OCT 30: AID CUTS ARE DEVASTATING HEALTH SERVICES IN AFRICA. Report by The Economist.
“It’s heartbreaking,” says Velontafa Jackia, a doctor based in Sambava, in the north-east of Madagascar. Until this year she was part of a project funded by the United States Agency for International Development (usaid) that helped send health workers to even the remotest parts of the impoverished island. But since the funding stopped, fewer patients have been seen. Ms Jackia lists the effects: more birth complications, more maternal deaths, more malarial deaths and “lots of outbreaks”. She sighs: “We’ve been reliant too much on aid and now it’s gone.”
Nine months after Donald Trump’s administration began dismantling usaid the effects are being felt across sub-Saharan Africa, where America supplied more than two-thirds of the bilateral aid for public health. The Trump administration says the largesse created a “culture of dependency”. Its America First Global Health Strategy, published in September, says recipient governments must do more of the work and pay for more of it themselves. This is a good idea in theory, but in practice many people are going to die as aid is reduced.
America became the “indispensable nation” for African public health, notes Jeremy Nel, a South African doctor specialising in hiv. In 21 African countries its aid equalled at least 20% of government health spending; in eight it was over 50%; and in three countries (Somalia, South Sudan and Malawi) it exceeded government spending (see chart). America was also the largest single donor to global bodies like the Global Fund to Fight aids, Tuberculosis and Malaria, and un agencies like Unicef (which helps children), the World Health Organisation (who) and the World Food Programme (wfp).
These contributions have “collapsed”, notes Charles Kenny of the Centre for Global Development (cgd), a think tank. According to estimates of disbursals for the 2025 fiscal year (which runs from October to September), wfp received $326m v $4.3bn in the previous fiscal year. Also cut were funds for the who ($133m v $553m), the Global Fund ($1.3bn v $2.3bn) and Unicef ($265m v $1.1bn).
The fate of bilateral aid—ie, money not spent via international groups—is harder to gauge. Typically this aid was disbursed via thousands of contracts with third parties, usually ngos, who then implemented programmes in the relevant country. As of August 1st, 86% of usaidcontracts (and 77% of those related to health) had been terminated. Since some of the largest contracts remain in place, the percentage drop in funding is less dramatic. Mr Kenny estimates that there will be a 38% drop in aid spending in 2025 from 2024.
Foreign aid could be constrained for many years; 2024 and 2025 will probably mark two years of consecutive bilateral aid cuts by the four largest donors (America, Britain, France and Germany) for the first time since the oecd, a club of mainly rich countries, started collecting data. Britain is cutting its aid spending from 0.5% of gross national income to 0.3% by 2027. Mr Trump’s proposed budget for 2026 has a two-thirds cut in bilateral health funding relative to 2025, and no money for the who, gavi (a vaccine funder) or the Global Fund.
The impact of aid cuts on Africans’ health is obscured by the fact that the data systems used to track disease were paid for by American aid—and have largely been shut down. But two sources of information suggest reasons to worry. The first are analysts’ estimates that take the relationship between previous aid spending and the deaths that it averted, then in effect undo it to estimate the additional mortality. Mr Kenny and Justin Sandefur, another economist, reckon that Mr Trump’s recent budget proposals would put as many as 1m lives at risk, mostly from more untreated cases of hiv, tuberculosis and malaria.
The State Department, which has absorbed some of usaid’s functions, has said it would maintain “life-saving” work. This includes antiretroviral drugs for hiv and salaries for health workers who administer them as part of pepfar, America’s flagship anti-aids programme. But another analysis for cgd found that contracts for these elements affecting 2.3m people had still been cancelled. In addition, cuts to preventive programmes put hundreds of thousands at risk of new hiv infections.
State has said it will provide “bridging” funding for countries until they strike new bilateral deals with America, but there is little sign of the money. And many of the ngos best placed to spend it have closed down operations. Meanwhile, the European governments that many Africans hoped might help fill gaps are, at least in some cases, doing the opposite.
The second source of information comes from on-the-ground reports of chaos across Africa. In South Africa, where pepfar paid for only a minority of anti-hiv programmes, clinics have been receiving “hivmigrants” from neighbouring Eswatini, Lesotho, Mozambique and Zimbabwe, unable to find drugs in their countries. “We are going backwards,” says Olive Shisana, a South African epidemiologist, who cites estimates by the un that there could be more than 6m new hiv infections and 4m more deaths from aids by 2030 than would otherwise be the case.
In Madagascar people who used to work for American-funded projects worry about a looming crisis in the island’s south. The area is subject to regular drought and mass hunger. But the supply of emergency food is “a tenth of what it was” last year, says a senior humanitarian figure.
Across Africa, refugee camps are vulnerable. In Kiryandongo, in Uganda, America paid for about 60% of the wfp budget. Ronald Onen, from South Sudan, says that in April he was told he no longer qualified for food rations. “You can imagine the problems, the stress, this has caused,” he says.
In July hundreds of South Sudanese refugees with sticks and machetes attacked a compound housing newcomers who had fled the war in Sudan—and supplies. Over a hundred were injured and one killed. One mother said the attackers stole food, including the dinner her children were about to eat, which was part of their food aid.
Similarly troubling reports come from north-eastern Nigeria, where America footed the bill for 60% of humanitarian costs. ngos say they are turning away famished children. In Somalia the wfp says it must cut the number getting food aid from 1.1m in August to 350,000, less than a tenth of those the agency says require help.
Basic preventive health care has suffered too. In early October cgdnoticed a rise in cholera in Angola, Congo, Sudan and South Sudan. In each case there was a reduction in American funding for “wash” projects—water, sanitation and hygiene.
African policymakers are paying lip service to the idea that the crisis offers an opportunity. “We cannot build healthier populations purely on the generosity of other nations,” said Muhammad Ali Pate, the Nigerian health minister, in August. But the ngos and local officials dealing with the fallout are gloomier. Seramila Teddy, who governs the Madagascan province where Dr Jackia works, says he has no money to dispatch health workers to remote areas. South Africa’s government has said it will replace the lost pepfar funding, but ngos say no cash has arrived.
A silent crisis could be dangerously convenient for both sides. America does not want to be blamed for contributing to the deaths of Africans; African governments do not want to look weak and incompetent. All the while, the signs are growing that America First also means Africa last. ■