Non-Profit Navigates New Realities In Funding-Starved Health Sector

The past few years have been tumultuous for the Ethiopian health sector. A global pandemic, conflict, and economic hurdles were just some of the problems weighing on the healthcare system when last year, the administration of Donald Trump moved to gut funding for American foreign assistance programs, most notably the US Agency for International Development (USAID).

The decision posed significant challenges, most acutely in the health sector, where hundreds of thousands of jobs were lost and health investment jeopardized. These financial constraints shook African healthcare systems, but many are now beginning to embrace greater prudence and resilience, unlocking the full potential of their own resources and breaking free from a mindset of dependency and charity.

Among the organizations that have had to adapt to the new climate is Amref Health Africa.Headquartered in Kenya, Amref stands as the continent’s largest Africa-based international health and development organization. Each year, it provides training and health services to more than 20 million people across at least 35 countries, including Ethiopia.

In Ethiopia, Misrak Makonnen serves as Country Director for Amref Health Africa. Leading a team of over 350 staff, she drives the organization’s mission to transform health systems, improve reproductive and maternal health, and expand access to clean water nationwide.

Her leadership has broadened its portfolio, focusing on sustainable, community-driven health solutions. Speaking to The Reporter’s SisaySahlu, she emphasized that Amref Health has weathered the financial cuts with unwavering persistence and strategic resilience sustaining its mission through innovation, community trust, and an unshakable commitment to health equity.EXCERPTS:

 

The Reporter: What exactly does Amref Health Africa do here in Ethiopia?

Misrak Makonnen: Amref is the largest African non-profit health organization. We began our work in Kenya more than six decades ago, and in just a couple of years we’ll be celebrating our 70th anniversary. In Ethiopia, we’ve been active for 23 years, working in the health and development space.

At the headquarters level, our work originally started with medical evacuation. We had a few planes that flew to remote areas to provide access to care for Kenyan communities that otherwise had none. That story began with three pilots and eventually grew into a non-profit organization focusing on key activities—particularly maternal and child health, water, sanitation and hygiene, youth programming, and disease prevention and control.

Across all the countries where we operate, our vision is to create lasting health change in Africa. Specifically in Ethiopia, our vision is lasting health change for Ethiopian communities. We follow a strategy running from 2003 to 2030, which focuses on supporting government primary health care systems and addressing development issues that are not strictly health-related.

We strongly believe that different components such as economic empowerment, water and sanitation, gender equality, and youth issues ultimately contribute to better health outcomes. These are the pillars of our work: strengthening primary health care systems and tackling the social determinants of health.

In Ethiopia, we are present across the entire country. Initially, we focused more on pastoralist and emerging regions in remote areas like Afar, Somali, Gambella, and Benishangul-Gumuz. But as our portfolio grew, we expanded into agrarian regions such as Amhara, Oromia, Southern Ethiopia, and Tigray.

Our work remains community-driven. Everything we do is centered on communities, which is why we take a holistic approach including addressing maternal and child health, health system strengthening, water and sanitation, disease prevention and control, and the needs of women and young people.

How did you join this continental health-driven organization as a country director?

I’ve been with Amref for a long time; it’s my longest employer. This coming April will mark 10 years with Amref in Ethiopia. Before joining Amref, I worked with different US-based NGOs in the health sector. Earlier in my career, I worked with an organization focused on trachoma and Guinea worm eradication. Later, I moved to another US-based NGO working on HIV treatment and prevention, though I was based here in Ethiopia.

I’ve been back from the US for 21 years now. I studied there, completing both my undergraduate and master’s degrees in public health and business administration. After working for a while in the US, I returned to Ethiopia and have since worked with several organizations, and now Amref has been my home for the past decade.

Amref has been in Ethiopia for more than two decades. What are some of its achievements in the health sector?

Our main intervention has been in the pastoralist regions, particularly in health systems, and service delivery, focusing on maternal and child health.

We had a series of programming working with regions which are not well progressing regions, mainly pastoralist regions, mostly working in maternal and child health, we also had some programs around trachoma control and elimination.

There is a lot of work around the community in terms of increasing communities’ health-seeking behavior. We work with communities and individuals, we work with primary health care systems, and we work on policy with government partners.

