It is no longer news that the new Trump administration on January 20, announced a 90-day freeze on all foreign aid awards by the United States Agency for International Development (USAID). The U.S. Secretary of State Marco Rubio subsequently issued a Stop Work Order (SWO) on all USAID-funded projects across the globe and promised to case-by-case review and issue waivers for what he called “life-saving humanitarian assistance,” which included “core life-saving medicine, medical services, food, shelter, and subsistence assistance. Nevertheless, the effects and potential risks of both the freeze order and the subsequent “vague” and “difficult-to-interpret” waiver has left a very sour taste especially as it affects health in Africa and much of the developing world.
In this write-up, I intend to dwell a little on the impact and implication of the cut in foreign aid especially from the USAID which is a major player among the several donor agencies. The write-up is restricted to the health sector where I spent 20 years working in the development sector either as a full-time staff or as a consultant. Foreign aid from USAID is not restricted to health as it intervenes in other sectors such as Agriculture, Water & sanitation, Education, etcetera. Even in the health sector, I just picked HIV and malaria as an example leaving other interventions such as Tuberculosis and many other diseases. I am also not dwelling on the political side of the discussion, especially the allegation that USAID is the one funding the activities of Boko Haram in Nigeria. I leave that to professionals on security to confirm or otherwise.
Firstly, let me start with the technical before coming to the financial implications. As an effect, African countries face immediate challenges due to the potential impact of USAID funding cuts on vital health programs, risking millions of lives reliant on life-saving medications. The African region is the most severely affected by HIV, with nearly 1 in every 25 adults living with the virus and the halt in funding has led to several millions not accessing needed care and resulting in an increase in the risk of viral rebound, immune system decline, potential development of drug resistance, increased risk of opportunistic infections, and ultimately, faster disease progression, potentially leading to complications like heart, liver, and kidney problems.
The World Health Organization (WHO) 2023 report on HIV/AIDS, which covers 2022 data, says an estimated 39.9 million people were living with HIV globally with 65% residing in Africa. It’s also diagnosed and treated, so this value can be used as the case burden. However, incidence from 2000 to 2022 shows a decrease incidence by 26%. According to UNAIDS 2023 data, the HIV population in Nigeria is between 1.9M – and 2.3M (Average of 2.1M). That is a proxy for treatment because the goal is to “test and treat” all diagnosed cases. Therefore, Nigeria accounts for about 5.3% of the global HIV cases.
It is pertinent to know that, most if not all the drugs and test kits for these 2.1m Nigerians come from donors, either USAID or Global Fund. In 2023 alone, Nigeria received $1.02 billion mostly from USAID for the treatment of HIV, and maternal and child care. Though, recently the Nigerian Government has budgeted NGN5 billion to augment the funding from the foreign donors, it is not clear whether the money has been released or not. The state governments hardly augment the efforts of the donors financially. On average, the cost of antiretroviral drugs per patient per year in 2022 was $134 (equivalent to over NGN450 billion for the 2.1M patients). This excludes the costs of diagnosis and awareness. These drugs are provided free to patients.
On malaria, with over 90% of global malaria cases occurring in sub-Saharan Africa, a pause in the testing, prevention and treatment (which is majorly funded by the US through the Presidential Malaria Initiative) is some sort of death sentence. Consequences of untreated, P. falciparum malaria include a speedy progression to severe illness within 24 hours, death from cerebral malaria which is nearly 100% fatal without treatment and the risk of antimalarial resistance which will only deepen the malaria challenge in the sub-region. In the MNCH sphere, almost 70% of global maternal deaths and 50% of child mortality occur in sub-Saharan Africa and the absence of life-saving medicines can only compound these problems. Note that while these are immediate consequences in the African region, they have a marked impact on global health security.
Nigeria faces a significant malaria burden, with an estimated 68 million cases in 2021 and accounting for nearly 27% of the global malaria burden. According to the 2023 World Malaria Report, almost 200,000 deaths from Malaria occurred in Nigeria mostly affected by pregnant women and children under five years. In 2021, the national malaria prevalence rate was 22% in children 6-59 months. The report shows that the rate in Kebbi State North Western Nigeria, was as high as 49%.
For prevention, the World Health Organization (WHO) recommended the use of long-term lasting insecticide-treated nets (LLINs). These nets in Nigeria are provided free by a combination of donors including USAID. On treatment, the average, direct medical cost of treatment of uncomplicated malaria in public health institutions in Nigeria is around NGN2, 234.07. Towards the end of 2024, USAID has committed $2, 3 million to procure 4.8 million doses of life-savings malaria tablets from Swiss Pharma (Swipha) for Nigeria. With the cut in USAID funding, there is less likelihood of getting these drugs which target the poor and vulnerable mostly in the rural areas.
The Nigerian Government through its National Malaria Elimination Programme (NMEP) under the Federal Ministry of Health equally makes an effort to provide malaria drugs. However, it is not clear if the Nigerian Government (States inclusive) have been budgeting and releasing funds for the procurement of malaria drugs.
From the Financial perspective, USAID and other donor agencies support the economy of Nigeria by providing direct and indirect jobs for Nigerians. Most of the capacity-building training is conducted in hotels and sometimes involves the travelling of participants and trainers. That helps hoteliers and airlines. These hotels and airlines in turn employ a lot of people and pay taxes to the Government in the form of PAYE and VAT. The USAID funding freeze will lead to job losses (not only in the NGO but possibly in the airline, hotel, Restaurant, printing businesses, etc) and lower taxes to the federal and state governments.
Many Nigerians argue that they have not seen any impact of the so-called foreign aid especially that of USAID. Firstly, it is difficult for a beneficiary HIV or TB patient to announce in public that he is a beneficiary. Moreover, most of the beneficiaries are not even aware that those free drugs for HIV, TB, or Malaria are from donors since they get them from government-owned health facilities.
Another reason why people do not appreciate foreign aid is because we assess foreign aid, the way we normally assess or gauge the performance of our political representatives using the number of roads, overhead bridges, or schools they build which we can glaringly see and touch. We do not know that aid is not coming to substitute or compete with the government. However, it comes to supplement the effort of the government and to set a legacy for the government to replicate and scale up the achievements.
It may take a while for the real impact of the USAID funding to be seen and felt, especially in Africa and Nigeria. The implication for the government is that continuous reliance on donors is no longer fashionable. Authorities must wake up and do the needful to save the lives of their citizenry. It is a wake-up call for the governments to find ways of bridging the funding gap, especially in the health sector. This will go a long way in reducing the negative impact of the US government policy.
Dakata, PhD wrote from Kano, Nigeria
