Implications of the USAID U-turn on women's health globally

Some 10 years after the end of the Millennium Development Goals period, global progress in reducing preventive maternal and newborn deaths has slowed down considerably. The Sustainable Development Goals, agreed by all the countries of the world in 2015, aim to continue the unfinished agenda of prioritizing maternal mortality reduction, with a global average target of < 70 per 100,000 live births by 2030. We are well short of that global target with almost 300,000 maternal deaths, 2.4 million newborn deaths and 2 million stillbirths annually. ¹ This global progress in improving maternal and newborn health, took several hits in the wake of the COVID-19 pandemic and the enormous global economic crisis that followed the conflict in Ukraine. Compounding this is the burgeoning debt burden on most economies in Africa. Africa's debt burden has grown exponentially over the last decade and 32 African countries spend more on debt servicing than on health care for their populations. ² It is precisely such countries with limited fiscal space where support from overseas development agencies, bilateral support from countries and instruments such as the global financing facility, are so critical to the health and welfare of millions of people.^3–5

It is in this context that the abrupt closure and roll back of the activities of U.S. Agency for International Development (USAID) recently is very concerning. With just 15 of the legally required positions remaining by September, almost all of the 10,000 USAID emplyees have been fired or placed on administrative leave. Manifolds more people have been affected among organizations in poor countries dependent upon such support for essential maternal child health and reproductive health services. Established in 1961, the USAID was explicitly set up to assist poor countries with food aid, economic and humanitarian assistance. Over time, its role expanded to include a range of health activities spanning the maternal, child, and reproductive health space. USAID spent almost $40 billion annually on global assistance, largely for health programs. This figure represents less than 1% of the U.S. government's annual spending on humanitarian assistance but was a critical pillar of support for key global programs for maternal as well as sexual and reproductive health services. ⁶

USAID was one of the largest providers of family planning services worldwide with almost $600 million for contraceptive services in poor countries. ⁷ The Bureau of Global Health Security and Diplomacy of the U.S. government also oversees the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), a nonpartisan program that has invested over $110 billion for the prevention and management of HIV/AIDS globally in over 50 countries to-date with a large proportion of the funding going toward supplies of antiretrovirals (ARVs). ⁸ Preexposure prophylaxis, a key intervention to prevent HIV infections globally, was largely supported by PEPFAR. Some 15 million people in sub-Saharan Africa depended on PEPFAR-funded ARVs. UNAIDS estimates that within months, at least 1 million people could face treatment disruptions, leading to tens of thousands of preventable deaths. ⁹

Altogether, the success of global HIV/AIDS control owes to a large measure to investments by PEPFAR, which can be credited with saving almost 26 million lives that would have otherwise perished due to HIV/AIDS. Such assistance isn’t just restricted to sexual and reproductive health or HIV/AIDS funding. United States was also the largest donor to the Global Fund to Fight AIDS, Tuberculosis, and Malaria, contributing over $1.5 billion annually, and its withdrawal jeopardizes efforts that have prevented 44 million malaria deaths since 2000. Once again Africa will face the disproportionate impact of this defunding. Africa has almost 95% of global burden of malaria and, U.S. funding provided free mosquito nets, diagnostic tests, and treatments in countries across the continent. There are now concerns that the programs could backslide with an almost 20% increase in malaria burden in some countries. ¹⁰

The implications of the stop order issued on January 24 for all foreign funding are huge. Almost two-thirds of all USAID supported contraceptives went to Africa where the reproductive health needs of girls and young women are huge. An analysis by the Guttmacher Institute ¹¹ suggest that if 11.7 million women and girls are denied access to contraceptive care in 2025 because of the USAID freeze, 4.2 million could experience unintended pregnancies, with an estimated 8340 maternal deaths due to complications encountered during pregnancy and childbirth. Given the huge contribution that family planning makes to social and economic development of countries, ¹² this backsliding on sexual and reproductive health could seriously impact global development.

For the highly indebted countries of the world, the impact of an abrupt end to USAID assistance would spell economic disaster. An analysis by the Centre for Global Development ¹³ indicates that 16 LMICs could lose over a fifth of their total foreign assistance with little to no ability by others to plug these gaps. ¹⁴ These include some of the poorest countries of the world with over 400 million population (South Sudan, Somalia, Democratic Republic of Congo, Liberia, Afghanistan, Sudan, and Uganda). Several of these countries are in the throes of national and subnational conflict and the economic crisis could significantly worsen an existing humanitarian disaster.

All of this could have been avoided. The U.S. government has every right to review its development assistance priorities but the sudden cessation of a major global assistance program spanning over six decades is disruptive with huge consequences among the most impoverished countries of the world. The specific defunding of women's health and reproductive health programs risks reversing hard earned progress in Africa and Asia and will be difficult to reverse. In an increasingly interconnected world, outbreaks anywhere threaten global security. Defunding the World Health Organization does not consider that little to no alternatives exist in global health governance.

We hope that the U.S. administration urgently reconsiders its decisions with respect to global development assistance and especially to protect the health and well-being of women and children in LMICs. The Copenhagen Consensus, one of the most respected global think tanks has underscored the importance of maternal and child health investments as critical to global development, with a return of $87 in societal and economic benefits for every $ spent on such quality programs. ¹⁵ A gradual negotiated process would be far less disruptive and also allow the planning and fiscal space for countries to increase their own investments in corresponding health and social sector programs, which ought to happen irrespective. ¹⁶