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My public health leadership journey began with the United States President’s Emergency Fund for AIDS Relief (PEPFAR) nearly two decades ago.
I joined the effort to strengthen blood services in Nigeria and other African countries that was led by that aid vehicle.
This programme which began in 2005, required collaborative agreements between the United States and partner countries such as Nigeria to develop centralised blood centres across their countries to enable access to quality blood and blood products and greatly reduce risks of infection from HIV, hepatitis B and C, and syphilis that could be transmitted through unsafely processed blood donations.
Between 2015 and 2016, this programme for blood services was shelved, as the conditions for the agreement were that countries would have leveraged on that aid opportunity, taken full ownership of the frameworks and built country-led sustainable blood services.
By January 28, 2023, PEPFAR marked its 20th anniversary, and in that time, it had invested over $100 billion in the global fight against HIV/AIDS and supported more than 20.1 million people on HIV treatment in over 50 countries globally. In Nigeria, PEPFAR over $7.8 billion had been disbursed to ensure that over 1.9 million Nigerians living with HIV/AIDS had comprehensive access to quality HIV prevention, care, and treatment services, thereby laying the groundwork for the eventual eradication of HIV.
It is no longer news that within days of the Trump Administration taking over at the White House, executive orders were signed, freezing funding for humanitarian aid efforts through United States Agency for International Development (USAID) and PEPFAR, with most staff put on indefinite leave and the future of the aid from the United States largely unknown. This executive decision from one of the world’s most powerful countries has raised significant uproar, and several legal tussles have ensued since then. However, I have a very strong feeling of ‘déjà vu’, that we have been here before, and should therefore not have been taken unawares.
In June 2020, then Prime Minister of the United Kingdom, Boris Johnson announced a 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. He did this barely a month after Donald Trump in his first tenure as President, threatened to end the United States’ relationship with the World Health Organization (WHO), signalling a de-prioritization of foreign aid by their governments.
When I led the joint PEPFAR-funded Federal Ministry of Health project for blood services in Northern Nigeria, 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, PEPFAR provided HIV treatments 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 covered 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.
About five years ago, in an article for Premium Times, I raised a question, “What Becomes of Africa As the Foreign Aid Taps Run Dry?”. We now have to urgently answer that question with intentionality and sustainability. For decades, the flow of aid has been regarded as a permanent source of income, I daresay, passive income, often taken for granted. The time has now come for us to consider it for what it implies, each U.S dollar and what it translates to in real-life terms for the people living with HIV/AIDS, and the children whose lives those dollars have saved, and our responsibility as African leaders to Africans. Perhaps Trump’s “freeze” on U.S. foreign aid is the wake up call we need to prioritise domestic financing and investment for health.
First, we must increase domestic healthcare funding. Historically, the allocation of insufficient funds to the healthcare sector has been the bane of many African nations. Governments must prioritize health in national budgets and explore innovative financing mechanisms, which include dedicated taxes, mandatory health insurance, and public-private partnerships. Public systems alone cannot meet the growing demand for healthcare services.
Therefore, strategic engagement of the private sector will diminish our dependence on foreign aid. One of the reasons why I am optimistic about Nigeria Health Sector Renewal Investment Initiative (NSHRII) is that it seeks to align national, sub-national, and partner financing through a tripartite agreement. This is within the context of one plan, one budget, and a common set of results to be delivered through government systems, thus enhancing efficiency, reducing wastages, and delivering concrete results for the people based on national and not foreign priorities.
In Rivers State, for the first time, 14.42% of the annual budget for 2025 has been earmarked for community-oriented healthcare delivery by Governor Fubara, unprecedentedly aligning closely with the 2001 Abuja Declaration of 15% as a benchmark for healthcare financing. However, increasing budgetary provisions must be accompanied by rigorous accountability mechanisms, to enhance transparency and the judicious use of funds, as corruption and inefficiency undermine African healthcare systems.
Secondly, investing in local pharmaceutical manufacturing. Currently, Africa imports up to 90% of its medicines, vaccines, and commodities, making it often detrimentally reliant on external suppliers. This was evident during the COVID-19 pandemic, when we were at the back of the queue for life-saving vaccines and commodities. Investing in local pharmaceutical manufacturing would reduce the percentage of imported medicines over the coming years and help to ensure medicine security on the continent.
Africa CDC appears to be making significant efforts towards local vaccine and other health products manufacturing—securing funding for manufacturers, improving regulatory instruments and mobilising support to establish local markets. Regulatory inequities in pharmaceutical manufacturing that favour the West persist and must be deliberately dismantled to open the African manufacturing space. Last week, on the margins of the African Union Summit in Addis Ababa, Africa CDC convened a High-Level Domestic Financing Meeting to chart a path on self-reliance beyond donor aid.
Thirdly, focusing on preventive healthcare. Nigeria’s leading causes of death include road traffic accidents, malaria, HIV, chest infections, heart disease, diarrhoea and complications from pregnancy and childbirth. These ailments are almost all preventable or treatable.
Most health resources are consumed in treating diseases rather than preventing them. Investing heavily and judiciously in primary healthcare by ensuring accessibility of centres, and availability of essential medicines and skilled manpower to drive vaccination campaigns against diseases such as measles, meningitis, tuberculosis and polio, health education on hygiene, nutrition, and lifestyle choices, in addition to early screening and detection of non-communicable diseases such as diabetes and hypertension. These will deliver excellent returns in terms of diseases prevented, and lives saved.
Africa, with its rich resources, vibrant youth population, and growing innovation ecosystems has the potential to chart its own course and be self-reliant. The recent Trump executive orders have presented Africa with an opportunity long overdue. International donors have facilitated significant gains in healthcare in Nigeria and across the continent. However, no matter how well-intentioned, aid cannot replace government investment and our own responsibility for building stronger and more sustainable health systems for ourselves.
A future where every citizen can access quality healthcare can only be driven by us, for us.
- Dr Adaeze Oreh is the Honourable Commissioner for Health in Rivers State. She is a Kofi Annan Global Health Leadership Fellow, Senior Fellow Aspen Global Innovators, Consultant family physician, public health expert and advocate for affordable universal healthcare for all Nigerians.