From dependency to strategic sovereignty: reframing global health financing in a fragmenting world—lessons from Angola

Development assistance for health has plateaued while sovereign debt burdens and geopolitical competition have intensified. Reform initiatives such as the Lusaka Agenda and the Accra Reset call for country ownership and sustainability, yet largely remain within existing power structures. This paper presents a conceptual and policy analysis, using Angola as an illustrative case, to examine how global health financing models can move beyond aid effectiveness towards what the paper defines as 'strategic sovereignty'. Strategic sovereignty is conceptualized here as both an analytic lens and a normative policy objective, referring to the capacity of states to align health financing with broader macro-fiscal and geoeconomic strategies while maintaining institutional autonomy and accountability. Using Angola's experience, the paper illustrates how dependency in lower-middle-income countries is increasingly shaped by fiscal volatility, bilateral debt exposure and geopolitical bargaining rather than grant reliance alone. Drawing on available macro-fiscal and health financing data, Angola's oil-dependent economy, high bilateral debt and fluctuating public expenditure patterns highlight constraints on health sector predictability and autonomy. The paper proposes three forward-looking and exploratory pathways towards sovereign health financing: sovereign health financing compacts linked to geoeconomic assets such as the Lobito Corridor; fiscal resilience mechanisms including countercyclical health funds and systems-linked debt-for-health swaps; regionalization of procurement and manufacturing to reduce structural supply dependency. These pathways are presented as policy options rather than empirically validated models. In conclusion, reducing dependency requires embedding health financing within national geoeconomic strategy. While the proposals remain prospective, they aim to frame a policy agenda for further empirical and operational development.