This commentary examines the ongoing shift from multilateral to bilateral health development aid in Africa and its implications for regional public health governance. Multilateral institutions, such as the World Health Organization (WHO) and the Africa Centre for Disease Control and Prevention (AfCDC), have fostered coordination and regional integration in Africa. However, recent geopolitical fragmentation, donor realignment, and pandemic-era disruptions, including vaccine nationalism and bilateral vaccine diplomacy, have shifted coordination structures, weakened harmonization, and increased political conditionalities, thereby challenging Africa's public health resilience. We explore the key drivers and consequences of this transition and propose seven policy recommendations, including revisiting regional coordination models, strengthening global health diplomacy, enhancing sustainable domestic financing, investing in local production, and fostering an enabling environment for regional knowledge generation. The implementation of these measures has grown particularly urgent, considering the recent shifts in development assistance priorities and the restructuring of major donor agencies and other multilateral and international non-governmental organizations that previously supported African governments with technical assistance, thereby increasing vulnerabilities. These findings suggest the importance of facilitating the adoption of a recalibrated, context-specific governance model to build resilient national health systems and safeguard continental health security amid current changes in development aid.
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