Adapting to the Aid Transition: South–South  Collaboration and Catalytic Investment in a Fragmented World

By Rahul S Reddy Kadarpeta, Muluken Argaw, Samson Kuhora, Charlotte Muheki

As traditional development aid declines sharply—with cuts exceeding 70% from major donors between 2021 and 2025—African and Asian countries are navigating an unprecedented transition that demands new approaches to achieving universal health coverage. This article examines how South-South collaboration and catalytic investment mechanisms are emerging as critical strategies for sustaining health system progress in the post-aid era. Drawing on global experiences, including from the Joint Learning Network for Universal Health Coverage (JLN) and its Joint Learning Fund (JLF), we share how countries are leveraging peer-to-peer learning to mobilize domestic resources, and innovative financing to build resilient, country-owned health systems that limit the dependence on unpredictable flows of external assistance.

Key Words

Universal Health Coverage, South-South collaboration, domestic resource mobilization, health financing, Joint Learning Network, aid transition, global health,  African health systems

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For decades, international development has been defined by the flow of aid, resources and expertise moving from wealthier governments, multilaterals, banks, private foundations, and non-governmental organizations – typically in the Global North – to those in need – typically in the Global South. 

The modern development model emerged as a post-colonial responsibility. After World War II and through the Cold War, it was used as a geopolitical tool by more dominant economic and political powers, including the United States, Western Europe, and the Soviet Union¹‚². However, this model has been changing as power, resources, and expertise have diversified—driven by the rise of middle-income countries, digital transformation, critiques of aid effectiveness, and stronger demands for locally led development.<3> 

The traditional development aid model has been further disrupted recently given significant political shifts and cuts to Official Development Assistance budgets by major donor countries like France, Germany, the United Kingdom, and the United States, as well as the impact of large-scale events like COVID-19 and the ongoing war in Ukraine.<4>  According to a recent World Bank report, 80% of low-income countries and 40% of low- and middle-income countries are expected to face a decline in combined government and donor-health spending by 2030.

Collectively, these forces have pushed the development ecosystem toward more partnership-based approaches and innovative funding models as many low- and middle-income countries have also begun proactively charting their own paths toward self-reliance, using shared learning and collaborative problem-solving, along with catalytic investments, to drive progress. 

Across Africa, the aid transition is exposing both the fragility of donor-dependent health systems and the untapped potential for homegrown solutions. Countries across Africa face health crises driven by aid cuts, shifting demography, and infectious and environmental threats. Renewed public health strategies, smarter investment, and stronger surveillance can help, but reversing funding cuts is vital.<6> Countries like Nigeria have lost over $600 million in health funding—more than a fifth of their annual health budget—while dramatic reductions in funding from the United States government threaten decades of progress in HIV treatment, tuberculosis control, and maternal health services.<7>  

Yet this crisis has catalyzed unprecedented political momentum, with the August 2025 Accra Health Sovereignty Summit marking a watershed moment where African heads of state committed to “health without aid” through domestic resource mobilization, pooled procurement, and regional pharmaceutical manufacturing. The challenge remains significant: only three African countries—Rwanda, Botswana, and Cabo Verde—consistently allocate 15% of national budgets to health.<8>

Investing in health is one of the most powerful drivers of human capital formation, economic growth, and job creation. Each additional dollar, well-spent, will save lives and deliver outsized returns. More and better health spending will facilitate the expansion of core health services and bring countries closer to reaching their UHC goals.  — World Bank.<5>

However, innovative financing mechanisms are emerging, from Ghana’s excise taxes on sugary drinks to Kenya’s restructured Social Health Insurance Fund, demonstrating that African countries are no longer waiting for external validation to chart their own paths.6  The shift from passive recipients to active architects of health systems requires not just more money, but strategic investments in primary healthcare, stronger health governance, and public-private partnerships that leverage Africa’s entrepreneurial spirit and digital innovation<9>. What we’re witnessing is not merely an adaptation to reduced aid, but a fundamental reimagining of health systems rooted in African agency, regional solidarity, and sustainable financing models.

These transformations across the African continent represent one of the most important global trends today – particularly when it comes to global health and the advancement of universal health coverage (UHC) and the Sustainable Development Goals.

Cross-Country Learning as a New Currency 

While peer-to-peer learning is increasingly important to sustain and drive change, it is not a new concept. Over the years, multiple learning networks have emerged to support locally led health systems in strengthening and driving policy change and action globally, regionally, as well as sub-nationally. These include the Linked Immunization Action Network, Strategic Purchasing Africa Resource Center, and, of course, the Joint Learning Network for Universal Health Coverage (JLN)<10>.

