The 'Accra Reset': Time’s up for the legacy aid system

As the global health architecture struggles to hold steady amid plummeting foreign aid, a group of African leaders, policymakers, and global health experts met in Ghana’s capital city of Accra in August to craft a new path toward health sovereignty — rooted in national ownership and more equitable global cooperation. And they reconvened last week during the United Nations General Assembly, alongside leaders of multilateral institutions, philanthropic organizations, business innovators, and civil society to expand this framework beyond health to development more broadly in areas such as climate resilience, food security, and economic growth — and to move beyond the African continent to serve as a global agenda. They’ve dubbed it the “Accra Reset,” an effort to declare an end to the era of development-as-usual and to push for the creation of new governance, business, and financing models. “The cracks in the global order are growing deeper,” said Ghana’s President John Dramani Mahama, during UNGA. He has led these efforts, with support from former Nigerian President Olusegun Obasanjo. “We need to strategize. The world needs a reset, a re-engineering of the very logic of development itself.” “From Accra, a message went out to the world: If we are to heal our health systems, we must first reset development itself,” he said. Mahama stressed that these efforts aren’t a rejection of the legacy aid system’s achievement, but the launch of a crucial next phase. “It is indeed right that the global south should take the lead, for it is in our countries that the collapse of the old world model will be felt most acutely, and it is from our innovations that the world can find new answers and solutions,” he said. Already, more than $1 billion in “reset-compatible pledges from African development finance institutions and private banks have been aligned with the new approach through the pooled pledged and deal rooms arrangements,” Mahama said. Reimaging global development Dr. Victor Bampoe, chief executive of Ghana's National Health Insurance Authority, said during a Devex event on UNGA’s sidelines that after funding gaps exposed by the Trump administration’s stop-work order, Mahama tasked the country’s finance minister with plugging holes. More broadly, Ghana began examining relationships with global financial institutions to ensure African countries are not “passive receivers,” but active negotiators. This led to the first endorsement of the Accra initiative in August, following the Africa Health Sovereignty Summit, which works to “foster a new era of health sovereignty rooted in national ownership, investment, and leadership.” The framework also integrates health into economic platforms, such as the African Continental Free Trade Area, and includes the launch of the SUSTAIN initiative to “promote country-led and investment-driven health systems, powered by domestic resources, private sector engagement, philanthropic partnerships, and technical expertise.” These efforts ultimately evolved into the broader “Accra Reset,” which aims to “rebuild global development around sovereignty, workability and shared value,” according to Mahama. Under it, African nations and others aim to jointly invest, design, and create solutions with external partners. This means moving beyond the temptation to craft another set of global goals once the Sustainable Development Goals expire in 2030, toward building executable business models and fit-for-purpose institutions and financing systems. These include innovative financing instruments, strategic deal rooms to facilitate risk sharing, and smarter coalitions to multiply rather than ration resources, he said. And there’s also a need for accepting new realities. “We live in an era of unpredictability. The post-war multilateral era is being ripped apart. It appears we must prepare for a period of global turbulence,” he said. “Accepting that diverse, even contradictory interests are now a permanent feature of our system, and turning these very tensions into the fuel for pragmatic cooperation and mutual investment is imperative.” Mahama also launched a global presidential council last week to provide political leadership for this vision, which includes government leaders from Africa, Asia, Latin America, and other key regions. Alongside this presidential council, a high-level advisory panel — “a partnership of the willing” — will bring together leaders from health, finance, innovation, and business to create designs and execute solutions, Mahama said. It will collaborate with the U.N., regional institutions, and the private sector — serving as a platform to test and refine new models. These councils will tackle questions such as how to govern in a polycrisis era and unlock trillions in climate finance. Health will serve as the proof-of-concept, given the long dependence on foreign aid, with lessons applied to other sectors. But before seeking global partnerships and external finance, the vision calls on countries to use existing funding more effectively. “We don't have to fight for resources. We can just be more creative with the resources and partnerships that we have,” Ngozi Erondu, technical director at the Global Institute for Disease Elimination, said during the Devex event. She said one barrier to early sovereignty has been the lack of clarity on the cost of health care in Africa. But part of the Accra Reset, she explained, includes calculating the price of delivering primary care, identifying redundancies, and mapping what the tax base can cover, alongside public-private partnerships. From there, countries