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US aid cuts to global health, especially in maternal and child health, pose a critical challenge but may drive sustainable, self-reliant health solutions in low- and middle-income countries
Image Source: Getty
This essay is part of the series: World Health Day 2025: Healthy Beginnings, Hopeful Futures
Women and children need global solidarity and commitment to addressing their health needs. January 2025 set off a series of unprecedented shockwaves across the global health landscape. The United States (US) President Donald Trump issued executive orders for the US to formally withdraw from the World Health Organisation (WHO), began the dismantlement of the United States Agency for International Aid (USAID), placed a leading HIV/AIDS initiative on hold, and reinstated the Global Gag Rule. Actions limiting global health activities have already commenced despite the withdrawal from WHO requiring a one-year transition period and congressional approval, while the disassembly of USAID is likely to have violated the US Constitution. Owing to the deep financial and technical impact these actions have on global health, these actions have collectively placed the health security of women and children at a critical crossroads.
The WHO estimates that 300,000 women lose their lives owing to pregnancy or childbirth every year, over 2 million babies are stillborn, and the same number die in the first month of life. Postpartum haemorrhage is the most common cause of maternal death, followed by indirect obstetric deaths (deaths caused due to underlying medical conditions that are exacerbated by pregnancy) and hypertension. Maternal deaths that are attributed to postpartum haemorrhage are preventable and have been almost completely eliminated in high-income countries. Geographically, sub-Saharan Africa, West Asia, North Africa, Latin America, and the Caribbean house the greatest proportion of maternal deaths.
Actions limiting global health activities have already commenced despite the withdrawal from WHO requiring a one-year transition period and congressional approval, while the disassembly of USAID is likely to have violated the US Constitution.
Latest reports from the WHO show that despite significant progress in reducing the global maternal mortality rate (MMR) between 2000 and 2015, where it stood at 339 maternal deaths per 100,000 live births in the year 2000 and 227 maternal deaths per 100,000 live births in 2015, the MMR since 2016 has stagnated and was found to be 223 in 2020. The sustainable development goal (SDG 3.1) to reduce the MMR to 70 per 100,000 live births by 2030 is unlikely to be attained at its current state and is likely to be worsened if funding gaps to ensure health system strengthening are not adequately addressed.
The timing could not be any worse—the global health landscape is undergoing seismic shifts. USAID, a legacy of the Cold War, and a formidable instrument of soft power that has provided vital humanitarian assistance across the globe has been dismantled by the newly formed US government. An estimated 3,296,991 lives are saved each year globally, through US foreign aid spanning across health initiatives for HIV/AIDS, tuberculosis, malaria, humanitarian relief, and vaccines. Over 80 percent of USAID’s projects have thus far been eliminated after the Trump administration reviewed the agency’s activities. Several of these programmes were in alignment with US’ core national interests according to US Secretary of State Marco Rubio. Eighty-three percent of the funding allocated by USAID for maternal and paediatric health (for the fiscal year 2024) has been slashed, making it one of the most severely impacted sectors.
The USAID contracts that administer funds from specific programmes have also been paused. The US global HIV/AIDS programme—the President’s Emergency Plan for AIDS Relief (PEPFAR)—is the single largest commitment to AIDS by any single nation. Introduced in 2003 under then-President George W Bush, PEPFAR has saved more than 26 million lives by providing treatment for HIV and by preventing millions from being infected, and is considered the ‘cornerstone of global progress against HIV/AIDS.’ The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that the loss of PEPFAR funding would result in a 10-fold increase in deaths related to HIV, which is approximately 6.3 million lives by the year 2035.
PEPFAR has also improved other avenues of maternal and child healthcare namely in the setting up of cervical cancer screening as HIV-infected women are more likely to develop cervical cancer, and in ensuring routine childhood immunisations occur systematically.
HIV poses a persistent challenge to addressing maternal and paediatric health in low- and middle-income countries (LMICs). PEPFAR has aided pregnant women in receiving HIV treatment and in preventing vertical transmission of HIV. Vertical transmission or mother-to-child transmission of HIV occurs during pregnancy, delivery, or breastfeeding. Antiretroviral treatment (ART) reduces the risk of HIV transmission to the foetus by less than 1 percent and is thus highly effective. PEPFAR extends to treatment for children as well; an estimated 1.37 million children are living with HIV across the globe. Over 100,000 new HIV infections were reported to have occurred globally in children between the ages of 0 and 14 in 2023. PEPFAR programmes extend to periodic HIV testing in early infants; at two months, nine months, and 18 months of age. Orphans and vulnerable children impacted by HIV/AIDS (such as adolescents living with HIV who have lost one or both parents to AIDS) receive counselling, education, HIV testing, and treatment. PEPFAR has also improved other avenues of maternal and child healthcare namely in the setting up of cervical cancer screening as HIV-infected women are more likely to develop cervical cancer, and in ensuring routine childhood immunisations occur systematically.
