I won’t pretend to have more experience with formulating counterfactuals than others here—but I’m interested to learn more! However, given the scale of these cuts and the central role of U.S. funding, I think a significant increase in malaria deaths is incredibly likely. The leaked USAID memo stated an “additional 12.5-17.9 million [malaria]cases and 71,000-166,000 deaths (39.1% increase) annually” could be possible if programs are permanently halted.
In 2020, there were around 80,000 additional deaths from malaria, largely due to disruptions in malaria prevention, diagnosis, and treatment. (“The age-standardized death rate from malaria was 9.3 deaths per 100,000 in 2019 and increased by around 12% to 10.3 deaths per 100,000, equivalent to around 80,000 additional deaths. Estimates from the World Health Organization also show a similar increase.” Our World in Data)
Even in 2020, the financial shortfalls were not as extreme as what we’re seeing today. I’d be curious to hear what people think is a more reasonable mortality estimate, based on that and the factors below.
----
U.S. funding accounts for the vast majority of global malaria financing, and African governments already operate under tight fiscal constraints. These cuts put them in an impossible position. The latest African Leaders Malaria Alliance (ALMA) progress report acknowledged this risk:
“A small number of external donors continue to provide the majority of financing for malaria interventions. Member states highlight the risks this presents to long-term sustainability and a need to diversify sources of funding.”
ALMA also commissioned modeling showing that, even with flatlined funding, Africa could see up to 280,700 additional malaria deaths between 2027 and 2029 due to upsurges and outbreaks. Instead of flatlining, funding is cratering.
The US bilaterally provides nearly 25% of global malaria financing through the President’s Malaria Initiative (PMI), including $795 million in FY24
The Global Fund to Fight AIDS, TB, and Malaria is the largest overall donor, contributing more than 60% of global donor financing.
However, the U.S. is the single largest donor to the Global Fund, but its contributions are capped at 33% of the total. If other donors (like the UK and Netherlands) go through with announcements to reduce ODA, including to orgs like the Global Fund, the U.S. will be forced to cut further. This already happened last year when the U.S. had to reduce its Global Fund contribution by $350 million.
Discussions within the Global Fund board about shifting the disease split for funding between AIDS, TB, and malaria could further reduce available malaria funding
Beyond financing, USAID played an immense operational role that no other donor can immediately replace. It was deeply embedded in ministries of health, funding frontline health workers, lab technicians, doctors, nurses, and supply chain logistics. Without these systems, malaria cases and fatality rates will rise.
In Kenya, at least 1,500 health workers have lost their jobs, and the CEO of the National Syndemic Disease Control Council estimates that at least 41,000 health workers are employed with USAID funding.
In Uganda, at least 3,000 doctors, nurses, and lab technicians have been furloughed or laid off and 29,000 could face job losses. The Health Ministry encouraged staff who were willing to work without pay to continue to do so “in the spirit of patriotism as volunteers…”
The idea that “many of the poorest people will buy medications if they have to” assumes that antimalarials will even be available. In the short term, many may not be.
A significant portion of malaria commodities—bed nets, diagnostic kits, and antimalarial drugs—are imported. Supply chains are already disrupted. Some frontline organizations report difficulties procuring antiretroviral drugs, even if they have independent funding, due to the USAID shutdown. Malaria commodities could face similar issues.
The U.S. withdrawal has been so abrupt that new procurement contracts or programs can’t be put in place quickly enough, causing immediate shortages and delays.
Materials already in the pipeline/under production that include the mandatory branding of “USAID—From the American People” may not be able to be legally distributed.
Suppliers don’t know what future demand will look like or whether they’ll be paid, leading to reduced production and inevitable supply bottlenecks and price spikes.
DAA Enrich wasn’t able to finalize the memo before being put on Administrative leave, so I think it’s fair to look at it with some additional grains of salt. But I am still more convinced than not that this abrupt termination of US aid programs—which is unprecedented in scale and breadth—could lead to tens of thousands, if not hundreds of thousands, of excess malaria deaths in one year.
That’s not to say that will become the new baseline level of mortality for every year moving forward…but these programs and procurement contracts are formulated on 3-5 year timelines normally, so this initial shock will be very destabilizing and deadly.
----
As a public health advocate I don’t know as much about counterfactuals as many in this forum. I’d be curious to hear what you (and others) think is a more reasonable mortality estimate, given these factors, so I can continue to learn and refine my opinions on this.
I have not done personal research into their cost effectiveness, but I wanted to flag two NGOs recommended by Vox’s Future Perfect at the end of last year. The commentary is my own though!
Alight Alight initially received a humanitarian waiver, but their USAID-funded program was later cancelled and they’re raising funds to continue operations. Alight is smaller/less well known than MSH (or other INGOs), and may face greater challenges in rapidly mobilizing emergency resources (medium confidence on this).
“We have anywhere between 15 to 30 infants in these stabilization centers at a time, and if they do not have care, within about a four to eight-hour period, they will die,” Jocelyn Wyatt, CEO of Alight (Devex, February 28, 2025).
Médecins Sans Frontières (Doctors Without Borders) – They have a long-standing presence, strong operational capacity, experience scaling humanitarian interventions, so they can probably absorb and deploy additional donations quickly to meet urgent needs.