Following enormous cuts in foreign aid by the US and its exit from the World Health Organisation, should we expect greater global sickness and suffering?
President Donald Trump’s disappointing decision was long previewed and should not have shocked anyone. That it did – and disrupted many life-saving programmes – reflects head-in-the-sand complacency in an unprepared aid system. Global health providers have been at the forefront of the panic, thereby making objective scrutiny of health financing surprisingly difficult for such a science-centred discipline.
That is because health agencies passionately advocate for their cause while maximising their own roles. This can create conflicts of interest, and when mixed with donors’ political ideologies, transparency and trust inevitably suffer.
How significant is the overall 28 per cent reduction in global health aid? It is trivial for most of the Asia-Pacific region and Latin America where foreign health aid constitutes less than 5 per cent of national health expenditure. Such modest shortfalls are easily compensated for by efficiency gains and increased domestic spending in the predominantly middle-income countries. As these also include more populous nations, the effect of aid cuts on aggregate global health indicators is not worrisome.
However, there are exceptions. Small economies, especially small-island Pacific states, need external health aid. So too do volatile or fragile states such as Afghanistan, Haiti, Syria and Yemen. But this is classified as humanitarian aid because there is insufficient stability to consider development assistance.
Thus, cuts to health aid matter mostly to sub-Saharan Africa. Even there, it is marginal to countries where foreign health aid is less than 10 per cent of national health expenditures. It is significant only in the 12-15 states that depend on foreign assistance for more than 20 per cent of their health budgets. Even so, middle-income countries like Kenya, South Africa, Nigeria, Angola and Tanzania can afford topping-up budgets to the $56 per capita annual investment necessary for healthcare provision.
More commendably, low-income countries such as Rwanda and Uganda are also boosting domestic healthcare spending, as are Ethiopia and Eritrea – two states beset by conflict. Raising up health sectors is something nearly all African countries can do so, given the right political will and supportive governance.
Of course, African populations in generalised conflict – as in Sudan and the Sahel – require humanitarian health support. But the case for development health financing applies only to a diminishing list of states, such as Somalia and South Sudan, that totter between crises but show development potential.
There is a counter argument that aid cuts reverse progress. Past official development assistance, or ODA, is credited with steep declines in the rates of HIV/AIDS, tuberculosis and other communicable and neglected tropical diseases. Various future defunding scenarios postulate 9-22 million additional deaths. However, such studies give insufficient recognition to states’ self-advancement, with much of that coming from broader strategies beyond health. Foreign aid has helped but whether that was decisive to progress is disputable.
What is the future of global health aid? The picture has brightened recently with the US reversing some earlier cuts through a $9.4 billion package under a new America First Global Health Strategy that supports much of the same priorities as before. More generally, geopolitical and economic trends show fraying international solidarity, and expenditures shifting towards defence and other priorities. So, ODA will continue drifting downwards from the already reduced $180 billion estimated in 2025?
Meanwhile, low and middle-income countries must spend $371 billion annually by 2030 to achieve the health target of the UN’s faltering Sustainable Development Goals. Happily, 85 per cent of that is achievable from domestic resources. The political choice of sovereign states not doing so may be deplored but it must be respected and not undermined by kind but fickle donors jumping in.
The remaining annual financing gap of about $55 billion for health development can be feasibly bridged by private philanthropy and enterprise, diaspora remittances and new concessional loans from multilateral development banks.
In short, panic around global health financing is overblown. Additional funds can be released by reforming bloated global health architecture, correcting overlaps between several large agencies and eliminating activities rendered unnecessary as nations became more capable. The residual work that is best done globally and multilaterally can be streamlined with responsible agencies downsized, merged and shifted to locations cheaper than Geneva and New York.
The WHO is providing a commendable example of such reform. That has necessitated trimming more than a third of its budgets, programmes and staff. But what is left still amounts to more than $4 billion in 2026-27 for core WHO activities, three quarters of which has already been funded.
Although the political implications of America’s withdrawal from the WHO will emerge over time, the financial fallout is an immediate opportunity to strengthen critical functions that a central health body must discharge – that is, to protect us from disease risks that do not stop at borders.
That is global health in its true sense and it should have first call on shrinking global aid funds. But implementation is a national, not global, responsibility. Yes, the WHO provides other valued “gap filling” services including in emergency contexts like Gaza but with other international and local actors capable of more efficient provision, these could be shifted to them without overall diminution in the global health effort.
However, this bargain requires a more thoughtful donor role. They should resist the temptation of shifting their own job and associated overheads to multilateral health agencies when channelling large funds through the WHO and similar technical bodies not constructed for that purpose. International financial institutions, such as the World Bank and regional development banks, make better funding conduits.
Multilateral agencies should not become tools or sub-contractors of donors. In that context, the bilateralisation of renewed US health aid to 14 low-income African countries may not be so bad, if associated conditionality delivers better results and accountability – not just American control.
At a time of considerable geopolitical turmoil, global health efforts face many risks. However, financing does not have to be one of them if the economies and efficiencies forced by ongoing changes are used as opportunities to help countries stand on their own feet.
That global health assistance is becoming less of a lifeline that it has been previously should be a cause for celebration, not concern.
