USAID withdrawal and the erosion of development assistance for health: Considerations for health system leadership in LMICs

Development assistance for health (DAH) is entering a period of retrenchment, exemplified by the withdrawal of USAID from global health. This commentary examines, the implications of a declining DAH landscape for health systems in low- and middleincome, countries (LMICs). The loss of donor support not only creates significant funding gaps but also removes certain benefits that donors have provided - such as sustained financing for high-impact vertical programs (e.g. immunization and disease control) and coordination functions. At the same time, the reduction in DAH may alleviate some longstanding distortions, including the fragmentation caused by vertical initiatives and the internal “brain drain” of talent into donor-funded projects, opening opportunities for countries to reclaim leadership. The immediate challenge for health system leaders is to mitigate service disruptions through short-term measures, while pursuing long-term strategies to increase domestic health investment and strengthen system-wide capacities. We emphasize the need for renewed commitment to the principles of country ownership and alignment - now driven by domestic stewardship rather than donor conditionality. In a changing global context, new arrangements that complement national efforts are needed to ensure that global solidarity and support for shared health goals persist despite a reduced role for traditional aid.