With reality setting in – that the United States is drastically diminishing its foreign assistance to developing countries – an urgent conversation is starting among governments, philanthropists, and global health and development organisations.
It is centred on one crucial question: who will fill the funding gap?
Last year, the US contributed about $12bn to global health, money that has funded treatment of HIV and prevention of new infections; children’s vaccines against polio, measles and pneumonia; clean water for refugees; and tests and medications for malaria.
The next largest funder is the Gates Foundation, which disburses a fraction of that amount: its global health division had a budget of $1.86bn in 2023, reports The Washington Post.
“The gap that has been filled by the US cannot be easily matched by anybody,” said Dr Ntobeko Ntusi, chief executive of the South African Medical Research Council.
US assistance has been channelled through the United States Agency for International Development, or USAID, which the Trump administration has largely dismantled, and other government agencies, including the National Institutes of Health, which is also facing substantial cuts in health research grants.
Many people are suggesting that other countries, particularly China, could move into some of the areas vacated by the US, Ntusi said. Others are making urgent appeals to big philanthropies including the Gates Foundation and Open Philanthropy.
This conversation is most consequential in Africa. About 85% of American spending on global health went to programmes in or for African countries.
For countries like Somalia, where US aid made up 25% of the government’s whole budget, or Tanzania, where the US funded a majority of public healthcare, the loss is catastrophic. And for the major global health agencies, the situation is similarly critical.
Trump has already pulled the US out of the World Health Organisation, which is now trying to make an initial budget cut of $500m for 2026-27 to cope with the withdrawal of American funds.
“Most of our neighbours on the continent have been completely reliant on the US to procure most of the lifesaving medications for endemic infections,” Ntusi said. “And I don’t see most of the governments – overnight – being able to have the resources to cope. So I think there are going to be devastating consequences on lives lost, from Africans who will die of preventable infections.”
The US is the largest donor to Gavi, which supplies essential vaccines to the world’s poorest countries, and to the Global Fund to Fight Aids, Tuberculosis and Malaria.
The US contribution is required by Congress. Asked about the commitment to these and other multilateral agencies, including the Pandemic Fund, a State Department spokesperson said that the programmes were being reviewed to see if they aligned with the national interest, and that funding would continue only for those that met this condition.
Who steps in?
There is no indication that additional funding will come from the other G7 countries, the European Union or other high-income nations. Britain, Germany, France, the Netherlands and Scandinavian countries have all reduced their foreign aid.
Some new donor countries have come forward to support the WHO, including Saudi Arabia and South Korea, but their spending is dwarfed by the amount America once gave.
Of non-governmental players, the World Bank is best placed to provide long-term support for health spending. The bank has said little so far. It could offer countries hit hard by the US cut-off innovative financing such as debt-for-health-care swops to give nations struggling under heavy debt burdens some fiscal freedom to make up lost funding.
However, the US is the largest shareholder of the bank, and the Trump administration would have influence over any such investment.
Much of the public discussion about filling the vacuum left by the US has focused on China, which has built a significant presence by financing infrastructure projects in African countries, particularly those with extensive mineral reserves or strategic ports.
“There is good reason for them to do so,” said Ja Ian Chong, an associate professor of political science at the National University of Singapore. China regards foreign aid as a soft-power tool in its superpower rivalry with the United States, much as the United States did when setting up USAID during the height of the Cold War with the Soviet Union.
China seeks to use aid to garner more support from developing countries in the United Nations.
While Chinese aid has largely come in loans to build infrastructure, it includes support for more varied projects. China’s answer to Western development aid, a programme unveiled in 2021 called the Global Development Initiative, includes $2bn for upgrading livestock production in Ethiopia, fighting malaria in Gambia and planting trees in Mongolia, among other projects.
Chong said China’s ability to fill the opening left by USAID could be constrained by its own financial limitations. China’s economy has stagnated because of a property crisis and rising government debt, and the country has already scaled back on big infrastructure loans.
To date, China has shown little interest in supporting global health programmes, or in providing grants on a scale anywhere near USAID levels.
AidData, a university research lab at The College of William & Mary in Virginia, estimates that Beijing provides about $6.8bn a year in grants and low-cost loans.
