Bellagio Report

Executive Summary

The April 2025 Bellagio convening, hosted by the Alliance for Health Finance in Africa (AHFIA), brought together policymakers and finance leaders to confront a structural reality that can no longer be deferred: Africa bears approximately 22% of the global burden of disease yet accounts for just 1% of global health expenditure. Keynote remarks from Dr. Donald Kaberuka set the terms of debate clearly. The global aid architecture that shaped African health systems for six decades is contracting, with development assistance for health falling from a peak of $25.8 billion in 2021 to roughly $13 billion in 2025. That decline is expected to continue.

The gathering pushed beyond diagnosis toward a reorientation of strategy. Rather than treating external financing shortfalls as a gap to be filled, participants framed the moment as an opportunity to build systems rooted in domestic ownership. Dr. Kaberuka drew on Vietnam’s trajectory, where the economy grew from $14 billion to $500 billion alongside sustained investment in national health infrastructure, as evidence that homegrown financing models can produce measurable gains.

Four priorities emerged: repositioning health as a driver of economic output rather than a cost; engaging finance ministries as active participants in health outcomes; shifting donor relationships toward long-term system support; and scaling community-based delivery through digital tools. With fewer than 40% of African countries currently meeting the WHO-recommended minimum of $86 per capita for essential health services, the case for structural change is grounded in numbers, not aspiration. Read the full Bellagio report here.

Key Takeaways

• The aid contraction is already here: Development assistance for health fell from $25.8 billion in 2021 to around $13 billion in 2025. USAID withdrawals in Kenya, Tanzania, and Rwanda illustrate what this looks like on the ground. Countries that have not begun building alternative financing pipelines are already exposed.
• Domestic commitment remains well below target: The Abuja Declaration of 2001 required AU member states to allocate at least 15% of national budgets to health. More than two decades later, only three countries (Rwanda, Botswana, and Cabo Verde) have consistently met this target. Over 30 member states still fall below the 10% mark, with some allocating as little as 5 to 7%.
• Out-of-pocket costs are pushing millions into poverty: Out-of-pocket payments account for 35% of total health expenditure across Africa, exposing an estimated 15 million people to catastrophic costs and poverty each year. This is the direct consequence of under-funded public systems and the absence of adequate pooling mechanisms.
• Health spending per person remains critically low: Sub-Saharan Africa spends roughly $92 per person on health annually, about one-fifth of the next lowest global region. Fewer than 40% of African countries meet the WHO-recommended floor of $86 per capita for a basic services package. Population growth from 1.4 billion today to a projected 2.5 billion by 2050 will erode per-capita gains unless spending scales accordingly.
• Finance ministries are the missing actor: Health budgets cannot be defended or expanded without finance ministry engagement. The convening called explicitly for treasury leaders to be accountable for health outcomes and for infrastructure, education, and energy investments to be assessed through a health lens. This is a political and institutional shift, not a technical one. Read about financing readiness across the continent.
• Donor partnerships need different terms: Public health emergencies on the continent surged 41% between 2022 and 2024, from 152 to 213 recorded events. Funding that responds to crises without building underlying systems is not financing reform. The convening called for alignment around long-term system strengthening rather than programme-level disbursements. See how the global health ecosystem needs to change.
• Local financing models, not copied ones: Dr. Kaberuka was direct: Africa cannot build durable health systems by replicating frameworks designed for different institutional and fiscal contexts. Countries need models built around their own revenue structures, delivery realities, and governance conditions. Explore financing innovations already emerging across the continent.