By: Ambulai Johnson
For over six decades (1960- 2025), Liberia’s health system has heavily depended on the United States Agency for International Development (USAID). USAID has invested more than three billion dollars in humanitarian, development, and health programs, that have been filing critical funding gaps where domestic resources have fallen short and strengthening infrastructure, service delivery, and public health resilience.
One prominent USAID-supported project is the John F. Kennedy Medical Center in Monrovia. Initiated in 1961 during a meeting between Liberian President William V. S. Tubman and U.S. President John F. Kennedy, the project received $6.8 million in loans and $9.2 million in grants from USAID, with Liberia contributing $1 million. Construction began in 1965, and the hospital officially opened in 1971, indicating a milestone in Liberia’s health sector. Since then, USAID has played a key role in expanding access to essential health services. Recently in November 2023, USAID and the Government of Liberia signed amendment to the USAID’s Development Objective Grant Agreement, committing $114.5 million to key development initiatives, including $61 million for health and population programs. Now frozen, these funds leave Liberia facing an imminent crisis that requires urgent action to prevent severe disruptions in health service delivery. The funding freeze at USAID and potential health service disruption in Liberia is sending shockwaves through Liberia, placing critical healthcare services at risk, jeopardizing public health gains, and leaving the government scrambling to fill the funding gap and cushion the pending disruption.
Why Does This Matter? A Health Systems Analysis
Liberia’s health system remains heavily donor-dependent, with 47% of total health expenditures reliant on external funding. USAID, the World Bank, and the Global Fund have been key players in infrastructure, diagnostics, and human resource development. While the 2015 Liberia Health System Assessment reported $150 million allocated to infrastructure and diagnostics and $50 million to human resources, donor contributions have remained the backbone of healthcare financing. A 2018 analysis by the Palladium Group estimated per capita health expenditure at $83, largely driven by donor funding and private out-of-pocket spending. The 2023 Liberia Equity and Social Determinants of Health Report reaffirmed this reality, exposing persistent disparities and the country’s dependence on external aid for equitable healthcare access. Similarly, the Liberia Health Service Resilience Project (2023) confirmed that donor-funded initiatives remain central to epidemic preparedness and primary healthcare delivery. These findings expose a fundamental weakness, as Liberia’s health system remains highly susceptible to funding shocks, reinforcing the urgent need for sustainable domestic financing based on these trends.
Liberia’s per capita health expenditure remains fragile. While spending was only $86 in 2015/16, donors covered 32% of total costs. By 2021, it reached $112.27, meeting the international target set for 2030 nearly a decade early. However, this progress remains donor-driven rather than the result of sustained domestic financing. The USAID funding freeze threatens to widen this gap, putting essential health services at risk and weakening public health emergency response.
The financial strain is severe. In FY2025, Liberia’s national health budget is $85.8 million, but FY2024 actual spending was only $52.6 million, leaving a $33.2 million shortfall. USAID has historically contributed $50–$70 million annually, covering health worker salaries ($58.8 million), essential goods and services ($13.3 million), and grants ($7.3 million). Without these funds, hospitals will shut down, supply chains will be disrupted, and lifesaving programs will cease.
One of the most devastating consequences of this funding suspension is its impact on USAID-supported health programs. One of which to begin with is HIV/AIDS prevention and treatment. The President’s Emergency Plan for AIDS Relief (PEPFAR) has provided lifesaving antiretroviral therapy (ART) to approximately 31,000 people. The largest concentration of HIV patients is in Montserrado County, which will be the hardest hit. Without funding, thousands could lose access to medication, leading to a resurgence of HIV transmission. The urgency is undeniable. On February 5, 2025, ELWA Hospital announced the suspension of HIV treatment services, leaving thousands, including pregnant women and infants, without critical medication.
Malaria, one of Liberia’s deadliest diseases, remains a major public health threat. The 2022 Liberia Malaria Indicator Survey found that 10% of children aged 6-59 months test positive for malaria at any given time. USAID’s President’s Malaria Initiative (PMI) has been instrumental in malaria control, funding over 1.5 million malaria tests and distributing 1.2 million treatments annually. The RTS,S malaria vaccine, introduced in April 2024 to protect 45,000 children, was funded jointly by Gavi, the Global Fund, and USAID. Without continued support, malaria cases and fatalities will spike, particularly in rural areas with limited healthcare access.
Beyond disease-specific programs, Liberia’s entire healthcare infrastructure is at risk. USAID’s Advancing Community Health Activity (ACHA) has trained community health assistants who provide maternal and child healthcare, nutrition support, and disease surveillance in remote regions. With Liberia’s doctor-to-patient ratio at a staggering 1:11,024, far below the World Health Organization’s recommended 1:1,000, the loss of community health assistants will severely impact healthcare accessibility, leaving millions vulnerable.
Health system governance will also suffer. USAID’s Health Systems Strengthening initiative embeds advisors in the Ministry of Health and the National Public Health Institute, supporting decentralized health management and workforce training. Without technical assistance, Liberia’s ability to train personnel and manage public health will deteriorate. The Liberian Medical and Dental Association reports that only 508 of the country’s 1,269 registered doctors are currently practicing, leaving just one doctor for every 11,024 people. Even when including inactive, retired, or overseas doctors, the ratio remains 1:4,413, still critically low. This shortage will increase wait times, overburden staff, and weaken emergency response, leading to preventable deaths.
