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US president Donald Trump has taken a series of decisions that have delivered body blows to the global management of health. He has announced that the US will leave the World Health Organization. And a 90-day freeze has been placed on money distributed by the US Agency for International Development (USAid) pending a review by the US State Department. This includes funds for the President’s Emergency Plan for Aids Relief (Pepfar). The decisions have triggered alarm in the global health sector. Catherine Kyobutungi, executive director of the African Population and Health Research Center, outlines which countries are most at risk and which health programmes will suffer the most damage. What does the US exit mean for Africa?The US exit from the WHO and the freeze announced on USAid funding are devastating moves that will have drastic effects on the health of millions of people in Africa. The US is by far the WHO’s largest state donor, contributing approximately 18% of the agency’s total funding. US development aid is used to run large-scale health programmes on the continent. For example, Nigeria received approximately US$600 million in health assistance from the US, over 21% of the 2023 health budget. The WHO is a global health body that synthesises scientific research and develops guidelines that countries in Africa rely on to shape their own policies and practices. The biggest loss for Africa under the USAID umbrella will be funding for Pepfar, which is used for HIV-related programmes including prevention, testing and treatment. Through Pepfar, the US government has invested over US$110 billion in the global HIV/Aids response. What’s going to be lost?A range of capabilities. Firstly, technical guidance. The WHO provides technical guidance to countries on issues ranging from TB management to cost-effective malaria control. Secondly, the ability to mobilise resources. The WHO has the mandate and mechanisms to assemble experts from across the globe to evaluate new therapeutics, diagnostics and vaccines. They can evaluate new evidence on emerging patterns of new bugs, resistance to current treatments, and so on. Thirdly, the WHO has tools and mechanisms that have been key to African countries’ health policy decisions. These include: the WHO’s list of Essential Medicines to inform decision-making on critical drugs a similar mechanism to evaluate new vaccines, resulting in guidance that makes regulatory approval faster and easier in African countries which don’t have strong systems. Fourth, the WHO also provides resources for emergency response, as in the event of disease outbreaks such as Ebola and COVID-19. The WHO is able to quickly mobilise experts and funds and to coordinate emergency responses. Fifth, the WHO provides evidence-informed guidelines. It does this by gathering and sharing information like the causes of outbreaks, while monitoring signals of potential outbreaks and coordinating efforts to develop new technologies, such as vaccines and medical devices. Sixth, the WHO’s ability to support critical programmes in tuberculosis prevention and emergency response will be reduced. Seventh, the withdrawal of US citizens working in these global agencies – and the orders to stop sharing data – mean the US is essentially excluded from global information-sharing mechanisms that keep us all safe. It will be harder to share information about emerging health threats in the US with the rest of the world and vice versa. Which countries will be most affected?Many African countries are heavily reliant on the support provided by Pepfar and USAID to fund programmes in the health sector and for humanitarian assistance. Countries which will be most affected are those with a high burden of HIV, TB and malaria and those with large populations of refugee and internally displaced people. Currently the top eight USAid recipients in Africa are: Nigeria, Mozambique, Tanzania, Uganda, South Africa, Kenya, Zambia and the Democratic Republic of Congo. Without funds being rapidly mobilised to fill the gap left by the US withdrawal, the effect on the health of millions of Africans is at stake. Failure to prevent new infections, and the threat of drug resistance developing because of disrupted treatment, will have far-reaching consequences. In Uganda, where about 1.4 million people are living with HIV/Aids, 60% of the spending on its HIV/Aids programme was from Pepfar, and about 20% from the Global Fund (partly funded from Pepfar). A drastic reduction in funding will be devastating for patients and the greater health system. The Pepfar programme, a lifeline for millions of Africans, has been under threat since before the most recent aid freeze. In 2024, the American congress only gave a one-year authorisation instead of the typical five-year funding authorisation. A conservative backlash against this programme has been growing for years with concerns that some funds may be used to fund abortion. The current authorisation expires in March 2025 and falls within the 90-day aid review period. With the current approval expiring next month, and in light of the current atmosphere, it is very likely that it may not be renewed. Read more: How US policy on abortion affects women in Africa What steps should African countries be taking?There has a been a lot of discussion around jobs and lives lost, but not much around what happens next: how African governments are planning on mitigating shortfalls in their health budget in the short term and foreseeable future. Therefore we need to ask our governments what that means for us and how they are planning to ensure that we do not reverse the gains made so far. This includes preventing millions of HIV infections, improved testing and provision of life-saving antiretroviral treatment. The sudden and drastic decisions taken by the Trump administration have been hailed by several commentators as the wake-up call the continent needs – to wean itself off dependency on a flawed “development aid” system that is admittedly a tool for geopolitical influence. The disbelief and chaos in the global health sector should be rapidly mobilised into citizen action, for governments to invest in a critical sector that has depended on foreign assistance for too long. In the absence of sustained investment, the gains

