Healthcare systems across Africa and the wider Global South face mounting pressure following the United States' withdrawal from major aid initiatives, according to a comprehensive report released on Monday, September 21, during the 81st UN General Assembly in New York. The crisis has been compounded by the Covid-19 pandemic and rising living costs, creating what experts describe as an urgent need for reform in how the region manages its health development.
The report, titled A Sovereign Future For, was produced by the Accra Reset, a global health initiative led by John Dramani Mahama, Ghana's president. The initiative advocates for countries in Africa and the Global South to exercise greater control over their health development rather than remaining dependent on aid from Western nations and international institutions.
A striking disparity underpins the case for change: Africa produces less than 1% of its vaccines while shouldering approximately 25% of the global disease burden. This imbalance has become increasingly untenable as external support diminishes.
How severe have the funding cuts been?
External financing for health in Africa contracted by close to 70% between 2021 and 2025, forcing African nations historically reliant on international aid to restructure their finances rapidly. The Trump administration's decision to disband the US Agency for International Development (USAID) exemplifies the scale of disruption: Nigeria was forced to absorb 28,000 health workers previously employed by the agency at a cost of $200 million.
According to an April 2026 analysis, roughly 65% of USAID-managed PEPFAR awards were terminated or left in limbo after the 2025 USAID disbanding, leaving millions of beneficiaries across sub-Saharan Africa without support.
The withdrawal of US Emergency Plan for Aids Relief (PEPFAR) funding has had particularly devastating consequences. South Africa lost over $78 million following the closure of USAID programs, which affected maternal healthcare, malaria treatment, nutrition, and HIV/Aids interventions. The loss of PEPFAR support led to HIV clinics closing across the country, leaving 1.4 million people living with HIV facing uncertainty about their treatment. PEPFAR, which has been credited with saving 26 million lives globally since 2003, is now being phased out in South Africa, with most programs scheduled to end by September 30, 2026, and critical personnel support continuing through March 31, 2027.
Research presented at the 26th International Aids Conference in Brazil earlier this year documented how these funding cuts caused "severe and devastating" disruption globally. Beyond South Africa, Sudan's health system was reported to be on the brink of collapse in September after funding cuts forced the closure of healthcare facilities and left dozens of organizations without replacement funding.
What does the Accra Reset propose?
The initiative's latest report, published on Monday, comes amid these major cuts to international aid and growing pressure on countries to take greater ownership of their health systems. The Accra Reset does not call for an abrupt end to international assistance; instead, it argues for a managed transition that protects essential services while countries build stronger national and regional health capabilities.
The report proposes five key pillars: a country-led "one-stop" health compact, sustainable financing transitions, stronger regional institutions, regional health manufacturing, and independent follow-up on commitments. According to the initiative, independent follow-up on these proposals is expected within six months of the September 21 launch, while country-led compacts should be developed within 12 months.
Mahama emphasizes that donor dependency is not sustainable.
"The past few years have shaken global health cooperation to its foundations. The Covid-19 pandemic exposed the risks created by concentrated production and unequal access to essential health products; rising debt and fiscal pressures have constrained national health budgets; and declining development assistance is placing programs and services under growing strain. These shocks have brought new urgency to reform debates that have continued for years with limited progress. It was in this context that we launched the Accra Reset and its Sovereign Health Agenda – to give renewed political force to the reform agenda and place the agency of countries of the Global South at its centre."
Naveen Rao, senior vice-president of the health initiative at the Rockefeller Foundation, framed the initiative as a call for reformed rather than reduced engagement from traditional donors.
"The Accra Reset is not an argument for traditional donors to do less on global health. It is an argument for doing it differently and doing it better. As countries take greater ownership of their health futures, donor countries should step up to support that transition – following the lead of countries that set their own priorities, and work alongside them to determine where outside support is most valuable. The Accra Reset shows how we can evolve to back country-led solutions while advancing our shared health and economic interests."
What do Americans think about foreign health aid?
A recent survey commissioned by the Rockefeller Foundation reveals that many US citizens hold progressive views on international health assistance. Polling of over 2,000 US adults found that 75% of Americans – including more than one in two (52%) who primarily support Donald Trump – agree that the US should restore disease prevention aid to contain the Ebola virus.
The polling also showed that 65% of US adults support international cooperation even if it means compromising some national interests, and 64% believe Americans have a shared responsibility to others, including people in other countries whom they do not know.
What happens next?
The implementation of the Accra Reset's proposals will unfold over the coming months. Independent follow-up mechanisms are expected to begin within six months, while country-led health compacts should be developed within 12 months. In South Africa, PEPFAR programming will continue its phased drawdown, with most programs ending by September 30, 2026, and critical personnel support extending through March 31, 2027.
Key Facts
- Africa produces less than 1% of its vaccines while carrying about 25% of the global disease burden
- External financing for health in Africa contracted by close to 70% between 2021 and 2025
- Nigeria absorbed 28,000 health workers from the disbanded USAID at a cost of $200 million
- PEPFAR has been credited with saving 26 million lives globally since 2003
- Roughly 65% of USAID-managed PEPFAR awards were terminated or left in limbo after the 2025 USAID disbanding
