The United States is significantly reducing foreign aid, with sub-Saharan Africa being the region most affected. This decision results in billions of dollars being cut from programs supporting health, humanitarian efforts, and overall development. Historically, the United States has been a primary donor during many African humanitarian crises.
Facing substantial funding cuts, Save the Children has had to close 463 health facilities and five nutrition centers, and halt child protection programs in 13 countries. In response to a 30 percent funding reduction, the International Organization for Migration is reorganizing its structure and reducing staff by over 20 percent. Doctors Without Borders/Médecins Sans Frontières also followed suit.
Without US foreign aid, nonprofits are now exploring alternative funding sources to sustain their operations. For instance, GiveDirectly, a charity focused on direct cash transfers to alleviate poverty, faced a $20 million funding shortfall due to cuts from USAID. Philanthropic foundations and major donors are also being approached to provide more stable, long-term financial backing.
“These USAID cuts will have an immediate and devastating impact on millions,” said Manenji Mangundu, Oxfam country director for the Democratic Republic of Congo, in a statement. Health systems will collapse in many countries, leading to half a million preventable HIV/AIDS deaths in South Africa. That’s not accounting for the up to 18 million additional malaria cases, 200,000 polio-related disabilities, and over one million deaths of children from severe malnutrition each year.
Map of Sub-Saharan Africa
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The End of an Era: USAID's Role and Its Retreat
The retreat of the United States from global health has left more than a funding gap; it has exposed the weakness of a system that leaned too heavily on a handful of donors. For decades, Washington was the single largest supporter of the World Health Organization, the Global Fund and Gavi, the vaccine alliance. USAID underpinned national HIV responses, immunization programmes and maternal and reproductive health initiatives across the African continent.
That era is unarguably over. Nigeria alone has lost more than $600 million in health funding, equivalent to over one fifth of its entire annual health budget. USAID's withdrawal from sub-Saharan Africa is particularly damaging. There, the agency has been instrumental in strengthening health care, education, and economic development.
The dissolution of USAID will significantly disrupt infectious disease response and surveillance efforts in sub-Saharan Africa. One of the most prominent examples of USAID's role occurred during the 2014-16 Ebola outbreak in West Africa that infected more than 28,000 people worldwide and killed 11,300, primarily in Guinea, Liberia, and Sierra Leone. Their efforts resulted in notable improvements in data tracking, disease management and isolation, and contact tracing efforts that have helped equip countries in sub-Saharan Africa with the capacity to address future outbreaks and enhance preparedness and curb cases sooner. More recently, in November 2024, USAID pledged $500,000 to combat Marburg virus in Tanzania by training health-care workers, enhancing laboratory testing capabilities, strengthening community health and surveillance, and improving emergency infrastructure to contain the spread. Although the outbreak is declared over, the agency's shutdown could threaten future response efforts in Tanzania and elsewhere in sub-Saharan Africa.
Economic and Political Ramifications
Multiple statistical models have predicted the long-term economic fallout of the aid freeze. If the Trump administration succeeds in pausing all funding, 5.7 million more Africans would fall below the extreme poverty level by 2030 than if funding continued. Ethiopia, Somalia, and the DRC, as the largest prior recipients of USAID, would be the countries most impacted. In 5 years, the economy of Sub-Saharan Africa would be $4.5 billion USD less than predicted levels prior to the funding cut.
USAID’s collapse will also produce a staggering impact on Africa’s startup economy. USAID has historically funded innovation and entrepreneurship in Kenya. Without startup capital and grants, thousands of small-scale farmers and business owners are now left without a safety net. In Kenya alone, startups will be left with a $100 million funding shortfall left by USAID cuts. Preliminary estimates suggest that this impact will result in Kenya’s startup economy shrinking by 15% within the next 3 years.
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The funding cuts also pose a direct threat to political stability in already fragile regions. In countries like Somalia and the Democratic Republic of the Congo (DRC), where governance is strained and security is often maintained through foreign aid. The removal of this funding may cause institutional collapse. In Somalia, USAID not only supported food and vaccination initiatives but also provided financial aid to local governments that provided peacekeeping. With power vacuums emerging in rural regions, militant groups, such as the Al-Shabaab terrorist organization, may fill the void without substantial resistance from the local government, which was previously supported by USAID. Even more concerning is the idea that without basic government services that were provided through USAID, recruitment into these groups may increase. This will certainly lead to an uptick in violence in the region.
Humanitarian Crisis
The humanitarian fallout of the rushed termination of USAID programs also cannot be understated. The suspension of funding caused an immediate stop to services for HIV testing, treatment, and prevention in 50 countries. Early estimates from the World Health Organization predict that these cuts could “lead to more than 10 million additional cases of HIV and three million HIV-related deaths, more than triple the number of deaths last year”. There have already been reports of mothers and their children in South Sudan dying after being unable to access a USAID clinic to receive life-saving HIV medication.
Already, more than 80% of the food kitchens that feed refugees from the Sudanese Civil War have been closed. The disappearance of vaccines and food aid has placed millions of lives at risk and eroded decades of developmental progress in a matter of months.
