A new era for Africa's leadership: driving health sovereignty, financing, and equity

The global health landscape is undergoing a seismic shift. A sharp decline in international financing for global health, fuelled by protectionist policies and a shift in government priorities towards domestic interests, has severely weakened global solidarity in addressing health crises. However, with every challenge comes an opportunity. These geopolitical shifts highlight the urgent need to rethink global health financing, which has traditionally been driven by donor priorities. Africa should assert its health sovereignty to mitigate risks posed by the loss of multilateral cooperation. In this Comment, we provide inspiration for transformative change and lasting impact, with a particular focus on the future of women, children and adolescents in Africa. Sub-Saharan Africa alone accounted for approximately 70% of global maternal deaths in 2023,¹ in addition to the biggest share of global deaths in children younger than 5 years (56·2% or 2·7 million deaths), despite making up only 30% of global livebirths.² In 2023, sub-Saharan Africa had the highest neonatal mortality globally, at 26 deaths per 1000 livebirths.²

Strengthening local manufacturing of medicines and vaccines, and improving diagnostics and health worker retention will reduce Africa's dependency on external suppliers, enhancing timely access to life-saving interventions, especially for women, children, and adolescents. Various initiatives offer promising opportunities. The Africa Vaccine Manufacturing Accelerator aims to reduce the startup costs and financial risks for local manufacturers by offering financial incentives, which would bolster local manufacturing. The African Medicines Agency aims to harmonise regulations and enhance laboratory capacities to ensure that locally produced health products meet global standards. The African Pooled Procurement Mechanism, by prioritising sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH) commodities, aims to strengthen Africa's ability to deliver life-saving interventions at scale. Together, these initiatives provide a robust foundation for self-reliance in health manufacturing in Africa and for the continent's growing role in the global health ecosystem.

Africa imports almost 80% of its pharmaceuticals, making it heavily dependent on external markets that often do not meet urgent demand.³ To address this dependency, the African Union has set an ambitious goal of manufacturing 60% of its vaccines locally by 2040. Achieving this vision requires a comprehensive approach that includes end-to-end capabilities, from research and development to the fill-and-finish stages of production. Policy makers should take bold, decisive action to make this vision a reality. This commitment should be mirrored for all essential maternal, newborn, and child health commodities.

Postpartum haemorrhage is the leading cause of maternal mortality on the continent.⁴ Tranexamic acid helps prevent postpartum haemorrhage by reducing excessive bleeding. Despite tranexamic acid being an affordable and effective intervention, Africa still imports 60% of its tranexamic acid supply from India.⁵ Yet, African manufacturers already have the capability to produce tranexamic acid domestically. A similar case applies to magnesium sulfate, the recommended anticonvulsant and first-line treatment for eclampsia and severe pre-eclampsia; hypertensive disorders remain the second-leading direct cause of maternal mortality in sub-Saharan Africa.⁵ The urgent need for widespread access to life-saving commodities and interventions, including family planning commodities, rapid diagnostic tests for malaria, which have the lowest coverage across the full range of care,⁶ applies to the full continuum of SRMNCAH services.

Ensuring the availability of essential commodities is only one part of the equation. Without a well-equipped and adequately staffed health workforce, even the most cost-effective interventions will not have an impact. Africa is home to 24% of the global disease burden but only 3% of the world's health workforce.⁷ This workforce is concentrated in urban areas, leaving rural areas underserved. For instance, in Uganda, 70% of medical doctors and 40% of nurses and midwives are based in urban regions, catering to only 12% of the population.⁸ Shortages in the health workforce in Africa are exacerbated by the emigration of health workers to countries that offer better remuneration and working conditions. For example, the Zambia doctor-to-patient ratio is 1 to 12 000 (WHO recommend 1 to 5000) and the nurse-to-patient ratio is 1 to 14 960 (WHO recommend 1 to 700)—shortages that are largely due to the exodus of health workers.⁹ Similarly, between 2016 and 2018, over 9000 medical doctors left Nigeria to work in the UK, USA, and Canada.¹⁰

Addressing this imbalance requires urgent investment in support systems for, and the recruitment, training, and retention of midwives, nurses, and community health workers, who are crucial for delivering essential health interventions. Addressing this imbalance also requires support for regional efforts to strengthen health workforce retention by balancing migration benefits with the need to maintain Africa's fragile health systems. The AU Migration Policy Framework for Africa (2018–30) recognises health worker migration as a priority and calls for well-managed mobility and retention strategies. Similarly, the Africa Health Strategy (2016–30) calls for improvements in health worker training, remuneration, and career opportunities across member states.

To accelerate progress in women's, children's, and adolescents’ health, a coordinated effort is needed to strengthen health systems and ensure equitable access to life-saving interventions. This effort requires strategic investments in community-led primary health-care systems, allowing essential services and commodities to be brought closer to where people live, work, and play.

Donors and development banks should prioritise investments in local pharmaceutical production and pooled procurement mechanisms, reducing dependency on costly imports and enhancing supply chain resilience. Public–private partnerships can play a key role in establishing sustainable financing models that expand access to essential medicines and services. Global health organisations should also support regulatory harmonisation to ensure that African-produced medicines meet international standards, which would bolster confidence in locally manufactured health products.