Global Health: Nigeria and the Pathology of the Hostage State in an Era of Fragmentation
Nelson Aghogho Evaborhene argues that in a post-hegemonic world, true health security is not a gift to be received; it is a position to be negotiated through structural decoupling and the legal formalization of sovereign rights.
As we navigate the increasingly fractured landscape of the 21st century, it is becoming clear that liberal multilateralism has yielded to a harder transactional realism. For decades, the global health architecture has relied on domestic co-financing as its primary metric for sustainability—a position now institutionalized in high-level reform frameworks that emerged in the wake of donor retrenchment. This logic is codified in the Lusaka Agenda (2023), which charts a roadmap for the evolution of Global Health Initiatives toward national ownership, and various regional discussion papers, and suggested new operating models.
These reformist efforts are technically coherent, yet they may be targeting the wrong pathology. The primary threat to health security in a post-hegemonic world is no longer simply fiscal capacity; it is strategic exposure. In the emerging order, the durability of a health system depends less on its ability to balance accounts and more on its resilience against abrupt policy shifts in donor states. What is evolving, therefore, is not merely a financing transition but the collapse of the "implicit bargain" that once underpinned global health cooperation. Today, that bargain has been replaced by the reality of the Hostage State, where clinical continuity is increasingly sensitive to volatile domestic political cycles of foreign powers.
The Death of the Implicit Bargain and the Unravelling of Hostage State
For two decades, an "implicit bargain" governed global health. This unwritten social contract relied on a trade-off between sovereignty and subsidy: donors provided financing through Global Health Initiatives, while recipient countries accepted vertical, externally aligned systems in exchange for the promise of continuity. This bargain functioned under a humanitarian mask of "solidarity" that obscured a reality of unilateral donor discretion. Under the America First Global Health Strategy (AFGHS), this ambiguity has dissolved, replaced by a model of mandated fiscal substitution.
The Nigeria-AFGHS Compact represents a landmark in this new era, pairing approximately $2.1 billion in U.S. grants with a landmark $3.0 billion domestic commitment from the Nigerian government. While the financial architecture is precise, the political framing is profoundly dissonant. From Washington’s perspective, the compact is embedded within a broader commitment to protect vulnerable faith communities and strengthen Christian healthcare providers in high-risk regions plague by Islamist extremist groups. This position is salient among key Republican advisors and influential congressional leaders who view health assistance as a primary lever for religious protection
By contrast, Nigeria’s Coordinating Minister of Health and Social Welfare, has consistently described the Memorandum of Understanding as inclusive and non-sectarian. He presents the agreement as a technocratic pathway toward health independence by 2030. Similarly, the presidency maintain that insecurity reflects a complex interplay of banditry, resource conflict, and insurgency affecting multiple communities irrespective of religion
This divergence between the U.S and Nigeria authorities has sparked severe domestic backlash. Opposition groups, such as the African Democratic Congress (ADC), argue that dedicated support for sectarian facilities violates Section 42(1) of the Nigerian Constitution, which mandates religious neutrality. The issue becomes especially problematic for the ruling party, given Nigeria’s large Muslim population and its electorate that is divided along religious lines. By embedding identity-based distinctions into public service, the health architecture is transformed into a transactional lever. This forces the Nigerian state into a "strategic hostage" position, compelled to choose between essential funding and its own constitutional principles of secular governance. Yet, even when such provisions can be administratively defended, the perception that donor financing favors one religious group risks politicizing health provision and aggravating social tensions.
This "hostage" dynamic is further underscored by a significant disconnect in official communications regarding national security. Following the Christmas day airstrikes in northwest Nigeria, the Trump administration framed the operations as a direct intervention to protect persecuted Christian communities. In stark contrast, the Nigerian Ministry of Foreign Affairs maintained that the strikes were coordinated counter-terrorism operations targeting Islamic State
The subsequent February 13, 2026 deployment of approximately 200 U.S. Special Operations troops to northwest Nigeria therefore places the state in a strategic double bind. Although this convergence does not imply a direct contractual linkage between military presence and health disbursement, it introduces systemic vulnerability. In arrangements where funding continuity depends on sustained political alignment, deterioration in the broader diplomatic or security relationship may plausibly carry downstream fiscal implications. Health systems in such contexts become indirectly sensitive to shifts in foreign policy posture, congressional priorities, or executive recalibration, as demonstrated by the 2025 suspension of PEPFAR support to South Africa, where diplomatic friction rather than epidemiological performance precipitated abrupt funding disruption.
The Evolution of Strategic Reciprocity
External influence over domestic policy is not without historical precedent. During the era of structural adjustment, the International Monetary Fund and the World Bank utilized macroeconomic ceilings to regulate public expenditure. Furthermore, the 2003 PEPFAR framework under George W. Bush effectively securitised global health by framing infectious disease as a primary destabilising force in fragile states.
