Setting the scene: the forces reshaping health in the African Region

No health system operates independently of the world around it. Five families of external forces (social, technological, economic, environmental and political: the STEEP framework) carved the operating environment for every result in this report (2). None of these external forces originates in the health sector, and all were brought to bear during the reporting period. Each is assessed for its effect on the health sector in general and on the health sector in the African Region in particular.

Social: a young, urbanizing and increasingly displaced population. Africa’s population passed 1.5 billion in 2024 and is projected to approach 2.5 billion by 2050. About 60% of the population of the WHO African Region is under 25 (3). This is the largest demographic opportunity of the century, with twin effects on the health sector. The first is sustained high demand for reproductive, maternal, newborn, child and adolescent health (RMNCAH) services, alongside a surging adult burden of noncommunicable disease (NCD) within the same households. The second is an opportunity, because a young and underemployed population makes the health sector one of the most credible engines of decent work on the continent. Urban populations in the Region are projected to double from roughly 700 million to 1.4 billion by 2050, absorbing most of that growth (4); urbanization concentrates both risks – with outbreaks amplifying in dense, informal settlements lacking adequate water and sanitation – and opportunities, since density lowers the unit cost of reaching people. Forced displacement reached record levels, increasing by 48% since 2020, with 12.7 million people forcibly displaced or stateless across West and Central Africa alone. Women and children account for approximately 80% of displaced people (5).

Impact on the health sector: demand rises fastest exactly where systems are weakest, widening equity gaps in coverage and utilization and placing the heaviest new load on RMNCAH services and on care in fragile, conflict-affected settings.

Technological: a data and manufacturing transition that could widen or narrow the gap. Digital tools, data systems and artificial intelligence (AI) have changed what health systems can see and how fast they can act. This year, the change was incorporated into routine regional practice in the form of an AI-enabled regional mental-health dashboard; a Preparedness Data Exchange linking hazard, preparedness and health-system data; the gathering of epidemic intelligence from open sources in 44 Member States; and real-time district dashboards to steer immunization campaigns. The Region currently manufactures less than 1% of the vaccines it uses; the African Union has set a target of 60% locally produced vaccines by 2040 (6). In addition, only about 38% of Africa’s population used the Internet in 2024, the lowest of any Region, with the widest urban-rural divide (7).

Impact on the health sector: technology is becoming a core determinant of health system performance and a route to sovereignty; however, without deliberate investment in access, interoperability and data governance these tools risk widening inequity rather than narrowing it.

Economic: a structural reset of health financing. The funding landscape shifted on three fronts simultaneously. Development assistance for health contracted by approximately 21% between 2024 and 2025, driven mainly by the approximately 67% fall in contributions from the largest bilateral donor. The cut hit sub-Saharan Africa the hardest: assistance dropped by approximately one-quarter (8). Bilateral programmes that had supported significant parts of the disease-control response were withdrawn or restructured. The Accelerating the Sustainable Control and Elimination of Neglected Tropical Diseases (ASCEND) programme of the United Kingdom was terminated early, and the freezing by the United States of United States Agency for International Development (USAID) funding for the Act to End neglected tropical diseases (NTD) programmes disrupted an estimated US$ 170 million of funding across 16 Member States. At the same time, multilateral platforms recalibrated their activities, with Gavi 6.0 of Gavi, The Vaccine Alliance and the Eighth Replenishment of the Global Fund to Fights Aids, Tuberculosis and Malaria both closing below target (9). This has a greater effect than earlier shocks for the following reasons. Firstly, about one-quarter of health spending on average in the Region is externally financed. Secondly, five Member States rely on external aid for 45% or more of their health spending. Thirdly, 27 Member States have a high degree of financing vulnerability to the cuts, even as nearly half are already in, or at high risk of, debt distress (10). Government health spending is an average of 7.3% of general government expenditure, less than half of the 15% set in the Abuja Declaration target of 2001 (11).

The external forces landed on health systems whose inherent capacities determined how much damage they could absorb and how much progress they could still deliver. It is tempting to make an artificial distinction between the Region’s low universal health coverage (UHC) service coverage index (51, against a global average of 71) and its government health spending, which is less than half of the target set in Abuja. It is more appropriate to read them as two expressions of a single capacity gap in financing and delivery. Four cross-cutting capacities determine performance: access, quality of care, demand for services and resilience to shocks. They rest on six pillars, which were tested during the year. The evidence for each is provided below.