The idea of the JLN itself emerged from a side session on UHC in May 2009 at the World Health Assembly. Representatives from Ghana, India, Thailand, and Vietnam were invited to speak on their efforts by the Rockefeller Foundation and while their presentations highlighted several common challenges, it also was clear that each country was largely working on their own. As a result, the JLN was born to bring countries together so practitioners could work alongside each other in a more intensive, structured, and egalitarian manner to co-develop solutions grounded in their experience, helping address the persistent and difficult problems of moving towards UHC more efficiently and effectively<11>.

As the development assistance landscape continues to shift, countries will be increasingly seeking ways to maintain momentum toward UHC without depending solely on traditional development models. Ultimately, this “post-aid” era may be defined by a new currency that emphasizes partnership, mutual accountability, and the exchange of ideas. 

The model of joint or collaborative learning aligns directly with the new reality of decreasing development aid. Through South–South cooperation, countries can collectively generate and refine knowledge that can be immediately applied to their contexts. The value lies not only in the tools or frameworks produced, but in the relationships of trust and shared purpose that emerge through the process. This collaborative exchange model empowers countries to build on each other’s progress, fostering a sense of ownership that traditional aid models often struggled to achieve.

Country Spotlight: Kenya’s Health Financing Transformation

The most compelling evidence of this shift comes from the countries themselves as they move from recipient-driven projects to tools and knowledge products co-created through technical initiatives that drive sustainable impact at the country level. As donor financing for HIV, tuberculosis, malaria, and childhood immunization declines, Kenya is leveraging JLN-informed Domestic Resource Mobilization (DRM) models and toolkits to responsibly and gradually absorb these costs, demonstrating how shared learning is translating into resilient, country-driven solutions.

This spirit of co-creation and country-led problem solving is vividly reflected in Kenya’s experience. “For Kenya, the JLN has been a bridge—connecting Kenya’s National Health Insurance Fund (NHIF) team (now the Social Health Authority) with peers in other countries who have faced the same implementation challenges,” shares Samson Kuhora, the previous NHIF Head of Benefits Design and Claims Management. “When we discuss financing reforms, we are not starting from theory, we are learning from real experiences in countries with similar socio-economic and cultural barriers. This has significantly aided in customizing global policies to respond to real and local challenges, and in using real-world evidence to model toolkits and impact evaluation indicators.”

Kenya has been an active participant in the JLN’s cross-country learning platforms, drawing on knowledge products related to benefits design, health technology assessment, primary healthcare financing, and domestic resource mobilization. These resources played a central role in shaping Kenya’s health financing transformation agenda following the UHC pilots in four counties in 2018-19. Guided by four core pillars—legislative reforms, health systems governance, health services and financing structures, and the digitalization of healthcare—Kenya used JLN toolkits to evaluate the sustainability of different financing models, including contributory and blended social health insurance arrangements. 

With this strengthened framework, Kenya currently projects that domestic resource mobilization will eventually cover about 54% of total healthcare costs, ensuring universal access to primary healthcare and co-financing for chronic and critical conditions. Additionally, domestic resource mobilization models are backed by value addition products and return on investment modeling validating that “a spend in health is an investment in the economy.” Kenya’s success demonstrates how collaborative learning translates into policy action. However, sustaining such reforms requires more than knowledge exchange alone—it demands innovative financing mechanisms that can support implementation at scale.

Innovative Investments in Action

As development aid funding becomes more scarce, innovative financing and investments become more important. Blended financing, social impact bonds, public-private partnerships, and usage taxes can help develop, implement, and scale sustainable systems change beyond donor cycles. For example, Development Impact Bonds, which tie investor returns to verified social outcomes, are being used in India to fund maternal and newborn health programs. In Kenya, a public-private partnership comprised of private telecom providers, nongovernmental organizations, and the Ministry of Health leverages the country’s high mobile-phone penetration rate to provide mobile-money and SMS bulk messaging. This partnership expands access to health financing, service verification platforms, and digital health services<12>,<13>.

In January 2025, the Joint Learning Network launched the Joint Learning Fund (JLF), with an initial investment of $1 million to support countries in translating joint learning into tangible action that strengthens health systems. Unlike traditional funding mechanisms tied to donor agendas, JLF is embedded within the JLN’s collaborative learning ecosystem that empowers countries to define what they need, design how to address it, and share results that others can adapt. Countries don’t just receive financial support—they can also leverage the insights and knowledge of peers facing similar challenges and opportunities, as well as guidance from technical experts and partners associated with the JLN.  

Encouraging ownership, creativity, and long-term sustainability, the JLN is investing in twelve countries across Africa and Asia in its first round, including Bangladesh, Ethiopia, Ghana, Indonesia, Kenya, Liberia, Malaysia, Mongolia, Nigeria, Philippines, South Africa, and Vietnam, to improve primary health care provider payment systems and performance management, strengthen digital health foundations, develop more inclusive health benefit packages, and harness public financial management reforms to drive health sector improvements. This approach not only accelerates progress but also inspires a new generation of reforms grounded in collaboration, learning, and shared ambition for stronger, more equitable health systems.