However, the AFGHS model represents a definitive shift in this trajectory. While the previous era utilized health assistance as a defensive mechanism to stabilize state structures, the current paradigm represents a transition toward transactional leverage. In doing so, the AFGHS model effectively moves beyond the stabilization of partner states toward their strategic synchronization, transforming a defensive security interest into an offensive transactional tool. In this reorganized order, health security is no longer merely a bulwark against state failure; it has become a central component of a sophisticated industrial and security compact, where clinical continuity is functionally traded for regional alignment and resource access.
Systemic Implications: Global Health in the Post-Multilateral Order
The pathology of the "Hostage State" in Nigeria is not an isolated diplomatic friction; it is the herald of a post-multilateral order. When clinical continuity is traded for strategic synchronization, the very foundations of global health—neutrality, epidemiological logic, and universal rights—are structurally eroded.
The first systemic implication is the obsolescence of technical metrics. For decades, the Global Fund and the WHO utilized viral suppression and bed-net distribution to justify investment. The Nigeria case proves that technical excellence provides no immunity against a "Political Exit." This devalues the work of public health technocrats and elevates the role of diplomats, rendering epidemiological logic secondary to geopolitical alignment.
Secondly, we are witnessing the rise of institutional fragmentation as a strategic defense against global volatility. As nations recognize that bilateral dependency carries an existential risk, the drive toward Structural Decoupling has accelerated. The landmark decisions of the 39th AU Assembly Summit in February 2026—specifically the operationalization of the African Pooled Procurement Mechanism (APPM)—represent a definitive move toward regional "Health Blocs." By converting fragmented national needs into collective market power and sovereign data clouds, these blocs prioritize local resilience over global integration. However, this shift simultaneously fragments the global response; in the next pandemic, the world may face a series of competing regional systems vying for resources rather than a unified global effort.
Finally, this shift marks the marginalization of the WHO’s managerial authority. Following the official U.S. withdrawal in January 2026, Washington’s focus on high-stakes bilateral deals effectively sidelines the WHO as a primary financier. To remain relevant, the WHO must reinvent itself as a Normative Anchor—a standard-setter rather than a manager. Failure to adapt risks reducing the organization to a secondary forum, while the real power over life-saving commodities is decided in bilateral negotiations in Washington, Beijing, or Brussels
The Crisis of Imagination in Global Health
As fragmentation deepens, the current search for a new "benevolent hegemon" to stabilize the global health landscape, a solution frequently proposed by International Relations (IR) scholars clinging to 20th-century Hegemonic Stability Theory—is ultimately a symptom of a "Crisis of Imagination." The arguement that without a single guarantor of global public goods, health systems in the Global South will inevitably collapse, ignores a fundamental reality: any new guarantor, whether a rising Eastern power or a philanthropic coalition, merely introduces a new set of conditionalities and strategic dependencies.
The "Hostage State" pathology cannot be cured by switching hegemons; it can only be resolved through Structural Decoupling. By reframing health as a site of strategic risk management rather than humanitarian solidarity, we reveal a more durable path forward. Realism dictates that in a post-hegemonic world, power is not granted; it is negotiated through the control of essential assets and the diversification of risk.
A Roadmap for Negotiated Autonomy
If exposure is the primary pathology, reform must move beyond incremental co-financing targets toward institutionalized safeguards.
- Legislative Ratification: Health compacts must transition from informal agreements to formal legislation requiring parliamentary approval. This ensures that the "hidden" conditionalities often embedded in diplomatic MOUs are subjected to public and judicial scrutiny, protecting health policy from unilateral executive shifts, as recently demonstrated in Kenya and Liberia.
- Codified Exit Protocols: countries must enforce "notice-of-exit" clauses, requiring a minimum 24-month financial off-ramp to mitigate the "fiscal cliff." This imposes a tangible reputational and geopolitical cost on any donor attempting a non-epidemiological withdrawal.
- Aggregated Sovereignty: Authority should be delegated to regional bodies like the Africa CDC and the African Medicines Agency (AMA). By consolidating fragmented national demand into a single, high-leverage "Health Bloc," nations convert vulnerability into market power, neutralizing the "divide and conquer" tactics of bilateralism.
- Strategic Risk Indices: Traditional co-financing targets should be replaced with metrics that measure a nation’s level of dependency on a singular foreign political cycle. This provides health ministries with a diagnostic tool to "stress-test" their systems against external geopolitical shocks.
In a post-hegemonic world, true health security is not a gift to be received; it is a position to be negotiated through structural decoupling and the legal formalization of sovereign rights. As Nigeria navigates this transition, the lesson for the continent is clear: only by governing the "exit" through legal counterweights, risk diversification, and aggregated sovereignty can countries navigate the volatility of this fragmented era and reclaim health as a fundamental, sovereign right.
Nelson Aghogho Evaborhene is a PhD Fellow in Global Health Governance at the Centre for Interdisciplinary Study of Pandemic Signatures, Roskilde University.
Photo by Ademola Adeola
