The present COVID-19 pandemic has revealed how vulnerable national health systems are and global tendencies towards nationalism and an inward-focus borne out of self-preservative instincts. If the foreign assistance tap is turned off permanently, millions of people in Africa will be left without the care they need, and lives will steadily be lost.

Earlier this week, Prime Minister Boris Johnson of the United Kingdom announced the merging of the U.K.’s Department for International Development (DfID) with the Foreign and Commonwealth Office in what is now to be known as the Foreign, Commonwealth and Development Office. DfID has, in the years of its existence, been key to offering development assistance to countries with high numbers of people living in poverty in the areas of primary education; access to reproductive health care; and the tackling of infant, child, and maternal deaths, and this role substantially aided many developing countries towards the achievement of the erstwhile Millennium Development Goals (MDGs). This announcement, which came barely a month after President Trump threatened to end the United States’ relationship with the World Health Organisation (WHO), signals a de-prioritisation of foreign aid by the governments of the U.K. and the U.S., and with current global economic realities, this could appear to be the beginning of a trend.

In a UNAIDS Data Report released last December, the organisation stated that funding for the global AIDS response had fallen for the first time since 2000. Given that funds for low- and middle-income countries were almost $1 billion less in 2018 than the previous year, UNAIDS estimated that an additional $7 billion would be required for the AIDS response in 2020.

Late last year, the Trump administration ordered both the State Department and the United States Agency for International Development to freeze billions of dollars in unspent foreign aid for the 2018/2019 fiscal year. In a move that side-stepped congressional approval, this was perceived as a sign that future foreign aid from the United States could be slashed altogether. In reality, these cuts in U.S foreign aid have started to make an impact in Africa, where many health interventions are highly dependent on aid. For example, since 2015, several national blood transfusion services that had been almost 100 per cent funded by the U.S government’s President’s Emergency Plan for AIDS Relief (PEPFAR) in places including Nigeria and Kenya, have been significantly cut. Now, not only are there major shortages of blood products, but the quality of supplies has plummeted with an increase in the prevalence of HIV, hepatitis, and syphilis in donated blood.

Since World War II, the U.S has been a major source of foreign aid across the world, especially to sub-Saharan Africa, with aid from the U.S. and other high-income countries to Africa averaging $49 billion annually and Africa alone accounting for 20 per cent of U.S. aid. However, with global economic downturns in the past decade, many other donor countries have equally revised their foreign aid commitments, threatening severe future aid cuts. Although the foreign aid tap has never completely dried out, the triple whammy of Boris Johnson’s recent announcement, Donald Trump’s economic policies and the threatened aid freeze highlight the vulnerability of countries that are greatly dependent on aid.

In Nigeria, when I led a joint PEPFAR-funded Federal Ministry of Health project, I saw how heavily we rely on U.S aid for ongoing costs in the health sector. With the second largest number of people living with HIV globally, the U.S.’s PEPFAR programme currently provides HIV therapy for about 90 per cent of Nigerians living with HIV/AIDS. For over one million HIV-infected children and 48 million people infected with malaria, aid from the U.S covers the full cost of their treatment, care and support. Through these assistance programmes, the mortality of children under five has reduced, and immunisation coverage has increased. Aid-sponsored family planning programmes have also prevented millions of unintended pregnancies – a key issue in a country projected to exceed 400 million people by the year 2050.

According to United Nations’ projections, by the end of this century, Africa will be home to one in three people on the planet and five of the world’s ten largest cities, and therefore the continent has little choice but to wean itself off aid. We can no longer expect the rest of the world to parent us.

Unfortunately, for decades, many African governments have treated the flow of aid as a permanent source of income. Perhaps Trump’s threatened “freeze” on U.S. foreign aid is a much-needed wake up call for African leaders to take the driver’s seat of economic management by prioritising domestic financing and investment.

According to United Nations’ projections, by the end of this century, Africa will be home to one in three people on the planet and five of the world’s ten largest cities, and therefore the continent has little choice but to wean itself off aid. We can no longer expect the rest of the world to parent us. The health and development of a country’s people should rest on its own shoulders and not those of taxpayers across the world. Aid-dependence is not only unbecoming, it is unsustainable.

