Not Every Country Can Absorb a Shock: Unequal Capacity to Withstand World Health Organization Aid Cuts

Area of Science:

• Global Health
• Health Systems Strengthening
• International Development

Background:

• External health aid is declining, posing a significant challenge to the resilience of health systems in low- and middle-income countries (LMICs).
• The withdrawal of external actors from essential health services highlights critical issues in global health ethics and governance, impacting access to care.
• The World Health Organization (WHO) projected a substantial decline in external health aid, urging LMICs to protect essential services and integrate programs.

Purpose of the Study:

• To analyze the impact of abrupt reductions in external health aid on essential services in LMICs.
• To identify gaps in global health governance regarding donor exits from fragile settings.
• To propose a new governance norm, "transition discipline," to mitigate the negative consequences of aid withdrawal.

Main Methods:

• Drawing on up-to-date evidence from Nepal and Afghanistan.
• Examining the disruption of specific health services including family planning, nutrition, immunization, community-based care, and disease surveillance.
• Analyzing the consequences of reduced support from key external actors like the WHO and the United States (US).

Main Results:

• Abrupt reductions in WHO and US support have severely disrupted essential health services in Nepal and Afghanistan.
• Nepal experienced system-wide operational strain due to single-donor dependence for critical supplies and financing.
• Afghanistan faced intensified outbreaks and amplified access barriers, particularly for women and girls, due to funding shortfalls impacting WHO-supported facilities.

Conclusions:

• Existing national reforms are insufficient to absorb abrupt donor exits when core functions rely on external finance and coordination.
• There is a critical need for a shared governance standard for how external actors should exit essential services in fragile settings.
• The proposed "transition discipline" norm, with a grace period, protected service package, and joint transition plan, can enhance predictability, accountability, and reduce harm during aid reductions.