With US and European aid drying up, Kenya's clinics are closing and mothers are paying cash. The continent is learning to fund its own survival.
Published 9 October 2026 · 14:15 GMT
International aid to Africa is drying up at a speed the continent's health systems cannot absorb. Official development assistance fell 23.1 percent in 2025, and sub-Saharan Africa absorbed the deepest losses of any region, with bilateral aid down by roughly a quarter. France24's programme The 51% reports from Kenya this week on what the cuts are doing to health programmes for women that once ran on American money, and on what is filling the gap: in many places, nothing.
The trigger was Washington's freeze of foreign aid in January 2025, but the retreat is now broad-based. Germany's development agency has pulled out of the health sector in Kenya, Britain's development office has deprioritised health and expects to exit the sector within two years, and the International Monetary Fund notes the cuts are hitting countries with limited room to adjust. The programme also hears from Nana Zulu of the African Women's Development Fund on what the retreat means for the region as a whole.
The story travels beyond Africa too. The same broadcast profiles Borneo's female firefighters, holding the line through Indonesia's worst fire season in eleven years amid a sexist backlash.
The numbers describe a system being dismantled faster than it can be rebuilt. At least 1,700 HIV sites across Africa have closed since the American freeze. Prevention spending fell 51 percent. Access to PrEP, the preventive HIV treatment, dropped 21 percent in Global Fund countries and by as much as 72 percent at clinics studied in Uganda and Zimbabwe. About two million fewer people are on PEPFAR-supported treatment, including 77,163 children.
Kenya shows the mechanics of the collapse. Between 2020 and 2025, USAID gave Kenya roughly 2.5 billion dollars, about 470 million a year, 80 percent for health. All 25 USAID-funded clinics for sex workers in western Kenya have closed. The Bar Hostess Empowerment and Support Programme, which had reached 14,500 sex workers, lost one of its two centres in September 2025. A Nairobi sex-worker outreach group recorded a 48 percent rise in new infections in the first half of 2026 compared with the same period of 2024.
The damage reaches beyond clinics. Drop-in centres for community HIV monitoring and prevention under PEPFAR have been abruptly suspended. In the Kakuma and Dadaab refugee camps, the World Food Programme has reduced or eliminated food rations and cash assistance, fuelling hunger and malnutrition among children, Across the continent, maternal and child health gains that had cut deaths by roughly 40 percent since the early 2000s have slowed sharply since 2016.
We do not know how much of the lost funding will ever return. Donor pledges to replace the American money have been vague and partial. The Gates Foundation and Gulf donors may give more, but experts doubt either will fill the shortfall. China, for its part, has shown little interest in replicating Western-style aid, preferring trade and infrastructure projects.
We do not know the full human cost yet. Confirmed deaths tied to closed clinics are documented in Kenya, but national statistics move slowly, and the children who lost treatment this year will show up in the mortality data later. A survey of maternal and child health organisations found nearly 90 percent directly affected, most forced to downsize programmes.
And we do not know whether domestic money can hold the line. Kenya has committed 58 million dollars from its own revenue to maternal, newborn and reproductive health under its 2026-2028 acceleration plan, a genuine experiment in self-reliance. Whether that pledge survives the next budget cycle is the open question. (See Kenya in the Magna Factbook.)
When money gets scarce, governments decide what can wait, and for women and children, almost nothing can safely be postponed. A delayed maternal health service can turn a pregnancy complication fatal. A missing health worker can determine whether a child survives a treatable illness.
The cuts are landing on top of a debt trap. More than 3.3 billion people now live in countries where governments spend more servicing debt than on health or education combined. Only three countries on the continent meet the Abuja target of allocating 15 percent of government spending to health. Aid once papered over that gap; with it gone, the arithmetic of the state budget becomes the arithmetic of who gets care.
For decades, foreign aid gave many African governments a quiet safety net. As it retreats, states must ask citizens to pay more, and citizens ask why they should trust the state with it. The aid crisis is becoming a legitimacy crisis.
What is collapsing is not only a funding stream but a division of labour that defined global health for a generation. The United States paid, through PEPFAR and USAID, for the clinics, the drugs and the outreach; African ministries of health managed around the edges; and the arrangement worked well enough that HIV became a treatable condition for millions. The freeze exposed how much of that system was American money wearing a local uniform, and how quickly a uniform comes off.
The sequence is already visible in Kenya. First the outreach stops: the visits that brought drugs to the sex workers of Mathare ended, and within a year, verified deaths followed, including Judy, 36, who died in August 2026 after her programme was shut down. Then the infections rise: 48 percent more new cases among Nairobi sex workers in eighteen months. Then the system adapts downward, rationing what remains.
The deeper shift is psychological. A continent that learned to plan its health budgets around donor cycles must now plan around its own revenue, its own debt and its own politics. The danger is the gap between the speed of the withdrawal and the speed of the replacement: clinics close in a month, tax systems take a decade, and the women and children in between pay the difference with their bodies.