Some of PEPFAR’s programmes run through the US Centres for Disease Control and Prevention (CDC), which is still operational. Nevertheless, USAID is PEPFAR’s primary implementing agency and regions including sub-Saharan Africa will be affected in their ability to provide HIV testing, ART, and social services in addressing HIV-related stigma. In India, ART and HIV testing is primarily sourced from domestic funds and PEPFAR funding account for only 5.6 percent of India’s HIV/AIDS budget. PEPFAR programmes based in India—Accelerate, Sunrise, and Sunshine—which apply innovative approaches to HIV-care services will affect the northeastern states, while technical activities including the conduct of clinical trials and surveillance are likely to be affected as well.
Finally, the reinstatement of the Global Gag Rule (GGR)—a policy that prohibits organisations that receive US global health funding from providing abortion services including advocacy and counselling efforts—severely impacts women’s health. The policy mandates that any foreign NGO that receives global health funding adhere to the policy that they will not ‘perform or actively promote abortion as a method of family planning’ from any funding source including non-US funds. This policy will worsen challenges in health programmes that address unintended pregnancies, maternal mortality, and sexually transmitted diseases (STDs) severely hampering the right of women to access sexual and reproductive health rights (SRHR). Failure to comply with the policy results in funding cuts that ultimately impede the delivery of essential healthcare services like maternal health, contraceptive provision, HIV/AIDS treatment, and post-abortion care. Reduced access to legal and safe abortion services leads women to seek alternatives, which may be unsafe and life-threatening. Reports from the WHO show that unsafe abortions account for 13 percent of maternal deaths globally. The GGR is likely to exacerbate these behavioural patterns severely endangering the lives of women and undermining SRHR. Under President Trump’s first term, the GGR devastatingly impacted vital reproductive rights; increased incidences of pregnancy-related deaths, reduced contraceptive use, and reproductive coercion were observed and disproportionately impacted women from marginalised communities.
Reduced access to legal and safe abortion services leads women to seek alternatives, which may be unsafe and life-threatening.
While the absence of US global health aid will continue to devastate LMICs, it may serve as an opportunity for the global health community to take cognisance of neglected issues, and devise actionable strategies to addressing maternal and child health. South Africa has heralded the changes as an opportunity for self-sufficiency and autonomy in decision-making, while the vast majority of other African nations have been mute. The efficiency of current aid models has been debated extensively with USAID audits characterised as lacking in strategic prioritisation of specific health issues, absence of substantial oversight, lack of tracking or progress of projects, and the dominance of intermediaries despite significant investments for localisation. Instead, existing aid models can be re-evaluated to ensure they are meeting the specific needs of the population and strengthen maternal and paediatric healthcare over the long term. Another consideration is the re-evaluation of PEPFAR’s activities and whether it can adapt to strengthen HIV programmes in recipient countries sustainably. For instance, PEPFAR supported the incorporation of HIV services into Vietnam’s national health insurance by applying an innovative financing model. This led to 100% of the people living with HIV to be covered by insurance in 2022. Similar models could be applied in other LMICs under PEPFAR. Other reforms to PEPFAR include increased investment in long-acting pre-exposure prophylaxis (PrEP) therapy, which is considered to be highly effective and is in various stages of commercial use and R&D, and the use of digital health technologies in predicting and modelling disease trends.
Existing aid models can be re-evaluated to ensure they are meeting the specific needs of the population and strengthen maternal and paediatric healthcare over the long term.
Finally, the aid cuts serve as an impetus for national governments to take on the path to self-reliance in healthcare. For instance, Ethiopia, which has made progress in the last couple of decades in improving reproductive health rights, is largely dependent on US aid. Two major NGOs failed to comply with the GGR during Trump 1.0, severely impacting reproductive health services as evidenced by decreased contraceptive use, increased births, and reduced post-abortion care services. The Ethiopian government, however, continued to provide safe abortion services in its public health facilities, supporting reproductive rights.
We have likely reached the ‘end of the golden age of global health’. Maternal and paediatric health forms the bedrock of public health security and requires concerted efforts to ensure each pregnancy, postnatal period, and birth is healthy. While outcries over abrupt funding cuts are justified, this juncture serves as an opportunity for LMICs to visualise aid as a catalyst for development that leads them onto the path to self-sufficiency. However, the current reluctance of the US to leverage global health as a form of soft power may be transient. There is potential to redesign the operationalisation of global health activities, including maternal and pediatric health, into sustainable practices that benefit the entire world.
Lakshmy Ramakrishnan is an Associate Fellow with the Health Initiative at the Observer Research Foundation.
The views expressed above belong to the author(s). ORF research and analyses now available on Telegram! Click here to access our curated content — blogs, longforms and interviews.
Lakshmy is an Associate Fellow with ORF’s Centre for New Economic Diplomacy. Her work focuses on the intersection of biotechnology, health, and international relations, with a ...
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