of panicking, Africa were to seize this ordeal as an opportunity for transformation? Since 2001, the Abuja Declaration has committed African countries to devoting at least 15% of their national budgets to health. Yet very few countries had met this commitment. Perhaps it was time to reverse the trend, break with the habit of external aid and build a truly autonomous healthcare system.   In the field, Amadou was already seeing the first signs of this change. Deprived of international resources, some communities were reorganizing. Local collections were set up, community health insurance initiatives were born, and partnerships between local businesses and health institutions began to emerge. Africa, resilient and ingenious, refused to give in.   Thus ended my dream, a dream imbued with profound meanings and valuable lessons. Allow me to explore some of these illuminating lessons.   Deciphering the storm and building for the future   The suspension of USAID aid is not just a crisis: it's an eye-opener. It exposes the weaknesses of a development model that has relied too long on international aid.  

1. Dependence on external aid: a sword of Damocles

  African healthcare systems have been built with international funding, leaving many countries vulnerable to donor decisions. "Last year, USAID allocated $8 billion in aid to Africa, of which seventy-three percent was dedicated to healthcare," said Jean Kaseya, Africa CDC's director general, on the BBC's Newsday program on January 29, 2025. By way of example, in 2023, Nigeria received almost $600 million in health aid from the United States, representing more than 21% of its national health budget for that year. For its part, South Africa is one of the main beneficiaries of the PEPFAR program, with an envelope of $332.6 million in 2024. However, in recent days, many HIV treatment centers have announced to their distraught patients that their services have been abruptly interrupted. The disruption in the supply of antiretroviral drugs is bound to have dramatic consequences, putting countless lives at risk.       Although the USA has made a significant contribution to global health efforts, its disproportionate influence is a structural obstacle to equity and justice, both in the field and on a global scale. While it is easy to measure the consequences of their withdrawal, it is more difficult to assess the cost of their "generosity".   When it comes to the production of academic knowledge, global health is a highly centralized field, where a handful of players, mainly based in the USA (and Western Europe), hold considerable power, to which others must submit or which they seek to imitate. This domination is not limited to funding: it shapes research orientations, methods, training, scientific publications, programmatic priorities and governance structures. This intellectual monopoly engenders and perpetuates inequitable practices that serve above all the interests of the United States, often to the detriment of the countries and populations for whom, with whom and in whose name this knowledge is supposed to be produced.   Faced with such an imbalance, how should the world react when the power and influence of a single country are so deeply rooted in global structures that its decisions alone can destabilize entire systems?   Like a tree whose roots sink into unstable soil, these systems falter as soon as the source of funding dries up. This crisis is a cruel reminder that dependence on external aid is not a viable solution. Above all, it highlights the urgent need for governments to step up their commitment to ensuring sufficient and sustainable domestic funding. The direction is uncertain and, to a large extent, beyond our control. However, it is an opportunity to express our aspirations and create new models. We are faced with a miniature space on which other horizons can be imagined.  

2. Investing in health: an underestimated economic lever

  In a document entitled A Heavy Burden: The Productivity Cost of Illness in Africa, published in 2019, the World Health Organization (WHO) estimates the loss of productivity caused by diseases and epidemics affecting the population of the 47 countries in the Africa region at 2,400 billion international dollars a year, equivalent to 630 million lost years of working life. The report also highlights the fact that 14 million Africans fall into poverty every year as a result of ever-increasing healthcare costs. "With around 100 health emergencies a year, costs are exploding for Africans, whose per capita out-of-pocket payments have risen from $15 in 1995 to $38 in 2014."   The 2024 Global Spending on Health: Emerging from the Pandemic report, published by the World Health Organization (WHO), reveals a decline in per capita public spending on health in 2022 compared to 2021, irrespective of countries' income levels. This trend follows a significant increase during the early years of the pandemic. The WHO also points out that, in 30 low- and lower-middle-income countries, out-of-pocket expenses remain the main source of financing for the healthcare system. Indeed, in 20 of these countries, more than half of total healthcare expenditure comes directly from patients' pockets, exacerbating the cycle of poverty and vulnerability.   Too often perceived as a cost or an expense, health is in fact a strategic investment. A healthy population is more productive, generates fewer unforeseen expenses and enables more stable economic growth. To ignore this aspect is to sacrifice the economic and human potential of a young and dynamic continent. The report Saving Lives, Spending Less: The Case for Investing in Noncommunicable Diseases (2021) analyzes the situation in 76 low- and lower-middle-income countries. The authors identify the "best options" for combating non-communicable diseases (NCDs) and demonstrate that every dollar invested in scaling up these interventions in the countries concerned could generate a return of US$7, which could represent a total of US$230 billion by 2030.  

