Navigating the Looming Crisis: When Health Aid Declines

In a recent perspective published in Public Health Challenges, Nepalese author Animesh Ghimire examined how reductions in external health aid affect vulnerable health systems and proposed governance strategies to minimize disruption.

The World Health Organization (WHO) warned that external health aid to low- and middle-income countries could fall by up to 40% in 2025, raising concerns about the sustainability of essential health services.

Many low- and middle-income countries rely heavily on donor support for immunization, nutrition, and disease control programs. An abrupt funding decline can cause a "shock" to service delivery, supply chains, and workforce stability. Responses to these funding shocks vary, with many low-income countries lacking the capacity to absorb or adapt to such cuts, leading to widespread dislocation and problems across their health systems. This can affect medication availability, healthcare, surveillance, and service delivery.

Case Studies: Nepal and Afghanistan

Nepal

Nepal exemplifies how aid withdrawal impacts multiple health services. When United States Agency for International Development (USAID) support declined in 2025, health facilities reported shortages of contraceptives, and nutrition programs faced uncertainty. Immunization programs were also affected, jeopardizing efforts to reduce child mortality.

These interruptions demonstrate that aid withdrawal can erode an entire healthcare system, impacting vaccine supply, contraceptive access, and maternal care.

Afghanistan

Afghanistan presents a similar pattern in a more fragile setting. By March 2025, funding shortages placed 80% of WHO-supported health facilities at risk of closure, potentially leaving millions without care. This led to primary healthcare clinics shutting down, weakened nutrition programs, and compromised disease surveillance systems. Cases of measles and malaria increased, and restrictions on women's employment further limited access to female healthcare providers, disproportionately affecting women and children.

This illustrates how financial shocks interact with existing vulnerabilities, potentially causing system collapse in fragile environments.

Rethinking Health System Resilience and Proposing Solutions

The perspective argues that while global health policies often focus on "building resilience" for countries to adapt to funding losses, global funding decisions significantly impact health outcomes. There is an ethical dilemma regarding accountability when assistance is withdrawn without notice, leading to foreseeable harms like missed vaccinations and untreated illnesses.

To address these challenges, a "transition discipline" governance framework is proposed. This framework relies on:

• A set grace period, allowing countries time to manage budgets during funding reductions.
• A minimum package of essential services, protecting critical services such as vaccines, maternal care, and disease monitoring.
• A transparent joint transition plan, clarifying responsibilities between donors and governments.

This approach aims to prevent sudden disruptions and reduce harm to vulnerable populations by ensuring predictability, transparency, and ethical management of funding reductions.

It highlights the need to shift focus from solely resilience narratives to also include the effective governance of aid withdrawal processes.