1foreword_p_1For many decades, the question of how African countries can sustainably finance essential public health services has remained both urgent and complex. The continent’s development aspirations are ambitious, yet traditional financing sources have proven insufficient to meet the scale of current needs. Today, African governments simultaneously face the challenges of underfunded health systems and the escalating demands brought about by pandemics, rising incidents of non-communicable diseases, and other public health crises.
2foreword_p_2These pressures have compelled policymakers, development institutions, and financial advisors to rethink conventional approaches to public financing. The African Legal Support Facility (ALSF) recognises and supports the pressing need of governments to identify and implement tools that enable effective and sustainable health sector financing. Innovative instruments are now central to global conversations on how countries can responsibly mobilise resources while maintaining fiscal stability.
3foreword_p_3It is against this backdrop that the ALSF, with the support of the Gates Foundation, convened a diverse group of leading experts in law, finance, public health, and policy to develop “Sustainable Finance for Health: A User Guide for African Governments” (“the User Guide”). This first-of-its-kind resource responds directly to the growing interest in mechanisms such as health-focused bonds and loans, sustainability-linked debt instruments, debt-for-health swaps, and health PPPs - instruments that have been deployed globally to catalyse key investments in priority health programmes.
4foreword_p_4Despite their promise, these innovative health financing mechanisms remain underutilised, in some cases due to their legal and structural complexities. The User Guide aims to close that knowledge gap. It provides clear, practical guidance to support governments in navigating the full lifecycle of these instruments: from conceptualisation and policy alignment, to transaction structuring, documentation, negotiation, and implementation. Drawing on lessons from global initiatives such as the Global Fund to Fight Aids, tuberculosis and malaria (the “Global Fund”) and other pioneering models, it presents best practices in an accessible, actionable format.
5foreword_p_5As with previous ALSF knowledge products, this User Guide reflects the collective expertise of contributors, in this case, drawn from multilateral institutions, law firms, academia, global health organisations, and advisory practices. Their perspectives have been shaped not only by sectoral knowledge but by extensive on-the-ground experience working with and within African governments. The result is a balanced, multidisciplinary reference designed to strengthen institutional capacity across ministries of finance, health, and planning as well as among debt managers and policymakers. To ensure a collaborative and time-efficient drafting process, the User Guide was produced using the Book Sprint methodology, an intensive group writing workshop. This approach, grounded in discussion, experience sharing, and expert insight, has ensured that the final product is firmly relevant to Africa’s real-world challenges and opportunities.
6foreword_p_6We hope this User Guide will support African governments in making informed and strategic decisions as they work to scale up health sector investments and strengthen public financial management. While these materials offer guidance and practical tools, they are not a substitute for professional advice. They should be used in conjunction with tailored legal and transactional expertise - which the ALSF was established to provide and stands ready to offer.
7foreword_p_7On behalf of the African Legal Support Facility, I extend my sincere appreciation to all contributing authors, remote collaborators, facilitators, and reviewers whose dedication and expertise made this User Guide possible. I also acknowledge our partners and stakeholders across the continent, whose continued commitment to advancing sustainable financing for health consistently informs and inspires our work. In particular, I wish to express special thanks to the West African Institute for Financial and Economic Management (WAIFEM) and the Macroeconomic and Financial Management Institute of Eastern and Southern Africa (MEFMI) for their valuable support during the review process, as well as to the senior African government technical experts whose insights ensured that the User Guide reflects the practical perspectives, priorities, and collective voice of its intended end users, the African governments.
8foreword_p_8As African countries navigate a rapidly shifting global landscape, the ALSF remains steadfast in its support for solutions that promote responsible borrowing, strengthened health systems, and long-term socio-economic development. We trust that this User Guide will be a valuable resource in advancing those goals.
9foreword_p_9Olivier Pognon
Director and CEO
African Legal Support Facility
THE AFRICAN LEGAL SUPPORT FACILITY
10foreword_p_10The African Legal Support Facility (ALSF) is an international organisation which broadly aims to remove asymmetric technical capacities between public- and private-sector stakeholders. The ALSF was initially established in response to the rise in vulture fund litigation against African sovereigns, but quickly expanded to assist African governments in negotiating complex commercial transactions. The ALSF intervenes in matters related to sovereign debt, power, infrastructure and the extractive sectors.
11foreword_p_11www.alsf.org
12foreword_p_12NB: This User Guide is issued under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence (CC BY-NC-SA 4.0), which allows anyone to copy, excerpt, rework, translate and re-use the text for any non-commercial purpose without seeking permission from the authors, so long as the resulting work is also issued under a Creative Commons Licence.