Donald Trump and Elon Musk’s attacks on the United States Agency for International Development (USAID) have had an immediate and devastating impact on the ground in low-income countries.
On 20 January, USAID issued a blanket “stop-work” order to all of its partners, demanding that organisations cease operations. In early February, the Trump administration fired the majority of all 10,000-plus USAID workers, leaving around just 290 employees.
Though a US federal judge issued a temporary order to lift the aid freeze on 14 February, there is no clear evidence yet that programmes are back in action, with many hesitant to act under rapidly changing guidance.
USAID’s reach across the world cannot be overstated. Some 141 countries relied on some form of USAID in 2024, worth $42.5bn (£33.3bn) in 2023 (the last available year).
For the latest full year (2023), 27 per cent of USAID money was allocated for economic development; with 22.3 per cent for health, 21.7 per cent for humanitarian assistance, and 14.2 per cent for peace and security.
The remaining aid (roughly 15 per cent) was allocated for a combination of programmes, and other sectors including democracy and governance, education, and the environment.
“To just all of a sudden, withdraw all of this aid... nobody can step in at the scale that the USA has. Nobody,” a USAID official, who works closely with partners worldwide, told The Independent.
Around $600m each year of USAID funding has been spent on family planning; and now, the impact of its withdrawal is being felt worldwide.
For every week without USAID, nearly one million women and girls worldwide are denied contraceptive care, according to analysis from the Guttmacher Institute, a leading reproductive health policy organisation.
An average of 130,390 women received contraceptive care each day from US-funded programmes before the freeze.
As a result of the immediate stop-work order, some 912,730 women will not receive contraception each week; amounting to approximately 3.8 million women who are estimated to have already been denied contraceptive care since the freeze (between 20 January and 18 February).
Though this number may seem high, a source within USAID said these numbers were “conservative” as they only considered direct family planning, and not broader maternal health services.
According to Guttmacher, at least 42 countries rely on USAID for family planning projects.
Most of these programmes are in sub-Saharan Africa, with funding going to family planning in Mali, Niger, South Sudan, Ethiopia, and more.
This means that reproductive health in sub-Saharan Africa will likely face the greatest impact from USAID withdrawal, with potential knock-back effects for generations.
Family planning largely includes the distribution of contraception to communities, and is essential for both broader sexual health, maternal health and population control.
In these regions, women are reliant on condoms and other contraception provided by USAID and its subsidiary programmes; and without access to reliable contraception, the consequences could be manifold.
Countries in Africa already have the highest fertility rates in the world, with Niger top at 6.6 births per 1,000 people, according to the World Bank. This is over four times higher than the UK (1.57) and the US (1.66).
On a macro level, a boom in population will put strain on economies that are already struggling, in areas with the highest poverty rates in the world.
Over 70 per cent of people in Nigeria, South Sudan and Somalia already live in extreme poverty. There is a struggle to find food and water, and for many, not enough money to survive.
Under the current stop-work orders, USAID is no longer providing contraceptive care.
But the withdrawal of USAID will impact all sectors of global health; not least maternal health, where USAID has been vital to healthcare infrastructure in many of these countries.
“Looking at the wider landscape in addition to family planning, when you take away maternal health services as well, which is what’s happening, there’s a cascading effect,” a USAID official explained.
With gaps in midwives, equipment, and pre- and post-natal care, the risk of maternal death is likely to increase, in addition to pregnancy complications.
And once children are born, a vacuum of USAID-funded children’s health programmes could mean worse infant health, and higher infant mortality; not least because vaccination programmes to prevent disease are already shutting their doors, whether for 90 days or longer.
For example, tuberculosis treatment programmes have already been told they cannot resume work until they receive explicit word that a waiver issued for life-saving projects applies explicitly to them, according to a report in The New York Times.
In Botswana, the non-profit Tebelopele testing centres – which provide nationwide STI screenings, HIV prevention, and TB treatment – closed down as a result of the USAID withdrawal, according to a Ministry of Health spokesperson.
Since then, Tebelopele’s executive director issued a statement that just six centres will remain in operation; while at least 17 operations across Botswana are suspended during the 90-day freeze.
Up to now, Tebelopele serviced over 150,000 people a year, in a country where one in five adults are living with HIV, according to UNICEF.
