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Since the 1960s, the United States has been a significant global donor to various African healthcare systems, particularly in Sub-Saharan Africa, through programs such as the United States Agency for International Development (USAID), the President’s Emergency Plan for AIDS Relief (PEPFAR), and the President's Malaria Initiative (1). Investments worth billions of dollars were annually donated to support disease-specific initiatives, healthcare infrastructure, and workforce training and development. Through this aid, African countries have made significant strides in improving their health infrastructure and outcomes (2). However, with the recent abrupt USAID funding freeze, various healthcare systems in Africa are facing several challenges, including budget constraints, potential re-emergence and relapse of infectious diseases, service delivery disruptions, and unemployment of healthcare personnel.

Pre-Freeze: Health Gains Underpinned by USAID
In the fiscal year 2023, it was reported that the US donated approximately $6.2 billion in bilateral global health funding to specific countries, 85% of which was targeted at sub-Saharan African countries. Of this amount, 73% was channeled through the USAID program (3) The top five countries receiving USAID funding in that year included Ethiopia ( $1.68 billion), Somalia ( $1.05 billion), the Democratic Republic of the Congo ( $0.94 billion), Nigeria ( $0.82 billion), and South Sudan ( $0.74 billion) (Table 1) (4). This funding supported several health initiatives, including maternal and child health services, tuberculosis treatment programs, malaria prevention, and PEPFAR for the provision of antiretroviral therapy. The impact of these investments is profound, as PEPFAR alone is estimated to have saved 25 million lives as of 2023 (5). Additionally, funding was used to construct, renovate, and equip several health facilities, particularly in rural areas of countries such as Malawi and South Sudan. Programs provided not just direct service delivery but also built human capital through scholarships, training modules, and skill-transfer mechanisms.

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Table 1.

Top 10 African countries receiving USAID aid for the 2023 fiscal year

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The Fallout: Post-Funding Freeze Consequences
With the abrupt fund freeze and little or no time for countries to respond or plan appropriately, several countries’ healthcare systems faced major crises (Table 2). Up to 90% of USAID contracts were terminated overnight, resulting in the layoff of thousands of employees across the continent with many former employees still struggling to find jobs (6, 7). 

More than $12 million in human immunodeficiency virus (HIV) prevention drugs and contraceptives became stranded in European and UAE warehouses; another $11 million worth of contraceptives similarly stalled (8, 9). Additionally, several ART clinics were shut down in countries such as Kenya, leaving over 72,000 HIV patients affected and concerned about the availability of their medications (10). Furthermore, in Zambia and Tanzania, tuberculosis outreach programs came to a halt, leading to widespread concern over untreated and potentially drug-resistant strains of the disease (11).

 

Table 2.

Summary of USAID contributions to African countries pre and post-funding freeze.

Perhaps the most alarming consequence was the resurgence of preventable diseases, as several healthcare professionals raised alarming concerns that without consistent access to ARTs for HIV, viral load suppression would decline, there could be increased resistance to drugs, and possibly increased transmission rates. Additionally, the WHO expressed further concerns regarding the matter, stating that South Africa alone would perhaps see over half a million HIV-related deaths over the next decade (12).
The financial aid withdrawal highlighted overdependence on foreign aid by several African governments. Despite the Abuja Declaration signed in 2001, where all African leaders pledged to allocate at least 15% of their national budgets to health, reports show that only Rwanda has managed to meet this target, allocating 15.1% of its national budget while other countries such as Kenya (7.4%), Uganda (6.9%), Tanzania (9.1%), and Burundi (4.8%) are yet to achieve this minimum (13). This underinvestment led to a state of panic following aid withdrawal, as no nations were fiscally prepared to step in and fill the financial void.

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A call for System Redesign
Since the freeze, several recommendations have been made, including expanding PEPFAR’s waivers and sourcing alternative donors for emergency funding (14). In Ghana, the president directed the bridging of the funding gap arising from the suspension of the funding gap, and in Nigeria, the legislature approved an additional $200 million for the health sector following the shortfall from the US funding cuts (15). This crisis has sparked an interest in an urgent call for “System Redesign.” Experts state that investments should be made toward ensuring adequate, sustainable, and locally funded primary healthcare (1). This would not only reduce dependency on external programs but also increase the resilience of healthcare systems against future shocks. Moreover, it would ensure continuity of care across a range of services, from maternal health and immunizations to chronic disease management. Despite causing several disruptions, the funding freeze did indeed highlight the overdependence of several governments on financial aid. In addition, these actions have opened the door to more self-driven and self-reliant financing models for healthcare, as now governments are forced to make mandatory budgetary commitments.

