The new paradigm in foreign aid was on full display at last week’s high-stakes financing event for the Global Fund to Fight Aids, Tuberculosis and Malaria.
All the rhetoric about multilateralism, solidarity and partnerships could not gloss over the fact that the $11.34bn raised fell woefully short of the fund’s $18bn target for its eighth replenishment conference, held on the eve of the G20 Leaders’ Summit in Johannesburg. South Africa, Nigeria and Spain were among just a handful of countries to increase their pledges, which pale into insignificance against the reduction in aid from some of the world’s most prosperous nations, including the US, Germany and the UK.
While several large donors, including France, Japan and the EU, have yet to announce their contributions, there is faint hope they will match previous commitments. The fund is thus facing difficult questions about how to prioritise its resources in an environment reeling from the Trump administration’s devastating cuts to foreign aid.
The US will continue to support the work of the fund, but it has cut back hard, promising just $4.6bn, compared with the Biden administration’s undertaking of $6bn. The Trump administration’s endorsement of the fund is striking, given that it has exited key health institutions such as the World Health Organisation and UNAids, and abruptly terminated grants channelled through the US President’s Plan for Emergency Aids Relief (Pepfar).
While some Pepfar funding has been restored recently, it is not to previous levels and future commitments remain uncertain. Many countries, including South Africa, are beneficiaries of a new six-month “Pepfar bridge plan”, which runs until March 2026, but there is little likelihood that many of the programmes that were forced to close will resume. Staff have been retrenched, trust with communities breached and irreparable harm done to some of society’s most vulnerable people.
The disruption to global health financing is particularly challenging for Africa, as it carries a disproportionate share of the world’s burden of HIV, TB and malaria. Africa is home to two-thirds of the world’s population living with HIV, more than 90% of global malaria cases, and a third of the world’s TB deaths.
The continent is doubly vulnerable, as most of its nations have for decades made meagre budget provisions for health and leant heavily on external funding sources to pay for staff and essential commodities such as vaccines and contraception. AU member states committed to allocate at least 15% of their national budgets to health in 2001, but few have ever met the target and none consistently so.
Politicising aid
Against this backdrop the Trump administration is aggressively pursuing a new “America First” global health strategy. It positions aid as a foreign policy tool, gives prominence to American companies and strips out nongovernmental organisations to deal directly with governments.
The US is negotiating bilateral agreements with 16 African countries, pushing them to commit to increasing their domestic resources for health and demanding access to information about disease outbreaks. In itself, asking African governments to take on greater responsibility for their own health services is no bad thing. Far more concerning is the US insistence that African governments commit to sharing crucial information on disease outbreaks — including pathogen samples and genetic sequencing data — with no guarantee they will have timely access to the tests, vaccines and treatments that are developed in response.
This flies in the face of ongoing negotiations by WHO member countries on a pathogen access and benefit-sharing annex to the pandemic agreement adopted earlier this year. The treaty was crafted in the wake of the world’s fractured response to Covid-19, and obliges wealthier nations to share information and technology so that poorer countries are not left scrambling for tests, vaccines and treatments.
African nations clearly still need foreign assistance to ensure their populations have continued access to health services. But it would be foolhardy to ransom their future to satisfy today’s needs.
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