can invite external financing. “That is a process that some African countries are starting, but overall it hasn't happened — and so until we know how much it actually costs, it'll be very difficult to know how much African countries can actually cover and ensure that they're able to provide the domestic resources necessary to deliver essential health services to their populations,” Erondu said. The Accra Reset is also about defining priorities, Bampoe said. In Ghana, for example, 45% of all deaths are attributable to noncommunicable diseases — such as cancers, strokes, and renal failure. While global health has long emphasized infectious diseases, Ghana passed a law requiring 20% of the National Health Insurance Authority funding to target NDCs. The government has also recently removed the former limit on the National Health Insurance Levy, a tax on specific goods and services. And then, ultimately, there’s a need for countries to commit to this reset for the long haul and ensure that whatever is agreed upon becomes a reality across all arms of governments and across the country, Bampoe said. “It's not just another flavor of the day, or flavor of the month.” ‘A new vision of global multilateralism’ Experts at UNGA noted that the last major attempt to reset global development was the Monterrey Consensus on Financing for Development in 2002, which demanded “a new partnership between developed and developing countries.” This was an attempt to shift from a paternalistic approach to international development, they said. At the time, the world was facing the HIV/AIDS crisis, which led African leaders such as Kofi Annan and Obasanjo to galvanize support — and this ultimately led to the creation of institutions such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, and Gavi, the Vaccine Alliance. “Just as Monterrey sought to reengineer development 25 years ago, today’s fragility calls for a new vision of global multilateralism. Health is once again at the forefront of this transformation, like it was then,” Mahama said. “It is the sector that is most exposed to the failures of aid dependency, but also the sector best positioned to provide sovereignty-led models that can succeed.” And while the steps taken over two decades ago made tremendous progress in saving lives, the vision of widespread equitable partnerships is still unfulfilled, experts said. External funding helped build up delivery capacity but often failed to strengthen management capacity for countries to take over systems, Mark Dybul, former executive director of the Global Fund, said during the Devex event. Part of the “sociology” of organizations and bureaucracies, he said, is to have their own systems, reporting requirements, and governance structures — rather than working within country-wide, integrated systems — leaving countries with balkanized systems. “How do we begin this shift away from the horrible word ‘aid’ to a partnership that we’ve been promising for 25 years? We have broken the promises we've made,” Dybul said. “If we'd been doing what we should have done 20 years ago — and been doing the last 20 years — we wouldn't be in this position.” Part of that prescribed shift includes a stronger relationship with the private sector. Thus far, global health’s engagement with the private sector has largely been “a joke,” Dybul said — often done without solid business plans. “We still don't know how to talk to the private sector.” Can self-interest evolve into shared interests? The dismantling of the U.S. Agency for International Development and massive cuts to programming are among the shocks prompting tremors in the global health system this year. Yet the U.S. recently unveiled its new “America First” global health strategy, and many global health experts see potential — chiefly its emphasis on bilateral agreements with countries. “The process will require intensive engagement with recipient country governments, other donors, and other in-country partners to shape a set of mutually agreeable priorities for future U.S. health assistance,” the strategy stated. This direct engagement with governments, rather than mainly through implementing partners, could support the Accra Reset. At UNGA, at least two African health ministers voiced support. “I actually think it's a solid strategy in terms of the principles,” Dybul said. Ultimately, the U.S. strategy prioritizes America’s interests — including opening African markets to American pharmaceutical companies. “But I think African countries can be smart about it. How do we work with these different countries with their interest and our interest and provide what our population needs to protect itself?” Erondu said. “This strategy lays out some type of process, at least from the U.S. side, which is huge, because the U.S. is the biggest donor country when it comes to overseas development aid for health,” she added. Still, experts raised questions about timelines for tapering U.S. support. Some countries will take longer than others, given realities like income levels, conflict, and natural disasters. Dybul said roughly a dozen African countries could handle a 25% to 30% cut in the first year by restructuring procurement, implementation, and management practices. Rwanda, for example, once navigated sharp cuts in external financing, yet continued programming and improved outcomes. A handful of countries successfully making transitions out of aid would change the dynamic, he said. “We've just been talking about it for 25 years — but if we actually see that, then there'll be confidence it can actually happen,” Dybul said. “Then, I think you'll see very strong bipartisan support.”