Submission ID 129653
| Issue/Objective | Sierra Leone's health system is highly dependent on external financing, with development assistance for health accounting for 46.7-47.1% of total health expenditure in 2020-2024, while government contributions remained low at 25-26%. Recent aid cuts have created a major fiscal shock: USAID health funding fell by 77% between 2024 and 2025, the Global Fund reduced support by 10-15%, and UK aid is expected to end by 2026. Per capita health expenditure declined from $40 in 2016-2018 to $27 in 2023. These shifts threaten essential services and deepen risks for rural donor-dependent populations. This study assesses the early impacts of aid cuts, emerging resilience strategies, and financing reforms under discussion, with relevance to the conference theme of reclaiming global health equity in a fragmented world. |
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| Methodology/Approach | This rapid mixed-methods study combined analysis of health financing and service delivery trends from 2019-2025 with 11 key informant interviews involving government, donor, and civil society stakeholders in Sierra Leone. Conducted during active donor withdrawal and fiscal contraction in 2025-2026, the study explored system-level impacts, coping responses, and options for reform. |
| Results | Aid cuts were associated with selective service disruptions, including family planning volumes 15-24% below expected levels in 2024-2025 and malaria testing 25-32% below expected levels in mid-2024. Short-term responses included resource reallocation, buffer stock use, and reprioritisation of budgets. Adaptive responses at facility and district levels included reduced service hours, limited referrals, informal procurement, and increased reliance on community mobilisation. While these measures may preserve access in the short term, they risk maladaptation by reducing quality, increasing inequity, and shifting costs to households. Longer-term options under discussion include earmarked taxes, increased domestic budget allocations, local financing, social health insurance expansion, and stronger donor coordination. |
| Discussion/Conclusion | Sierra Leone's experience shows that aid cuts are not only a funding problem but an equity and governance challenge. Short-term resilience strategies may sustain services temporarily, but without deliberate protection of vulnerable groups, they can worsen exclusion. Reclaiming global health equity in fragile settings requires politically feasible financing reforms, stronger domestic leadership, and coordinated support aligned with national priorities. |
| Presenters and Affiliations | Augustus Osborne Institute for Development Augustus Osborne Institute for Development Maria Bertone Queen Margaret University Halimatu Kamara Institute for Development Ayesha Idriss Institute for Development Sophie Witter Queen Margaret University |