Countries are also pursuing innovative health financing measures to respond not only to a shifting global aid landscape but also to long-standing challenges of inadequate, unreliable, and unsustainable health sector funding. While many of these efforts rightly focus on strengthening domestic resource mobilization, ensuring the effective and efficient use of existing health budgets is equally critical. In this context, assessing how health services are purchased—and shifting from passive to strategic purchasing—has become essential for driving better value, accountability, and outcomes.

Ethiopia exemplifies this effort through a series of ambitious reforms, including the introduction of multiple provider payment modalities. Notably, the Ethiopian Health Insurance Service has piloted capitation payments for primary health care facilities as a transformative provider payment mechanism. With catalytic funding from the JLF, Ethiopia has launched an assessment of this ongoing capitation pilot for Primary Health Care Units, examining how it interacts with other provider payment mechanisms. The goal is to generate actionable evidence on how different payment methods influence service delivery, efficiency, and the financial sustainability of primary health care.

This assessment is guided by key JLN knowledge products:  Assessing Health Provider Payment Systems: A Practical Guide for Countries Working Toward Universal Health Coverage (2015) and Financing and Payment Models for Primary Health Care: Six Lessons from JLN. The insights generated will help inform policy adjustments and strategic refinements, contributing to Ethiopia’s continued leadership in advancing resilient and sustainable healthcare financing reforms.

Accelerating a New Model

The lessons emerging from collaborative learning and catalytic funding mechanisms go beyond the co-development of technical tools and successful policy reforms and implementation investments. They reveal a deeper truth: collaboration and innovation are a form of resilience. In a world marked by geopolitical shifts, pandemics, and climate pressures, countries are realizing that their strongest resource is collective intelligence.

For example, in Brazil, the Brazilian Agricultural Research Corporation, is sharing tropical-agriculture expertise through South–South partnerships and technical cooperation, helping countries in Africa and Latin America adapt resilient, context-appropriate practices rather than importing northern models. This collaboration demonstrates how peer learning between countries with similar agroecologies can accelerate productivity and climate-smart farming<14>.

The resilience built through collaborative learning proved critical during the crisis. Examples of this new model were particularly visible as the global health sector sought to respond to the COVID-19 pandemic. The Africa Centres for Disease Control and Prevention, leveraged regional collaboration and cooperation to coordinate pooled procurement, knowledge-sharing, and a continental vaccine-manufacturing agenda leading to improved supply security, local manufacturing capacity, and better terms with manufacturers<15>.

And, through JLN’s National Coordination of Pandemic Responses Collaborative, member countries were supported in developing and sharing real-world strategies for coordinating multisectoral responses. As a result: Kenya developed a publicly accessible COVID-19 data dashboard and deployed community volunteers and religious leaders to build trust and counter vaccine hesitancy; Ethiopia reinforced the importance of multisectoral coordination, political leadership, and mobilization of health extension workers to reach remote areas; and, Bangladesh set up a nationwide coordination committee that linked multi-level government bodies, engaged community health structures, and deployed financial support systems to cushion vulnerable communities<16>,<17>,<18>.

As the JLN marks over fifteen years of partnership and innovation, its community of practitioners continues to expand and evolve. The network’s growing relevance lies in its adaptability to address emergent and high-priority topics, as well as its ability to serve as a platform for technical problem-solving, a community of practice that amplifies and centres country voices, and as an investor in sustainable change through the JLF. By fostering mutual accountability and shared learning, the JLN has helped its members build a culture of openness and trust — one where experience and collaboration, not hierarchy, drives progress. This model offers a glimpse into what a more equitable, multipolar global health architecture can look like: one grounded in solidarity, shared purpose, and mutual respect.

The future of UHC will not be written by any single country or institution, but by the collective wisdom of those who share the vision of health for all. As countries navigate the post-aid transition, collaborative learning and innovative funding mechanisms can help elevate the right questions while building lasting and impactful tools, policies, and approaches that advance the well-being of our communities.