Our achievements are mostly in maternal and child health, but recently our work has been around strengthening health systems. We used to do a lot of service delivery, now we’re looking more into how we can support health systems in terms of human resources, governance and leadership, information systems, supply chains. We have a youth program called Kefeta aimed at elevating and empowering Ethiopian youth. It’s more of a comprehensive technical support. In a nutshell, that’s what we’ve been doing for 20 years.

The Trump administration’s decision to strip down USAID sparked strong reactions from health organizations and advocates concerned about the consequences for African health systems. How has Amref been managing the challenges posed by Washington’s funding cuts?

It was a major wake-up call, I would say. It was very difficult for us across Amref, across all our country programs, not just Ethiopia. Ethiopia was the hardest hit in terms of health systems, particularly around maternal and child health. Our programming had to stop in other countries as well. We were also supported by USAID.

We had the largest USAID program for youth. It was called Kefeta, it was a 60 million dollar, five-year program. And we had also just won a new healthcare financing program for 40 million dollars. So, it was a major setback.

For us, it was a major success to have won a new grant in the healthcare financing space, which is very important in the current context. We were shocked of course, it was very difficult, because we had to let go of staff, and that’s very difficult.

The way we had developed that grant was 50 percent of the funding for Kefeta went to local CSOs. They were the ones doing the implementation. You can imagine the cascade it had in terms of affecting the CSOs and, most importantly, young people. I really liked Kefeta because it had the health component, it had advocacy and agency for them to understand their rights, and had an economic empowerment component.

It was very holistic for young people. When you cut that back, it’s devastating, because we had it in 18 cities. We had vibrant young people who were really bringing change in their lives. For the young people it was a major hit, for us it was a major hit. Yes, it affected us, but we had to really think it through and say, okay, somehow, we must recover.

Many non-profits have faced layoffs and project cancellations. How did Amref fare?

We laid off about 56 people. But, including seven local CSOs within our circle, there were around 120 staff layoffs.

How do you assess the impact of financial cuts on the sector?

It’s difficult to measure precisely, but from my observation, the cuts have had a significant impact. Direct support to government programs and NGOs has been reduced, and many organizations that were doing important work have been affected.

For all of us, it was a wake-up call. We need to think strategically about where we spend our resources. That’s why, right now, the Ministry of Health is prioritizing health care financing—how to become more efficient and effective. This has become a major priority not only for the government, but also for NGOs and CSOs like us.

We’re now holding a series of meetings with the authorities to discuss how we can work together more effectively. This is not the time to fall apart; we must come together and think carefully about mechanisms to address the health financing challenge. The Ministry is leading this effort, but each organization is also reflecting on its own approach. Collectively, we’re exploring domestic resource mobilization, non-traditional funding sources, and public-private partnerships. The goal is to mobilize resources we can control and sustain.

When you say mobilizing domestic resources, is there really a culture of philanthropy or national funding for CSOs and organizations like yours in Ethiopia?

One of the things we’re trying to do is individual fundraising. It’s not yet a common practice in Ethiopia, but we believe it has potential. We know there are well-off individuals who could contribute. The question is: how can we creatively build those partnerships?

Awareness creation is crucial. Change begins when people are exposed to the idea of doing good for their communities. It doesn’t always have to be through an NGO. I know individuals who have built roads, schools, health facilities, and many other projects quietly, without recognition. Culturally, there’s a belief that when you give, you shouldn’t make it public, so much of this philanthropic work goes unnoticed.

In Ethiopia, traditional community support systems like edir and religious contributions are forms of philanthropy, though structured differently from Western models. These are powerful stories, but they need to be magnified and organized. In the US, philanthropy is often incentivized through tax exemptions. Here, many Ethiopians are already doing good work, but it’s not visible in the media. We need to think about how to elevate and structure these efforts.

There must also be ways to incentivize giving. Where are those possibilities? How can we target this content cleverly to encourage more support? Public-private partnerships are another avenue. For example, a few years ago we worked with Awash Bank on a corporate responsibility plan and co-created a water, sanitation, and hygiene project in Addis Ababa.

When local organizations or companies support your projects, do you approach them as Amref, or do they come to you?

We approach them. You have to be proactive. It’s not just about charity; it has to be a win-win situation. We ask: what’s the benefit for the private sector, and what’s the benefit for us? Building relationships is key. Trust and accountability are essential. Donors and partners must trust Amref, and they must trust me as a leader. That kind of relationship doesn’t happen overnight; it takes time to build.

