The following discussion is based on insights from the joint WHO–World Bank Group/GFF Health Financing and Primary Health Care webinar (no. 17) on aid disruption, held in April 2026, and OECD’s ODA projections for 2026 and the near term, published in June 2026. 

External financing for health had been on a constant growth trajectory in aggregate since 2000 — tripling in volume between 2000 and 2023. The focus of transition considerations assumed in large part that decreases to a specific country would be triggered by domestic GDP growth, in that countries would be able to compensate for the reductions with additional domestic revenues. In 2025, the trend and underlying assumptions collapsed. OECD’s June 2026 projections estimate that net official development assistance fell by 23.3% in 2025 and could decline by a further 6.9% in 2026. Bilateral aid for health is projected to fall by 29% to 46% between 2024 and 2026 — a loss of US$5 billion to US$8 billion — leaving it 63% below its 2022 peak and close to levels last seen in 2008, with clear implications for vulnerable populations like women, children and adolescents and services previously supported with this external financing.

The shock did not create the underlying fragilities. The increases in domestic public spending on health per capita in low-income countries during 2020 and 2021 had declined to pre-pandemic levels, while health’s share of total government spending had remained below 6% for more than a decade. The sudden contraction in aid underscored how dependent many essential services and core system functions had become on financing that governments could not control, reliably predict, or even knew was in their country’s health system. 

In April 2026, a joint WHO–World Bank Group/Global Financing Facility (GFF) webinar brought together more than 600 policymakers and practitioners virtually to examine what countries are experiencing and how they are responding to these changes. Experiences from Nigeria, Sierra Leone and Uganda pointed to a common thread: when external financing changes abruptly, the ability to see who is funding what — and to act on that information — often separates a strategic response from an improvised one. 

Data is the first line of response 

When a donor withdraws, governments need to know which programs, regions, facilities and populations are exposed. Yet much external financing remains off-budget, reported through program-specific systems or visible only after significant delay. Although national health accounts provide data on health spending trends, when a crisis hits, there is need for more close to real-time data from nimble health resource tracking exercises to immediately connect with decision making. 

Nigeria illustrates what becomes possible when those connections exist. Using its sectorwide approach architecture, the government rapidly convened agencies and mapped financing gaps by program. The resulting evidence supported negotiations with the National Assembly and helped to commit an additional US$200 million in domestic resources to health. Resource mapping was not a passive accounting exercise; it became a tool for budget negotiation, prioritization and reform. 

Uganda has similarly invested in a partners’ portal aligned with government priorities and joint donor monitoring. This portal was established to track, monitor, and report on both on- and off-budget donor funds. Shared information gives government and partners a common picture of external support and disruption risks, reducing dependence on competing spreadsheets and bilateral conversations. As a result, the government had a baseline established for what donors were funding prior to the 2025 reductions. This enabled a fast policy response whereby a government circular was released in February 2025 that set a clear agenda based on prioritization, integration, and health officials were able to work with the Ministry of Finance to secure additional budget resources for health. 

Sierra Leone offers an important caution. Despite having national health accounts and resource-mapping systems, the government still needed deeper analysis to understand the full impact of declining bilateral and multilateral support. The lesson is not that existing systems failed, but that data availability is different from data utility. Information must be timely, sufficiently disaggregated and embedded in governance structures that can use it. 

GFF and WHO have supported these partner countries in strengthening near real-time data availability, including through resource mapping and expenditure tracking (RMET), helping governments and partners understand resource flows, and align investments with national priorities. In a period of aid disruption, governments need these data to make difficult prioritization decisions while safeguarding essential services for women, children and adolescents.

Integration must move beyond the slogan 

Aid disruption has also made system fragmentation and duplications harder to tolerate. Parallel supply chains, program-specific information systems, separate planning processes and donor-funded staffing arrangements may have delivered important results, but they also created duplication and costs that domestic budgets may be unable to absorb. 

This has renewed interest in sectorwide approaches built around one plan, one budget and one reporting framework. Sierra Leone is moving in this direction, with the Office of the Vice President providing high-level convening power. Nigeria is using its existing approach to coordinate agencies and strengthen integrated planning. Uganda’s joint integration framework links partner monitoring to government priorities and service disruption risks. 

These efforts recognize that changes to funding flows, provider incentives, reporting requirements and accountability arrangements need to be made to effectively address issues of fragmentation. Without these changes, there is a risk that “integration” is assumed to happen simply by asking the frontline worker to delivery more services.  System redesign requires information about what is currently fragmented, which services should be brought together, and which shared functions — workforce, supply chains, laboratories, information systems and facilities — must be strengthened, and how to finance and account for the outputs and outcomes. Without those enabling systems, integration risks becoming an unfunded transfer of responsibilities to already stretched workers and facilities. 

The co-financing paradox 

At the same time, countries face growing domestic, co-financing obligations from Gavi, the Global Fund and other partners. These obligations are intended to encourage sustainability and country ownership. But they are increasing precisely as external resources contract, debt-service pressures rise and fiscal space narrows. At the same time the country systems’ capacities remain limited to ensure co-financing obligations are realistic and traceable. 

The absence of a consolidated view across institutions and programs on the various domestic, co-financing obligation raises many questions around the viability of these commitments. Ministries need a single framework showing the size and timing of commitments, where requirements overlap, and how they fit within the national budget. Development partners also need to coordinate their demands so that program-specific conditions do not distort country priorities or create liabilities that cannot be met. 

Domestic resource mobilization remains essential, but it is neither rapid nor purely technical. It depends on sustained engagement with ministries of finance and planning, legislatures and senior political leaders. Nigeria’s and Uganda’s additional allocation demonstrates what credible evidence and political advocacy can achieve. Sierra Leone’s decision to anchor the agenda in the vice president’s office recognizes that health financing resilience is a whole-of-government issue, not the responsibility of the health ministry alone. 

From emergency response to durable reform 

The response is not about countries replacing every lost external dollar with domestic spending. The near-term task is to protect essential services, vulnerable populations and the system functions on which multiple programs depend — especially services for women, children and adolescents. This requires explicit prioritization rather than across-the-board reductions that do not effectively support or align with service delivery practices.  

Five actions stand out:  

  • First, build a shared and routinely updated picture of domestic and external financing for primary health care.  

  • Second, embed that information in the institutions that make budget and program decisions.  

  • Third, align and move partners to use a feasible, government-owned service and financing model.  

  • Fourth, use evidence on costs, budget execution and service performance to identify genuine efficiency gains rather than assuming that services can simply do more with less.  

  • Finally, manage integration as a financed reform of planning, incentives and accountability focused on enabling service delivery — not as an administrative instruction. 

The era of managed fragmentation, in which expanding aid could compensate for weaknesses in the underlying system has ended. Nigeria, Sierra Leone and Uganda show that the disruption is severe, but they also show what active and targeted intervention can achieve. Better and more transparent information, political leadership and coherent health financing arrangements can turn a shock into a platform to build systems that are more efficient, more accountable and more firmly anchored in national priorities.

In an era of aid disruption, data is not just a monitoring tool. It is negotiating power — and a foundation for protecting the essential services the most vulnerable populations rely on. 

 

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