GFO Issue 467, Article Number: 4
ABSTRACT
This article analyzes the creation of a veritable "health austerity" in Africa, with the continent at its epicenter, due to the rapid decline in international aid, particularly in health, combined with the budgetary under-prioritization of health by many African governments. The article shows that the Global Fund is at the heart of this crisis, caught between donor disengagement and the failure to honor domestic commitments, such as the Abuja Budgets and the promises made during the seventh replenishment. The article argues for a two-pronged approach: wealthy countries must fulfill their commitments, and African states must finally assume their share of responsibility by adequately funding health.
For years, the pervasive sense of an "aid retreat" has haunted discussions. By 2025, however, the figures had ceased to be an abstract concern; they now depicted a genuine rupture. After six years of growth, official development assistance (ODA) from OECD Development Assistance Committee (DAC) countries fell by 7.1 percent in 2024, dropping to 0.33 percent of their gross national income. The OECD anticipates a further decline of 9 to 17 percent in 2025. The shock is even more brutal in the health sector: the Institute for Health Metrics and Evaluation (IHME) estimates that global health assistance (GHA) will shrink by 20 percent between 2024 and 2025, dropping to levels not seen in over fifteen years.
For Africa, where health systems are underfunded and heavily dependent on donors, this is not just a cyclical correction, but rather a shift toward global "health austerity." At a time when epidemics of tuberculosis, cholera, and malaria serve as reminders that infectious risks have not disappeared, funding is declining, budgets are stretched thin, and room for maneuvering is evaporating. For the Global Fund, which is entering the crucial cycle of its eighth replenishment, the convergence of these dynamics raises a simple yet stark question: Can it continue to play its role as a mechanism of global solidarity when solidarity itself is shrinking?
1. A historic turning point for aid: when overall averages mask a health crisis
Paradoxically, the post-2015 era has not been one of a sudden collapse in ODA, but rather of creeping fatigue. Between 2018 and 2023, the total volume of aid continued to grow, reaching approximately $275 billion in 2023 according to some estimates, even though the share allocated to health stagnated and spending related to hosting refugees in donor countries artificially inflated the figures . What is changing in 2024-2025 is the combination of a quantitative reversal and a qualitative shift: the amounts are decreasing, and the share available for health in low-income countries is shrinking even faster.
Analyses from IHME and other teams show that DAH, after its peak during the COVID-19 period in 2021, has begun a rapid decline (Figure 1).
Figure 1: Overall development assistance for health, 2003-2023
Estimates for 2025 are approximately $39 billion, which is less than half of the levels reached at the height of the pandemic. Projections suggest a continued decline until 2030. The network coordinated this assessment was P4H. For its part, P4H suggests that, in the absence of readjustment, DAC countries' Official Development Assistance (ODA) dedicated specifically to health could fall by nearly 40% between 2023 and 2025 (Figure 2).
Figure 2: Bilateral ODA for health, DAC members, in constant million US$ (2014-2025)
Source: P4H
These aggregate trends mask an even bleaker reality for African countries. According to ONE's analysis, official development assistance (ODA) for health recently dropped to its lowest level in ten years (Figure 3). Meanwhile, 14.5 million children did not receive routine vaccinations in 2023, and malaria cases have steadily increased since 2018. In other words, the cuts are occurring not after a victory but during a period of weakening achievements. The post-2015 promise of a linear path toward achieving the SDGs seems like an outdated narrative. The reality is that hard-won gains are being eroded by a series of crises.
Figure 3:
Source: ONE
Finally, the political dimension of this shift is just as important as the budgetary one. The refocusing of several donors on border security, the war in Ukraine, technological competition, and climate change has drained a significant portion of the "political capital" previously devoted to global health. Budgets are not simply shrinking due to austerity measures; they are being redeployed toward other priorities perceived as more strategic, leaving health on the margins of an already saturated geopolitical agenda .
2. 2025, the year of the convergence of shocks
If we were to pinpoint the tipping point, 2025 would stand out as a key convergence point. In terms of macroeconomics, the OECD warns of an additional 9-17% contraction in ODA this year, following the decline already recorded in 2024 (Figure 4). In terms of health, IHME models project a 21% to 22% decrease in health aid from 2024 to 2025, primarily due to a collapse in U.S. funding. Historically, the U.S. has been the cornerstone of global health architecture. A recent study in The Lancet estimates that five donors accounting for over 90% of international HIV funding are announcing cuts ranging from 10% to 70% for 2025–2026.