President Trump and Elon Musk’s attempt to gut the decades-old USAID agency is likely to end millions of dollars in U.S. funding earmarked for women’s economic empowerment across the globe, including programs championed during Mr. Trump’s first term by his daughter Ivanka. While Mr. Trump’s bid to put virtually all of the agency’s workers on leave is currently tied up in a U.S. court battle, the pause ordered by Secretary of State Marco Rubio at the end of January on all new U.S. foreign assistance programs funded by the State Department and USAID remains in place. The Women’s Global Development and Prosperity Initiative was intended to help 50 million women “realize their economic potential” by 2025, an issue the president’s daughter called at the time a crucial area in which Republicans and Democrats could find common ground. President Trump Signs Memorandum Launching The “Women’s Global Development And Prosperity” InitiativePresident Trump displays a signed National Security Presidential Memorandum in the Oval Office, Feb. 7, 2019 in Washington. With the memorandum, Mr. Trump launched the Women’s Global Development and Prosperity Initiative, led by his daughter Ivanka Trump, seen behind the president, standing next to Lillian Achom (2nd from left), a projects manager for AFCHIX, a network for women in technology.Win McNamee/GettyLillian Achom was a projects manager for AFCHIX, a network for women in technology, that was part of USAID’s Women Connect Challenge. In 2019, she was invited to the White House to meet Ivanka Trump, who was then an advisor to her father, and to attend the W-GDP announcement. To coincide with the launch, Ivanka Trump wrote a Wall Street Journal op-ed in which she said W-GDP would, “for the first time coordinate America’s commitment to one of the most undervalued resources in the developing world — the talent, ambition and genius of women.” Achom was one of nine grantees who were invited to the White House, where President Trump signed the memorandum in the Oval House on February 7, 2019. Mr. Trump’s administration pledged $50 million to W-GDP — to be allocated by USAID. Workers say Trump’s aid freeze could cost even more lives in war-torn SudanAchom told CBS News on Monday that while the president had made supportive comments about the initiative, Ivanka “was somebody who really cared,” saying the president’s daughter seemed genuinely concerned about women’s development and economic empowerment. “I could see that she really loves stories of our success, stories of how women are impacting communities around the globe,” Achom said. The first Trump administration later said the program had reached 12 million women in its first year. The Biden administration continued W-GDP’s work under the Gender Equity and Equality Action Fund, which invested $300 million in direct resources and another $200 million in indirect funding between 2021 and 2023, according to USAID documents provided to CBS News. Ivanka Trump did not immediately reply to a CBS News request for comment on the program or the USAID funding cuts. A State Department spokesperson, asked about the W-GDP program, noted to CBS News Rubio’s review of foreign assistance programs, “to ensure they are efficient and consistent with U.S. foreign policy under the America First agenda.” The spokesperson said the department was “judiciously reviewing all the waivers submitted” by various programs and personnel in a bid to keep aid flowing, and they said the results would be communicated “transparently.” One of the focuses of the W-GDP program was women’s access to technology, which still lags behind that of men globally. According to White House documents from the time, more than 1.7 billion women in low and middle-income countries did not own a mobile phone, and they were far less likely to use mobile internet. Rural communities in Africa have been less able to access new and emerging technologies, Achom explained, because of the cost of the internet and devices, but also because for many people, medical bills, education, and food remain the priorities. In northern Uganda, where the prevalence of HIV among women and children has historically been higher than in other parts of the country, additional USAID funding provided through the aid relief program, PEPFAR, gave communities access to ongoing supplies of antiretroviral drugs. Such support is limited from Uganda’s own government because of its restrained finances, Achom said. “USAID has really treated those in the community like their friend,” she said. “Like their number one friend, I should say, because they’ve visited them, they’ve given them grants, not only to support them with medical facilities and access to medicine, but to access economic empowerment.” USAID funding was also consistent and reliable, unlike some other programs, and shutting down agency-funded programs, Achom said, will affect more than just women’s access to technology. “The ability of the entire community to move out of poverty is really going to be slowed down or compromised,” she told CBS News.