What are Amref’s priorities for maintaining resilience in Ethiopia’s health system?

With strong engagement with communities, local CSO and government partners, Amref’s priority is to help strengthen a people-centered, resilient primary healthcare system that can withstand shocks from climate stress to financial uncertainty.

This requires looking beyond the health sector alone. For Amref, health outcomes are shaped not only by health services, but also by the social and economic conditions in which people live. That is why we deliberately integrate key social determinants of health, such as youth and women’s economic empowerment into our health programming. We believe that economically empowered communities are healthier, more resilient, and better able to sustain health gains over time.

The message to partners and donors is simple: this is a moment for action, not retreat. Investing in strong systems, prevention, and community-based care, integrated with social determinants of health, remains the most effective way to protect health gains and support Ethiopia’s future.

Do you believe Amref’s two decades of health investment in Ethiopia have earned it a good reputation?

Absolutely. We’ve been here for many years and have built a strong footprint, especially in pastoralist communities. Projects like Kefeta for youth and many others have created very positive public sentiment about our work.

Health is a global issue. In the volatile Horn of Africa region, challenges such as climate change, drought, flooding, conflict, low education levels, and limited public awareness converge to create a serious burden on communities. How do you assess the health situation in this country, considering your role as one of the main actors working to eradicate health-related issues?

It’s a very difficult situation. We’ve faced COVID, and we continue to deal with climate change, drought, and flooding. In places like Omo and Afar, we’ve encountered repeated disasters. Resilience is essential.

When I say resilience, I mean the ability to plan ahead and respond effectively when challenges arise. For example, in our programs we allocate about 10-15 percent of donor funds as a contingency, explaining to donors: “We have a development program, but if emergencies occur, we must be able to respond.”

We need to be prepared for outbreaks or disasters. When floods happen, we must be ready to set up temporary centers and provide first response. To do that, we build a financial buffer before catastrophe strikes.

Regular planning and programming are essential, but we must also remain cautious and ready to assist communities affected by drought or flooding. Building a buffer based on experience with both the organization and the community is critical.

We are also part of a flood risk committee, which coordinates responses when floods occur locally or abroad. If a crisis arises, we don’t immediately turn to donors for funds; instead, we rely on the buffer we’ve already set aside. Communities expect us to be present, and we must stand with them in times of need.

Floods and other disasters are recurrent, so we must always be prepared. That means adjusting our environment and strategies to ensure we can respond effectively when these challenges arise.

How do you ensure vulnerable communities are not left behind during these challenging times?

The principle of “leaving no one behind” is built into our system not just for difficult times, but for our everyday planning. We integrate social determinants of health, gender, youth, and disability into everything we do. Whether it’s a cancer program or a general health initiative, we specifically ask: What are we doing for women? What are we doing for young people?

In targeted crisis activities, we utilize “crisis modifier funding,” which acts as a buffer. This ensures that women and children remain the priority. Even before a crisis hits, we ensure they are at the center of the plan because, ultimately, they are the most vulnerable.

How sustainable are Amref’s programs?

In response to funding reductions, shifting toward a social enterprise model is key. We don’t want communities to simply wait for our support; we co-create programs with them. We are increasingly looking at “spin-offs” and business-style interventions.

Our approach to funding has also changed. Previously, we would simply write a proposal and compete for a grant. Now, when a call for funding arises, we first consult with the Woreda or local administration to identify actual needs. We approach funders with 20 years of data to show them the trends and what is truly required on the ground. By aligning our projects with government priorities and regional demands from the start, we ensure that the programs become part of the government’s own long-term strategy. That is how you achieve true sustainability.

What legacy do you want to leave behind in Ethiopia’s health sector?

For me, achieving lasting health change in Ethiopia is the goal. That is my vision.

The biggest piece of that puzzle is the youth. Healthy young people are the economic engine of this country. We must ensure we have the right people to develop and safeguard our investments. Economic empowerment, financial accessibility, and entrepreneurship should be major areas of investment alongside health.

Our primary healthcare system is very well-structured and on the right track, but having been in this space for 20 years, I believe investing in our youth is the most critical path forward.