The human costs of foreign aid cuts 

Sonia el-Ali, John Musenze, Ruth Douglas, Aleida Rueda, Claudia Caruana and Abdul Qader Othman write about how global aid cuts are endangering lives across Africa, Asia, and the Middle East, as critical health and humanitarian programmes grind to a halt for SciDev.net.


Image by USAID US Agency for International Development | Flickr

Outside Syria’s Qah refugee camp, in northern Idlib, garbage has been piling up, causing foul smells and fears of disease outbreaks.

The stench signals the deteriorating conditions seen by the families who live here in tents after the Green Hands project, Al-Ayadi Al-Khadraa, stopped its support.

The grassroots programme is one of thousands around the world affected by a mass termination of US Agency for International Development (USAID) contracts under President Donald Trump’s administration that have left the development sector reeling.

The Green Hands project provided clean water, sanitation, and waste management for Qah, a makeshift camp in northern Syria housing some of the 14 million people who have fled their homes since 2011 due to ongoing violence.

Hussein Al-Nahlawi, a 51-year-old staying in Qah camp, told SciDev.Net: “We used to receive water for free, but now we must buy it ourselves, costing US$15 per month. I earn only US$80 a month, barely enough to cover my family’s basic needs.”

The worsening situation has left many people concerned about the new financial burden they must bear, he says.

Leaving is not an option, stressed Al-Nahlawi. Most of the displaced have seen their homes destroyed by war and rely on humanitarian organisations for medical services, food aid, and heating materials.

With these projects shrinking or disappearing, their health is at risk and lives are at stake.

USAID dismantled

The unravelling of USAID began on January 20, when President Trump issued an executive order halting foreign aid programmes pending a 90-day review. Within weeks, thousands of agency staff had been put on leave, leading to ongoing challenges in the US federal courts.

On February 26, government officials revealed in court documents that they had completed their review of foreign aid and would terminate 10,000 USAID awards, about 90 per cent of the agency’s work.

In the same month, the UK government said it planned to slash its spending on overseas aid from 0.5 to 0.3 per cent of GDP (gross domestic product) to fund an increase in defence spending, prompting fears from global health organisations of a domino effect in overseas aid funding.

In total, 26 low- and middle-income countries, with a combined population of 1.4 billion, are highly vulnerable to the cuts and lack the resources to plug the gap, according to analysis by the Center for Global Development.

In Syria, the US is the single largest donor, contributing nearly US$1.2 billion to the humanitarian response in the 2024 financial year and more than US$18 billion since the start of the 13-year crisis, according to the US State Department.

Abdel Hakim Al-Masri, minister of finance and economy in the Syrian Interim Government, said the country is among the worst affected by the halt to US aid.

As well as essential water, sanitation and waste management services provided by NGOs in northern Syria’s camps, Al-Masri said medical projects, food aid and livelihood programmes have been severely disrupted, worsening conditions for an already struggling population.

Since the executive order was issued, around 200 humanitarian organisations in Syria have shut their doors, leaving many workers unemployed. Their salaries, ranging from US$400 to US$500 a month, were a crucial source of income in a country with few alternatives.

Hospitals shuttered

Al-Masri warned that Syria’s healthcare sector will suffer greatly, as many hospitals rely on humanitarian aid to provide free medical services to those unable to afford private care. The aid cuts have driven up prices of food, medicine, and medical supplies.

Syrian nurse Ahmad Al-Barakat lost his only source of income following the suspension of funding for Bab Al-Hawa Hospital by the Syrian American Medical Society (SAMS).

He told SciDev.Net: “My life turned upside down. I used to earn US$400 a month, enough to support myself and my sick mother. Now, I have no income.”

Bab Al-Hawa Hospital is a key medical centre in northwest Syria, serving more than 1.7 million people with free healthcare, including emergency services, specialist surgeries, and cancer treatments. Now it is closed for all but emergency cases, with doctors working on a voluntary basis.

“Its closure will be a disaster, especially for chronic patients who depend on it,” Al-Barakat added.

Al-Barakat noted that many humanitarian organisations have had to halt operations, including ACTED, Shafak, Takaful Al Sham, People in Need, and SAMS, all of which supported Bab Al-Hawa Hospital and other healthcare facilities.

