Abstract / Summary
Abstract Background African states bear a disproportionate share of the global disease burden, yet they have historically occupied the margins of agenda-setting in global health governance, where dependency and developmentalist framings cast them as recipients of aid rather than authors of policy. This article asks how African states assert agency and influence within global health governance despite, and at times through, that structural burden. It advances a framework of ‘agency under constraint’ and specifies observable mechanisms through which structurally weak actors widen their room for manoeuvring. Methods This study employs a qualitative, documentary design focusing on bounded diplomatic episodes spanning from the COVID-19 pandemic to early 2026. Using a purposively selected sample, the research conducts a structured thematic comparison of primary official texts, institutional communiqués, negotiation records, vetted news reports, and peer-reviewed scholarship. The episodes are analyzed to trace diplomatic practice, negotiating posture, and institutional engagement, evaluating how strategies shift across different governance arenas Results The analysis identifies two complementary diplomatic strategies employed by African states. First, in multilateral arenas, states utilize collective action through regional integration to pool sovereignty and amplify bargaining weight. This is evidenced by the autonomous elevation of the Africa Centres for Disease Control and Prevention, pooled vaccine procurement platforms, the African Medicines Agency, and coalition diplomacy regarding intellectual property waivers. Second, in bilateral arenas, states deploy strategic "(de)partnership" to manage dominant patrons. This involves resisting asymmetrical terms in health agreements, such as mandatory epidemiological data-sharing without guaranteed benefit-sharing, while diversifying partnerships to mitigate risk. However, this agency remains structurally bounded. Collective efforts occasionally face material vetoes from resource-rich states, and diversifying partners may merely substitute one form of dependency for another. Conclusions For structurally constrained actors, diplomatic agency is better defined as the strategic management of a portfolio of dependencies rather than the absolute attainment of autonomy. By outlining how and when structural burden is converted into leverage, this research contributes to debates on African agency and underscores the necessity of treating African institutions as vital co-architects of global health governance.