In late September, the United States announced that it will release $160 million in “bridge funding” to keep Mozambique’s HIV and tuberculosis programs afloat for the next six months. On the surface, this appears to be another instalment in the long history of U.S. global health assistance. Yet when viewed through the lens of Africa’s broader struggle for sustainable health systems, the pledge tells a far more complex story, one of dependence, resilience, and the urgent need for home-grown solutions.
Mozambique sits at the heart of southern Africa’s HIV crisis. More than two million of its adults live with the virus, giving the country one of the highest prevalence rates in the world. Tuberculosis, which thrives where HIV has weakened immune systems, continues to stalk hospitals and villages alike. For two decades, the President’s Emergency Plan for AIDS Relief (PEPFAR) has underwritten the bulk of Mozambique’s response, contributing to a continental transformation: across sub-Saharan Africa, the number of people receiving antiretroviral therapy rose from near zero at the dawn of the millennium to roughly 21 million by 2023. Deaths from AIDS-related causes fell from 2.2 million in 2003 to fewer than 400,000 last year, and annual new infections dropped from 3.2 million to about 640,000. Those numbers reveal a public-health success without precedent.
However, they also expose a structural fragility. When Washington slowed its foreign-aid disbursements earlier this year during a policy review, Mozambique’s clinics faced sudden shortages of test kits and essential drugs. The new $160 million allocation will keep the doors open only through March. After that, the future is uncertain. It is a reminder that life-saving treatment for millions of Africans still hinges on the budget cycles and political priorities of distant capitals.
The implications extend well beyond Mozambique. In neighboring Malawi, where roughly 8 percent of adults are HIV-positive, PEPFAR and the Global Fund together finance more than 70 percent of antiretroviral procurement. Kenya depends on external partners for about two-thirds of its HIV budget, even as its economy expands. Nigeria, despite its oil wealth, still receives nearly half of its HIV funding from international donors. Should donor enthusiasm wane, these countries would confront immediate shortfalls that domestic tax revenues cannot yet fill.
The “bridge” metaphor is apt but troubling: A bridge is meant to lead somewhere, yet African health financing often feels like a series of temporary crossings with no firm land on the other side. The United States remains the largest bilateral donor to Mozambique, historically providing over $560 million each year. That generosity has saved lives, but it has also delayed the painful work of building robust national systems that can withstand economic shocks and political change.
Consider the human workforce. PEPFAR dollars pay the salaries of thousands of community health workers who track patients in remote districts and maintain adherence to antiretroviral therapy. Without predictable funding, governments hesitate to absorb these workers into permanent payrolls. Mozambique’s public-sector wage bill is already strained; adding thousands more positions would require either new revenue streams or reallocation from other pressing needs such as education and infrastructure.
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The new funding package prioritizes frontline health workers and essential supplies but excludes certain services—male circumcision, abortion care, and related public-information campaigns. Those omissions are not merely technical; they shape epidemiological outcomes. Voluntary medical male circumcision, for instance, has been shown to reduce heterosexual transmission of HIV by roughly 60 percent. A pause in those programs today could translate into higher infection rates in five or ten years, compounding future treatment costs.
The lesson is clear: external aid remains a lifeline but cannot be the foundation. Countries such as Rwanda and Botswana offer glimpses of a different path. Rwanda finances more than half of its health budget domestically and has integrated HIV care into a broader system of universal primary healthcare. Botswana, once heavily donor-dependent, now covers the majority of its antiretroviral therapy costs through national resources, leveraging diamond revenues and innovative insurance schemes. Their experiences demonstrate that with political will, efficient tax collection, and strategic investment, domestic financing can gradually eclipse external aid.
Economic realities, of course, vary. Mozambique’s GDP per capita hovers around $550, and climate-driven disasters, from cyclones to prolonged droughts, regularly sap government coffers. Yet even in low-income settings, incremental reforms can build resilience. Expanding sin taxes on alcohol and tobacco, earmarking a fraction of natural-gas revenues for health, and strengthening regional procurement mechanisms to lower drug prices are all practical steps. The African Union’s African Medicines Agency, if fully operationalized, could help countries negotiate better prices and reduce dependence on single donors or suppliers.
The U.S. bridge funding therefore carries a double message. It underscores America’s continued commitment to the fight against HIV and tuberculosis, reaffirming a two-decade partnership that has saved millions of African lives, but it also signals a shift toward shorter, more conditional support, in line with Washington’s “America First Global Health Strategy,” which seeks to prioritize procurement from U.S. companies and to reduce long-term dependency. For African nations, this should be less a cause for alarm than a clarion call to accelerate domestic strategies.