Figure 4: After increasing to meet the demands of recent consecutive crises, ODA is set to fall further in 2025 and in the near term
Source : OCDE
This aggregate dynamic translates into a series of concrete political decisions. In the United States, the sudden reevaluation of foreign aid, including long-standing programs such as USAID and PEPFAR, has resulted in the interruption or termination of most health funding in several countries. Projections indicate that millions of additional deaths could occur by 2030 if this funding is not reinstated. In the United Kingdom, the decision to stabilize ODA at 0.5% of GNI and then reduce it to 0.3% starting in 2027 effectively establishes a permanent decrease in international solidarity efforts.
This shift directly impacts multilateralism in the health sector. In November 2025, London announced a 15% reduction in its contribution to the Global Fund for the 2027–2029 cycle (£850 million compared to £1 billion previously), despite its role as co-host of the replenishment process. Meanwhile, the World Health Organization faces a nearly $600 million shortfall by the end of 2025 and a projected $1.9 billion gap for the 2026–2027 budget, forcing the organization to cut its activities in Africa by over $150 million.
In addition to budgetary constraints, there is a fundamental debate about the fragmentation of the system. Several voices, including those within the G20 and technical forums, are calling for fewer agencies and a streamlined global health architecture, hoping to increase efficiency in a scarce resource environment. However, while this discourse addresses the issue of duplication, it can also be used to justify broader disengagement. When the number of actors and the volume of resources are reduced simultaneously, improved coordination is not guaranteed; rather, the supply of public health goods simply decreases.
3. Africa on the front line: from budget gaps to empty hospital beds
In Africa, the reduction in aid is most rapidly translating into health consequences. The WHO Regional Office for Africa estimates that out-of-pocket healthcare expenditures are pushing over 150 million people into extreme poverty, and more than 200 million Africans are facing catastrophic healthcare costs. As aid declines, these expenditures increase further. Surveys conducted in 2025 in 108 low- and middle-income countries show that up to 70% of essential services (e.g., immunization, maternal health, and epidemiological surveillance) would be reduced. Nearly a quarter of WHO country offices report an increase in out-of-pocket payments from patients.
National examples are multiplying. Liberia starkly illustrates a country's structural dependence on aid: According to some analyses, USAID covered nearly 60% of a $851 million national budget for 2025. The announcement of the dismantling of the American agency created a budget shortfall of at least $114 million, causing the suspension of numerous projects, particularly in the health sector. Hospitals are running out of essential medicines, staff salaries are delayed, and maternal and child health programs are disrupted. In a country still recovering from civil war and the Ebola crisis, this rapid contraction cannot be absorbed by limited domestic resources.
In Nigeria, the end of U.S. funding and the restructuring of several international budget lines have eliminated over $600 million in health funding, which is more than one-fifth of the national health budget. This has directly impacted HIV, immunization, and reproductive health programs. In Malawi and southern Africa, orders sent to suspend USAID-funding have halted the delivery of antiretroviral treatments, exacerbating the vulnerability of people living with HIV to outbreaks of medullary tuberculosis and other opportunistic infections.
In this context, the decline in ODA translates into more than just less comprehensive Excel spreadsheets; it also translates into empty hospital beds because healthcare workers have left, community health centers that are only open two days a week due to budget constraints, and canceled mosquito net and tuberculosis screening campaigns. A recent study draws a parallel between the announced cuts to HIV funding and a scenario in which nearly 2.9 million additional deaths and up to 10.8 million new infections could occur by 2030, primarily in sub-Saharan Africa, if funding is not restored or compensated.
Today's weak signals- rising Mox-like illness outbreaks, a resurgence of malaria, and an increase in "zero-dose children"- foreshadow significant trends. The WHO Africa region has reported more than 52,000 cases of mox-like illness and nearly 1,800 deaths by 2025, in health systems weakened by budget cuts and rising household costs. Africa is not only "on the front line"; it also serves as an early warning system for the consequences of prolonged global health austerity.
