The abrupt shuttering of USAID one year ago was outrageous and tragic. The journal Nature recently published an estimate of up to 25 million deaths over 15 years that could result from these funding cuts to TB, HIV/AIDS, family planning, and maternal and child health. 

This experience also exposes how our very model of aid, which relied on U.S. NGOs over these last decades of global health aid expansion, has made the impact of these abrupt cuts exponentially worse in the Global South. 

Excellent USAID-funded work has clearly been accomplished, and we have much to be proud of in global health progress; yet, a reckoning is overdue. The shuttering of USAID provides an opportunity to reflect on how U.S. aid was often spent in unsustainable and sometimes harmful ways. While the future of U.S. foreign global health aid is unclear, a new vision for how we support global health is urgent and vital. 

The shuttering of USAID provides an opportunity to reflect on how U.S. aid was often spent in unsustainable and sometimes harmful ways.

For the past several years, leaders from  recipient countries have been warning us that too much of the global health agenda was driven by wealthy countries. These power agenda-setters controlled the priorities for research and implementation of development projects with only perfunctory local collaboration, undermining sustainability. The great majority of U.S. foreign aid funding was channeled to American NGOs, contractors, and universities rather than state governments and institutions that were ostensibly there to strengthen. 

For nearly 30 years I worked with the American NGO Health Alliance International (HAI), a medium-sized organization affiliated with the School of Public at the University of Washington, serving as HAI Executive Director from 2013 to 2022. We conducted global health projects primarily in Mozambique, Côte d’Ivoire, and Timor-Leste funded by USAID, PEPFAR, CDC, World Bank, UNICEF, among many others. Most of these projects were funded and managed by UW faculty, including myself. Over recent decades, we watched as growing American foreign aid financed a veritable deluge of NGOs that flooded Mozambique and much of Africa. 

This was by design. Driven by an embrace of privatization and small government, USAID argued that financing civil society rather than government/public systems was their priority. The words “civil society” explicitly meant NGOs. Before the USAID cuts, many recipient countries hosted hundreds of NGOs financed by USAID to conduct myriad projects in the health and development sectors with total aid funding that often exceeded the budgets of Ministries of Health where they worked. 

American aid and most NGOs failed to strengthen, finance, or build meaningful capacity to help sustain desperately underfunded public sector health systems and institutions.

This NGO “unruly mélange” engaged in activities that ranged from direct service delivery to large development projects, where NGOs focused on a wide range of programs that might include education, health, agriculture, water or sanitation. Some NGOs addressed specific diseases (such as HIV, TB or malaria), and others specialized in health system strengthening through logistics support. The result in our experience, especially in Mozambique, was an uncoordinated, fragmented, inefficient health sector landscape where local health officials were often sidelined.  American aid and most NGOs failed to strengthen, finance, or build meaningful capacity to help sustain desperately underfunded public sector health systems and institutions.

Why the NGO Model Undermines Foreign Aid

Then came the cuts. Our partners have clearly communicated  the calamitous consequences of USAID’s NGO model, which often put foreign organizations over public institutions. In one case, a Ministry of Health colleague described to me how USAID chose to channel PEPFAR resources to an NGO contractor rather than the Mozambique National Health Service. The program was specifically designed  to manage the supply chain for lifesaving HIV/AIDS antiretroviral drugs across the country. With the abrupt cuts to USAID funding, the contractor closed up shop and the supply chain stopped — a dynamic repeated in other countries in Africa. My colleague, who now helps represent the government of Mozambique at the UN in Geneva, explained how warehouses were filled with medications without a system to distribute them. The contractor eventually obtained substitute funding in late 2025, but thousands missed months of medication coverage. 

American NGOs and contractors have provided direct services and run key programs parallel to local health systems across Africa. Instead of building local institutional capacity to, for example, distribute HIV/AIDS drugs, supply malaria bednets, provide family planning, develop and maintain health databases, support prenatal care, and the list goes on, these funds were directed to foreign NGOs to do so. Millions are now left without services as many American NGOs have closed projects, packed up, and left little behind.

Instead of building local health systems, aid funds were routed through foreign NGOs — leaving millions without services when those organizations packed up and left.

At the same time, 54 countries report deep debt distress, and many have signed on to austerity programs with the IMF that severely restrict public investment in health and education in order to pay back the debt and shrink the government. There is substantial evidence that privatization of public goods can cause populations to become sicker because many people cannot provide out-of-pocket payments and delay care seeking. This is why investing in state systems is so critical. The pandemic worsened an already long-term and unendurable international debt crisis and era of austerity that over decades has prevented a meaningful increase in health workforce and funding of health system building blocks, especially in Africa. While public systems were starved of funds in order to pay back debt, billions flowed to American NGOs.  

How to Reimagine US Foreign Aid

The future of U.S. aid for global health is impossible to predict due to the current administration’s unpredictability in how it plans to engage in global health. But the end of USAID opens up an opportunity to re-imagine how foreign aid can be better invested. 

I argue for three principles that should guide us:

1. First, recipient country leaders should lead the discussion and articulate a national vision for what they need to improve the health and development of their population. And we in donor countries, including the U.S., should listen. 
2. Second, long-term investment in national health services and other public institutions is the starting place. It is only through the expansion and strengthening of these public institutions, following the lead of local leadership, that national health can progress and universal health coverage can become achievable and sustainable. 
3. Finally, donor countries need to join leaders in recipient countries in demanding cancellation of debt and the end to austerity that continues to undermine sustainable health efforts around the world. While this may appear to be an extraordinary request, this point is vital to ensure that countries can overcome financial barriers to become independent and obtain self-determination.   

Ending dependency on foreign aid will be possible only with an end to austerity and cancellation of debt to actually allow public investment in health and the social sector. NGOs can still have an important role in this new dispensation by supporting community mobilization, holding public services accountable, and experimenting with new innovative approaches to health improvement in collaboration with local partners. 

For now, our responsibility is to struggle to restore U.S. aid for global health. However, we also have the responsibility to learn life-saving lessons from the past and agitate for change in how we work.