Nigeria and Mozambique Show How Health Systems Can Withstand Funding Cuts
Yagazie Emezi/Acasus
Health workers in Sokoto, Nigeria.
12 August 2026
allAfrica.com
By Melody Chironda
For decades, many health programmes across sub-Saharan Africa have relied on a familiar model: donors fund disease-specific projects, parallel delivery structures are built around them, and services expand or contract with the funding cycle.
That model is now under pressure.
As bilateral aid shrinks, countries that have relied heavily on external financing are confronting the vulnerabilities created by fragmented systems. But experiences in Nigeria and Mozambique suggest that resilience may not always require replacing every dollar lost. In some cases, it may begin with changing how existing resources are organised.
In both countries, local health leaders have been testing approaches that put governments more firmly in control, integrate services and financing, and reduce duplication between programmes and partners.
The results point to a broader lesson: when health systems are designed around government priorities rather than individual funding streams, they may be better equipped to absorb financial shocks.
Moving beyond "siloed" aid
Nigeria's experience is fast becoming a reference point for how countries can strengthen their health systems by taking greater ownership of financing and delivery, even as global donor funding grows less certain.
Folake Oni, Project Director for Nigeria at Acasus, said that the shift is built on two pillars: consolidating fragmented, donor-driven projects into a single government-led architecture, and expanding domestic financing for primary healthcare.
"There are two key things that stand out just from our perspective on what Nigeria has done differently to strengthen its health system," she said. The first is "shifting from where you have siloed disease-specific donor-funded projects towards a single government-owned sort of architecture."
That shift, Oni said, began roughly three years ago when Nigeria's sitting president launched the Health Sector Renewal Investment Initiative (NHSRII) and signed a compact with states, donors, and partners. Under the new approach, projects are implemented through what she called a "sector-wide approach that pulls domestic resources, donor aid, or donor funding under one government-led plan." This replaced the old model of "parallel, siloed, disease-specific donor-funded programs," which left health gains vulnerable whenever a donor pulled out or funding froze.
The second pillar is domestic resourcing.
In Nigeria, this sits under the Basic Healthcare Provision Fund, which Oni described as having "become like the backbone of primary healthcare financing in Nigeria." The government contributes 1% of its consolidated revenue fund toward strengthening primary healthcare, with financing structured to be performance-based - pushing facilities to be more accountable to the communities they serve and more motivated to improve.
Funding cuts expose vulnerabilities
The stakes of this shift became clear in Sokoto State, in northern Nigeria, where donor funding cuts, particularly from USAID, hit malaria programming hard. "Malaria progress stalled," Oni said, "because the system relied a lot on that funding. We saw stockouts of nets, of commodities, of malaria commodities and medicines."
But in that same period, she said, a state-led primary healthcare reform was taking hold. It was built around government ownership, integrated financing through a program called IMPACT, real-time data visibility, and local accountability. The results, according to Oni, were striking: stock-outs of family planning commodities fell from 43% to 22% in just six months between January and June. Maternal delivery infrastructure improved, and the number of women using modern family planning methods rose 24%, from roughly 40,000 to over 50,000.
The difference, Oni said, was government ownership.
"When donor funding freezes, it risks the continuity of those programmes and reverses the hard-won gains."
"It's not so much just about the funding being cut," she said. "It is also the lesson that we're learning from there," that a government-owned, data-driven system can absorb external shocks without collapsing.
A resilient health system, she said, should be able to absorb reductions in external funding without services collapsing.
"We're not saying donor funding is not important," Oni said. "But we're saying when it freezes or when it reduces, it's not fatal to the system. The system is still able to withstand those shocks and is even ready to do more and deliver more impact."
Oni also highlighted the importance of increasing domestic production of medicines and vaccines as countries seek greater control over their health systems.
"You want to make sure that the resources that you need are available from within, because that way you are more resilient," she said. "You're not dependent on any external forces or... external resourcing that you don't have influence or control over."
However, she cautioned that local pharmaceutical and vaccine manufacturing requires strong government leadership, adequate investment and coordination among governments, donors and other partners.
Government ownership of that goal is a prerequisite, she said, along with coalition-building among donors and partners to align on shared metrics for success.
"If you want to do local medicines manufacturing or local vaccine manufacturing, government has to own that goal," she said.
Nigeria has discussed several initiatives aimed at strengthening domestic manufacturing, although Oni said some of these efforts remain at the design, discussion and resourcing stages. She said that partners and donors could still play an important role by aligning behind government priorities rather than creating parallel systems.
Ultimately, she said, implementation will determine whether those ambitions become reality.
Government, donors and implementing partners will need to work as a coalition, agree on measurable outcomes and commit the resources needed to achieve them, she said. "Everyone will commit to delivering those outcomes, to resourcing the delivery of those outcomes and would be accountable to the metrics that are being tracked to ensure success," said Oni.
She also challenged the idea that malaria should continue to be treated as a standalone programme.
