Africa stands at a crossroads. The old model: donor driven, fragmented and reactive is fading. The new model: nationally owned, intelligence driven, and accountable is emerging. The US decision to channel billions directly to African governments is not just a funding shift. It is an invitation to build health systems that are resilient, equitable, data driven, community-centred, and politically credible.
Africa’s public health crisis is not new, but the stakes have never been higher. Despite decades of donor investment, health systems across the continent remain under-resourced, fragmented and dangerously dependent on external actors. The United States’ decision to channel billions of dollars directly to African governments marks a dramatic shift in global health financing. It places responsibility squarely where it belongs: in national institutions. The future of African public health now hinges on whether governments can turn this moment into meaningful reform.
For years, African health systems have been shaped by a persistent contradiction: billions in donor funding, yet chronic fragility in service delivery, data systems, and ineffective governance. The COVID 19 pandemic exposed this contradiction with painful clarity. Ministries of Health were forced to make life and death decisions using lagging indicators, fragmented reporting tools and donor driven priorities that often-bypassed national systems entirely.
This fragility is structural. Africa accounts for 17 per cent of the world’s population but only 3 per cent of global health spending. Out of pocket payments make up 37 per cent of total health expenditure – double the global average. In many countries, 30 to 70 per cent of primary health facilities experience regular stock outs and more than 80 per cent of health information systems remain paper based. These are not technical glitches. They are governance failures. Yet, a quiet revolution is underway.
In 2025, the United States began restructuring its global health engagement, signing a wave of direct government-to-government funding agreements across Africa. Kenya secured $1.5 billion. Côte d’Ivoire received $480 million. Ethiopia, Botswana, Sierra Leone and Madagascar, together obtained $2.3 billion. Nigeria, with its more than 230 million people, has now joined this new wave of direct partnerships. Crucially, these agreements channel US funding through government systems rather than through NGO-managed programmes. This is not just a funding change. It is a governance revolution.
Africa’s Health Intelligence Gap Is the Real Crisis
African health systems do not struggle because leaders just lack commitment or because money is scarce. They struggle because decision makers also lack real time health intelligence. Most ministries still rely on reports that arrive 30 to 90 days late; donor systems that create up to 40 per cent of data fragmentation; manual aggregation that hides local realities; and weak feedback loops from communities.
The consequences are predictable: outbreaks detected too late, stock outs that could have been prevented, and budgets that do not match actual needs. Africa takes 10 days longer than global averages to detect disease outbreaks, which is a delay that costs lives and money. If governments are now receiving billions directly, they must be able to see what is happening in their systems in real time. That requires intelligence-driven governance systems.
Why Health Intelligence Matters Now
Intelligence driven governance is not about gadgets or dashboards. It is about the discipline to see, decide and act quickly. When governments integrate facility level data, supply chain visibility, workforce deployment, disease surveillance, citizen feedback and budget execution, they can detect service disruptions early, allocate resources on the basis of evidence and hold managers accountable. Predictive analytics can cut outbreak response time by up to 40 per cent. Smarter procurement can save up to $2 billion annually. Every dollar invested in health intelligence yields up to ten dollars in efficiency gains. This is the logic behind innovations like the Health Systems Intelligence Lab (HSIL), which demonstrates how real time data and governance diagnostics can transform decision making.
Intelligence driven governance is not a technical upgrade. It is a political disruption. Real time visibility threatens actors who benefit from opacity, fragmentation, and slow decision cycles. Every African health system has its own political economy equilibrium, an informal balance of interests, incentives and power brokers who shape how resources flow and who gets to decide.
A Once in a Generation Opening
Direct funding changes everything. For the first time in decades, governments control the money; donors demand results, not reports; parallel systems lose their justification; and political leaders can claim visible wins. Côte d’Ivoire committed 60 per cent domestic co-financing. Ethiopia, Botswana, Sierra Leone and Madagascar are to come up with $900 million of their own budgets. Nigeria’s commitments are expected to grow. This is not charity. It is partnership and it is reshaping incentives across the continent.
The Politics: Why Reform Will Be Hard
Intelligence driven governance is not a technical upgrade. It is a political disruption. Real time visibility threatens actors who benefit from opacity, fragmentation, and slow decision cycles. Every African health system has its own political economy equilibrium, an informal balance of interests, incentives and power brokers who shape how resources flow and who gets to decide.
