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The United States Agency for International Development (USAID), a byproduct of the Cold War, was set up by former President John F Kennedy as a single agency to promote and enable social and economic development. Its roots connect back to the Marshall Plan (1948), technically referred to as the Economic Recovery Act of 1948, signed by former President Truman to provide financial and technical assistance to Europe’s reconstruction post-Second World War, laying the foundations of international development assistance. Born during the 1970s in what is referred to as the ‘decade of development,’ the USAID’s focus areas comprised food and nutrition, population planning, health, education, and human resource development. This progress subsequently transformed into large programmes implemented through private voluntary organisations (PVOs) and nongovernmental organisations (NGOs). Its 2013 mission statement underscored partnerships to end extreme poverty and promote resilient, democratic societies while advancing the ‘security and prosperity’ of the US.
USAID in India’s health system
President Trump’s administration has indicated it will shut USAID down as an independent agency and possibly move it under the state departments. The USAID/India Health Office, a partnership positing a direct impact on India’s health and social sectors, has remained engaged with the health sector in India for nearly seven decades now, over a wide landscape. Critical areas of engagement include maternal and child health, malnutrition, family planning, adolescent health, polio eradication, immunisation, tuberculosis, Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS), disease surveillance, health security, health systems reforms including urban health, and pandemic preparedness.
The USAID/India Health Office, a partnership positing a direct impact on India’s health and social sectors, has remained engaged with the health sector in India for nearly seven decades now, over a wide landscape.
An analysis indicated that India received an average of about US$90 million in assistance between 1990 and 2000. It rose significantly during the COVID-19 period, dipping nonetheless to about US$152 million in 2024. The health sector accounted for US$120 million in India in 2023. There are two pertinent issues here: (i) whether the Union Budget has sufficient provisions to address this gap, about INR12–13 billion, and (ii) what are the programmatic implications?
The union government’s healthcare budget allocation for FY26 (Fiscal Year) is INR 959.58 billion. While this is an increase in nominal terms, it has been critiqued for not aligning adequately to the National Health Policy 2017 imperatives. Overall, spending remains around 2 percent of the Gross Domestic Product in contrast to the 3–5 percent allocations in peer economies. India’s dependence on external sources for health-related budgets is low, easing the process of topping this gap, albeit just in theory.. The recent National Health Accounts estimated that, as a percentage, external or donor funding within India’s health sector is just 0.66 percent of the current health expenditure (CHE), hinting at low dependency on external sources.
The COVID-19 years were remarkable for the highest contribution by the USAID to the health sector in India—US$228.2 million, up from an average of about US$80 million in the past three years. In the first phase (April 2020 to April 2022), the NISHTHA (National Initiative for School Heads' and Teachers' Holistic Advancement) project supported need-based technical assistance to strengthen the COVID-19 response at the national level and in the 13 project intervention states. The second phase (May 2021 to May 2023) focused on strengthening emergency response mechanisms. An additional US$5 million was allocated in April 2021 to support the oxygen ecosystem when the country braved the Delta wave..
The USAID has contributed consistently in India’s Revised National TB Control Programme in supporting its elimination goal components such as diagnostics, e-training modules, tool kits for community engagement, partnership guidelines, workplace policy interventions, and building a network of TB Champions.
The Food and Agriculture Organization-Office International des Epizooties-World Health Organisation (FAO-OIE-WHO) tripartite is collaborating through the ‘One Health’ Initiative to promote a multisectoral response. The Emerging Pandemic Threats Programme (PREDICT) is enhancing its capacity for the detection and discovery of zoonotic viruses (with pandemic potential as well as targeted surveillance on key wildlife and livestock species and communities relying on them for food security, livelihoods, and cultural practices. It also contributed to the National Action Plan on Antimicrobial Resistance and on strengthening AMR containment in six states.
The SAMAGRA programme was designed to support an urban health ecosystem that is responsive, affordable, and equitable and provides quality preventive, promotive, and curative primary health care for the urban poor with a focus on vulnerable communities.
There has been a consistent focus on vaccine-preventable diseases, most notably the polio eradication programme, and the introduction of newer vaccines such as rotavirus and pneumococcal vaccines more recently. The SAMAGRA programme was designed to support an urban health ecosystem that is responsive, affordable, and equitable and provides quality preventive, promotive, and curative primary health care for the urban poor with a focus on vulnerable communities.
