Aid cuts, health financing fragility, and maladaptive resilience in Sierra Leone: a rapid mixed-methods study.

Sierra Leone's health system remains highly dependent on external aid, with donor funding accounting for approximately 47% of total health expenditure between 2020 and 2024, compared with a government contribution of around 25-26%. Recent reductions in development assistance for health, including a sharp in-year contraction of USAID-supported health programming during 2024-25 and an approximately 15% reduction in Global Fund allocations, have exposed major structural vulnerabilities in the health financing system. We conducted a rapid mixed-methods study to examine the effects of recent and anticipated aid reductions and the resilience responses emerging across Sierra Leone's health system. The study drew on a review of 19 documents and 11 key informant interviews with stakeholders from government, development partners, civil society, non-governmental organisations, and independent experts. Documentary and interview data were analysed descriptively and thematically, and findings were integrated during interpretation. Several service areas were identified as highly exposed to financing disruption, including reproductive, maternal, newborn and child health, HIV, tuberculosis, immunisation, and pharmaceutical supply chains. However, available evidence indicates that immediate service disruptions have so far been limited, and current data do not support firm conclusions about which services have been most affected. Maternal health and immunisation indicators remained comparatively stable in the short term. Documents and interviewees indicated that absorptive responses have prioritised core commodities and selected priority services, while reducing expenditure on outreach, supervision, training, logistics, and other enabling functions. Interviewees reported that households were absorbing much of the financial burden through increased out-of-pocket spending, forgone care, and informal coping mechanisms. Sierra Leone's response shows elements of absorptive and adaptive resilience, but several coping strategies show features consistent with maladaptive resilience and risk becoming maladaptive if prolonged, because they shift costs downward, threaten to deepen inequity, and erode the operational foundations of the health system.