The secondary effects compound through the household. When a clinic closes, the cost of care does not vanish; it moves into the family, usually onto women, who become the nurse, the pharmacist and the fundraiser. When a refugee camp's food ration is cut, the malnutrition shows up in children first. When prevention spending falls by half, the infections that result will need treatment for decades
There is also a demographic arithmetic. Children who lose HIV treatment now, adolescents who lose reproductive health services, mothers who deliver without skilled care: these are not one-year setbacks but lifetime trajectories bent at the start. The 40 percent decline in maternal and child deaths since the early 2000s was one of the great quiet victories of this century.
And the fire season in Borneo points to the other ledger. As climate stress intensifies, the unpaid and underpaid work of holding communities together, fighting fires, nursing the sick, feeding the displaced, keeps falling to women. The sexist backlash the Borneo firefighters face is the cultural version of the fiscal one in Africa.
The immediate horizon is the budget season across African capitals. Kenya's 58 million dollar maternal health pledge, announced at the UN General Assembly in September, will be tested when the money has to be found in the treasury rather than in a speech. Whether the promised 5,000 nurses and midwives materialise will measure the pledge.
Ethiopia's matching-fund compact, which turns political commitments into available funding, and Malawi's unified civil society coalition, which strengthened engagement with government, were shared by advocates from ten countries at a recent peer exchange as practical ways to navigate the fiscal pressure. At the UN General Assembly, the World Health Organization's director-general urged governments to shield health budgets from cuts and "return with numbers rather than intentions."
For the women holding the front lines, the next phase is already here. The African Women's Development Fund and its peers are trying to keep sexual and reproductive health services alive with a fraction of the old funding. The Borneo firefighters profiled this week show the other side of the same coin: when systems retreat, women step into the gap, and the gap does not thank them.
The Western framing treats the cuts as a fiscal and political choice, and judges them on efficiency grounds. From this angle, the USAID freeze is an assertion of donor sovereignty: taxpayers' money, taxpayers' priorities.
The weakness of this framing is the speed. A planned, multi-year transition is a policy; a freeze is an amputation. The 51 percent fall in prevention spending and the closure of 1,700 sites did not happen after a debate about sustainability; they happened because a stop-work order arrived. Judging the outcome as if it were a designed reform mistakes the demolition for the blueprint. (See South Africa and Nigeria in the Magna Factbook.)
The Eastern framing notes who is not filling the gap. China has shown little interest in replicating Western-style health aid, preferring trade corridors and infrastructure. The Gulf states may increase humanitarian spending, but their money follows their own crises and alliances. The result, from this angle, is a vacuum, not a handover: the West withdraws, the East invests differently, and the clinics close in between.
This framing also reads the moment as a lesson in the terms of partnership. Chinese-built hospitals and roads come as commercial deals, not charity, which makes them harder to freeze by executive order but also less oriented toward the community health and sexual and reproductive services that reach women first.
The Global South framing centres the response, not the retreat. Kenya committing 58 million dollars of its own money to maternal and newborn care, Ethiopia's matching-fund compact, Malawi's civil society coalition: these are the beginnings of a health system financed from inside.
This framing also refuses to separate the clinic from the fire line. The Borneo firefighters, the Kenyan nurses, the women's funds stretching a shrunken budget: the pattern is women holding essential systems together while being told, by budgets and by backlash, that their work is expendable. The demand emerging from the South is not for the old aid to return but for the work to be counted, funded and respected where it happens. (See Indonesia in the Magna Factbook.)
Official development assistance fell 23.1 percent in 2025, the steepest single-year cut on record, and sub-Saharan Africa absorbed the deepest losses at roughly 25 to 26 percent. The trigger was the US freeze of foreign aid in January 2025, but Germany has since pulled out of Kenya's health sector and Britain's development office is exiting health within two years.
They are dismantling the programmes that reached women first. All 25 USAID-funded clinics for sex workers in western Kenya closed, community HIV outreach was suspended, and verified deaths followed the shutdowns, including sex workers who had been stable on treatment. New infections among Nairobi sex workers rose 48 percent in the first half of 2026 against the same period of 2024.
Kenya has committed 58 million dollars of its own revenue to maternal, newborn and reproductive health, plus insurance for pregnant women and 5,000 planned nurses and midwives. Ethiopia is piloting a matching-fund compact and Malawi a unified civil society coalition. But only three countries meet the Abuja target of spending 15 percent of budgets on health, so most cannot replace the lost aid quickly.
They are the women holding the fire line through Indonesia's worst fire season in eleven years, profiled this week by France24's The 51%. Their story runs parallel to Africa's: when systems retreat, women step into the gap. The firefighters are also facing a sexist backlash, the cultural version of the fiscal version now hitting African health workers.