In Nigeria, where malaria is endemic, people often assume that fever or headache is malaria without first being tested, Oni said. Rather than describing this as a misconception, she called it a deeply established attitude towards a disease that has been part of everyday life for generations.
The answer, she argued, lies in integrating malaria more firmly into primary healthcare.
"Not thinking of malaria as a standalone program, but building it into the primary healthcare system that is already strengthening," she said.
That means ensuring malaria remains a priority when investments are made in primary healthcare, while integrating services and strengthening accountability at the local level.
"If that is in place and everyone has that understanding, then Nigeria will be strongly positioned to address the malaria gap that we see," she said.
For countries facing shrinking external resources, Nigeria's experience suggests that resilience may depend less on replacing every lost dollar of donor funding and more on building systems that make better use of the resources they control.
The challenge now is to ensure that reforms designed to strengthen country ownership translate into sustained financing, effective implementation, and better health outcomes for communities that remain furthest from care.
Fixing fragmentation, not just funding
Mozambique is showing how better coordination between government and health partners can help protect essential services when international funding comes under pressure. Local leaders proved that severe financial constraints do not have to mean a decline in life-saving care. Rather than accepting reductions in community visits, provincial health authorities restructured how external aid and local resources operate on the ground.
Mauro Cuna, who has spent nearly eight years with Acasus in Mozambique helping the government strengthen its immunization systems, said the 2025 USAID funding cuts hit malaria, HIV, tuberculosis, and immunization programs across the country.
But in Tete Province, government leaders took a different approach: rather than allowing reduced funding to further fragment services, they looked at how existing resources could be used more efficiently.
"The main issue wasn't just the lack of money - it was the fact that we weren't working together. Fragmentation was the core challenge."
The province was already home to multiple partners supporting different health programmes. One organisation might finance immunisation, another nutrition, another malaria, and another family planning. Yet many of them were sending government health workers to the same communities at different times.
Tete's leadership realised that better coordination could allow the province to stretch the resources that remained.
The first step was to create a single plan so that different programmes could reach communities together, rather than making repeated visits.
Cuna said this helped address what is known in public health as "community fatigue" - when communities are repeatedly asked to participate in separate health activities. "If all these programmes go out at the same time, it's much easier," he said. "It avoids the community fatigue."
The fix was a single, shared visit schedule.
The province also began combining resources. Instead of different programmes hiring separate vehicles to reach the same communities, health workers from different programmes could travel together.
The savings could then be redirected towards other needs, including allowances for vaccinators and technicians working in the field and community mobilisation.
The third change involved data. Rather than having different programmes operate separate monitoring systems, the government encouraged partners to use a common system and indicators.
The same principle was applied to meetings. Instead of government officials attending multiple meetings with different partners, Tete's leadership pushed for a single forum where partners could coordinate their activities.
According to Cuna, resolving that fragmentation had an outsized effect: Tete went from reaching 35% of communities to 96% in a single quarter - three times the coverage of the previous period. More children were vaccinated, more women received services, and more children received nutrition products. "Only by unlocking the fragmentation part, having better coordination, was easy to achieve this impact," he said.
While integration may sound straightforward, Cuna said one of the biggest obstacles was uncertainty about what could actually be combined across different funding streams.
Much of the initial barrier, Cuna said, wasn't logistical but a lack of clarity about what was actually allowed. "Everyone around Mozambique was thinking about integration, but no one was actually doing it to show others how to do it."
Tete began by asking practical questions: Could resources from different programmes be pooled? Could a vehicle funded for one programme transport health workers from another? Could partners use the same monitoring system?
Those questions helped uncover opportunities for collaboration.
One reason integration made sense was that different programmes were often targeting the same people. A child receiving a vaccine might also need vitamin A or deworming, for example.
"A child that needs vaccines also needs deworming, needs vitamin A. So, it's the same child," said Cuna.
But he stressed that integration was not driven by partners imposing a new model on government. The provincial leadership remained at the centre, with partners helping facilitate discussions and identify what could be done within existing rules. That distinction, he said, was critical to making the approach work.
Start small, then scale
Cuna believes other African countries facing financial pressures could learn from Mozambique, but he cautioned against spending years designing integration models from the top down.
"Do not start from the top," he said. "I think the best thing we can do is to visit the field to see in practice how it can be done."
Rather than sitting at central level and designing an integration strategy in the abstract, governments should visit communities and see how programmes can work together in practice.
Mozambique started with one province and used its experience to identify the practical "do's and don'ts" of integration.
For other countries, Cuna said the same approach could be applied at an even smaller scale; a single district or local government area could serve as a testing ground.
"Don't spend, like, a year planning how to do integration," he said. "Just do something fast, pick one province. It can be just one district or one LGA in one province and say, 'We will start here.'"
The lesson from Mozambique is therefore not simply about doing more with less. It is about changing how existing resources are organised.
As donor funding becomes less predictable, Cuna argues that governments can strengthen resilience by reducing duplication, coordinating partners and making different health programmes work together around the same communities.
"You learn faster when you do it by learning by doing than when you spend, let's say, a year just planning how to integrate," he said.