Without access to contraception, the spread of HIV and other sexually transmitted diseases will increase – and without adequate care, HIV is more likely to be transmitted from mothers to children during pregnancy or labour.
Trump’s foreign aid freeze has hindered the operations of President’s Emergency Plan for AIDS Relief (PEPFAR), an HIV programme, with ambiguity over what is allowed to continue under the waivers. As a result of the 90-day freeze, an estimated 136,000 babies could be born with HIV, according to analysis by the Foundation for AIDS Research (amFAR).
Contraceptive and sexual healthcare is also crucial when women face the threat of rape.
South Africa, Botswana and Lesotho have the highest rates of rape in the world. Without safe contraception and sexual health programmes funded by USAID, the consequences of rape can be made more devastating.
This data also does not show the scale of unsafe abortions which would arise from unwanted pregnancies.
Unsafe abortions are one of the top five drivers of maternal death worldwide, according to the World Health Organisation.
In both his first and now second term, President Trump reinstated the “Mexico City Policy”, which prohibits the use of federal taxpayer dollars for organisations providing or promoting abortion overseas.
Compounded with the disrupted aid services for contraception, maternal healthcare, and broader health, the implications are dangerous for women and society in sub-Saharan Africa and worldwide.
Waivers are ‘contradictory’
Even despite new waivers from the State Department on 6 February, which explicitly included HIV care and treatment (but not prevention), thousands of staff who handle these projects have already been dismissed, and international organisation Human Rights Watch says that many programmes are not back in operation.
“President Trump’s sudden suspension of US foreign aid has forced health programmes all over the world to halt or curtail operations, including HIV prevention programmes, and deny patients lifesaving medicines,” said John Sifton, an advocacy director at Human Rights Watch.
“Despite the State Department’s claims about resuming some ‘life-saving humanitarian assistance’, many programmes remain paused due to massive staffing disruptions and inconsistent and unclear guidance.”
Dr Carole Sekimpi, director of global reproductive clinic MSI Africa, reiterated in a press call that since USAID offices on the ground are in chaos, there is no one to implement the waivers, even for HIV programmes.
The confusion over where waivers apply is rife both among department staff and partners relying on aid funding, said a USAID official; made worse by a blanket gag on communication during the freeze, except for designated contracting officers.
“USAID staff were told, zero communication with programme partners. I mean, it’s just brutal. It’s so cruel,” the official said.
There will be a spike in deaths of women and girls across the region, said Dr Sekimpi, whose organisation lost $40m in funding.
“Women and girls woke up one morning and there was no care, whether it was contraception or HIV care,” she said. “There was no forewarning, so there’s a lot of panic.”
Global ripples from unemployment
The livelihood of tens of thousands of people depends on USAID-funded programmes; particularly in African countries.
The International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), the country’s largest non-governmental organisation (NGO) which provides treatment for various health problems including tuberculosis, let go of over 1,000 employees following the USAID freeze.
And in Lesotho, the health ministry has confirmed that around 1,500 health workers have been directly affected by the suspension of USAID. The Lesotho government is trying to find R27 million (approximately £1.2m) to cover salaries for these workers.
In Zambia, the organisation Development Aid from People to People (DAPP) supports hundreds of thousands with programmes for HIV, agriculture, health, education and more.
DAPP’s programme for orphans and vulnerable children was funded via USAID under PEPFAR.
Brian Litiya, a 31-year-old employee of this programme, was told last Friday that he shouldn’t report in for work; losing his source of income as a result.
On Saturday morning, he was found to have died by suicide, according to local police commissioner Robertson Mweemba reported in The Zambian Observer.
Mr Litiya is one of over 51,000 people who have lost their jobs worldwide as a result of the freeze, according to usaidstopwork.com, who estimate that over 100,000 jobs will ultimately be lost around the world.
On 7 February, a judge temporarily blocked the Trump administration from placing 2,200 USAID workers on paid leave; but employees of partner organisations have already been let go in many cases, and are unlikely to be rehired under such uncertainty.
The Independent receives funding from The Gates Foundation to help support its reporting on international aid, maternal health and the climate crisis in low and middle-income countries. All of the journalism is editorially independent.