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Conclusion
Despite the Abuja Declaration, the 2025 USAID fund freeze highlighted African governmental overdependence on foreign aid. With the abrupt withdrawal of funding, several health services have been halted, thousands have lost jobs, and there is an increased risk of a resurgence in preventable diseases. Several African governments now face the challenge of redesigning policy in healthcare and provision of adequate financing to compensate for what was once covered by external financial aid.

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Author contributions
MAE led in conceptualization, data curation, methodology, project administration, resources, visualization and in writing, reviewing & editing of the original draft. JK equally contributed.
 

References

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2. Rautenbach SP, Whittles LK, Meyer-Rath G, et al. Future HIV epidemic trajectories in South Africa and projected long-term consequences of reductions in general population HIV testing: a mathematical modelling study. Lancet Public Health. 2024; 9(4): e218-30.

3. KFF. How Much Global Health Funding Goes Through USAID? 2025. Available from https://www.kff.org/policy- watch/how-much-global-health-funding-goes-through-usaid.

4. US Foreign Assistance. https://foreignassistance.gov/cd.

5. DevelopmentAid. An Overview of U.S. Health Assistance for Africa: Transforming Lives in Developing Nations. 2024. Available    from   https://www.developmentaid.org/news- stream/post/183303/overview-of-u-s-health-assistance-for- africa.

6. amfAR. Trump Administration’s Order Requiring Immediate Suspension of All HIV Services Provided by PEPFAR Will Place    Lives  at    Risk.    2025.    Available    from https://www.amfar.org/press-releases/trump- administrations-order-requiring-immediate-suspension-of- all-hiv-services-provided-by-pepfar-will-place-lives-at-risk.

7. “We Have to Try Lifting Ourselves”: USAID Workers Fired Months Ago Are Still Scrambling for Jobs. USA Today. Available    from https://eu.usatoday.com/story/news/politics/2025/05/19/usai d-workers-next-job/83332416007/.

8. Reuters. Contraceptives for Poorest Countries Stuck in Warehouses after US Aid Cuts. 2025. Available from https://www.reuters.com/business/healthcare-pharmaceuticals/contraceptives-poorest-countries-stuck- warehouses-after-us-aid-cuts-2025-06-06.

9. The U.S. Bought $12 Million in Aid for Poor Nations. Under Trump, It May Be Destroyed. 2025. The Washington Post. https://www.washingtonpost.com/investigations/2025/06/05/usaid-money-hiv-contraceptives-trump-destroyed.

10. GHJ Team. Global Health Catastrophe from 2025 U.S. Foreign    Budget    Freeze.    2025. https://depts.washington.edu/globalhealthjustice/global- health-catastrophic-from-the-2025-u-s-foreign-budget- freeze.

11. So Dark and Full of Fear’: Here’s What’s Happening in Africa since DOGE’s USAID Cuts. San Francisco Chronicle. 2025. https://www.sfchronicle.com/opinion/openforum/article/uga nda-africa-usaid-trump-20298512.php.

12. US Shutdown of HIV/Aids Funding ‘Could Lead to 500,000 Deaths    in    South    Africa.’    2025.    The    Guardian. https://www.theguardian.com/global- development/2025/feb/28/usaid-funding-health- development-hiv-aids-antiretroviral-mothers-lgbt-sex- workers-south-africa.

13. Public Services International. Budget Commitments vs. Reality: The Abuja Declaration Betrayed—Except in Rwanda.    2025. https://publicservices.international/resources/news/health- in-the-balance-how-the-usaid-pullout-exposed-east-africas- over-reliance-on-donor-driven-systems?id=15767&lang=en.

14. Ashinze P, Owoicho AI, Olanite M. Partial waivers: PEPFAR’s 2025 funding suspension and the looming HIV/AIDS catastrophe in Sub-Saharan Africa. Retrovirology. 2025; 22(1): 5.

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