Aid cuts: Where do we go from here?
USAID has been a strong partner for public health in Africa since the 1960s. The immediate impact of overnight US-funded programme closures is catastrophic for communities across Africa.
In 2017, Ethiopia was certified polio-free. The termination of polio surveillance and control programming with USAID withdrawal, combined with the ongoing conflict, could mean up to 200,000 cases of paralytic polio. In South Sudan, where US support accounted for 70% of all nutrition assistance, 550,000 people could die within a year without this food aid. (Figures from New York Times: U.S.A.I.D Memos Detail Human Costs of Cuts to Foreign Aid, 2 March 2025)
Every passing day the human cost of this crisis grows. It is with this backdrop that Amref hosted the Africa Health Agenda International Conference (AHAIC) in Kigali, Rwanda earlier this month. The convening brought together close to 2,000 people in person and virtually, including Ministerial delegations from Rwanda (as AHAIC co-hosts), Kenya, Ivory Coast, Malawi, Sierra Leone, Tanzania, Zambia, and high-level delegations from the Africa Centres for Disease Control (Africa CDC) and World Health Organisation (WHO).
"We knew this was coming," says Dr Mercy Mwangangi, "so the question now is: how do we move forward?"
National budgets for health
African governments must urgently look at their national budgets for health - and discuss ways that they can increase the money that is allocated to health. We know that this will not fill the gap left with the withdrawal of USAID, and other international aid including UK Government funding, but our focus now is on finding the solutions to enable us to protect the most vulnerable and move forward.
Part of that conversation is a radical change in how health financing works. Dr Mercy Mwangangi shared that in high-level conversations at AHAIC, Ministers of Health and other regional health leaders had a clear call to action: systems redesign.
"This [conversation] was electric in the room," she shares. "There is a focus now on looking in - to see what there is going on in governments to move the needle."
Primary healthcare
The foundation of that systems redesign is primary healthcare. This is the level at which 80% of people seek care, yet, Dr Mercy shared that "national health budgets in Africa currently support only 1-2% of primary healthcare funding. External funding supports the rest."
That means the salaries or incentives that some health workers are paid, essential medicines, other health commodities, supplemental nutrition, health promotion activities, and disease case tracing is all externally funded.
Dr Mercy brought this into stark view with an example. The WHO recommends four antenatal care coverage appointments for every pregnant woman. This standard is set to ensure the health of the mother and her baby. This is a key indicator that governments track using health workers, technology, and health systems data. But, Dr Mercy estimates, most African governments' health budgets do not include a budget line for what is called 'ANC defaulter tracking' - meaning that without external funding, this indicator simply will not be tracked. The consequences on this on antenatal care, maternal and newborn health is huge.
"The solutions are with us"
At a roundtable discussion of Ministers of Health, Africa CDC and the WHO, health leaders were able to discuss what is working for them in the immediate aftermath of the cuts. This included how to better integrate the health workforce and health programming for budget efficiency, including training programmes, how to protect the essential medicines supply chain and what can be done to ensure health security.
What is Amref doing?
Amref continues to facilitate convenings - both formal and informal - of African health leaders. The connections and meetings at AHAIC in Kigali will be followed by a series of meetings on the sidelines of global health events including the World Health Assembly, the UN General Assembly and the G20 Johannesburg later in the year.
As a facilitator, we provide technical expertise to our government colleagues. In collaboration with the Clinton Health Access Initiative (CHAI), we conducted a gap analysis on health financing, and on health systems. These analyses then inform the next step; the development of transition plans at the national level. These plans will focus on sustainable financing and health service delivery, emphasising prevention and primary care.
Amref's key role here is to ensure that we support health ministries to strengthen national capacity to deliver these plans. Specifically, we are supporting with advocacy for these transition plans in the upcoming budget planning cycles for governments across the continent.
This includes working with countries where the health and finance ministries have formed adaptive technical working groups, and where the health ministries are leading these efforts.
Where is the focus now?
What is the blueprint for self-reliance in health? That could seem like a big question, but the mood is optimistic among health leaders. Dr Mercy concluded with the five key areas of focus where the impact of the cuts is huge, but where there is already momentum from the starting blocks to build a locally-driven, integrated and effective health system.
- Connection with each other - Health leaders are already working together to share learning, best practice and successes. This support is vital as we navigate these new paths to self-reliance.
- Health workforce - In Kenya, Amref was supporting around 100,000 health workers across all levels from lab technicians to community health workers through training, monitoring and capacity building. Their salaries and stipends were covered by national budgets, but without the operational costs covered externally, these health workers will go without critical training. There is a move to integrate to create efficiency - which has been shown to work. But the concern here is on health outcomes; what effect will this have on communities when health workers play multiple roles?
- Commodities - Discussions centred on protecting supplies of life-saving medicines. While most national stocks may be able to last until September 2025, after that, the supply chain breaks down. This is where the focus will be: creating solutions to protect the supply chain.
- Laboratory diagnostics for health - Without access to diagnostic tools, disease surveillance and control methods are critically weakened. Discussions will focus on how to safeguard the lab diagnostics networks nationally to ensure that they can meet needs.
- Adaptive leadership - These are complex problems which need effective adaptive leadership to ensure we stay focussed on the priorities. Dr Mercy set this in context of an issue that arose with externally-funded national data systems for HIV in Kenya. After the cuts announcement, hospitals had no access to national HIV data on these systems. They were forced to think on their feet and go back to manual recording of data.
This shows that African health leaders are navigating choppy waters, but that their optimism is driving them forward. Innovation, collaboration and transparency are key as we move ahead.
Watch the discussion here
Watch the full conversation (31 mins) with Dr Mercy Mwangangi and Bob Kelty to learn more about what African governments are doing in the aftermath of the US Government funding cuts, and how Amref is supporting this work.
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