Workforce. The Region has roughly 46% of the health workers its population needs and is projected to face a needs-based shortage of about 6.1 million health workers by 2030. This shortfall could be deepened to 6.4–6.6 million by the financing cuts if the ability to absorb new graduates falls, given that workforce absorption capacity stood at only approximately 70% before the cuts (20). An estimated one million trained health workers are unemployed or underemployed, even as facilities remain understaffed. This is a labour-market failure rooted in pay, geography and regulation, not training capacity alone.

Financing and financial protection. Beyond the 7.3% average government spending on health, which is below the 15% set by the Abuja Declaration, out-of-pocket payments account for approximately 36 of every 100 dollars spent on health and exceed the 20% financial-hardship threshold in 35 Member States (10). In this report, financing is treated not only as a constraint but also as the principal driver of reform (see Chapters 5 and 6).

Governance and stewardship. In this context, governance is understood as stewardship; the capacity of ministries of health to set priorities, direct all resources (public, private and external) towards these priorities and account for results, rather than organizational reform alone. The year showed both the gap (fragmented, donor-driven planning) and the momentum (a wave of health-tax legislation and the elevation of health to Heads-of-State level).

When the external and internal forces are analysed, it is clear that the combined impact of events that occurred during the year was severe but sharply uneven. The Region was not uniformly affected; the analysis below presents that effect in the order of country, neighbours of the country, its subregion and Region, and the global context. The criteria used are explicitly stated.

The country and its neighbours. The heaviest combined impact fell on Member States where three exposures overlap: high dependence on external health financing, protracted conflict or displacement, and a high malaria and HIV burden. On that basis, the hardest-hit group is concentrated in the fragile and conflict-affected settings of the Sahel and the Lake Chad basin and in the settings of Central and East Africa that have experienced protracted crisis, where displacement and insecurity compounded the financing shock; and in the high-HIV-prevalence economies of East and Southern Africa, which received the largest volumes of the now withdrawn external health assistance. About three-quarters of that assistance went to 10 Member States, all but one of them in East and Southern Africa (10). Exposure was lowest in the Region’s upper-middle-income and small-island economies, where external financing is a small share of health spending and domestic systems can substitute. This section does not rank individual Member States: the criteria are stated so that each minister can locate their own country within the pattern. The subregional distribution is set out in Table 1.

The subregion and the Region. At the subregional level, the constraint differs. Financing dependence and HIV exposure dominate in East and Southern Africa; conflict, displacement and workforce scarcity dominate in Central Africa and the Sahel; and climate-driven food insecurity and cholera dominate across the Sahel and the Horn of Africa. Region-wide, the transmission was consistent: the withdrawal of external financing affected services through the programmes that received the most external financing.

Who is left behind. Within every subregion, the burden fell hardest on the same populations: women and children, who account for approximately 80% of displaced people (5); children in the poorest and most remote districts, where zero-dose immunization is concentrated; adolescent girls and young women, who carry a disproportionate share of new HIV infection; people living with NCD and mental illness, for whom coverage was lowest before the contraction began; and health workers themselves, in the settings where posts remained unfilled. The Region cannot yet report this systematically. As recorded in Part 2, too few headline indicators can be disaggregated by sex, age, disability or place and closing that gap is a priority addressed in Chapters 2 to 4.

The global framework. Set against the rest of the world, the Region absorbed the largest regional cut to development assistance for health while carrying the highest burdens of malaria and of new HIV infection. This is the clearest possible illustration of why sustained, and increasingly domestic, investment matters.

This report is the Regional Director’s authoritative account of how political, social, economic and environmental forces shaped health outcomes across the African Region between 1 July 2025 and 30 June 2026. It documents how Member States responded to these pressures, the progress achieved collectively by the Region, and the specific contributions WHO made in support of those efforts. The report is structured around the mission of the Fourteenth General Programme of Work to promote, provide and protect health, and around the RC76 theme, Delivering results, driving reform, securing Africa’s health future. Each chapter connects back to the forces outlined in this section.

Chapter 2 examines the delivery of essential services and progress towards universal health and well-being. It shows how the Region sustained care and protected coverage through the financing shock, providing a direct test of the access and demand capacities.

Chapter 3 examines how the Region protected populations from health emergencies. It presents the operational response to an environment characterized by emergencies and demonstrates the resilience capacities discussed above.

Chapter 4 examines how the Region promoted health by addressing the social, commercial and environmental determinants that shape health outcomes. It reflects the health sector’s response to the social and environmental forces.