NextBillion - A WDI Publication

Recent drastic cuts in global health financing are prompting African health systems to reassess their operating models. Across the continent, leaders are increasingly, and rightly, rallying around the idea of health sovereignty — the ability of countries to set their own health priorities and manage their health systems without structural dependence on external actors. But that goal is unfolding against an already-difficult fiscal reality: a longstanding lack of sufficient funding that has only been exacerbated by these recent cuts. 

Twenty-five years after the Abuja Declaration called on African Union members to allocate 15% of public expenditure to health, roughly 96% still fall short. As a result, as governments are taking on greater operational responsibility in an attempt to strengthen their health sovereignty, they face the dual challenge of dealing with more limited fiscal space, while also attempting to replace the diminishing support structures that were initially provided by external entities.

For decades, core operational functions in the African health sector which includes planning, procurement, cold-chain logistics and last-mile distribution, have often been supported or co-managed by external partners, including bilateral donors, multilateral health funds and international NGOs. Their support has gone well beyond financing. In many cases, these partners embedded technical staff directly within government systems, covering functions such as supply chain planning, procurement oversight and data management. 

However, this has not always happened in an integrated manner, resulting in duplication and fragmentation, as multiple implementers have often supported the same functions independently, creating overlapping activities and parallel systems. As financing arrangements evolve and a greater share of responsibility shifts toward governments, a deeper capacity gap is becoming clear: Many governments do not yet possess operational sovereignty over their own health systems, i.e., the ability to finance, coordinate and optimize core functions.

This is a critical limitation. Strengthening these mission-critical functions, especially those that involve the healthcare supply chain, will be essential to ensuring the long-term resilience and effectiveness of the continent’s healthcare systems.

That does not mean governments must operate every function themselves. Rather, they must be strategic in deciding which functions they are equipped to operate themselves, which they must outsource to specialized service providers, and which may need to remain supported by external partners due to insufficient government resources. This process of assessment and coordination represents the first time many governments are exercising real stewardship over their national health supply networks, based on their unique needs and institutional capacity. 

Nigeria’s National Health Products Supply Chain Strategy offers a useful example. To bring together previously fragmented, donor-led supply chains, the strategy adopted a managed outsourcing model that integrates private third-party logistics providers into zonal hubs, enabling the system to operate as a unified whole. The model was designed to improve  reliability across key commodity groups such as HIV/ARVS, malaria treatments, TB commodities, vaccines and reproductive health products.

Nigeria’s efforts in this area do not stand alone. In 2012, facing a crisis where health facilities experienced contraceptive stock-outs for up to 83% of the year, the Senegalese Ministry of Health transitioned from a traditional pull system, where individual facilities had to request and wait for resupply, often leading to delays, to a government-managed “informed push distribution model” (IPM). By leveraging private third-party logistics providers to deliver contraceptives directly to facilities on a fixed schedule, shifting the logistics burden from facility staff to trained professionals, the government reduced the proportion of health facilities experiencing stock-outs from more than 80% to less than 2% while simultaneously reducing yearly distribution costs by 36%.

However, for most African nations, these remain islands of excellence rather than the continental norm. The shift from government as provider to strategic orchestrator of the healthy supply network highlights an important stewardship gap. Unlike the specialized units managing Nigeria’s National Health Products Supply Chain or Senegal’s IPM, many ministries do not yet have the full visibility needed to understand what their logistics systems  (which span government, private sector and development sector actors)  actually cost, or how they perform. In many cases, for instance, fragmented, disease-specific supply chains were often shaped by historical vertical programming approaches, whereby HIV, malaria, TB and other programmes developed and operated separate supply chains rather than an integrated system, obscuring the true price of delivery. Without this end-to-end visibility, governments are left unable to justify outsourcing decisions, negotiate performance-based contracts, or ensure that public resources are delivering real value for money.

