Health systems ownership in fragile and conflict-affected settings after aid cuts

What happens to an already fragile health system and its users when its major sources of income are severely cut? This is the challenge many countries are facing following massive global cuts to health financing. Coupled with skepticism towards global institutions, these cuts have contributed to severely disrupted service delivery and further exposed deep structural vulnerabilities in fragile and conflict-affected settings.

HSG’s Thematic Working Group on Health Systems in Fragile and Conflict-Affected Settings (TWG FCAS) has produced case studies on this very issue with a view to presenting the work at HSR 2026. We have found that while cuts are a profound shock, they can also catalyze domestic resource mobilization, institutional coordination, and reform of the health system.

Global contraction of external support

Recent reductions in development assistance and multilateral cooperation among major donor countries have contributed to a global contraction in international aid. After the US government dismantled USAID and withdrew from numerous multilateral organizations and agreements, countries such as the UK moved to inward-looking politics, leading to a sharp reversal in funding trends globally. Health is among the sectors consistently cited to be most affected, with core health funding levels anticipated to drop below pre-COVID-19 levels. These developments occur within a context of increasing skepticism towards global institutions and financing architecture, disproportionately affecting low-income countries and specifically health systems in fragile and conflict-affected settings given their high reliance on external support.

Effects of sudden aid withdrawal

Against this backdrop, research in Sierra Leone and Somalia shows that sudden aid withdrawal rapidly translates into financing gaps, service disruptions, and institutional stress, with implications that extend beyond short-term budgetary shortfalls. The literature documents that abrupt reductions in external health financing can severely disrupt service delivery and expose deeper structural vulnerabilities in health systems. Beyond immediate effects, prolonged aid dependency tends to weaken domestic planning, fiscal discipline, and accountability, leaving systems ill-prepared to absorb funding shocks. Responses typically combine short-term mitigation with longer-term adaptation, reflecting the tension between urgent service continuity and strategic resilience. In these contexts, governments navigate constrained budgets, limited revenue, weak institutional capacity, and insecurity, while aiming to maintain fragile legitimacy and minimize social unrest through guaranteeing some form of care for the most vulnerable population. In practice, the impact of funding shocks appears uneven: essential services may be reduced in conflict-affected areas, outreach to internally displaced persons may decline, and user fees or supply shortages can disproportionately affect those with the greatest health needs.

Nigeria and Cameroon case studies

Collaborative work conducted under the TWG FCAS in selected contexts (Nigeria, Cameroon) between October 2025 and March 2026 also identifies and documents a positive trend within aid cuts: many countries in FCAS are mobilizing domestic resources to sustain core services and strengthen national ownership and resilience, even though financial constraints and limited fiscal space mean that progress remains partial and uneven. These cases challenge the interpretations of “aid withdrawal as crisis.” In practice, abrupt donor reductions often expose pre-existing structural vulnerabilities, including high dependence on external financing, fragmented service delivery, and gaps in governance, rather than creating new failures. In Nigeria, rapid domestic mobilization - including the absorption of health workers, emergency funding for HIV programs, and vaccine procurement - helped sustain core services, while in Cameroon, institutional coordination, consolidation of vertical programs, and the introduction of dedicated domestic budgets illustrate steps toward greater national ownership and system rationalization. These responses show both strategic resilience and the capacity for reform under pressure, even when options are constrained.

Risks and opportunities in donor transitions

Overall, these experiences underscore that abrupt donor transitions can be both destabilizing and catalytic. They reveal how exit design, timing, and domestic absorptive capacity shape outcomes, and how governments in FCAS actively balance maintaining fragile legitimacy, limiting social unrest, and sustaining essential services. As global health financing enters a period of contraction and volatility, these lessons highlight the importance of reimagining health system operations: supporting predictable, context-sensitive financing, integrating external programs into national systems, and strengthening domestic capacity to reduce aid dependency. Recognizing both the risks and the opportunities inherent in donor transitions is critical to protecting past gains and building resilient health systems in fragile contexts.

Next steps: evidence and dialogue at HSR 2026

The TWG FCAS is preparing to publish this work through its communication channels and to stage an organized session at the HSR 2026 symposium in Dubai. We aim to comparatively discuss practical experiences of aid cuts, looking across various fragile and conflict-affected settings. This work will also inform a parallel discussion on health diplomacy, examining how countries in FCAS negotiate shifting global financing landscapes and reshape partnerships in an increasingly fragmented aid architecture.