{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T16:44:06Z","timestamp":1792169046488,"version":"4.4.0"},"reference-count":53,"publisher":"Oxford University Press (OUP)","license":[{"start":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T00:00:00Z","timestamp":1791158400000},"content-version":"am","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"funder":[{"name":"Resilience Consortium"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Sierra Leone\u2019s health system remains highly dependent on external aid, with donor funding accounting for \u223c47% of total health expenditure between 2020 and 2024, compared with a government contribution of \u223c25%\u201326%. Recent reductions in development assistance for health, including a sharp in-year contraction of United States Agency for International Development-supported health programming during 2024\u201325 and an \u223c15% 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\u2019s 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 organizations, 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, human immunodeficiency virus, tuberculosis, immunization, 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 immunization indicators remained comparatively stable in the short term. Documents and interviewees indicated that absorptive responses have prioritized 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\u2019s 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.<\/jats:p>","DOI":"10.1093\/heapol\/czag117","type":"journal-article","created":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T11:56:02Z","timestamp":1790855762000},"source":"Crossref","is-referenced-by-count":0,"title":["Aid cuts, health financing fragility, and maladaptive resilience in Sierra Leone: a rapid mixed-methods study"],"prefix":"10.1093","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0226-841X","authenticated-orcid":false,"given":"Augustus","family":"Osborne","sequence":"first","affiliation":[{"name":"Institute for Development , Western Area, Freetown ,","place":["Sierra Leone"]},{"name":"ReBUILD for Resilience Consortium , c\/o Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA ,","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria Paola","family":"Bertone","sequence":"additional","affiliation":[{"name":"ReBUILD for Resilience Consortium , c\/o Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA ,","place":["United Kingdom"]},{"name":"Institute for Global Health and Development, Queen Margaret University \u00a0 Edinburgh, Queen Margaret University Drive, Musselburgh, East Lothian EH21 6UU ,","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Halimatu","family":"Kamara","sequence":"additional","affiliation":[{"name":"Institute for Development , Western Area, Freetown ,","place":["Sierra Leone"]},{"name":"ReBUILD for Resilience Consortium , c\/o Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA ,","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ayesha","family":"Idriss","sequence":"additional","affiliation":[{"name":"Institute for Development , Western Area, Freetown ,","place":["Sierra Leone"]},{"name":"ReBUILD for Resilience Consortium , c\/o Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA ,","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7656-6188","authenticated-orcid":false,"given":"Sophie","family":"Witter","sequence":"additional","affiliation":[{"name":"ReBUILD for Resilience Consortium , c\/o Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA ,","place":["United Kingdom"]},{"name":"Institute for Global Health and Development, Queen Margaret University \u00a0 Edinburgh, Queen Margaret University Drive, Musselburgh, East Lothian EH21 6UU ,","place":["United 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