Aid Cuts in Nepal & Afghanistan: Protecting Health Services During Donor Withdrawal

The delicate balance of essential healthcare in low- and middle-income countries is increasingly threatened by declining global health aid. New analysis, focusing on Nepal and Afghanistan, reveals how sudden reductions in funding from organizations like the World Health Organization (WHO) and the United States can quickly unravel critical services – from family planning and nutrition to immunization and disease surveillance. The findings underscore a growing concern: that current global health governance lacks clear rules for managing donor exits, leaving vulnerable populations at risk.

The Widening Gap in Global Health Funding

In 2025, the WHO projected a potential 30-40% decrease in external health aid to low- and middle-income countries (LMICs). This warning prompted calls for governments to bolster their own health systems and improve efficiency. However, recent events in Nepal and Afghanistan demonstrate that national efforts alone are often insufficient when core health functions are heavily reliant on external support. The issue isn’t simply about financial constraints. it’s about the ethical implications of withdrawing essential care and the lack of a standardized approach to managing these transitions.

Nepal: A Cascade of Shortages Following USAID Support Reduction

Nepal provides a stark example of how interconnected health services can be destabilized by aid withdrawal. For years, the country depended on the United States Agency for International Development (USAID) for funding of key programs, including nutrition initiatives, vaccine access, and family planning services. When this support diminished in 2025, the consequences were swift and widespread.

Health facilities began reporting shortages of vital contraceptives, such as Depo-Provera injections and intrauterine devices. Simultaneously, currency fluctuations drove up the cost of imported medical supplies, exacerbating the funding gap. This resulted in increased demand on already strained public facilities. Nutrition programs, crucial for maintaining gains in child health, faced uncertainty. Even immunization programs, reliant on both domestic and international funding, were impacted, potentially jeopardizing progress in reducing child mortality. These disruptions highlight a critical point: aid withdrawal doesn’t affect isolated programs; it erodes the entire healthcare system.

Afghanistan: A System on the Brink of Collapse

The situation in Afghanistan is even more acute. By March 2025, funding shortfalls placed 80% of WHO-supported health facilities at risk of closure by June, potentially cutting off millions from essential care. WHO data shows Afghanistan’s population at 41,454,761 (2023), with a current health expenditure representing just 1.13% of its GDP. This pre-existing fragility made the country particularly vulnerable to external funding cuts.

The potential closure of primary healthcare clinics threatened access to basic treatment for infections and chronic diseases. Nutrition programs, already struggling in a food-insecure environment, were further weakened. Critically, disease surveillance systems were compromised as WHO-led coordination structures lost staff and logistical support, hindering the detection and response to outbreaks. Cases of measles, malaria, and other infectious diseases began to rise, and the lack of functioning clinics made effective control even more challenging. Adding to these challenges, restrictions on women’s employment limited access to female healthcare providers, intensifying existing barriers to care.

Beyond Resilience: The Need for “Transition Discipline”

The conventional approach to addressing these challenges has focused on “building resilience” – encouraging countries to adapt their systems to funding losses. However, the experiences of Nepal and Afghanistan suggest that this framing overlooks a crucial factor: the significant influence of global funding decisions made by international agencies and governments. The perspective published in Public Health Challenges argues for a shift in focus towards a more ethical and accountable approach to aid withdrawal.

The authors propose a framework called “transition discipline,” built on three core principles: a set grace period for countries to adjust to funding reductions, a commitment to maintaining a minimum package of essential services, and the development of transparent joint transition plans between donors and governments. A grace period would allow for smoother budget management during funding cuts. A minimum service package would prioritize essential services like vaccinations, maternal care, and disease monitoring. A joint transition plan would clarify responsibilities and ensure a coordinated approach.

Governance Gaps and Ethical Considerations

The current lack of standardized rules for donor exits creates a significant ethical dilemma. When assistance is withdrawn without adequate planning, individuals are inevitably denied access to essential services. This raises questions of accountability within the global health governance system. Foreseeable harms – missed vaccinations, untreated illnesses, and disruptions to continuity of care – demand careful consideration when formulating policy.

The cases of Nepal and Afghanistan demonstrate that abrupt funding cuts disrupt multiple services simultaneously, with potentially far-reaching consequences for access to care. This highlights the need to move beyond a sole focus on resilience and address the governance of the aid withdrawal process itself. Transition discipline offers a potential pathway towards a more predictable, transparent, and ethically sound approach to managing funding reductions.

What Comes Next: Strengthening Global Health Governance

The reduction in external health aid exposes critical weaknesses in global health systems, particularly in countries with high donor dependence. The WHO maintains a comprehensive list of countries and their associated regional distribution, available on their website. Moving forward, strengthening the links between donor accountability, comprehensive planning, and sustained funding will be essential to protect essential services and minimize avoidable harm during periods of transition. This requires a collaborative effort involving governments, international organizations, and donor agencies to establish clear guidelines and ensure a more equitable and sustainable future for global health.