Global health toll

More than a month on from the initial suspension of USAID contracts, the cost to human lives is becoming clear, in Syria and around the world.

Until now, the US has been the world’s biggest global health funder, spending US$12.4 billion in the 2024 financial year.

The stop-work orders have left millions of people globally without essential medical care and at risk from disease outbreaks such as mpox and Marburg, according to an impact report by the Global Health Council, a US-based non-profit.

Polio vaccination, malaria control, and HIV/AIDS services are among the critical interventions curtailed.

Much of the burden will fall on women and children. The stop-work order halted medical supplies and staff providing prenatal care, safe childbirth, and vaccines for 90 million women and girls, the Global Health Council report says.

The report gives a breakdown of some of these effects by country. In Afghanistan, 191 health clinics, the only source of maternal healthcare in rural areas, will close. In Ethiopia, almost 50,000 women and girls will be at risk of potentially fatal malnutrition. In the Democratic Republic of Congo, 4.5 million children under the age of five face acute malnutrition without access to therapeutic feeding centres and support for breastfeeding mothers.

“Each day that these life-saving programs remain paused and unfunded, decades of progress are undone, and the trust and leadership the US has built with global partners are eroded,” the report stated.

In Yemen, where more than 19 million people require humanitarian assistance, funding cuts will worsen the suffering of the most vulnerable, particularly in food security and healthcare, said Nasim Al-Musllmi, executive director of Madani Foundation for Development, an NGO.

In the northern areas of the country, almost all aid has stopped, including emergency interventions, SciDev.Net has learned. This is despite a US waiver issued by US Secretary of State Marco Rubio on January 28 for ‘life-saving humanitarian assistance’, including medicines and food.

Yemen’s annual humanitarian aid is estimated at US$2 billion, but recent declines and unfulfilled donor commitments have significantly reduced economic inflows.

The effect spans multiple sectors. In health, shortages of medicine and medical supplies will lead to higher mortality rates, especially among children, pregnant women, and chronic disease patients, said Al-Musllmi.

In the climate sector, he said already limited environmental projects such as renewable energy and afforestation will face further setbacks, increasing vulnerability to climate change.

HIV response in turmoil

By far the biggest chunk of US spending on global health has gone traditionally to HIV/AIDS. Through the US President’s Emergency Plan for AIDS Relief (PEPFAR), launched in 2003, the US government has invested over US$110 billion in the global HIV/AIDS response, the largest commitment by any nation to tackle a single disease.

The most recently available UNAIDS financing data showed that PEPFAR paid for 19 per cent of antiretrovirals and other HIV medicines in 36 low- and middle-income countries.

There was some hope that HIV/AIDS treatment would be spared from the cuts through the waiver for life-saving medicines. But South African organisations funded by PEPFAR through USAID have been directed to close operations permanently.

Termination letters seen by SciDev.Net inform recipients that their awards no longer align with USAID priorities and are not considered in the national interest.

On February 27, the US administration also ended its contract with UNAIDS, the joint UN programme for HIV/AIDS, with immediate effect. UNAIDS said the move affected the entire HIV response, including the continuity of life-saving treatment for people with HIV.

In an update on March 3, UNAIDS said the waiver had been keeping testing and treatment services running ‘but often at reduced capacity, quality, acceptability and accessibility’.

Uganda on a knife-edge

In Uganda, one of the countries most vulnerable to the US cuts, HIV/AIDS programmes are on the brink of collapse, leaving thousands of lives hanging in the balance. Around 1.5 million people in the country are living with HIV.

HIV communities fear stocks of preventative drugs and treatments are running low.

Flavia Kyomukama from the National Forum of People Living with HIV said many of their members are only receiving refills of antiretrovirals that last two weeks, compared to the three months’ worth previously handed out.

She noted the country’s antiretroviral stock only lasts until April, and there is uncertainty about what will happen thereafter.

Guminkiriza Kagwa, an HIV focal person at a health centre in Bushenyi district, said access to free HIV preventive medicines is hard or impossible in most regions of the country. 

“Most of the hospitals are having stockouts on PEP and PrEP. We were told this was not part of the PEPFAR waiver,” Kagwa told SciDev.Net, continuing: “New infections are expected to double because many young people and sex workers were using them for prevention.”