From pilot to policy
The global contraction of donor assistance has made one truth undeniable: the era of fragmented, externally funded emergency health programs in Africa is coming to an end. What began as emergency adaptation in provinces like Sokoto in Nigeria and Tete in Mozambique has codified into a permanent, national policy shift.
For Mozambique, what began as a provincial experiment in Tete is now becoming part of a broader national approach.
Cuna said the success of the integrated model has prompted Mozambique's Ministry of Health to recommend integration across provinces, turning what was initially a response to funding constraints into a longer-term strategy for delivering health services.
"Because there were funding cuts, of course, in the past, but this will be the new normal now," he said, pointing to the growing pressure on health funding globally.
Integration is also central to Mozambique's new 2026–2030 health strategy, while the country's agreement with the United States also emphasizes integrated service delivery. For Cuna, that creates an opportunity to build new funding on systems that are already becoming more coordinated.
"What gives me hope is that ... integration, again, is a central piece of that work," he said.
The lesson emerging from Mozambique is not simply that countries can survive funding cuts by doing more with less. It is that the way health programmes are organised can determine how far limited resources go.
For Oni, that lesson extends beyond Mozambique and Nigeria.
She said the disruption to donor funding was forcing countries to confront the risks of relying too heavily on external resources, while also creating greater recognition of the importance of government ownership and sustainable domestic financing.
"The freezing or reduction in the funding donor landscape is helping more and more countries to realise that heavy dependence on donor funding is not sustainable," Oni said.
Both Mozambique and Nigeria, she argued, provide examples of what can happen when governments take ownership, partners align behind a common plan and data is used to identify where resources are most needed.
"In some pockets of countries, like Mozambique, as Mauro has said, in Nigeria, we've started to see what's possible," Oni said.
In Nigeria, even as malaria funding was disrupted, maternal health, family planning and routine immunisation improved in the same geography where broader government-led reforms were underway.
For Oni, the significance lies in what those experiences demonstrate: health systems can continue improving even amid funding shocks when governments have the structures and information needed to coordinate resources effectively.
"What is possible when we have a strong government, when we have one plan under that government, an integrated delivery platform, all partners, all donors aligned behind that platform," he said.
But both experts stressed that agreements and strategies will only matter if they are implemented.
For Oni, government must remain firmly in the driver's seat, bringing partners together around shared goals and ensuring that everyone understands their responsibilities.
"Designs, I don't think Africa has ever lacked great policies and strategy designs," she said. "Implementation is usually where we then need to bring the same creativity that we bring to the design."
That implementation requires strong government leadership, coordinated partnerships, functioning data systems, clear metrics and accountability.
Cuna similarly emphasised the importance of giving provinces and local governments the capacity to turn national commitments into action, arguing that integration must be visible in planning, data-sharing and coordination at the level where services are actually delivered.
For Oni, the ultimate prize goes beyond simply protecting existing programmes.
A stronger, more integrated health system could allow countries to reach more people with scarce resources while creating a foundation for future innovations, including new technologies and artificial intelligence.
"It's only a country or only a health system that is already strong that can even start to think about AI and ... other advanced forms of technology to continue to strengthen the system and deliver health services," she said.
Making MOUs real
The experiences of Mozambique and Nigeria therefore point to a broader shift in how health systems may need to operate in an era of tighter international funding: less fragmentation, stronger government ownership, better coordination and greater visibility of what is happening at the last mile.
For Cuna, Mozambique's experience offers a simple lesson for countries considering the same path: start small, learn from implementation and scale what works. For Oni, the evidence from both countries offers something equally important - proof that resilience is possible.
Cuna described how, even before formal MOUs existed, partnerships were already forming at the sub-national and sub-provincial level, driven largely by planning needs. He said the emerging Mozambique MOU places heavy emphasis on integrated delivery, but stressed that integration also has to be made visible: partners need to share data regularly, for example, linking facility supervision data with mobile outreach data, so that execution of the plan can actually be tracked and improved. His third point was coordination itself: strengthening provincial-level capacity to plan and execute, particularly given Mozambique's decentralized structure of government.
"We've seen what's possible," he said. "It's been done in some geographies, we've seen results, and that is now fueling the motivation and reassuring us that this is possible and it can be done if we all align behind it."
Oni laid out what she sees as the necessary conditions, in sequence. First is ownership: "There has to be an owner; there needs to be a strong owner, and that's always the government," she said, with government "in the driver's seat" responsible for assembling the coalition. Second is partner coordination - government must determine who belongs at the table, who brings the right expertise and shares the same goals, and then actively coordinate that coalition. Third is data and technology: aligned data systems are what make gaps and opportunities visible to both government and its partners, enabling more realistic, resource-aware planning. Fourth, once integration is underway, the coalition needs shared metrics for success, with clear ownership of who tracks and reports on what. And finally, accountability - everyone in the coalition needs to understand what they're accountable for, and hold up their end of it.
"Government being in the driver's seat, government-led reform, government-driven reform, with integration at the center of it", she said, is what ties all of it together.