4. The Global Fund at a crossroads: arbitrating scarcity, renegotiating the contract with Africa
The Global Fund is not immune to this crisis. It is both a victim and a buffer. The seventh replenishment, which began in 2022 and will finance the 2023–2025 period, raised $15.7 billion a record amount, though it fell short of the $18 billion target needed to put HIV, tuberculosis (TB), and malaria on track to meet the Sustainable Development Goals (SDGs). At the time, some suggested that the shortfall could be made up during the replenishment cycle through additional contributions or efficiency gains. Three years later, the context is less favorable than ever.
In February 2025, the Fund published its investment case for the eighth replenishment, calling for the mobilization of at least $18 billion for the 2027-2029 period. The Fund argues that this effort would save an additional 23 million lives and reduce combined mortality from the three diseases by 64%. However, the political environment has since deteriorated. US aid cuts, the UK's decision to reduce its commitment by 15%, and the absence of new pledges from key donors like Canada suggest a challenging replenishment.
The Fund has announced it will focus its resources on the poorest countries facing multiple shocks, such as conflict, climate change, and macroeconomic instability. The Fund is also warning some countries of possible cuts of around 11% to their 2025–2026 grants due to a $1.4 billion shortfall. Understandable given its mandate, this choice raises a critical question for Africa: How can lower-middle-income countries, where the disease burden remains high but more domestic financing is expected, prevent a "double shock" of reduced Global Fund grants and simultaneous withdrawal of other bilateral donors?
The Global Fund's allocation mechanism is already complex and under strain. The combination of poverty criteria, disease burden, and concentration ceilings can lead to difficult trade-offs between countries with high incidence rates and middle incomes - for example, some Southern African countries with high rates of HIV - and countries with lower incomes and a less concentrated disease burden. In a context of scarcity, there is a strong temptation to further refocus funding on a select group of "priority" countries. This could create pockets of vulnerability in more advanced health systems that depend on external funding for key populations or rural areas.
Finally, the debate on the contribution of the countries themselves, through co-financing requirements and transitions, is taking on a new tone. Many African governments already face severe budgetary constraints, rising debt servicing costs, and a narrow tax base. Asking them to "replace" withdrawing international financing at a time when growth is slowing and needs are increasing seems more like wishful thinking than strategy. Yet, the Global Fund will be judged precisely on this ability in the coming years: to leverage support for progressive tax reforms, innovations such as health taxes or debt-for-health swaps, and better coordination with regional and continental development banks.
Moving beyond the reflex of health austerity
The stakes in 2025 are much higher than just calibrating a replenishment cycle. Since the early 2000s, we have been witnessing the end of a funding regime based on an implicit pact. In exchange for aligning with certain priorities, such as HIV, TB, malaria, and, more recently, health security, low-income countries could count on the relative predictability of aid. This pact is unraveling due to political fragmentation, waning public support in donor countries, and the absence of an ambitious new narrative for global health.
The Global Fund and its African partners may be tempted to focus exclusively on maintaining the status quo: preserving every budget line, arguing that contributions shouldn't decrease too much, and hoping for an improved economic situation. This would be a mistake. Signals from major donors indicate that the period of nearly automatic growth in ODA is over. Therefore, it will be necessary to defend the funding envelope by placing health at the heart of debates on security, climate, and macroeconomic stability. It will also be necessary to rethink how these limited resources are used, including achieving greater coherence between vertical and systemic approaches, paying more attention to inequalities within countries, and granting more real power to community actors.
At this pivotal moment, the Global Fund community - including donors, recipient countries, civil society, and the secretariat - has a unique role to play. Through its equal governance, strong African roots, and ability to demonstrate impact, the partnership has the rare credibility to argue that health is an investment in global stability and prosperity, not an adjustment item. However, this requires clearly naming what is happening: global health austerity. The poorest populations in Africa are the first victims of this austerity.
Rejecting this austerity does not mean denying the reality of budgetary constraints; rather, it means challenging the political choices that underpin it. By 2025, the architecture of global health, particularly the Global Fund, will reach a crossroads. We must either accept that the fight against HIV, tuberculosis, and malaria will become increasingly narrow, reserved for a few countries and a few "priority" interventions, or reaffirm that health solidarity remains a pillar of the international order with appropriate instruments and renewed alliances. This debate, rather than the amount of pledges announced at replenishment conferences, will determine whether we look back on 2025 as the year we allowed austerity to take hold or the year we chose to fight it.