Transitions ahead and its uncertainties
Recalibrating the ongoing programmes is a formidable challenge even while assuming that the resource shortfalls will be met. The standard building blocks include leadership and governance, service delivery, financing, workforce, medical products, vaccines, technologies, and health information systems. The transitioning of healthcare programmes is ideally defined by technically, managerially, and politically complex operations and requires a strategy for transition. The United Nations Development Programme (UNDP) has a detailed step-by-step transitioning strategy that calls for prior planning but is far from being suitable for an administrative and funding emergency such as this. The processes are instructive nevertheless and raise urgent questions to consider and prepare for. Which national or state entities will take over the management? Can the government and the civil society find the necessary synergy? What will be the approval processes? Will it be possible for all the functions to transition, and if not, which functions will transition and when?
The transitioning of healthcare programmes is ideally defined by technically, managerially, and politically complex operations and requires a strategy for transition.
The transition options will thus have to be discussed and agreed to by the central and state-level decision-makers. The critical elements to consider include legal context and requirements, relevant national policies to support implementation including social contracting, capacity to reach the beneficiary communities while ensuring a continuum of care, and modifying implementation models to address specific needs of key population subgroups.
Some challenges are foreseeable but not easy to negotiate. New management arrangements will need to be devised, including staff contracts, contracts with pending delivery of goods and services, and access to key programmatic and financial records. The implementing partners who will continue must not face any interruptions in their contracts and may require new programme management units. A transition schedule and milestone indicators will need to be worked out as well. Disruptions must be averted as far as possible, and a risk mitigation plan must be drawn up. New operation manuals and Standards Of Procedures (SOPs) to address implementation elements, including finance, reporting, asset management, procurement, and software transition, will need to be worked out.
It cannot be overstated that these are formidable challenges at best, and significant disruptions may be unavoidable or imminent at worst. The Sustainable Development Goals (SDG) India Index is currently at a score of 71 out of 100, up from 66 in the previous round of assessment. At the same time, India lags on several key indicators, too, necessitating urgent action. The critical off-target indicators identified by the analysis include access to basic services, wasting and overweight children, anaemia, child marriage, partner violence, tobacco use, and modern contraceptive use. The affected projects contribute to several of these areas, and the off-target districts are concentrated in Madhya Pradesh, Chhattisgarh, Jharkhand, Bihar, and Odisha. Will some of the gains slide back and inequities widen?
The critical off-target indicators identified by the analysis include access to basic services, wasting and overweight children, anaemia, child marriage, partner violence, tobacco use, and modern contraceptive use.
Global health security is in focus more than ever in the post-COVID world. The US Centers for Disease Control and Prevention (CDC) supports a range of related activities, including technical guidance for the Integrated Public Health Laboratory (IPHL), training programmes for One Health, implementation of key infectious disease programmes, strengthening surveillance and reporting for AMR, and workforce development through the Field Epidemiology Training Program (FETP). The USAID also supports the development and training related to the Integrated Health Information Portal (IHIP). There is an overall emphasis on strengthening the One Health approach and preventing cross-border transmission of pathogens. Can some of the inevitable slowing down of programmes lead to an increase in mortality in specific contexts?
Navigating uncertainties
The USAID has been termed as a ‘US$42 billion soft-power glove’ that works in tandem with the Pentagon's (nearly) ‘US$900 billion hard-power fist’. Political slugfests around the USAID’s roles are emerging across South Asia—in India, Bangladesh and Pakistan; the dust is unlikely to settle any time soon. Consequently, central and state governments must recognise that public health programmes and commitments are at stake and need to get to the drawing board forthwith to draw up transition plans. In the face of imminent lessons, will the governments respond with some agility or remain reluctant to learn? The Ebola crisis foregrounded the resilience of health systems – considered resilient if they protect human life and produce good health outcomes for all during a crisis and in its aftermath. Resilient health systems have also been recognised to be of critical importance in delivering routine services, leading to positive health outcomes, referred to as ‘the resilience dividend’. While there is no denying that the health system in India suffers from systemic weaknesses, the performance of the polio eradication programme or the COVID-19 response bears testimony to an inherent resilience, made possible by the demonstration of some of the key elements of health systems resilience: accountability, commitment of workforce, and adaptive mechanisms with inbuilt systems to encourage innovation. Resilient systems are the ‘next big evolution in global health’ and here is an opportunity coupled with urgency to make that leap.
Rajib Dasgupta is a Professor and Chairperson at the Centre of Social Medicine Community Health at Jawaharlal Nehru University. He is also a member of the National AEFI (Adverse Effects Following Immunisation) Committee.
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