Across Africa, deaths from HIV have reduced by about 50 per cent, however, if African governments do not start to think strategically about how to domestically raise finances in a climate with fast-dwindling foreign aid, much of the gains of the last decade could be wiped out. When it comes to HIV/AIDS, these are the steps African governments can take to ensure that funds are available to ensure the health and wellbeing of the roughly 27 million people on the continent living with the disease, and prevent further new infections.

First, it is critical that African governments develop robust and sustainable domestic financing mechanisms for accessible healthcare delivery. By encouraging competitive markets with stable monetary policies, creating jobs, and supporting regional and international trade, governments could boost domestic economic activity that can attract investment across the healthcare value chain. In 2016, only about 44 per cent of health expenditures on the continent was financed through domestic government funds, whereas 37 per cent came from out-of-pocket payments from African households without any commensurate improvement in the quality of healthcare, thus exposing them to significant hardships and worsening poverty. Ethiopia, Tanzania and Rwanda have recently shown high economic growth rates by consciously de-emphasising foreign aid and encouraging market growth. In Rwanda, life expectancy has increased by almost 20 years, 90 per cent of the population have access to primary care, over 97 per cent are immunised and the annual economic growth rate averaged about 9 per cent between 2018 and 2019. Nearby Ethiopia has succeeded in cutting child and maternal mortality by half.

…elected representatives must be held accountable for health. Executives and legislators at national, state, and local council levels must be interested and sufficiently answerable for health interventions and health outcomes in their constituencies and should be regularly confronted with these issues in the public domain, before and even more importantly after elections.

Secondly, countries on the continent cannot evade a universal health insurance approach that captures the predominant informal sector of the population. National and state health insurance schemes must now be rigorously re-designed such that the premiums of vulnerable individuals are contributed by government. Furthermore, community-based health insurance schemes could be linked up and fed into the larger state health insurance schemes to widen the pool of coverage. A couple of years ago, I encountered a middle-aged man who had been receiving HIV treatment for about 10 years. His treatment regimen was no longer effective and due to poor access to quality care, he had been tossed about until the complications of the infection left him bed-ridden and in critical condition. Unfortunately, by the time he was referred to a centre that could help him, he gave up the struggle and died. His story is just one of many examples of the millions living with HIV, whose lives are at stake when foreign aid is stopped, and domestic resources are not made available to take up that slack.

Third, African corporate organisations in developing countries must begin to play a more substantial role in the financing and delivery of healthcare on the continent. In fact, Nigeria’s recent achievement of polio eradication would not have been possible without the substantial contributions of Nigerian businessman and philanthropist, Aliko Dangote, and American philanthropist and co-founder of Microsoft, Bill Gates, working with indigenous community structures. In Nigeria, 88 per cent of the healthcare facilities in the country are primary healthcare centres. The efficient running of these 30,000 primary healthcare clinics, many of which are decrepit and abandoned, cannot be borne by government alone, and this highlights the urgent need for well-structured public-private partnerships with keen regulatory oversight, to ensure the delivery of quality, accessible and affordable health services, including HIV care and treatment, to the majority of the population. This model is being explored in some states in Nigeria such as Lagos, Delta and Rivers, with encouraging results and prospects for quality and affordable healthcare delivery.

Lastly, elected representatives must be held accountable for health. Executives and legislators at national, state, and local council levels must be interested and sufficiently answerable for health interventions and health outcomes in their constituencies and should be regularly confronted with these issues in the public domain, before and even more importantly after elections.

The present COVID-19 pandemic has revealed how vulnerable national health systems are and global tendencies towards nationalism and an inward-focus borne out of self-preservative instincts. If the foreign assistance tap is turned off permanently, millions of people in Africa will be left without the care they need, and lives will steadily be lost. African governments need to prepare proactively to safeguard the lives of their people – aid or no aid.

Adaeze Oreh is a Fellow of the West African College of Physicians who led a joint PEPFAR-funded Federal Ministry of Nigeria project between 2009 and 2014. She is a Senior Fellow for Global Health with the Aspen Institute in Washington DC.