Health economics and financing for health systems transformation: lessons from five African epistemological frameworks.

Persistent financing challenges in African health systems are often attributed to resource scarcity or weak implementation. This paper argues that a deeper structural issue lies in the continued reliance on inherited vertical health architectures and economic evaluation frameworks that remain epistemically misaligned with local social realities. Many contemporary financing models, shaped by colonial and postcolonial donor interventions and operationalized through tools such as disability-adjusted life years (DALYs) and cost-effectiveness thresholds, prioritize externally defined metrics of value. As external funding declines and fiscal pressures intensify, sustaining these imported models exposes tensions between technical efficiency and social legitimacy. This study examines whether reorienting health economics through African epistemological frameworks can improve the sustainability, legitimacy, and governance of health financing. The paper employs a decolonial analytical framework drawing on the work of Ngũgĩ wa Thiong'o, Felwine Sarr, Samir Amin, Valentin Mudimbe, and Paulin Hountondji. It combines historical analysis of colonial health system design, conceptual synthesis of African epistemic frameworks, and applied examination of contemporary financing domains, including insurance uptake, community health worker compensation, and decentralised budgeting. Secondary literature from health policy, political economy, and governance studies is used to assess how epistemic assumptions shape institutional outcomes and financing sustainability. The analysis demonstrates that financing challenges are not solely fiscal but epistemic. Imported models often fail where they conflict with social understandings of care, reciprocity, and collective responsibility, contributing to enrollment gaps, workforce tensions, and performative participation in budgeting. African intellectual frameworks converge in identifying language, valuation systems, and institutional design as sites where power and legitimacy are negotiated. Evidence from insurance reform, workforce governance, and participatory budgeting shows that when financing mechanisms are adapted to locally grounded priorities, they are more likely to generate trust, accountability, and durable engagement. However, risks persist, including elite capture and the symbolic adoption of decolonial language without structural change. Decolonizing health economics and financing requires more than redistributing resources; it demands epistemic and institutional transformation. Aligning financing models with community-defined priorities, plural valuation frameworks, and participatory governance can reduce structural friction and improve legitimacy, even within globally interconnected economies. While such reform will not resolve all fiscal constraints, it offers a pathway toward more socially grounded and sustainable health systems. This reframing, described as a "structural adjustment of the soul", calls for African-led intellectual and institutional renewal capable of integrating analytical rigor with epistemic legitimacy in health policymaking.