Financing global health: cuts to development assistance for health

A new study takes a novel approach to examining current and forecast cuts to development assistance for health, or DAH.

In 2025, many donors, including the United States, cut back sharply on their contributions. DAH fell more than 50% in 2024 from an all-time high of $80 billion in 2021. Looking ahead, if current policies remain unchanged, total development assistance for health is forecasted to decline by another 8% to $36 billion by 2030. There are concerns that cuts to development assistance for health would reverse decades of progress made in treating and preventing diseases and health conditions.

We discuss the data with study authors Professor Joe Dieleman and Assistant Professor Angela Apeagyei.

Podcast transcript

This transcript has been lightly edited for clarity

Rhonda Stewart: Welcome to Global Health Insights, a podcast from IHME, the Institute for Health Metrics and Evaluation. Hi, I’m Rhonda Stewart.

In this episode, we’ll hear from IHME Professor Joe Dieleman and Assistant Professor Angela Apeagyei as they discuss the latest Financing Global Health report focused on cuts to development assistance for health, or DAH. Development assistance for health is at its lowest level in 15 years. In 2025, many donors, including the United States, cut back sharply on their contributions. DAH fell more than 50% in 2024 from an all-time high of $80 billion in 2021.

Looking ahead, if current policies remain unchanged, total development assistance for health is forecasted to decline by another 6% to $36 billion in 2030. This funding supports health programs around the world and is intended to support disease prevention and treatment. DAH addresses diseases and conditions including HIV/AIDS, malaria, tuberculosis, and maternal and child health. It also impacts food security, water safety, and sanitation. There are concerns that cuts to development assistance for health would reverse decades of progress made. Children would be especially impacted as well as people throughout sub-Saharan Africa.

Give us an overview of the findings and first, let’s break the findings down into two: current funding levels and forecasted levels. Angela, what did you see with respect to current funding levels?

Angela Apeagyei: What we are seeing with current funding levels is that in 2025, due to various announced budget cuts, we are seeing levels of total development assistance for health that are similar to levels we last saw in 2009. And that’s putting us at around $38 to $39 billion. That’s about 21% less than what was provided in development assistance for health in 2024.

Rhonda Stewart: Those are some pretty significant cuts. And Joe, tell us about what’s seen when it comes to forecasted changes for levels in development assistance for health.

Joe Dieleman: Yeah, thanks, Rhonda. We put a lot of effort into generating short-term and long-term forecasts of development assistance for health.

For our short-term forecasts, which really extend through about 2030, we expect to see small reductions even further from 2025 and then a slight climb. But by time we get to 2030, our estimates really are about the same as current 2025 spending levels, so somewhere around between $35 and $39 billion dollars per year. You know, we just don’t expect many donors, especially traditional donors, to dramatically increase the amount of development assistance that they’re able to contribute.

Rhonda Stewart: Okay, let’s talk a little bit more about how levels of development assistance for health have changed over time. Angela, can you walk us through that in terms of especially how these levels have changed since the COVID-19 pandemic?

Angela Apeagyei: Thanks, Rhonda. So development assistance for health levels have sort of fluctuated with the demand for resources. So during the COVID-19 pandemic we saw historic levels, almost $80 billion in funds that were committed toward the health response during the COVID pandemic. And since then, we were on a trajectory to return to levels of DAH funding similar to the pre-pandemic levels. And current funding levels have declined so significantly.

Rhonda Stewart: And Angela, can you also tell us about the countries and organizations that are the major sources of development assistance for health and how that has changed over time?

Angela Apeagyei: Historically, development assistance for health has moved from high-income countries, or advanced countries, to low- and middle-income countries. That’s part of how development assistance for health is defined. And countries such as the US, the UK, Germany, France have historically been major contributors to the resources that have been used as development assistance for health.

One of the reasons why we sit at a unique time this year is because we are seeing announced cuts from most of these major donors of development assistance.