References

• ^[1] USAID History. https://web.archive.org/web/20111009131110/http://www.usaid.gov/about_usaid/usaidhist.html
• ^[2] Severino, Jean-Michel; Olivier, Ray (2009). “The End of ODA: Death and Rebirth of a Global Public Policy”. Center for Global Development. https://www.cosv.org/download/centrodocumentazione/End_of_ODA_FINAL.pdf
• ^[3] Development Co‑operation Report 2023, Debating the Aid System, OECD. https://www.oecd.org/content/dam/oecd/en/publications/reports/2023/02/development-co-operation-report-2023_be7899d0/f6edc3c2-en.pdf
• ^[4] Cuts in Official Development Assistance: OECD projects for 2025 and the near term. https://www.oecd.org/en/publications/2025/06/cuts-in-official-development-assistance_e161f0c5/full-report.html
• ^[5]  Kumar, Anurag, Jacopo Gabani, Alberto Marino, Julio Cesar Mieses Ramirez, and Patrick Hoang-Vu Eozenou. At a Crossroads: Prospects for Government Health Financing Amidst Declining Aid. Government Resources and Projections for Health (GRPH) Series. Washington, DC: World Bank, November 2025. https://hdl.handle.net/10986/43745.
• ^[6] MacPherson, P., Nliwasa, M., & Choko, A. T. (2025). Reductions in development assistance for health funding threaten decades of progress in Africa. PLOS Medicine, 22(8), e1004695. https://doi.org/10.1371/journal.pmed.1004695
• ^[7] Chatham House. (2025, October 16). Africa after USAID: who will pay the health bill? https://www.chathamhouse.org/2025/10/africa-after-usaid-who-will-pay-health-bill
• ^[8] Africa CDC. (2025, April). Africa’s Health Financing in a New Era. https://africacdc.org/news-item/africas-health-financing-in-a-new-era-april-2025/
• ^[9] Amref Health Africa Newsroom. (2025, March 3). African health leaders call for stronger health systems amid shrinking financial support. https://newsroom.amref.org/press-releases/2025/03/african-health-leaders-call-for-stronger-health-systems-amid-shrinking-financial-support/
• ^[10] Collaborative Learning to Drive Policy Change and Action: Strengthening health systems through peer-to-peer collaborative learning. Health Systems Strenthening Practic Spotlight, USAID, November 2023. https://www.acceleratehss.org/wp-content/uploads/2023/11/LHSS_Practice-Spotlight_Collaborative-Learning-to-Drive-Policy-Change-and-Action_508c-1.pdf
• ^[11] A Decade of the Joint Learning Network: A Vision Realized. https://jointlearningnetwork.org/a-decade-of-the-joint-learning-network-a-vision-realized/
• ^[12] Independent Assessor for the Utkrisht Development Impact Bond in India, Mathematica. https://mathematica.org/projects/independent-assessor-for-maternal-and-neonatal-health-impact-bond-in-india
• ^[13] Risk Sharing and Transactions Costs: Evidence from Kenya’s Mobile Money Revolution, American Economic Review, https://www.aeaweb.org/articles?id=10.1257/aer.104.1.183
• [14] EMBRAPA, the Brazilian Cooperation Agency and IICA take key step to strengthen cooperation between the Americas and Africa for food security and sustainable farming. https://iica.int/en/press/news/embrapa-the-brazilian-cooperation-agency-and-iica-take-key-step-to-strengthen-cooperation-between-the-americas-and-africa-for-food-security-and-sustainable-farming/?utm_source=chatgpt.com
• ^[15] Strengthening vaccine capacity building on the African continent. Nat Commun 16, 7525 (2025). https://doi.org/10.1038/s41467-025-62839-y
• ^[16] Coordinating the National Pandemic Response in Kenya. https://jointlearningnetwork.org/wp-content/uploads/2022/03/Covid-Collaborative-Kenya-Case-Study.pdf
• ^[17] Coordinating the National Pandemic Response in Ethiopia. https://jointlearningnetwork.org/wp-content/uploads/2022/03/Covid-Collaborative-Ethiopia-Case-Study.pdf
• ^[18] Coordinating the National Pandemic Response in Bangladesh. https://jointlearningnetwork.org/wp-content/uploads/2022/03/Covid-Collaborative-Bangladesh-Case-Study.pdf

To learn more about the JLN and explore opportunities for collaboration, visit www.jointlearningnetwork.org. Countries interested in joining the network or applying for JLF support can contact i[email protected]. 

About the Authors:

1. Rahul S Reddy Kadarpeta, Executive Director, Joint Learning Network
2. Muluken Argaw, Executive Officer, Federal Ministry of Health, Ethiopia
3. Samson Kuhora, Head, Benefits Design and Claims Management, Social Health Authority, Kenya
4. Charlotte Muheki, Senior Director, Health Systems Strengthening Unit, Amref Health Africa

 Further reading on the value of catalytic investment:

1. Bennett, S., et al. (2018). Building the resilience of health systems in low- and middle-income countries: A review of the literature. Health Research Policy and Systems.
2. Kharas, H., & Prizzon, A. (2014). Financing the post-2015 Sustainable Development Goals. ODI.
3. Piatti-Fünfkirchen, M., & Schneider, P. (2018). From stumbling block to enabler: The role of public financial management in health service delivery. Health Systems & Reform.
4. Akhnif, E., et al. (2018). Are our ‘UHC systems’ learning systems? Piloting an assessment tool and process in six African countries. Health Research Policy and Systems.
5. Patcharanarumol, Walaiporn et al. (2018). Strategic purchasing and health system efficiency.