Uganda’s Ministry of Health declined to comment.

Steven Watiti, a retired doctor who has lived with HIV himself since 1999, has dedicated his life to HIV advocacy. His work, supported by the USAID-funded Makerere University Joint AIDS Program (MJAP), has played a crucial role in the fight against HIV in Uganda.

“I have seen first-hand the transformative power of advocacy and activism in stopping stigma and discrimination and promoting peer education among young people,” he told SciDev.Net, adding: “Without these, many will die.”

He urges people living with HIV to try to adjust to the current situation, adding: “services are still available, and they should look for them.”

However, many services are severely stretched.

Robert Kiwanuka, programme manager at Muvubuka Agunjuse, an NGO providing youth-friendly sexual and reproductive health services in Uganda, said: “We used to receive around 80 people a day, but now the number is over 150 because most of the organisations who were giving similar services shut. Our Tuesday HIV clinic now attracts over 250 young people.”

The Ugandan Ministry of Health responded by ordering HIV and other specialist health services to be integrated into general healthcare.

But there are fears that the system will collapse under the pressure. Uganda has one of the lowest doctor-to-patient ratios in the world, with only one doctor to every 25,000 people.

“People have been lining up for almost the whole day,” Kiwanuka added, continuing: “What is going to happen when 1.5 million people and those with TB join the [hospital] queues, and yet there is no increase in doctors to attend to them?”

Big three

African countries are not the only ones to suffer the loss of HIV services. In the Philippines, Health Secretary Teodoro Herbosa said last month that the freeze order will affect crucial programmes worth US$262 million, including US$168 million for the so-called ‘big three’ diseases, HIV/AIDS, malaria and TB.

USAID is the largest donor to the Global Fund to Fight AIDS, Tuberculosis and Malaria and has contributed US$26.31 billion since it was founded in 2002.

At the country level, the US government has provided about US$200 to US$250 million a year in bilateral funding for the TB response, around one quarter of the total amount of international donor funding for the disease. Prevention, testing and treatment services averted 3.65 million deaths last year alone, according to the WHO.

“Abrupt funding cuts now threaten to undo these hard-won gains, putting millions, especially the most vulnerable, at grave risk,” the WHO warned in a departmental update on March 5.

In malaria prevention, the effects are already being felt. Insecticide spraying operations are being halted in Kenya, Uganda, and Ghana, affecting almost six million people, according to the Global Health Council. In Ethiopia, 2.6 million people will miss out on bed nets.

‘Ripple effect’

Katie Dain, chief executive officer of the NCD Alliance, which focuses on non-communicable diseases (NCDs) such as cancer, diabetes and heart disease, says the USAID cuts will have a ripple effect on all different health issues, including the NCD burden in Sub-Saharan Africa.

“NCDs have already been under-prioritised,” said Dain. “Anything on the bottom of the list is going to get even further deprioritised. It’s going to have a huge impact.”

Sexual and reproductive health services for women and girls is another area to be hit hard by the cuts from their biggest donor.

“From a sexual and reproductive health perspective, it’s absolutely catastrophic,” said Sarah Shaw, associate director of advocacy at MSI Reproductive Choices, an international NGO which advocates for access to contraception and safe abortion.

“By the end of the 90 days, an estimated 11.7 million women and girls will have lost access to contraceptive services, so that’s an estimated 4.2 million unintended pregnancies and 8,300 maternal deaths, all of which were preventable,” said Shaw, citing figures from the research and policy organisation the Guttmacher Institute.

In Uganda, confusion around the US orders gave rise to the spread of misinformation around family planning and condom use, putting women into a panic, Shaw added.

“The buy-in for family planning and reproductive health in some communities was pretty fragile anyway. This is just going to destroy all trust that had been built up. It’s going to take generations to resolve,” Shaw continued.

Waiting to erupt

The effects of aid cuts on diseases like HIV and malaria have grabbed the headlines since the USAID shutdown.

But around the world, there are programmes that will quietly suffer the loss of funding, with the full consequences still to emerge.