Rhonda Stewart: And it’s impossible not to discuss these cuts when thinking about the human toll of these cuts, the impact that they will have on people. And certainly they will also have a significant impact with respect to certain diseases. Those would include HIV/AIDS, malaria, and then also addressing conditions such as maternal and child health. So Joe, can you talk about how these changes in DAH impact specific diseases or conditions?

Joe Dieleman: Yes,  I think the increase in development assistance for health that we saw at the beginning of the millennium, in about 2001–2010, where there was really the genesis of a number of major development organizations – organizations like Global Fund and Gavi – in many ways, we’re seeing the reverse of that huge increase.

And so to take things a little bit further from what Angela was saying, there’s this huge increase in development assistance, especially focused on HIV, TB, and malaria, as well as maternal and child health; that scale-up occurs really through 2010 or 2011. Then things are relatively flat. And then as Angela was saying, there’s this really dramatic increase in funding for COVID-19.

Where we are today is that a lot of that growth that has happened in allocation for development assistance for health, for TB, malaria, and HIV, is probably the most at risk. And one of the reasons for that is while a number of major development partners and governments are cutting resources that they provide for development assistance for health, the US, which has been a champion especially of funding for HIV/AIDS, is cutting more dramatically than the other donors.

And so when you see some organizations are cutting 10–15%, the United States is, on the other hand, cutting closer to 65% of all development assistance for health. So really major reductions. And that means that the health focus areas that the US has historically prioritized are, I think, the health focus areas that are most at risk for major reductions. And that really, while it includes HIV, TB, malaria, child health, maternal health, all of those focus areas that grew dramatically at the beginning of the century, HIV is probably most at risk again, because historically the US has played such a major role in providing development assistance for health for HIV/AIDS.

Rhonda Stewart: And Joe, with the kinds of cuts that you mentioned, which countries will be most impacted by these changes to development assistance for health?

Joe Dieleman: So our definition of development assistance for health really spans resources that are transferred to low- and middle-income countries. And we certainly see development assistance for health going to middle-income countries. But in middle-income countries there tends to be a lot of domestic resources spent on health as well. And so the countries that are going to experience these cuts in a very unique way, because historically, or at least recently maybe, they were so dependent on development assistance for health, are a small set of low-income countries, especially in sub-Saharan Africa. Those are countries that have received the most development assistance for health. And when you look at development assistance for health as a fraction of their total health spending, it really is substantially large. And so even little cuts, and in this case large cuts, have a large impact on resources for health in those countries.

Rhonda Stewart: And Angela, how are countries and organizations responding to these cuts in DAH?

Angela Apeagyei: Thanks, Rhonda. The abruptness of the cuts has made it imperative that countries respond and for them to respond quickly. While we don’t know necessarily all the official responses from the various countries, we have seen reports of Nigeria increasing its 2025 health sector budget by $200 million. And that’s been hailed as a good example of African countries responding appropriately to these unexpected cuts.

There are other indications of other African countries that are reallocating personnel into the key sectors like HIV that have been affected. But for now, I think the Nigeria example is the most well documented. Additionally, there are reports of the Africa CDC introducing an overarching health financing strategy for the continent and encouraging African governments not only to increase their domestic spending on health, but also to adapt or venture into more creative ways of supporting the health sector, including maybe introducing what’s called solidarity taxes or health-related taxes to support the revenue generation for the health sector.

So all of that to say that there are some indications of country reports – it’s still early days to have all that well documented, but that’s certainly a space that we are interested in and focused on tracking as well in the near term.

Rhonda Stewart: So it sounds very much like collaboration and innovation are going to be key as countries learn how to navigate these unexpected cuts. And Joe, I’d like to go back to something that you mentioned about the cuts in DAH on the part of the United States, a 65% cut that will particularly impact HIV/AIDS programs. And it’s clear that recipient countries are obviously impacted by these cuts to development assistance for health. But how are donor countries also impacted? I mean, given the global nature of health, given the way that disease crosses borders.

