Washington’s new health financing shift: What it means for Uganda

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OPINION

By Dr Henry Kyobe Bosa, MBChB, MSc, FRSPH

For nearly two decades, Africa’s health architecture has been dominated by a model in which international NGOs served as the primary implementation machinery for Western-funded programmes.

This arrangement emerged during the height of the HIV/AIDS crisis, when speed, technical capacity, and transparent financial systems were urgently needed.

In those early years, many African governments lacked the institutional muscle donors required, and NGOs—armed with ready-to-deploy structures—stepped in to fill the void. The model helped save millions of lives. But over time, it also created a parallel health ecosystem that often operated alongside, rather than within, national institutions.

Today, the United States government is rewriting this script. Washington’s shift toward government-to-government health financing represents the most significant strategic reorientation in global health assistance to Africa in nearly 20 years. For Uganda, this is more than a change in administrative flow; it is a defining moment that could reshape our health system for a generation.

The old model was born out of necessity. Donors were under pressure to deliver results rapidly, and concerns about accountability shaped their risk appetite. Large NGOs offered assurance: robust financial controls, detailed reporting, and efficient procurement systems. But this also meant that billions of dollars in global health assistance were routed through organisations headquartered thousands of miles away.

Overhead costs grew, parallel reporting structures emerged, and ministries sometimes found themselves coordinating two systems—one owned by government, and the other driven by NGO workplans.

The pandemic years exposed the limitations of this arrangement more clearly. COVID-19, Ebola, and mpox demonstrated that epidemic response cannot be outsourced. National command structures, trusted public health institutions, and government legitimacy are indispensable. As Uganda’s national technical lead during COVID-19, Ebola outbreaks in 2022 and 2025, and the recent mpox response, I witnessed first-hand how decisive national systems must be in moments of crisis. No external implementer can replace the authority and speed of a well-organised national response.

Washington’s new position is influenced by several forces. African governments, regional bodies, and the Africa CDC have increasingly demanded locally led health systems. Donors have also grown concerned about inefficiencies, with too much money absorbed by overhead rather than frontline services. And in a world where geopolitical competition is reshaping global development, the United States is seeking a more direct partnership model—one that reinforces sovereignty and strengthens state institutions.

For Uganda, the immediate implication is that resources will increasingly flow directly into national systems—from the Ministry of Health and national public health institutes, to laboratories, surveillance networks, and district health structures. This offers a chance to accelerate long-delayed reforms: building a stable health workforce, strengthening procurement systems, improving emergency preparedness, and investing in the kind of infrastructure that underpins long-term resilience.

But this opportunity comes with expectations. Government-to-government financing demands high standards of transparency, speed, and efficiency. Donors will expect more rigorous audits, faster absorption, and leaner bureaucratic processes. This means Uganda must address old bottlenecks: procurement delays, fragmented planning, inconsistent financial reporting, and occasional vulnerabilities to corruption. If these weaknesses are not tackled directly, the promise of this new era could be undermined.

This shift will also redefine the role of NGOs. They will not disappear—far from it. But their role will evolve toward technical assistance, innovation, research, community engagement, and niche expertise. Rather than being the default implementers, they will become partners in strengthening national systems rather than substitutes for them.

In the long run, this new model could be transformative for Africa. It could finally enable genuine institution building—something donors have long spoken about but which the previous architecture often struggled to achieve. It could stabilise health workforce pipelines, ensuring that critical functions are not tied to short-term project cycles. It could reduce fragmentation and strengthen coordination across districts. Most importantly, it could enhance our readiness for the inevitable infectious threats of the future.

Uganda should welcome this shift, but not complacently. We must modernise our public health financing mechanisms, invest in institutional capacity, and ensure that resources reach the facilities, laboratories, and frontline workers who carry the weight of our health system.

Washington’s pivot toward directly supporting national institutions is a rare alignment of global policy and African priorities. It is an invitation for Uganda to assert its health sovereignty and build a system capable of protecting its people long after donor cycles shift again.

The question now is not whether the model is changing—it already has. The question is whether we are prepared to step into this moment and shape the future of our health system with the ambition and seriousness it requires.

The writer is a senior military officer, Global Health Security Specialist, and National Technical Lead on COVID-19 pandemic, Ebola (2022 & 2025) and  Mpox Outbreaks