In Central America there were projects to support young people into work through training and others on human rights, transparency, citizen security, and social reintegration, according to the Chief of Staff of a USAID-funded project in El Salvador.

Like many people affected by the stop-work orders, she spoke on condition of anonymity, fearing that if US cooperation returned, her job would not if she spoke openly.

“There is an atmosphere of uncertainty and fear. Nobody wants to expose themselves because they don’t know what is going to happen,” she told SciDev.Net.

Another casualty for Latin America is the USAID-funded Volcano Disaster Assistance Program, which carries out volcano monitoring, training and risk-prevention activities in the region and elsewhere alongside partner organisations.

Jersy Marino is a researcher at the Geological, Mining and Metallurgical Institute, in Peru, which has received substantial support from the Volcano Disaster Assistance Program for almost 20 years.

“We have installed equipment in volcanos, seismic equipment, high precision GPS equipment, and equipment for monitoring volcanic gases,” said Marino, adding: “Thanks to this cooperation we have implemented the monitoring system in the Sabancaya volcano, for example, which is currently erupting in Peru.”

He said the organisation has developed hazard maps to highlight safe zones around the volcano and those most at risk.

Implementing a complete monitoring system in a volcano is a heavy investment, added Marino, one which countries such as Argentina, Peru, and especially Guatemala, Nicaragua and El Salvador will struggle to make alone.

“Good monitoring allows you to know if this volcano is going to erupt or not in the future,” he explained, continuing: “And from that knowledge you send alerts to the authorities and the population to manage the danger, the eruption, the emergency. So, in the absence of good monitoring, we are going to have vulnerable populations, especially in developing countries.”

A list of terminated USAID contracts disclosed via court proceedings last month (February 13) shows the range of projects affected by the USAID stoppages. They include low-carbon power solutions in Nigeria; water, sanitation and conservation initiatives in Lebanon; literacy programmes in Kenya and East Africa; and climate adaptation and mitigation in Honduras.

A US$250 million contract with Chemonics International to implement green platforms and scale up climate adaptation in low- and middle-income countries is another casualty.

Lawrence White, an economics professor at the Stern School of Business, New York University, acknowledged that USAID programmes have not been without their faults and ‘resources were surely wasted’.

But he believed the overall effects were positive.

“USAID has not been perfect, and intelligent reform would have been worthwhile,” he told SciDev.Net, adding: “But a meat-axe approach is highly unlikely to achieve that result.”

UK aid cuts

The UK government’s decision to slash its overseas aid budget last month is a further shock to the international development sector, already scrambling to pick up the pieces from the Trump administration’s actions.

The decision by Prime Minister Keir Starmer’s government to reduce overseas aid spending from 0.5 to 0.3 per cent of GDP is the latest in a series of cuts made since 2020 and puts the UK’s aid budget at its lowest for decades.

In 2023, the US accounted for 29 per cent of all OECD (Organisation for Economic Co-operation and Development) countries’ aid funding – the UK was just over eight per cent.

While the UK cuts won’t kick in until 2027, for many NGO leaders, their announcement in the wake of the USAID shutdown is an immediate body blow.

It is part of a wider picture of diminishing aid, with France and Germany also cutting aid budgets in recent years.

“The UK announcement of cuts couldn’t have come at a worse time,” said Katie Husselby, director at Action for Global Health, a UK-based network of global health organisations which is calling on the government to reverse its decision.

“Coming in the wake of the widespread decimation of health services from USAID [the UK cuts] will be a double whammy to global health,” she told SciDev.Net.

She said Action for Global Health analysis of the effects of previous UK aid cuts in 2021 from 0.7 to 0.5 per cent of GDP showed devastation of health services around the world, with many lives lost, at a time when the world was still grappling with the Covid-19 pandemic.

“Pretty much overnight, clinics closed, projects stopped, and people were unable to access health services that they had been able to access the day before.”

Husselby said the latest cuts will utterly decimate trust with low- and middle-income partner governments and civil society organisations. She feared it could also lead to a ‘domino effect’ in overseas aid spending.

She added: “The cumulative impact of USAID cuts, the UK announcement, and other cuts that we’re seeing now across European countries such as the Netherlands. I think it’s impossible for any other stakeholder, organisation, or country to fill that void.”