Regional Health Financing

For over thirty years, U.S. global health assistance has been a determinant factor in the healthcare architecture of Southern Africa. This is particularly evident in Zimbabwe and Zambia, where external funding has financed HIV treatment, maternal health, laboratory networks, and supply-chain logistics. Consequently, the U.S. role expanded from that of a development partner to a primary financing mechanism for national public health operations, with domestic budgets often acting in a supplementary capacity.

This architecture has produced documented improvements in health outcomes. Analyses from UNAIDS indicate that AIDS-related mortality in eastern and southern Africa decreased by more than half between the mid-2000s and early 2020s, driven by treatment scale-up and viral suppression. However, this model also established structural dependencies: critical functions—including procurement, data systems, and service delivery components—remained externally funded and managed. Recent pressure on U.S. health budgets has highlighted these systemic vulnerabilities.

Zimbabwe and Zambia have been central beneficiaries of this framework. PEPFAR resources supported treatment sites and infrastructure, while Global Fund and bilateral programs provided complementary support. UNAIDS notes that eastern and southern Africa hosts the largest cohort of people living with HIV on treatment globally. Yet, the system retained inherent fragility. In Zimbabwe, external partners financed the majority of HIV expenditure for an extended period. In Zambia, implementing partners managed significant operational aspects. In both contexts, parallel implementation structures operated alongside public sector systems.

Factors Influencing Funding Reallocation

Multiple factors have driven the current retrenchment in assistance. Politically, the reauthorization of PEPFAR has faced legislative adjustments, shifting towards shorter-term arrangements. This uncertainty impacts long-term planning, with UNAIDS officials noting potential risks to the 2030 public health targets.

Simultaneously, sustainability assessments have highlighted that the region’s transition to domestic financing has been slower than anticipated given the duration of external investment. Policy analysis has also scrutinized the intermediary implementation model, where significant portions of health budgets are utilized by contractors rather than building direct state capability.

Analysis of Implementation Models

The donor-centric model achieved health outcomes but maintained specific structural characteristics:

• Zimbabwe: External financing covered the majority of HIV program costs, with non-governmental payrolls affecting health-worker retention and procurement often managed outside Ministry control.
• Zambia: Operational functions—including ART distribution and monitoring—were frequently administered by funded contractors. Domestic health spending lagged behind epidemiological requirements, and efficiency assessments noted high overhead costs.

The data indicates that while service delivery was effective, the underlying systems remained reliant on external support.

Strategic Realignment and Fiscal Policy

Reductions in external aid have necessitated policy adjustments. In Zimbabwe, authorities have reinforced the national AIDS Levy to increase domestic revenue capture for the HIV response. Personnel previously funded by donors are being transitioned into government structures, and there is a strategic focus on local manufacturing of essential medicines.

Zambia is increasing budget allocations to the Ministry of Health and investing in national data systems. The government is revising partnership agreements to ensure external programs integrate with, rather than duplicate, national systems. This aligns with broader development frameworks emphasizing locally led development and direct government partnership.

Current Transition Indicators

The transition presents fiscal and operational challenges, including commodity security and workforce management. However, early indicators suggest a shift in governance:

• Increases in domestic health budget allocations.
• Integration of HIV and TB programs into government management structures.
• Direct engagement between governments and development partners regarding strategic alignment.
• Regional collaboration through SADC on procurement and manufacturing.

Future Outlook: Health System Autonomy

The coming decade will be critical for consolidating health system autonomy. Success will depend on sustained domestic financing, governance strengthening, and the integration of previously donor-managed systems. The trajectory suggests a move from external reliance towards healthcare systems designed and financed by the respective nations.

U.S. assistance has played a historic role in stabilizing health systems in the region. However, the model of outsourcing public health functions to external entities is evolving. The objective of the current realignment is to establish healthcare systems that are fiscally sustainable and governed by national authorities.