Joe Dieleman: Yeah, thanks for that really important question. I think there’s a lot of misperceptions about development assistance for health, especially in the United States. You know, the most common and important misperception to clarify is that as a fraction of the US government budget as a whole, development assistance for health is very small.

The other big misperception is exactly what you’re asking about: that development assistance for health only benefits people in other countries, sub-Saharan Africa, low-income countries, and that’s not the case. We know that development assistance for health really contributes to global health infrastructure, the governance organizations that set standards that kind of run the health system of the world as we know it. And so cutting resources to those organizations and that infrastructure really has large implications.

Some of that is pandemic preparedness. Of course, it wasn’t so long ago that we were all only thinking about COVID-19. You know, there’s a lot of research that shows that we are as at risk or even more so from future pandemics. And by cutting resources, in particular to low-income partners around the world, we’re setting them up and as a global community, setting ourselves up for really scary possible repercussions.

And so there’s a pandemic preparedness component that we benefit from as people in the United States from development assistance for health funding. There’s also just the industry that contributes to the disbursement of development assistance. These are major organizations, many of which are people based in the United States, who are contributing again to global health infrastructure, to providing development assistance for health. These are Americans’ jobs that have in many cases been lost because of the cuts.

So there are a lot of ways, through infrastructure, through pandemic preparedness, and then of course just communicable diseases in general, in which the development assistance for health contributions have major impacts both abroad but also in the United States.

Rhonda Stewart: And then one final question for both of you, which is what’s the main thing that people should take away from these findings? Angela, let’s go to you first and then to Joe.

Angela Apeagyei: Thanks, Rhonda. A couple of things I think people can take away from these findings: One, the aid ecosystem has changed. The cuts are significant and will matter if the response to it is not appropriate from the country perspective. Countries can either respond by dedicating more of their own money to the health sector, and that will vary depending on the country’s own ability to do that.

Alternatively, countries can work toward improving health sector system efficiency. And that’s the technical way of saying that countries could try to do more with less. And that’s something that’s always easier to say than actually do. So that leaves room there to see how all of that plays out.

And lastly, if we’re not successful at any of the above two options, then inevitably I think there would have to be some reduction in health services in countries, which is not a good prospect. So some important takeaways here, and hopefully with the information this report is providing, the appropriate response from all the key stakeholders will happen.

Rhonda Stewart: Yeah, thanks so much, Angela. And Joe, how about you?

Joe Dieleman: To echo a little bit of what Angela was saying, I really think we’ve seen a paradigm shift in just the last six to eight months, 10 months, in how development assistance for health is perceived, especially in high-income countries that historically have provided a lot of the development assistance.

So again, speaking about the United States specifically, historically, development assistance for health was bipartisan. It wasn’t a very political issue. Both Republicans and Democrats supported the appropriations to key programs like PEPFAR, the President’s Malaria Initiative, Global Fund, and Gavi, some of those major organizations that the US really was instrumental in supporting. And so to see such a dramatic shift in a short amount of time really is a paradigm shift and I think is really important.

The second thing, the second and last takeaway that I have is that I think the countries that are going to experience the cuts in development assistance for health most acutely are also the countries that are least equipped to be able to fill the gaps that are being created by donors essentially removing funds. And that’s really important. I mentioned before that development assistance for health goes to middle-income countries as well as low-income countries, but it’s the low-income countries that are most dependent on that development assistance for health.

And of course, by the very nature of being a low-income country, they have the smallest essentially government tax revenue and the least essentially household spending on health – so the least amount of opportunities to fill those key gaps. And that makes me very nervous. I think that’s really critical for people to understand that these gaps, where they are being felt the most are also the places where filling the gaps, at least domestically, is the hardest.

Rhonda Stewart: Absolutely. Well, Angela and Joe, thank you both so much for talking with us about this important research.

Angela Apeagyei: Thanks for having us.

Joe Dieleman: Rhonda, thanks so much.

Rhonda Stewart: Details about the 2025 Financing Global Health Report can be found at healthdata.org.