Furthermore, the institutional muscle required to manage these transitions is often underdeveloped. Supply chain oversight is frequently split across multiple agencies, making integrated models difficult to coordinate. Even when the will exists, financial risks like unpredictable government payments discourage the private providers whose services are needed to bridge the gap. Additionally, if governments take on a larger procurement portfolio without strong internal audit and compliance functions, this can increase their exposure to waste, fraud and conflicts of interest, which can erode public trust if not proactively managed. 

Efforts to consolidate these fragmented structures into cost-efficient and resilient health supply networks can be supported by focusing on seven practical areas:

1. Design a people-centered healthcare service delivery strategy: Operational sovereignty must begin with an understanding of where and how people actually access healthcare, and how it is financed. And if these functions depend on entities across the public, private for-profit or private not-for-profit sectors, designing a workable strategy requires a whole-of-market approach. Governments must align their health supply networks with customer journeys, which may include service delivery at clinics, pharmacies or community programs. This integration ensures that systems are not just theoretically sound, but responsive to demand and resilient during real-world disruptions.
2. Build a segmented health supply network with tailored distribution channels: Governments should move away from one-size-fits-all distribution models. Different products and types of medical equipment, from vaccines to laboratory commodities, have different handling requirements and servicing/maintenance needs. It’s important to intentionally design segmented supply networks that match product needs with the most cost-effective delivery channels.
3. Clarify what governments now own: As governments take on greater responsibility to pay for the provision of health services, ministries must clearly define the core functions they can sustain, which may include regulation, financing, integrated financial and operational planning, procurement oversight, contracting, payment management, data governance, performance monitoring, and quality assurance. More importantly, they must determine how they expect to steward the entire network, with a clear focus on affordability and equitable access. Without explicit role definition, governments risk inheriting responsibilities without the institutional structures needed to manage them effectively. Clear ownership strengthens accountability and establishes the foundation for sustainable outsourcing and partnership models.
4. Establish cost and performance visibility across the network: Governments cannot continuously optimize resources without a clear understanding of how their systems perform. Establishing baselines for delivery performance, service reliability and true end-to-end logistics costs enables ministries and network actors to identify inefficiencies, adapt operating models, improve services, and drive down costs in line with evolving priorities. It also supports evidence-based planning, rather than allowing decisions to be driven by assumptions or short-term budget pressures.
5. Strengthen sourcing, contract management, digital oversight, and compliance and oversight assurance capabilities: Ministries must build capacity in strategic sourcing, contract design and vendor management. Equally important is strengthening internal assurance functions, such as auditing and compliance processes to deter waste, fraud and abuse. Global good and digital platforms such as Logistics Marketplace are already in place to support this shift. Funded by the Global Fund, in partnership with the Gates Foundation, this innovative digital platform centralizes the discovery of logistics providers and streamlines the procurement of logistics services, making it easier for key stakeholders;  including governments, non-profit and development organizations, manufacturers, wholesalers, and retailers  to find, assess and engage logistics providers.
6. Align regulations, procurement and financing with whole-of-market goals: Policy frameworks must enable partnerships, not constrain them. This means moving to performance-based contracting, where incentives reward transparency and service reliability rather than just the speed of disbursement. Predictable payment systems are also foundational for attracting capable private partners.
7. Reorient external support to build stewardship models: Technical assistance must evolve from parallel implementation to governance building. Instead of donors running delivery systems, they should prioritize building the capability of national governments to oversee them. Long-term sovereignty depends on institutional capability, not short-term implementer support.

The costs of fragmented logistics systems are increasingly difficult for health systems to absorb. True health sovereignty will not be measured only by the size of a national health budget, but also by whether a country’s health system has a properly managed supply chain, where products move seamlessly because the state has mastered the art of stewardship. The next phase of health sovereignty will depend on how effectively governments steward the markets and systems that support public health delivery.

Scott Dubin is the Creator of Logistics Marketplace – a first-of-its-kind global good, designed to strengthen health and humanitarian supply chains in low- and middle-income countries (LMICs). 

Photo credit: Jacob Wackerhausen