Growth in alternative funding models
A Shift Towards Self-Reliance and Sustainable Development
The former president of the African Development Bank, Donald Kaberuka, has echoed the idea that current funding cuts led by the United States under Trump’s presidency could encourage African nations to focus on self-reliance and sustainable development. “Africa must change its perception of aid. We should start seeing it as a thing of the past,” said Ngozi Okonjo-Iweala, director-general of the World Trade Organization.
In parallel, efforts to build local capacity are becoming a central focus for communities. Organizations are implementing leadership training programs to equip community-based staff with the skills needed to manage and sustain development projects independently. Grassroots organizations are playing a larger role in delivering aid and services, as international groups emphasize locally driven solutions over externally managed initiatives.
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Transparency in financial management and project execution has become a key consideration as organizations work to maintain donor confidence. In the policy space, some groups are advocating for regulatory frameworks that support nonprofit sustainability, recognizing the changing landscape of international development funding.
Progress on African Health Sovereignty
It is important to acknowledge that African leaders were already debating these issues before the 2025 USAID withdrawal. Nigeria’s Health Sector Renewal Initiative, launched in 2023, brought federal, state and partner resources into a single framework with one plan and one budget, signaling a determination to shift coordination back to Abuja. Ghana followed with a 20 per cent excise tax on sugary drinks in 2023. Kenya legislated the replacement of its health insurance fund with a broader Social Health Insurance Fund to expand access and restructure purchasing of essential products. These are domestic fiscal choices that reflect a recognition that aid cannot remain the foundation of health financing.
At the Accra Health Sovereignty Summit in August 2025, African heads of state and ministers gave political expression to this shift. They called for ‘health without aid’ and committed to mobilizing domestic resources, pooling procurement and investing in regional manufacturing of medicines, vaccines and other health products. As Nigeria’s Coordinating Minister of Health and Social Welfare, Muhammad Ali Pate, said at the meeting, ‘we cannot build healthier populations purely on the generosity of other nations.
Institutions already exist that could support this direction if they are properly resourced. The Africa Centres for Disease Control and Prevention (Africa CDC), established in 2017, demonstrated its value during the COVID-19 pandemic and again in 2023 when it declared a Public Health Emergency of Continental Security in response to the mpox outbreak in the Democratic Republic of Congo. Africa CDC is creating a platform for pooled procurement and leading efforts to build the continental ecosystem for manufacturing health products. The number of WHO Maturity Level 3 (ML3) national regulatory authorities, essential for a pharmaceutical manufacturing industry, has grown exponentially from just two in 2021, to nine by September 2025. The African Medicines Agency, formally launched in 2021 and now with its first director general in place, is advancing regulatory harmonization that is essential for building viable regional pharmaceutical production. These institutions represent a continental capacity that did not exist a decade ago.
The Role of New Health Patrons and Philanthropy
Yet the temptation remains for African governments to fill the vacuum with new patrons. China has pledged an additional $500 million to the WHO, financed the Africa CDC headquarters, and continues to link its ‘Health Silk Road’ initiatives to African vaccine and medicine production. During COVID-19, Beijing delivered vaccines to countries such as Zimbabwe and Equatorial Guinea, and at the Forum on China-Africa Cooperation it has promised investment in health manufacturing. The UAE has also entered the space. Alongside partners, the UAE launched the $500 million Beginnings Fund. The UAE has traditionally shown a preference for channelling their assistance through national governments.
Philanthropy is sometimes presented as a softer alternative. The Gates Foundation has pledged $1.6 billion to Gavi for the 2026-30 period and continues to be one of the largest donors to the Global Fund. It has also announced new investment in women’s health research.
Without alignment with national health planning and domestic prioritization, these new donors could reproduce the same vulnerabilities that exist today. The donors may change, but the concern about externally driven priorities remains legitimate.
Strategies for a Post-USAID Era
To strengthen pandemic preparedness in a post-USAID era, Africa should focus on empowering regional and local institutions, such as the Africa CDC. If the Africa CDC can secure its targeted annual budget of $1 billion, it can enhance existing surveillance systems, such as the Integrated Disease Surveillance and Response system, develop rapid response and disaster-preparedness protocols, and implement measures to contain outbreaks and prevent cross-border transmission.
Pursuant to the African Growth and Opportunity Act (2000) USAID established several investment hubs across the region. One of these, the East African Trade and Investment Hub, reported around 600 million exports and created more than 40,000 local jobs between 2014 and 2019, predominantly within the agricultural sector. For the region to maintain its economic growth without USAID support, countries should support local entrepreneurship and investment in agricultural, infrastructural, and technological development.
As an example, the African Development Bank Group pledged 74 million euros (roughly $80 million) in 2024 to promote young and female entrepreneurs in Senegal, underscoring the critical role that small and medium enterprises play in the economy. Bloomberg Philanthropies has invested more than $500 million in improving road infrastructure across Africa since 2007, funding bridges, roads, and traffic systems to enhance transportation safety.
