Many commentators anticipated a downturn in the fortunes of the United States Agency of International Development (USAID) after the re-election of President Trump. Nonetheless, its abrupt demise has sent shockwaves through low- and middle-income countries (LMICs). Optimists may hope that this is a Trumpian flash in the pan, which will be quickly reversed with a change in government. However, overseas development assistance (ODA) cuts announced by the British, French and German governments suggest that this is an inflection point for global health.

In the short term, affected LMICs will need to respond to substantial budget cuts. This may necessitate the withdrawal of effective services — an unpopular move, which risks political difficulty for local and national governments, further sowing global instability. In the medium term, multilateral institutions are due for funding replenishment in the next 1–2 years. The USA has historically provided around one-sixth of total funding to Gavi, the Vaccine Alliance¹, and one-third of pledges to the Global Fund to Fight AIDS, Tuberculosis and Malaria². Without prompt action to meet anticipated funding gaps, an extra 14.9 million malaria cases and 107,000 deaths could occur in 2025 alone³. Countless vaccine-preventable childhood deaths are estimated to follow in the next decade.

Long-term forecasts are more challenging. Philanthropists may try to fill the void, but their donations pale in comparison to aid flows from high-income countries. Recipient LMICs might see this as an opportunity to diversify their support and spend on their own priorities. USAID disbursed grants with short one-year timeframes, and, for decades, fragile health systems have been buried by reporting requirements for multiple, parallel, vertical programs, focused on donor-centric outputs.

Renewed focus should be placed on horizontal health systems strengthening; measuring meaningful outcomes for patients; and supporting grass-roots entrepreneurship and community-led approaches for research and health improvement. Here, we highlight examples of successful initiatives that might act as models for responding to overseas aid cuts and discuss evolving leadership structures in global health.