USAID Defunding: An Investment Call for Low-Income and Middle-Income Countries.

Abstract

Substantial investments through official development assistance, including USAID, have contributed to major gains in global health outcomes in low-income and middle-income countries (LMICs), particularly reductions in under-5 mortality since 2000. However, recent cuts to USAID bilateral aid in 2025, alongside broader declines in development assistance, raise concerns about reversals in mortality trends, especially as health systems continue to recover from COVID-19 disruptions. This commentary synthesizes evidence from a Lancet retrospective impact evaluation and forecasting analysis assessing two decades of USAID assistance across 133 eligible LMICs and projecting mortality outcomes under defunding scenarios to 2030. High levels of USAID funding were associated with significant reductions in under-5 and all-cause mortality, with the strongest effects observed in lower-income, higher-inequality settings and among women of reproductive age. The analysis estimates that USAID funding averted tens of millions of deaths over the study period, with particularly large mortality reductions for HIV/AIDS, malaria, and neglected tropical diseases. Projections suggest that full defunding could result in substantial excess deaths by 2030, including millions of additional under-5 deaths. The commentary argues for urgent domestic resource mobilization, improved targeting toward marginalised populations, and strengthened accountability mechanisms to sustain health gains amid shrinking external financing.