For years, the pervasive sense of an "aid retreat" has haunted discussions. By 2025, however, the figures had ceased to be an abstract concern; they now depicted a genuine rupture. After six years of growth, official development assistance (ODA) from OECD Development Assistance Committee (DAC) countries fell by 7.1 percent in 2024, dropping to 0.33 percent of their gross national income. The OECD anticipates a further decline of 9 to 17 percent in 2025. The shock is even more brutal in the health sector: the Institute for Health Metrics and Evaluation (IHME) estimates that global health assistance (GHA) will shrink by 20 percent between 2024 and 2025, dropping to levels not seen in over fifteen years.
For Africa, where health systems are underfunded and heavily dependent on donors, this is not just a cyclical correction, but rather a shift toward global "health austerity." At a time when epidemics of tuberculosis, cholera, and malaria serve as reminders that infectious risks have not disappeared, funding is declining, budgets are stretched thin, and room for maneuvering is evaporating. For the Global Fund, which is entering the crucial cycle of its eighth replenishment, the convergence of these dynamics raises a simple yet stark question: Can it continue to play its role as a mechanism of global solidarity when solidarity itself is shrinking?
1. A historic turning point for aid: when overall averages mask a health crisis
Paradoxically, the post-2015 era has not been one of a sudden collapse in ODA, but rather of creeping fatigue. Between 2018 and 2023, the total volume of aid continued to grow, reaching approximately $275 billion in 2023 according to some estimates, even though the share allocated to health stagnated and spending related to hosting refugees in donor countries artificially inflated the figures . What is changing in 2024-2025 is the combination of a quantitative reversal and a qualitative shift: the amounts are decreasing, and the share available for health in low-income countries is shrinking even faster.
Analyses from IHME and other teams show that DAH, after its peak during the COVID-19 period in 2021, has begun a rapid decline (Figure 1).
Figure 1: Overall development assistance for health, 2003-2023
Estimates for 2025 are approximately $39 billion, which is less than half of the levels reached at the height of the pandemic. Projections suggest a continued decline until 2030. The network coordinated this assessment was P4H. For its part, P4H suggests that, in the absence of readjustment, DAC countries' Official Development Assistance (ODA) dedicated specifically to health could fall by nearly 40% between 2023 and 2025 (Figure 2).
Figure 2: Bilateral ODA for health, DAC members, in constant million US$ (2014-2025)
Source: P4H
These aggregate trends mask an even bleaker reality for African countries. According to ONE's analysis, official development assistance (ODA) for health recently dropped to its lowest level in ten years (Figure 3). Meanwhile, 14.5 million children did not receive routine vaccinations in 2023, and malaria cases have steadily increased since 2018. In other words, the cuts are occurring not after a victory but during a period of weakening achievements. The post-2015 promise of a linear path toward achieving the SDGs seems like an outdated narrative. The reality is that hard-won gains are being eroded by a series of crises.
Figure 3:
Source: ONE
Finally, the political dimension of this shift is just as important as the budgetary one. The refocusing of several donors on border security, the war in Ukraine, technological competition, and climate change has drained a significant portion of the "political capital" previously devoted to global health. Budgets are not simply shrinking due to austerity measures; they are being redeployed toward other priorities perceived as more strategic, leaving health on the margins of an already saturated geopolitical agenda .
2. 2025, the year of the convergence of shocks
If we were to pinpoint the tipping point, 2025 would stand out as a key convergence point. In terms of macroeconomics, the OECD warns of an additional 9-17% contraction in ODA this year, following the decline already recorded in 2024 (Figure 4). In terms of health, IHME models project a 21% to 22% decrease in health aid from 2024 to 2025, primarily due to a collapse in U.S. funding. Historically, the U.S. has been the cornerstone of global health architecture. A recent study in The Lancet estimates that five donors accounting for over 90% of international HIV funding are announcing cuts ranging from 10% to 70% for 2025–2026.