3. Building health sovereignty

  One of the most encouraging aspects of this crisis is that it could potentially lead to an increase in domestic health funding. Indeed, if the suspension of US aid has had such a significant impact and such serious consequences, it is precisely because health funding in Africa has never been up to the level of the health challenges facing the continent. The cases of Nigeria and South Africa mentioned above illustrate our point once again. Despite the Abuja Declaration of 2001 and numerous recent commitments by governments to devote up to 15% of their budgets to health, the situation has not really changed (see Figures 1 and 2).     Long before the suspension of US aid, the COVID-19 pandemic highlighted the need for African countries to build sustainable sovereignty. This implies, as Aidspan has regularly stressed, a substantial, systemic and sustainable increase in domestic funding for the health sector.   Long before U.S. aid was suspended, the COVID-19 pandemic brought into sharp focus the need for African countries to build sustainable health sovereignty. As Ntobeko Ntusi in Nature magazinerightly reminds us: "If African countries, for example, had taken control of HIV treatment in the region, PEPFAR's retreat would have had only a limited impact. If Africa had a regional vaccine manufacturing system, the continent would not have been left behind during the COVID-19 or Mpox crises".   Taken in isolation, African states remain vulnerable, hampered by limited resources that impede the development of a robust local pharmaceutical industry. It is against this backdrop that the creation, in 2021, of the African Medicines Agency (AMA) marks a strategic step forward. With a mandate to pool resources and expertise on a continental scale, the AMA could play a decisive role in reducing Africa's pharmaceutical dependence. Provided, however, that it receives substantial political, financial and material support from its member states. By reinforcing access to safe, affordable medical products, it would not only contribute to the continent's health autonomy, but also to its resilience in the face of the gradual disengagement of international donors, particularly American.   Making Africa the master of its health destiny requires a profound rethinking of priorities: intensifying local drug production, investing in the training of health professionals and modernizing medical infrastructures. Like a lion that must learn to hunt rather than rely on opportunistic carcasses, the continent can no longer afford chronic dependence on external funding for public health.   Conclusion   The harmattan, though merciless, often heralds the rainy season and the rebirth of parched lands. In the same way, this sudden suspension of foreign aid could be the catalyst for change, a test that forces African states to reconsider their approach to public health.  Cristian Montenegro's words speak for themselves:   "The withdrawal of the United States from WHO and the potential collapse of USAID have revealed the extent to which the field has become dependent on a single actor. More precisely, they reveal how the global health system has been designed around this dependence. This is a difficult moment, but also an inflection point. The temptation to restore the status quo and breathe a sigh of relief is strong - to see the US return to the center, injecting resources to keep existing structures afloat. Others might wish to replace American leadership with an equally centralized arrangement, but this would only perpetuate the status quo, plugging systemic gaps rather than addressing the deeper inequalities that have long defined global health. Such relief would be understandable, but ultimately short-sighted. Instead, we must use this moment to confront the deeper structural inequalities that have shaped global health, and work towards meaningful transformation."   While the shadow of precariousness hangs over the immediate future in many African countries, it can also be dispelled by a strong political will and the strategic mobilization of local resources. Health is not a cost, but a vital investment in the continent's development. Africa must not only weather this storm; it must emerge stronger, more resilient and, above all, in control of its own health destiny. Let's hope that the high-level meeting of African leaders, held on the sidelines of the African Union summit on February 14, 2025, marks a decisive turning point in favor of national health financing and the effective alignment of investments with the continent's priorities. Sustainable solutions exist: the African Epidemic Fund offers an autonomous response to crises, independent of donors, while health taxes, strategic partnerships and the ALM Declaration are essential levers for sustainable financing.