Medical Drones, Fragile Health Systems, and the Politics of Priority in Africa
Updated: Sep 30
Medical drone programmes are in fashion in Africa. In November 2025 the U.S. State Department pledged up to US$150 million to expand Zipline's drone network across five African countries. The pledge covers the expansion but does not cover operating costs, which the receiving governments have agreed to cover as the systems scale. What is imminent is that over the next few years, the use of medical drones in Africa will be scaled. This piece asks what governments will be paying, out of which budget, the opportunity costs and whether medical drones should be a priority in Africa's fragile health systems.
For states with fragile health systems and no resource rents to draw on, those questions are the governance problem. Procuring the aircraft is the simpler part.
Why some African states can afford drones and most cannot
A small number of African states earn enough from oil and other resource rents to fund expensive infrastructure from their own revenue. Nigeria, Angola, and Gabon are the standard examples of rentier economies, as is Equatorial Guinea, where hydrocarbons supply over 70% of government revenue. In the classical sense, rentier capital buys autonomy: a government can adopt and sustain a technology on political grounds without first asking whether the budget can carry it.
Most African states are in a different position. They run their health systems on thin tax bases, household out-of-pocket spending, and external financing from bilateral aid, multilateral grants, foundations, and concessional lending. Donor flows substitute for rents in these budgets, but they arrive on someone else’s terms. The state receives revenue without the political autonomy that domestic taxation would bring.
This matters for drones because of their cost structure and financing model's weakness. The programmes carry large up-front capital and integration costs, and they also carry recurring fees that do not fall once the system is running. Unlike a vaccination campaign, which ends, a drone programme behaves like a subscription.
A gift with a monthly bill attached: the $150 million pledge
The weakness of the financing model became visible in November 2025. The U.S. State Department pledged up to $150 million to Zipline to expand its network across Côte d’Ivoire, Ghana, Kenya, Nigeria, and Rwanda, and to triple its reach from about 5,000 to 15,000 health facilities. The State Department presented the pledge as part of its “America First” foreign-assistance agenda.
The structure is pay-for-performance. U.S. funds underwrite the expansion, and African governments sign contracts committing to cover the operating costs as the systems scale, with the receiving states expected to contribute up to $400 million in utilisation fees.
In fiscal terms, the U.S. state is capitalising an American company so that it can secure recurring revenue from African states, which will then have to find the money in domestic budgets or in the next donor cycle.
For a non-rentier state with a fragile health system, this amounts to a long-term structural commitment rather than a programme with an end date, and it is the point at which priority-setting can no longer be postponed.
Ghana's contract: pay whether the drones fly or not
Ghana signed its contract with Zipline in 2018. It ran four years and was worth about US$12.5 million. The parliamentary minority attacked the deal as injurious and improperly sole-sourced rather than competitively tendered, and an independent evaluation by the Ghanaian think-tank IMANI Africa questioned whether the cost was justified at all.
Three features of the deal have drawn the most scrutiny. Ghana pays whether or not the capacity is used; the current health minister describes it as a “take-or-pay” contract costing about US$88,000 per centre, or more than US$500,000 a month across six centres. The fees are denominated in U.S. dollars, so exchange-rate risk sits with the Ghanaian state and the cedi. The vendor also builds and owns a parallel cold chain that Ghana rents. IMANI Africa warned that drone delivery cannot substitute for the Central and Regional Medical Stores that anchor the public supply chain.
None of this disqualifies the partnership, and the public-health gains are real.
These terms nonetheless decide whether a fragile health system controls its own supply chain or pays a foreign vendor to control it on the state’s behalf.
By 2025 the pressure was showing. The health minister reported that only 12% of Zipline’s activity served hard-to-reach areas, and only 4% covered emergencies. By late 2025, three of its six centres were at risk of closure as the government weighed termination amid about GH¢175 million, roughly US$16 million, in arrears. Gains in some places, contractual lock-in, and an unresolved sustainability question: other African states should expect the same pattern.