Empowering local educational institutions can help maintain access to education for African youth. Additionally, leveraging public-private partnerships in the education sector is essential. One example is the Vodacom e-School, a flagship initiative between Vodacom and the South African government that provides free, online education content learners from the first year of formal schooling to grade 12. Philanthropic contributions will be crucial for advancing education, particularly higher education.
Although the agency's contributions have been instrumental in the region's development over the past few decades, African nations should now prioritize regional collaboration, investment in local institutions, and strategic partnerships with the private sector to sustain progress in health, economic development, and education. Strengthening organizations such as the Africa CDC, fostering entrepreneurship, expanding agricultural investments, and leveraging philanthropic and private-sector contributions will be essential in navigating this transition.
Open Abdomen (OA) in Africa
The open abdomen (OA) or laparostomy is defined as the intentional separation of the cutaneous and musculofascial layers of the abdominal wall [1]. Since its inception, it has steadily gained acceptance among surgeons as a means of attenuating the effects of select life-threatening abdominal insults that lead to intra-abdominal hypertension (IAH) and the development of abdominal compartment syndrome (ACS). Both globally and in Africa, the commonest insults warranting an OA are abdominal trauma and sepsis [2].
Between 17.4% and 25% of patients with these conditions in Africa have IAH on admission, and mortality varies from 2.4% to 24.4% [3, 4]. Nonetheless, there is ample evidence that control of IAH through the use of the OA mitigates the potentially lethal effects of ACS [5]. The main goal after the creation of an OA is fascial closure as soon as the underlying insult has resolved [1]. However, in the interim, there is a need for temporary abdominal closure (TAC), which is fraught with multiple local and systemic complications.
TAC techniques vary, and each carries its own set of advantages and disadvantages. As such, managing OA is resource intensive and a multidisciplinary approach is often warranted. The intensive care unit (ICU) may be needed for ventilatory support, correction of coagulopathy, fluid, electrolyte and acid/base disorders, as well as prevention of hypothermia [5]. In addition, there is a need for appropriate antibiotic therapy, pain control, and sedation, with many patients requiring paralysis throughout their course to avoid evisceration. Patients are often hypercatabolic and require supplemental nutritional support and intensive nursing care.
Although the use of the OA in contemporary surgical practice is widely accepted, there is a paucity of information from Africa regarding its use and subsequent outcomes. A single center study done nearly two decades ago reported abdominal trauma and abdominal sepsis as the commonest reasons for an OA, with a low rate of fascial closure and mortality as high as 44% [2]. More recent data corroborates the high prevalence of abdominal trauma and sepsis in Africa [4, 6, 7]. However, the use of the OA in the care and subsequent outcome of these conditions remains obscure, and more studies are warranted.
Overall, a total of N=268 adults and N=15 neonates were included. The mortality rate among adults was 44%, versus 20% among neonates. A total of N=67 adult patients had fascial closure translating to a rate of 25%. Twelve (80%) of neonates had fascial closure. Other complications included inability of the TAC method to contain abdominal contents leading to evisceration i.e.
In contemporary surgical practice, the use of the OA to diminish the deleterious effects of IAH/ACS is widely accepted. However, in as much as the OA may be lifesaving, historically it is a resource intensive undertaking with high mortality, and morbidities that may affect the quality of life of involved patients. Despite the high prevalence of IAH/ACS among general surgery patients in Africa, the indications, use, and outcomes of the OA in the region remain inadequately documented. From this report, the commonest reasons for utilizing OA management in the African region are abdominal trauma and sepsis.
Proper patient selection for OA management is imperative, which must include informed consent that covers prognosis and estimated cost of care. Our patients were managed using the Bogotá bag. However, this technique is associated with frequent and time-consuming dressing changes, intensive nursing care, and prolonged treatment before definitive wound closure, all of which negatively impact quality of life. For these reasons, TAC techniques that employ negative wound pressure are recommended [5]. In addition, patients with OAs typically require ICU care, strict monitoring of fluid balance, and supplemental nutrition.
The mortality attributable to OA in Africa is higher than in high-income countries. This is likely due to multiple variables, including the severity of the underlying condition warranting OA management, rather than solely the OA management itself. In a systematic review of delayed fascial closure for the OA, vanHensbroek and colleagues included studies from high-income countries, with an overall mortality of 26% [16]. Additionally, mortality was lower for studies that utilized negative pressure for TAC versus those that employed the Bogotá bag. The fascial closure rate for adults was 44.6% in this report. This means approximately half of the survivors did not have fascial closure and were left with ventral hernias. Although the OA may alleviate mortality, it is clear that quality of life can be severely affected.
The use of the OA in Africa is historically associated with high mortality and low rates of fascial closure, which likely affects quality of life among survivors. These outcomes undoubtedly are linked to the severity of the underlying abdominal insult, which is difficult to separate from the OA technique itself. With published data only reflecting a section of the region, more longitudinal studies from other settings across Africa are warranted.
Table 1: Mortality & Fascial Closure Rates in Africa
| Outcome | Adults | Neonates |
|---|---|---|
| Mortality Rate | 44% | 20% |
| Fascial Closure Rate | 25% | 80% |
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