When health budgets shrink, the consequences are immediate and devastating for Africa’s youngest citizens. Drawing from frontline experience and broader fiscal realities, Dr. William Menson makes a clear case: under-five survival is not just a health priority, but a defining economic and political choice – one that will shape the continent’s future.
In the wake of the One Health Summit in Lyon at the beginning of April, the piece doesn’t just diagnose the problem. It calls on leaders to act before the cost is measured in lost lives.
During my time as a doctor at the Princess Marie Louise Children’s Hospital in Accra, I watched children under five arrive so critically ill that survival seemed unlikely. Many were severely malnourished. Some were struggling to breathe from pneumonia. Others had infections that had progressed too far simply because care had come too late.
And yet, time and again, with antibiotics, oxygen, therapeutic feeding, careful nursing and close monitoring, those same children began to recover. They sat up. They smiled. They played. They became children again.
That experience taught me something simple and enduring: for millions of African children, survival is rarely about miracle medicine. It is about whether basic systems work early enough.
The Fiscal Squeeze on Child Survival
As aid cuts deepen and fiscal pressure grows, African governments are being forced to make harder choices about what they will protect. At the same time, leaders across the continent are speaking more confidently about sovereignty, self-reliance, and economic transformation. But no continent can speak seriously about its future while allowing preventable deaths in the first five years of life.
By 2050, Africa’s population is projected to reach close to 2.5 billion. That is not only a demographic fact. It is an economic forecast, and one that will only be realised if the people within that projection are healthy enough to fulfil it. Africa’s greatest asset is not oil, gold, lithium, or cobalt. It is its people. But people do not become an asset by numbers alone. They become an asset when they are healthy, nourished, educated, and able to contribute productively.
Every dollar invested in the early years can generate very high long-term returns, making it one of the highest-yield investments in public finance. That is why protecting funding for children under five must become one of the most urgent fiscal decisions African governments make now. Not after elections. Not when budgets become easier. Now.
How Africa’s Debt Crisis Is Defunding Primary Care
The services that matter most are well known: primary healthcare, immunisation, nutrition, malaria prevention and treatment, and newborn care. These are not optional social expenditures to be funded when circumstances allow. They are foundational economic investments. Health and nutrition in the first years of life shape cognitive development, educational attainment, adult productivity, and lifetime earnings.
When children are malnourished, unvaccinated, or denied basic care, the consequences do not end in childhood. They follow those children into adulthood and hollow out the economies they will one day be asked to build. Under-five survival is not a health issue alone. It is a state-building issue, a labour-force issue, and an economic strategy issue.
And yet this is precisely where many African budgets are becoming most vulnerable. Donor financing is declining. Development assistance is under growing pressure. Many governments are also facing tighter fiscal space, rising debt obligations, and competing demands.
This reality demands honesty: no one is coming from outside to resolve this. The era in which African governments could assume that immunisation gaps, nutrition deficits, malaria commodities and primary care shortfalls would eventually be covered externally is ending. This is not ideology, it is arithmetic.
Ghana’s Budget: A Window Into a Continental Pattern
In Ghana’s 2025 budget for example, projected interest payments of GH¢59.9 billion exceed the combined allocations to health, education, and social protection. That is exactly why under-five services must be protected when budgets tighten.
The Abuja Declaration has long called on governments to allocate 15% of public expenditure to health. Most countries have still not met that target, and even full compliance would be insufficient where overall budgets remain thin. What matters is not only the share assigned to health, but whether limited fiscal space consistently protects the services with the highest survival return.
That means funding primary care before prestige projects, reaching unvaccinated children before celebrating national averages, treating nutrition as strategy not charity, seeing malaria as both a fiscal and child-survival priority, and making child-health budgets transparent so people can see what is protected and what is not.
What Resilient Health Financing Actually Looks Like
When the roof is leaking, you do not paint the walls. You fix the roof. For Africa, children under five are part of that roof. If they do not survive, everything else weakens.
My country, Ghana carries a special responsibility in this moment. In 1957, it showed Africa that freedom was possible. Today, it must help show that sovereignty means protecting life when money is tight. The Accra Reset has opened the conversation. Now the budget must answer it. If one generation won political independence, this one must finance survival.
History will not remember our declarations. It will remember whether Africa protected its children when financing became difficult. Perhaps that is the real test of sovereignty, and the answer will be written not in summits, but in budget lines.
Dr. William Nii Ayitey Menson is Director of Health Financing for Africa at The ONE Campaign (ONE). ONE drives the investments needed to create economic opportunities and healthier lives in Africa.