The opportunity cost
A health budget in a state with severe primary-care shortages records what was not bought as much as what was. Drones save lives; the evidence on that is not in dispute. The relevant question is whether the same money, allocated differently, would save more lives at the same level of equity.
On show, on blocks: a delivery drone on exhibition, and an ambulance donated for maternal health with a wheel missing. Photos: the author.
.Take Ghana’s US$12.5 million over four years, roughly US$3 million a year, as a reference envelope. The same annual amount could expand community health worker stipends. It could fund several thousand additional skilled birth attendant deployments. It could equip dozens of district laboratories with GeneXpert platforms for drug-resistant TB. It could keep refrigeration and electrification running at hundreds of rural clinics whose cold chain is failing. Each option addresses a different bottleneck in the same 2030 health targets that drones are recruited to advance.
The argument here is about sequencing. Priority-setting should happen before signing. In most African states, drone adoption has so far been decided on political and symbolic grounds, whether national prestige, donor preference or ministerial signalling, and rarely through Health Technology Assessment, multi-criteria decision analysis, or equity-weighted cost-effectiveness review. Ghana now has a formal HTA process, adopted in 2022, and South Africa is building an HTA agency within its National Health Insurance reforms. Where such processes exist, they tend to be under-resourced relative to the size of the contracts they would need to evaluate.
Protect the budget for drones, or for clinics?
Ring-fencing dedicates specific revenues to specific purposes. It is a defensible response to political volatility in health budgets, because it protects priority programmes from being raided in tight years. Its effects, though, depend entirely on what gets ring-fenced.
Ring-fence for medical drones and the state locks in spending on a single vendor’s recurring fees for years, which narrows fiscal flexibility and deepens platform dependency. Ring-fence for primary health care, meaning community health workers, midwives, essential medicines and district laboratories, and the state protects the foundation on which any technology layer, drone or otherwise, has to operate.
Drone programmes should therefore be evaluated against the same envelope as primary-care strengthening rather than added on top as an innovation premium.
If a primary-care system cannot keep its refrigerators powered, faster delivery adds little at the margin, while fixing the refrigeration adds a great deal.
Five things to settle before signing drone contracts
For African states with fragile health systems and no rentier cushion, the following should be procedural defaults rather than concessions extracted in negotiation.
An independent HTA review of the proposed programme against named alternatives, with explicit equity weighting for rural and remote populations.
A multi-year fiscal sustainability plan showing what the state will pay once donor co-financing ends, and which other line items will absorb the cost.
Contract terms modelled on utility regulation rather than consumer subscription: pricing reviews, renegotiation rights, exit options, technology-transfer milestones, and pricing in domestic currency.
Parliamentary scrutiny of the contract itself, with public disclosure ocost per deliveryry, monthly fees, and forex exposure.
A primary-care budget protection clause, so that drone programmes do not draw from the primary-care envelope without an explicit, justified reallocation.
None of this is hostile to innovation. It is the minimum required if a state wants the benefits of leapfrogging care without giving up fiscal sovereignty. Another is a primary-care system that reaches a clinic the same day, by road, with a trained midwife on site.
The politics of priority
Medical drones may well be cost-effective in narrow comparative terms, for specific use cases. Whether fragile African health systems without rentier capital can afford them indefinitely is a separate question, and the answer becomes less certain once the donor co-financing that currently subsidises them recedes.
A technology can be cost-effective without being affordable.
The underlying issue is whose priorities the health system encodes. A drone fleet underwritten by an American state department, run by an American company, and paid for through recurring fees that the receiving state must cover from a thin tax base is one configuration. A primary-care system that reaches a clinic the same day, by road, with a trained midwife on site, is another.
Both can serve the 2030 health goals. The second is far more likely to survive the next donor cycle without renegotiation. The task for health governance is to decide which configuration African states want and to ensure the decision is taken deliberately, in their own currency, by their own institutions, before the contract is signed.
DISCLAIMER: The views expressed in this blog are those of the author and do not necessarily reflect the official position of Governance and Development Advisory, or any institution with which the author is affiliated. This piece is written in a personal capacity to contribute to critical dialogue on Health Governance in Africa
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