From Aid Dependence to Fiscal Sovereignty: Nigeria's Country-Owned Response to Declining Development Assistance for Health and Lessons for Health System Resilience in the Post-Aid Era

From Aid Dependence to Fiscal Sovereignty: Nigeria's Country-Owned Response to Declining Development Assistance for Health and Lessons for Health System Resilience in the Post-Aid Era Felix Abrahams Obi Results for Development Institute (R4D), Abuja, Nigeria fobi@r4d.org; obifelix@gmail.com Introduction and Objectives: Cuts in development assistance for health (DAH), including the US funding freeze, an 11% (over US$100m) reduction in Nigeria's US$933m Global Fund Grant Cycle 7 allocation (2024–2026) and a rise in Gavi co-financing from US$8m to US$57m, exposed Nigeria's dependence on external financing. This work describes how Nigeria (over 200 million people; 36 states, the FCT and 774 local government areas [LGAs]) is responding, and draws lessons for health system resilience in the post-aid era. Methodology: A descriptive policy analysis combined a desk review of legislation, policies, budgets, programme and quarterly performance reports (2014–2026) with insights from the author's technical engagement as a member of the Sector-Wide Approach (SWAp) National Technical Working Group on Health Financing. Reforms were mapped against six pillars: governance, financing, service delivery, digital health, supply chain and partnerships. Results and Discussion: Earlier reforms laid foundations: the 2014 National Health Act created the Basic Health Care Provision Fund (at least 1% of federal revenue) and the 2022 NHIA Act made health insurance mandatory. Since 2023, the SWAp ("One Plan, One Budget, One M&E") and a Health Compact signed in December 2024 by the President, governors and donors have aligned partners, with Joint Annual Reviews and data-informed plans in every state. Government responded to the cuts with a US$200m emergency domestic buffer for HIV, TB and malaria, a US$150m annual in-kind contribution to PEPFAR and higher co-financing. Insurance enrolment rose from 15 to 22 million (about 10%) through linkage to national ID. Free emergency obstetric care reached over 32,000 women and 1,700 newborns, and direct financing to primary health care more than doubled. A national digital health office (2026) aims to raise digital data capture from 9% of LGAs to 80% by 2030. Zero tariffs for local manufacturers, pooled procurement and local bed-net production target import dependence above 50%. Fragility persists; health's budget share fell from 5.18% (2025) to 4.2% (2026 proposal), releases are delayed and out-of-pocket spending exceeds 70%. Conclusions: Aid cuts can catalyze fiscal and data sovereignty. Nigeria's experience suggests that universal health coverage after aid is won not by replacing donors but by aligning governance, financing, service delivery and data under a country-owned compact, with sustained equity financing for the poor.