Three forces, in particular, will resist this shift.
1. Bureaucratic Gatekeepers Who Benefit from Information Asymmetry
In many ministries, data is power. Directors, programme managers and subnational officials often control information flows as a way of maintaining influence, negotiating budgets, or shielding underperformance. When dashboards expose facility level realities instantly, these gatekeepers lose leverage. Resistance will not be loud; it will be procedural, such as delays, “pilots,” committees, and endless validation cycles designed to slow down change.
2. Procurement and Supply Chain Interests
Opaque procurement systems are among the most politically sensitive spaces in African health sectors. Stock out manipulation, inflated tenders, ghost deliveries, and politically connected suppliers thrive in environments where no one can see what is happening in real time. Intelligence systems that track commodities from central warehouses to facilities threaten these networks directly. Expect pushback disguised as “capacity concerns,” “system incompatibility,” or “the need for further consultation.” In short, never-ending analysis leading to paralysis.
3. Donor and INGO Incentives that Favour Parallelism
For decades, donors and INGOs have built careers, budgets, institutional identities around parallel systems. These systems were justified as “efficient,” “accountable,” or “risk mitigating,” but they also entrenched a political economy in which governments were bystanders, not stewards. Direct funding flips this logic. Donors must now align with national systems; INGOs must shift from implementers to enablers. Some will adapt. Others will fight to preserve the old order.
The Real Battle: Control of Information
At its core, this reform moment is about who controls the truth of the health system.
• If governments control the truth, they can govern.
• If donors control the truth, they can dictate.
• If bureaucratic networks control the truth, they can extract.
• If no one controls the truth, the system collapses into fragmentation.
Intelligence driven governance redistributes power by redistributing information. This is real systems change at work. That is why it will face resistance and why it is essential. But even the best intelligence systems mean little if they fail to serve those most often left behind.
International NGOs have been central to Africa’s health gains. They have expertise, infrastructure, and decades of experience. But the era of parallel implementation is ending. To stay relevant, NGOs must shift from doing to enabling.
Equity Must Be the North Star
A health system can be efficient and still be unjust. Women make up 70 per cent of the health workforce but only 25 per cent of its leadership. Maternal mortality in Africa is 533 per 100,000 births, compared to 12 in high income countries. Up to 40 per cent of rural births occur without a skilled provider. People in informal settlements are three to five times more likely to face service disruptions.
Intelligence systems must make the invisible visible: women, the poor, rural communities, informal workers, and people living far from political power. Achieving this level of equity will require partners who understand their role in a new governance landscape. That is where NGOs fit in.
NGOs Fit in this New Era
International NGOs have been central to Africa’s health gains. They have expertise, infrastructure, and decades of experience. But the era of parallel implementation is ending. To stay relevant, NGOs must shift from doing to enabling. They must:
1. Strengthen government systems, not substitute for them.
2. Support real time intelligence and data integration.
3. Build financial governance and procurement capacity.
4. Transfer skills to local organisations.
5. Help governments navigate political economy bottlenecks.
6. Facilitate social accountability between citizens and providers.
7. Redesign business models around technical excellence, not project volume.
The INGOs that thrive will be those that evolve.
A Blueprint for African Governments
To seize this moment, African governments must:
1. Build national health intelligence labs.
2. Establish subnational decision rooms.
3. Integrate citizen feedback into decision-making.
4. Strengthen data governance and privacy.
5. Align donor reporting to national systems.
6. Train leaders in intelligence driven governance.
Technology alone will not save us. Leadership will.
Africa’s Moment to Lead
Africa stands at a crossroads. The old model: donor driven, fragmented and reactive is fading. The new model: nationally owned, intelligence driven, and accountable is emerging. The US decision to channel billions directly to African governments is not just a funding shift. It is an invitation to build health systems that are resilient, equitable, data driven, community-centred, and politically credible. If governments, donors, and INGOs rise to this moment, Africa can finally move from crisis response to a future defined by intelligence, dignity and shared prosperity.
Wale Osofisan is a seasoned governance strategist and policy analyst with over 23 years of experience advancing African-led, evidence-based solutions to political economy issues, humanitarian crises and development challenges.