Philanthropies that were already working in global health have been deluged with panicked calls from organisations with frozen funds.
“I have talked to some foundations who have all said we’re being inundated with people saying, ‘Help us, help us, help us’, and I think they’re trying to patch little holes,” said Sheila Davis, the chief executive of the non-profit Partners in Health, which works with local governments to bring healthcare to communities in developing countries.
But if a patchwork bailout can cover just 20% of what the US was paying for, what should a new donor save? she asked.
“Do you choose to save one programme fully and then let others go? Or what is the best strategy?”
Chief among the foundations fielding pleas for help is the Gates Foundation, which has been warning its grant recipients that it cannot make up the gap. In addition to funding global health programmes, the foundation also supports health research and is a major contributor to Gavi.
“There is no foundation – or group of foundations – that can provide the funding, work force capacity, expertise, or leadership that the United States has historically provided to combat and control deadly diseases and address hunger and poverty around the world,” said the foundation’s North America director, Rob Nabors.
Multiple recipients of Gates Foundation funding, who declined to speak on the record because they were describing confidential conversations, said they had been told by Foundation staff that it would continue to fund research and programmes in the areas it already worked, but wouldn’t expand significantly, and that while some grants might be restructured to try to compensate for part of the lost US funding, its work would continue to be “catalytic” rather than support large-scale programming as USAID did.
John-Arne Røttingen, chief executive of the Wellcome Trust, which is among the largest donors to global health research, said it was “exploring what options might exist” in the new landscape. But, he said, its help would be “a drop in the ocean compared with what governments across the world need to provide”.
A couple of small organisations, like Founders Pledge, have started “bridge funds”, ranging from about $20m to $200m, to try to help plug immediate gaps.
But the philanthropic sector has largely been silent about the momentous change in the landscape. Major players that have already put hundreds of millions of dollars into healthcare in Africa, such as the Susan T Buffett Foundation, did not respond to questions about their plans. The Delta Foundation (co-founded by the Zimbabwean telecom billionaire Strive Masiyiwa) declined to discuss the issue.
Two executives at smaller private foundations said there was a reluctance to say anything publicly because of fear of retribution from the Trump administration, including a potential loss of charitable status.
African governments
African governments are under tremendous pressure from frustrated citizens to assume responsibility for the health spending that was coming from the US. The issue led the agenda at a meeting of the continent’s Health Ministers at an African Union summit last week.
In the 24 years since the Union adopted what’s called the Abuja Declaration, committing its 42 members to spending 15% of their budgets on health, only a couple of states have ever hit that target, and for a year or two at most. Average health spending by African countries is less than half that amount.
In Nigeria, the pPesident convened an emergency Cabinet committee to make a plan for the budget shortfall, and Parliament allotted an extra $200m to the national budget last week. But that extraordinary measure illustrates the scale of what’s been lost: it’s less than half of the $512m that the US gave Nigeria for healthcare in 2023.
Nigerian Health Minister Dr Muhammad Pate said that nearly 28 000 healthcare workers in the country had been paid in whole or part by USAID, which also covered three-quarters of the bill for drugs and test kits for the 1.3m Nigerians with HIV.
Nigeria will quickly need to find new ways of operating, he said, including boosting manufacturing of some of those items domestically. “It may not be as fancy, but at least it will serve,” he said.
He also predicted that the end of American aid would accelerate what he called a “realignment” in Africa. “The world has shifted in the past 20 years,” he said. “So we have other actors: we have China, India, Brazil, Mexico and others.”
Deisy Ventura, a professor of global health ethics at the University of São Paulo, said the change could open opportunities for other countries to exert newfound influence.
“The retreat of the United States may open space for new leaders now,” she said. “It’s important for us in the global south to imagine an international coordination of emergency preparedness and response without the United States.”
See more from MedicalBrief archives:
Trump’s aid cuts halt crucial SA-led HIV vaccine trials
WHO scrabbles to comply with Trump demands
SA should prepare for 'worst case scenario' after Trump cuts
Global healthcare on shaky ground as Trump’s moves take effect