Figure 4: After increasing to meet the demands of recent consecutive crises, ODA is set to fall further in 2025 and in the near term
Source : OCDE
This aggregate dynamic translates into a series of concrete political decisions. In the United States, the sudden reevaluation of foreign aid, including long-standing programs such as USAID and PEPFAR, has resulted in the interruption or termination of most health funding in several countries. Projections indicate that millions of additional deaths could occur by 2030 if this funding is not reinstated. In the United Kingdom, the decision to stabilize ODA at 0.5% of GNI and then reduce it to 0.3% starting in 2027 effectively establishes a permanent decrease in international solidarity efforts.
This shift directly impacts multilateralism in the health sector. In November 2025, London announced a 15% reduction in its contribution to the Global Fund for the 2027–2029 cycle (£850 million compared to £1 billion previously), despite its role as co-host of the replenishment process. Meanwhile, the World Health Organization faces a nearly $600 million shortfall by the end of 2025 and a projected $1.9 billion gap for the 2026–2027 budget, forcing the organization to cut its activities in Africa by over $150 million.
In addition to budgetary constraints, there is a fundamental debate about the fragmentation of the system. Several voices, including those within the G20 and technical forums, are calling for fewer agencies and a streamlined global health architecture, hoping to increase efficiency in a scarce resource environment. However, while this discourse addresses the issue of duplication, it can also be used to justify broader disengagement. When the number of actors and the volume of resources are reduced simultaneously, improved coordination is not guaranteed; rather, the supply of public health goods simply decreases.
3. Africa on the front line: from budget gaps to empty hospital beds
In Africa, the reduction in aid is most rapidly translating into health consequences. The WHO Regional Office for Africa estimates that out-of-pocket healthcare expenditures are pushing over 150 million people into extreme poverty, and more than 200 million Africans are facing catastrophic healthcare costs. As aid declines, these expenditures increase further. Surveys conducted in 2025 in 108 low- and middle-income countries show that up to 70% of essential services (e.g., immunization, maternal health, and epidemiological surveillance) would be reduced. Nearly a quarter of WHO country offices report an increase in out-of-pocket payments from patients.
National examples are multiplying. Liberia starkly illustrates a country's structural dependence on aid: According to some analyses, USAID covered nearly 60% of a $851 million national budget for 2025. The announcement of the dismantling of the American agency created a budget shortfall of at least $114 million, causing the suspension of numerous projects, particularly in the health sector. Hospitals are running out of essential medicines, staff salaries are delayed, and maternal and child health programs are disrupted. In a country still recovering from civil war and the Ebola crisis, this rapid contraction cannot be absorbed by limited domestic resources.
In Nigeria, the end of U.S. funding and the restructuring of several international budget lines have eliminated over $600 million in health funding, which is more than one-fifth of the national health budget. This has directly impacted HIV, immunization, and reproductive health programs. In Malawi and southern Africa, orders sent to suspend USAID-funding have halted the delivery of antiretroviral treatments, exacerbating the vulnerability of people living with HIV to outbreaks of medullary tuberculosis and other opportunistic infections.
In this context, the decline in ODA translates into more than just less comprehensive Excel spreadsheets; it also translates into empty hospital beds because healthcare workers have left, community health centers that are only open two days a week due to budget constraints, and canceled mosquito net and tuberculosis screening campaigns. A recent study draws a parallel between the announced cuts to HIV funding and a scenario in which nearly 2.9 million additional deaths and up to 10.8 million new infections could occur by 2030, primarily in sub-Saharan Africa, if funding is not restored or compensated.
Today's weak signals- rising Mox-like illness outbreaks, a resurgence of malaria, and an increase in "zero-dose children"- foreshadow significant trends. The WHO Africa region has reported more than 52,000 cases of mox-like illness and nearly 1,800 deaths by 2025, in health systems weakened by budget cuts and rising household costs. Africa is not only "on the front line"; it also serves as an early warning system for the consequences of prolonged global health austerity.
