Peer-reviewed article
Aid cuts, health financing fragility, and maladaptive resilience in Sierra Leone: a rapid mixed-methods study
Augustus Osborne, Maria Paola Bertone, Halimatu Kamara, Ayesha Idriss, Sophie Witter ·
Summary
Written by AI, not yet AICS's view · claude-sonnet-5-5This rapid mixed-methods study looks at how cuts in international health aid affect Sierra Leone's health system. It reviewed 19 documents and interviewed 11 stakeholders from government, development partners, civil society, NGOs and independent experts. Services for mothers, newborns and children, as well as immunisation, were found to be highly exposed to funding disruption. So far, immediate service disruption appears limited and maternal health and immunisation indicators stayed comparatively stable in the short term. Interviewees reported that households are covering more of the cost through out-of-pocket spending and forgone care, and that some coping strategies could become harmful if they continue.
Key points
- Donor funding made up about 47% of total health expenditure in 2020-2024, against about 25-26% from government.
- USAID-supported health programming contracted sharply in 2024-25, and Global Fund allocations were reduced by about 15%.
- Reproductive, maternal, newborn and child health, HIV, tuberculosis, immunisation and pharmaceutical supply chains were identified as highly exposed.
- Maternal health and immunisation indicators remained comparatively stable in the short term, but current data do not support firm conclusions about which services were most affected.
- Spending on outreach, supervision, training and logistics was reduced, while interviewees reported households taking on more out-of-pocket costs and forgoing care.
Limitations
The study is based on 19 documents and 11 interviews, and the abstract says current data cannot show which services were most affected. It looks at the health system as a whole and does not provide child-specific outcome data, and short-term stability may not last.
Abstract
Sierra Leone's health system remains highly dependent on external aid, with donor funding accounting for approximately 47% of total health expenditure between 2020 and 2024, compared with a government contribution of around 25-26%. Recent reductions in development assistance for health, including a sharp in-year contraction of USAID-supported health programming during 2024-25 and an approximately 15% reduction in Global Fund allocations, have exposed major structural vulnerabilities in the health financing system. We conducted a rapid mixed-methods study to examine the effects of recent and anticipated aid reductions and the resilience responses emerging across Sierra Leone's health system. The study drew on a review of 19 documents and 11 key informant interviews with stakeholders from government, development partners, civil society, non-governmental organisations, and independent experts. Documentary and interview data were analysed descriptively and thematically, and findings were integrated during interpretation. Several service areas were identified as highly exposed to financing disruption, including reproductive, maternal, newborn and child health, HIV, tuberculosis, immunisation, and pharmaceutical supply chains. However, available evidence indicates that immediate service disruptions have so far been limited, and current data do not support firm conclusions about which services have been most affected. Maternal health and immunisation indicators remained comparatively stable in the short term. Documents and interviewees indicated that absorptive responses have prioritised core commodities and selected priority services, while reducing expenditure on outreach, supervision, training, logistics, and other enabling functions. Interviewees reported that households were absorbing much of the financial burden through increased out-of-pocket spending, forgone care, and informal coping mechanisms. Sierra Leone's response shows elements of absorptive and adaptive resilience, but several coping strategies show features consistent with maladaptive resilience and risk becoming maladaptive if prolonged, because they shift costs downward, threaten to deepen inequity, and erode the operational foundations of the health system.