Sovereignty without austerity: designing a health security framework for equitable health coverage for Africa after aid contraction

Abstract

Development assistance for health to sub-Saharan Africa contracted by 25% in 2025, threatening coverage gains for vulnerable populations including women, persons with disabilities, and the rural poor. This policy paper examines the structural fragility of African health systems through dependency theory, the social determinants of health, and health systems strengthening, and asks how inclusion can be protected as external financing withdraws. Its analytical approach is a structured expert synthesis anchored in coverage models from Africa and the Global South (Rwanda's community-based health insurance, Ghana's insurance exemptions, Thailand's Universal Coverage Scheme, Brazil's Family Health Strategy, and the cautionary dismantlement of Mexico's Seguro Popular), with selected US Medicaid and Medicare mechanisms as secondary comparative inputs. The paper recommends an African Vulnerable Population Health Security (AVPHS) framework: categorical vulnerability entitlement on a progressive-universalist trajectory; national risk pooling with progressive central-subnational cost-sharing; district-level purchasing with community health worker care coordination; an explicitly priority-set benefit package incorporating health-related social needs; and vulnerability-adjusted payment sequenced to data capacity. The framework specifies its risk-bearing structure, priority-setting method, preconditions, and adoption stages, and states the trade-offs adoption imposes, offering a domestically financed pathway that protects inclusion during aid transition.