Turning Crisis into an Opportunity for Reform
The USAID funding freeze should be wake-up call that ensures Liberia turns the crisis into an opportunity. The government must act now to implement health financing reforms that ensure long-term resilience and sustainability. A key priority or starting point is the establishment and enactment of the Liberia Health Equity Fund (LHEF), an innovative financing model, that can improve efficiency and build a self-reliant healthcare system. The LHEF is a national risk-pooling insurance scheme designed to reduce out-of-pocket healthcare expenses and improve healthcare quality. Currently, only 3% of Liberia’s population has health insurance. Implementing the LHEF would protect low-income populations while ensuring predictable revenue for the healthcare sector. As of 2023, the LHEF remains under legislative review in the National Legislature, awaiting approval to establish a sustainable financing mechanism for universal health coverage.
While the Liberia Health Equity Fund (LHEF) offers a long-term strategy for sustainable health financing, immediate action is required to address critical funding gaps and mitigate the impact of donor funding disruptions. A multi-pronged domestic financing strategy—incorporating targeted taxation, remittance-based contributions, and public-private partnerships (PPPs)—is essential to strengthening Liberia’s health system and reducing donor dependency.
One effective approach is introducing a 1-2% tax on alcohol and tobacco, with revenues tagged specifically for healthcare financing to sustain essential, lifesaving services. Several low- and middle-income countries (LMICs) have successfully implemented similar models. Rwanda has used excise taxes on alcohol and tobacco to fund its Community-Based Health Insurance (CBHI), Mutuelle de Santé, which now covers over 80% of the population, significantly reducing out-of-pocket healthcare costs. Ghana has leveraged a 2.5% value-added tax (VAT) increase to sustain its National Health Insurance Scheme (NHIS), ensuring broader healthcare coverage while attracting private-sector investment. Botswana, once highly donor-dependent, now funds nearly 70% of its health budget through domestic taxation, effectively utilizing revenues from excise taxes and natural resources to sustain healthcare and social services. These examples demonstrate that well-structured tax policies can provide sustainable financing, reduce external reliance, and fortify public healthcare systems.
Beyond taxation, remittances from the Liberian diaspora accounting for 17% of Liberia’s GDP—offer an untapped financial resource. A remittance-based health financing model could divert a portion of these funds into a dedicated health fund, ensuring a stable revenue stream for healthcare services. This could be achieved through voluntary contributions, small levies on remittance transfers, or direct partnerships with financial institutions to support health insurance payments. Successful models include Mexico’s 3×1 Program, where remittances co-finance local health projects, and the Philippines’ Migrant Health Fund, which allows overseas workers to contribute to national health insurance, expanding coverage for low-income families. Liberia can adopt this model to strengthen health financing, ensuring expanded healthcare access while reducing donor dependency.
Strengthening public-private partnerships (PPPs) can unlock private sector investment in medical infrastructure, pharmaceutical distribution, and healthcare service delivery. Well-structured PPPs, as seen in Kenya and India, have expanded healthcare facilities, strengthened supply chains, and improved financial sustainability. When properly regulated and transparent, PPPs can serve as a catalyst for scaling up healthcare access, enhancing service delivery, and reducing financial pressure on the government.
Liberia’s health sector spending remains skewed toward hospital-based care, limiting efficiency and accessibility. Redirecting funds to primary healthcare and community-based services would improve access, particularly in rural areas. Task-shifting should empower trained health workers, including nurses and community health assistants, to handle routine care, alleviating pressure on the country’s limited number of doctors. Strengthening financial accountability is equally critical, ensuring effective allocation of resources, reducing waste, and curbing corruption.
To bridge immediate funding gaps, Liberia must secure emergency funding from global health institutions such as the Global Fund, the World Bank, the African Development Bank, ECOWAS, and Africa CDC while enhancing procurement transparency and financial controls to maximize impact.
Building on these recommendations, the Government of Liberia must also rethink sustainable financing. Economist Dambisa Moyo, in Dead Aid, argues that foreign aid fosters dependency, weakens governance, and stifles economic growth. She advocates for self-reliance through investment, trade, and market-driven solutions over perpetual aid. Liberia can draw valuable lessons from LMICs that have successfully transitioned toward domestic financing. By implementing targeted excise taxes, expanding health insurance coverage, and leveraging natural resource revenues, countries like Rwanda, Ghana, and Botswana have reduced donor dependency and strengthened financial sustainability. Liberia must adopt a similar strategic approach, prioritizing domestic resource mobilization and economic diversification to build a resilient health system.
About the Author
Ambulai Johnson, MSc, MPH (Doctoral Candidate), CEO, Center for Advancing Health Systems Innovations, Faculty Research Associate, Johns Hopkins. Expertise: Global Health Systems | Health Security | Epidemic Preparedness | Decision Science | Leadership & Strategy | Dean Scholar (Johns Hopkins) | GHDI Scholar (Harvard University).
