The world was still amidst the making of new year’s resolutions when it was hit with the shocking news of the withdrawal of more than 90% USAID foreign assistance on January 20, 2025. At first, we thought Trump was just having a laugh and pulling the world’s leg with one of his classic bad taste jokes, like a magician pulling a rabbit out of a hat—only this time, the rabbit was missing.

A few days, later a friend and former workmate who was working with one of the USAID funded NGOs in Uganda that supports people living with HIV called me with news that they had been told to lay down their tools. I could tell from the tone of his voice that he was worried as I imagine many other USAID- funded project employees were. By now, we know how that sorry saga ended – Trump, Musk & co have dismantled most of USAID, with also lots of USAID-funded project employees in Uganda as ‘collateral damage’, not to mention their patients. 

Nevertheless, the writing had been on the wall for quite a while. And Uganda even got an explicit warning in 2023.

“Whoever signs the cheque keeps you in check”

For decades, the West’s neocolonial stranglehold on low- and middle-income countries (LMICs) has been glaringly apparent through the conditional strings attached to aid. Only a few years ago, in 2023, Uganda was thrust into the spotlight, teetering on the brink of losing PEPFAR funding due to its draconian anti-gay legislation. The backdrop: i n 2024 alone, the US government channeled more than $471 million in health and development assistance to Uganda. And in the fiscal year 2020/21, international financing entities provided around 50% of the funding for HIV programs in Uganda. More generally, in a country where development partners finance more than half of the health budget, one would have expected a higher level of preparedness to handle health crises independently. Did the Ugandan government learn anything from this reliance, or was the threatened PEPFAR funding in 2023 cut just another wake-up call that went unheeded?

In response to a recent Ebola outbreak in the country amidst USAID funding cuts in early February, the permanent secretary of the Ministry of Health, Diana Atwine  responded with the following :  “I just want to assure you that with or without the current freeze we are going to work within our means,” “We have … everything at our disposal to handle the situation.”

But can Uganda truly sustain its health financing without foreign aid, or was this assurance merely a brave face in the face of an impending crisis? If left without a choice, can the Ugandan government re- prioritize and find innovative ways to fund its health budget?

Experts have argued that this dependency on aid has stifled local innovation and self-reliance. Aid dependency has worsened corruption in Uganda with corrupt government officials seeing aid as a “free cash flow”. Corruption is so rampant that news of officials embezzling public funds barely raises an eyebrow anymore in Uganda. Alarmingly, a recent Inspectorate of Government report revealed that 20% of surveyed households had been asked to pay bribes to health workers, highlighting the dire state of Uganda’s healthcare system.

Impact so far

As the dust settles from the U.S. pulling the plug on its foreign assistance to Uganda, the health sector is left gasping for air—quite literally. With a $160 (UGX 604 Billion) million-sized hole blown into the budget, programs that once thrived on PEPFAR’s generosity—HIV/AIDS treatment, malaria prevention, maternal health—are now scrambling for survival. Clinics are understaffed, testing kits are running dry, and thousands of health workers funded by USAID are now involuntarily “on leave,” scrolling job boards instead of patient charts.

End of March, Health Minister Dr. Ruth Aceng, addressing Parliament’s Health Committee called for urgent alternative funding to sustain critical health programs—ranging from HIV/AIDS and malaria to nutrition and health worker salaries. A cabinet paper has been drafted, and the Ministry is scrambling to integrate affected services into routine care.

In sum, this crisis has exposed the fragility of a system too dependent on foreign lifelines, and while it may be a painful wake-up call, it’s also a rare opportunity to rethink, rebuild, and reclaim ownership of national health financing.

A new era

In the face of the imminent public health risks confronting Uganda, I align with the optimists who perceive this as an opportunity rather than a catastrophe – at least in the medium term.

There is much to be gleaned from the experiences of other Sub-Saharan African nations that have markedly diminished their reliance on donor funding. In the previous decade for example, Ghana’s external assistance for health, as a proportion of total health expenditure, declined from 25% to 11% (between 2015 and 2019).    Ghana is currently ramping up domestic resource mobilization and exploring innovative health financing models to insulate its health system from external aid volatility.  And it’s clear that Ghana is far from the only country now embarking on this road, also advocated by Africa CDC  in a recent note, Africa’s Health Financing in a New Era.

As Dambisa Moyo aptly put it in 2009, “Africa is addicted to aid. For the past sixty years it has been fed aid. Like any addict it needs and depends on its regular fix, finding it hard, if not impossible, to contemplate existence in an aid-less world. In Africa, the West has found its perfect client to deal to.” Dead Aid: Why aid is not working and how there is another way for Africa

As Uganda stands at this critical crossroads, the question remains: Can Uganda break free from the cycle of aid dependency and forge a path towards sustainable, self-reliant health financing?

From my side, it’s a resounding “Yes”.