Dangerous Dependence: What Aid Cuts Reveal About Structural Risk in Global Health

Recent modelling on reductions in official development assistance (ODA) has raised serious concerns about global health outcomes over the coming decade. Researchers at the University of California, Los Angeles (UCLA) estimate that deep reductions in the United States Agency for International Development (USAID) could result in more than 14 million additional deaths by 2030, including approximately 4.5 million among children under five.1 A subsequent analysis incorporating reductions in European aid suggests that combined cuts by the United States, United Kingdom, France, and Germany could lead to as many as 22.6 million additional deaths worldwide.2

These projections are alarming. They are also instructive from a governance perspective.

Over the past 20 years, global health progress has been financed through a concentrated set of bilateral and multilateral funding sources. USAID alone is estimated to have helped prevent approximately 91 million deaths between 2001 and 2021, including roughly 30 million among children under five.1 Those achievements are substantial.

What the modelling exposes is structural weakness. When a single agency's budget decisions can materially influence global mortality trends, the issue is not only funding volume. It is concentration risk.

In most sectors, this level of dependency would trigger formal risk assessment. In global health financing, similar exposure is often treated as context rather than as a governance question.

From experience working across donor funded portfolios, multilateral programmes, and country level implementation environments, I have seen how financing structures shape system behaviour. Staffing models, procurement systems, and service delivery patterns frequently evolve around assumptions of continued external support. These dependencies are rarely visible in high level reporting. They become visible when funding contracts.

Structural gains and structural gaps

Large global initiatives have contributed to substantial reductions in mortality from human immunodeficiency virus (HIV), malaria, tuberculosis, and other preventable causes.3 At the same time, much of this progress has been delivered through disease specific programmes, often described as vertical delivery models. Parliamentary reviews and peer reviewed studies have documented the effects of parallel reporting systems, ring fenced financing, and programme specific supply chains.4,5

Research from multiple settings describes duplication of administrative structures, competition for scarce health workers, and data systems that prioritise programme outputs over broader surveillance capacity.5,6 Global health initiatives (GHIs) frequently state health system strengthening as an objective, yet the evidence shows implementation remains uneven across contexts and funding models.7

In several contexts where I have worked, externally financed initiatives operated alongside public systems with separate funding and reporting channels. While this accelerated disease specific gains, integration into national budgeting and planning processes was often incomplete.

When funding expands, these arrangements can function. When funding contracts, fragmentation becomes more visible. Gains achieved within programme boundaries may not translate into system level resilience.

A more volatile funding environment

The current reductions are notable for their synchronisation. Analysts have observed that this is the first time in decades that several major European donors and the United States have reduced ODA budgets in parallel.2,8 At the same time, humanitarian need is rising, debt pressures in low income countries remain significant, and domestic political constraints within donor countries are intensifying.

Independent analysis has also noted that United Kingdom aid reductions are now proportionally deeper than those in the United States following Congressional pushback, underscoring how domestic political dynamics can rapidly alter external financing trajectories.10

The result is not simply a leaner funding environment, but a structurally more volatile one. Forecasting becomes less reliable. Long term planning becomes more complex. Stop start funding cycles can undermine workforce stability and supply chain efficiency.

Financial institutions routinely assess exposure to political shocks, liquidity constraints, and concentrated counterparties. Impact portfolios are rarely examined through comparable structural stress testing. Yet as social impact capital grows in scale and visibility, it is exposed to the same macro volatility.

In a more volatile landscape, maintaining impact will depend less on scale alone and more on structural discipline.

These are not questions of intent. They are questions of exposure.

The evolving role of private capital

As public funding becomes less predictable, private capital and philanthropic institutions are likely to assume a greater role in global health financing. Corporate foundations, institutional philanthropies, and blended finance mechanisms already contribute meaningfully in several sectors.

This shift increases the importance of portfolio design. Without deliberate integration into national systems and diversification of exposure, private capital can replicate the same structural vulnerabilities it seeks to address.

Modelling from Malawi suggests that investments combining disease specific objectives with broader system strengthening can generate greater overall health impact than purely vertical approaches.9 Structural integration, rather than parallel expansion, appears to improve longer term outcomes.

In discussions with senior funders and delivery partners, transition planning is often treated as an operational detail. In a more volatile environment, it becomes a governance responsibility.

Designing for resilience

Well designed aid programmes have saved millions of lives.1 The challenge now is ensuring that progress is not undermined by concentrated exposure and insufficient integration.

Portfolio level resilience refers to the capacity of an impact portfolio to sustain outcomes under funding disruption and political change, without triggering systemic collapse or distortion. It requires attention to diversification, integration, and transition planning.

Structural resilience is not automatic. It is the result of deliberate portfolio design and governance discipline.

References View references

Note: All mortality projections cited are based on modelling estimates and are subject to uncertainty.

1. Bendavid E, et al. Projected mortality impact of reductions in United States Agency for International Development funding. UCLA Newsroom, 2025. Available at: newsroom.ucla.edu
2. Reuters. US and European aid cuts could result in 22.6 million deaths worldwide, study finds. 17 November 2025. Available at: reuters.com
3. Lu C, Schneider MT, Gubbins P, Leach Kemon K, Jamison D, Murray CJ. Public financing of health in developing countries: a cross national systematic analysis. Lancet. 2010;375(9723):1375–1387.
4. UK House of Commons International Development Committee. Strengthening Health Systems in Developing Countries. 2014–15 Report. Available at: publications.parliament.uk
5. Travis P, Bennett S, Haines A, et al. Overcoming health systems constraints to achieve the Millennium Development Goals. Lancet. 2004;364(9437):900–906.
6. Biesma RG, Brugha R, Harmer A, Walsh A, Spicer N, Walt G. The effects of global health initiatives on country health systems: a review of the evidence from HIV AIDS control. Health Policy Plan. 2009;24(4):239–252.
7. Marchal B, Cavalli A, Kegels G. Global health actors claim to support health system strengthening: is this reality or rhetoric? PLoS Med. 2009;6(4):e1000059.
8. The Brussels Times. Aid cuts could lead to 22.6 million deaths by 2030, study warns. 2025. Available at: brusselstimes.com
9. Thanzi Programme Consortium. System wide investments enhance HIV, TB and malaria control in Malawi and deliver greater health impact. Available at: thanzi.org
10. Center for Global Development. UK aid cuts now deeper than US after Congress pushes back. 2025. Available at: cgdev.org