4. The Global Fund at a crossroads: arbitrating scarcity, renegotiating the contract with Africa
The Global Fund is not immune to this crisis. It is both a victim and a buffer. The seventh replenishment, which began in 2022 and will finance the 2023–2025 period, raised $15.7 billion a record amount, though it fell short of the $18 billion target needed to put HIV, tuberculosis (TB), and malaria on track to meet the Sustainable Development Goals (SDGs). At the time, some suggested that the shortfall could be made up during the replenishment cycle through additional contributions or efficiency gains. Three years later, the context is less favorable than ever.
In February 2025, the Fund published its investment case for the eighth replenishment, calling for the mobilization of at least $18 billion for the 2027-2029 period. The Fund argues that this effort would save an additional 23 million lives and reduce combined mortality from the three diseases by 64%. However, the political environment has since deteriorated. US aid cuts, the UK's decision to reduce its commitment by 15%, and the absence of new pledges from key donors like Canada suggest a challenging replenishment.
The Fund has announced it will focus its resources on the poorest countries facing multiple shocks, such as conflict, climate change, and macroeconomic instability. The Fund is also warning some countries of possible cuts of around 11% to their 2025–2026 grants due to a $1.4 billion shortfall. Understandable given its mandate, this choice raises a critical question for Africa: How can lower-middle-income countries, where the disease burden remains high but more domestic financing is expected, prevent a "double shock" of reduced Global Fund grants and simultaneous withdrawal of other bilateral donors?
The Global Fund's allocation mechanism is already complex and under strain. The combination of poverty criteria, disease burden, and concentration ceilings can lead to difficult trade-offs between countries with high incidence rates and middle incomes - for example, some Southern African countries with high rates of HIV - and countries with lower incomes and a less concentrated disease burden. In a context of scarcity, there is a strong temptation to further refocus funding on a select group of "priority" countries. This could create pockets of vulnerability in more advanced health systems that depend on external funding for key populations or rural areas.
Finally, the debate on the contribution of the countries themselves, through co-financing requirements and transitions, is taking on a new tone. Many African governments already face severe budgetary constraints, rising debt servicing costs, and a narrow tax base. Asking them to "replace" withdrawing international financing at a time when growth is slowing and needs are increasing seems more like wishful thinking than strategy. Yet, the Global Fund will be judged precisely on this ability in the coming years: to leverage support for progressive tax reforms, innovations such as health taxes or debt-for-health swaps, and better coordination with regional and continental development banks.
Moving beyond the reflex of health austerity
The stakes in 2025 are much higher than just calibrating a replenishment cycle. Since the early 2000s, we have been witnessing the end of a funding regime based on an implicit pact. In exchange for aligning with certain priorities, such as HIV, TB, malaria, and, more recently, health security, low-income countries could count on the relative predictability of aid. This pact is unraveling due to political fragmentation, waning public support in donor countries, and the absence of an ambitious new narrative for global health.
The Global Fund and its African partners may be tempted to focus exclusively on maintaining the status quo: preserving every budget line, arguing that contributions shouldn't decrease too much, and hoping for an improved economic situation. This would be a mistake. Signals from major donors indicate that the period of nearly automatic growth in ODA is over. Therefore, it will be necessary to defend the funding envelope by placing health at the heart of debates on security, climate, and macroeconomic stability. It will also be necessary to rethink how these limited resources are used, including achieving greater coherence between vertical and systemic approaches, paying more attention to inequalities within countries, and granting more real power to community actors.
At this pivotal moment, the Global Fund community - including donors, recipient countries, civil society, and the secretariat - has a unique role to play. Through its equal governance, strong African roots, and ability to demonstrate impact, the partnership has the rare credibility to argue that health is an investment in global stability and prosperity, not an adjustment item. However, this requires clearly naming what is happening: global health austerity. The poorest populations in Africa are the first victims of this austerity.
Rejecting this austerity does not mean denying the reality of budgetary constraints; rather, it means challenging the political choices that underpin it. By 2025, the architecture of global health, particularly the Global Fund, will reach a crossroads. We must either accept that the fight against HIV, tuberculosis, and malaria will become increasingly narrow, reserved for a few countries and a few "priority" interventions, or reaffirm that health solidarity remains a pillar of the international order with appropriate instruments and renewed alliances. This debate, rather than the amount of pledges announced at replenishment conferences, will determine whether we look back on 2025 as the year we allowed austerity to take hold or the year we chose to fight it.
