TRIGGER WARNING: In this post I will reflect (as I have done on many occasions previously) on how the aid system was broken, and how the ongoing aid crisis may be a blessing in disguise, creating yet another opportunity for us to “build back better” (we seem to have completely missed the boat post-COVID).

Firstly, I recognize the immense privilege I have of saying this from a position of relative safety and stability. Secondly, I completely understand that this may be triggering for some of you who are suffering right now. I will encourage you to stop reading beyond this if so.

But given I trust this community so much, I hope you will take this with the intent this is meant; i.e. that of radical self-reflection and a strive for true and lasting impact. If I thought me (a puny Substacker with ~500 subscribers) writing about this would make the world any worse for our sector, I would certainly not have written it.

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Like all of you, I've spent the last ~2 months processing the seismic shock that hit global aid and development starting on January 20th. The sudden freeze of USAID, and the swift and decisive dismantling of this 50-year old institution sent shockwaves through the entire sector. My own friends, family members and colleagues lost jobs overnight. One organization I helped co-found in Bangladesh had to lay off or furlough a majority of its staff to survive the sudden drying up of projects, as did numerous other organizations. Most devastating of all, I couldn’t stop thinking of the millions of vulnerable populations who depended on aid-funded health services and were now left in limbo.

In Nairobi's Mathare slum, a TB screening program had to let go of their X-ray technicians when salaries vanished. In rural clinics across Africa, shelves of HIV medications are running low with no resupply in sight, and children are already dying as a result. Women affected by domestic violence are suddenly left with no legal resources, their only lifeline, to turn to. Clinical trials testing critical new treatments were suspended mid-stream, leaving patients without care. The human cost is staggering and will continue to mount in the months and years to come, unless other funders (philanthropists, governments, etc.) step in to bridge the gaping hole in last mile services and products.

As someone who has worked in global health for over 15 years, my initial reaction was profound shock and grief. How could decades of progress be upended so suddenly? My empathy and solidarity for the affected people were clouding my every thought. But as weeks turned to months, I found myself wondering why I’m suddenly bemoaning the “death” of USAID when I have long criticized the entire model of aid-funded development for decades? In order to remain true to my beliefs and values, I must be able to simultaneously hold my empathy for my colleagues in the sector AND own up to my belief that the way aid was done was a huge part of the problem, as evidenced by the way health systems are faltering like a house of cards as a result of one country’s political whims. And that led me to the next (and in my belief, all-important) question: What if this crisis, painful as it is, finally forces us to fix what was broken in global health all along?

The Broken Aid System We Created

To understand where we go from here, we need to look clear-eyed at the system that just collapsed. The post-WWII aid architecture which culminated in the creation of USAID under JFK in 1961, while well-intentioned, created some fundamental problems:

1. In the quest to reduce mortality, it reduced people to statistics. In order to show up on most public health charts, you would have to be dead. But for billions around the world, death can be a welcome end to a lifetime of suffering, as I have heard in various forms from numerous poor patients during my work at mPower and Jeeon. Unfortunately, we rarely if ever understood or measured suffering, and focused all our attention on averting deaths. A corollary to this is that we approached “poor people’s health” in a very different way to how we would approach our own healthcare, where continuity of care, quality of care or the experience delivered mattered much less than superficial and rudimentary measures like “access”.

2. It favored vertical disease programs over integrated primary care. This was needed to secure quick wins initially (for example to avert deaths), but became a liability when funding flows through separate channels for HIV, TB, Malaria, MNCH, etc. crowded out investments in primary care and health systems more broadly. Take the example of Rwanda - between 2003-2008, it received $187 million exclusively for HIV/AIDS programs (affecting ~3% of the population), over 5x its entire annual health budget of $37 million. Many health problems went unaddressed due to such narrow focus — e.g. acute respiratory infections, which, despite being 26% of the communicable disease burden globally (and which the same HIV patient might be suffering from), received only 2.5% of all aid. Finally, aid-funded programs often poached providers from the public sector, weakening health systems further — for example, a Global Fund funded program paid triple the average pay for local medical staff in Ethiopia.

   Aside from skewing priorities, such vertical funding silos also caused tremendous fragmentation. I saw this firsthand in Bangladesh - different agencies (multiple public agencies and non-profits) would send their own cadres of community health workers to the same households for overlapping tasks around a pregnancy. The inefficiency was stunning. Moreover, it caused tremendous confusion and intimidation for a poor patient to navigate this complex maze — as a result, many of them would default to bypassing the health system altogether, and relying on informal providers like drug shops.

3. It promoted donor dependency over self-reliance. If you ask anyone in the aid sector, they will idealistically tell you that their goal is to work themselves out of a job. Yet, in 50 years of aid-funded development, we have made little progress towards self-sufficiency and sustainability. In 2013, while designing a $80M USAID FTF funded agriculture program with a renowned global NGO, I advocated for obvious sources of earned revenue so that the project could sustain beyond the 5 year contract term, only to be summarily told off that “we don’t have the apparatus to manage revenue”! Just last week, I was speaking to an impressive community-based non-profit in Kenya called Afya Research Africa who told me that an aid-funded program providing free malaria medication destroyed their previously sustainable business model around treating malaria, and eventually left the community with no services after the donor-funded program packed up and left 5 years later. In these and many other ways, top-down aid warped national priorities and created vulnerability to exactly the kind of funding shock we're seeing now.

4. It prioritized compliance over outcomes. As I wrote about in a prior piece on incentives, the aid industry's obsession with process metrics and reporting requirements often came at the expense of actual health impact. In the same 2013 proposal for the $80M USAID grant, the DC-based consultant declined to even visit the implementation sites with me — the priority clearly was to check the proposal boxes in the three days she had before going back, despite working with a very superficial understanding of ground realities.

The Silver Lining: Yet Another Chance to Build Back Better

So, is the aid freeze/reduction a crisis or an opportunity? It’s both. In the short term, it’s unquestionably a crisis – lives are at risk, and urgent efforts are needed to fill the gaps. But it’s also a stark illustration of why the status quo was flawed. Many of us in global health have long recognized these issues and advocated for change. The WHO's 2016 Framework for Integrated People-Centered Health Servces called for a fundamental shift in how care is funded and delivered, following up on the promise made in Alma Ata almost 50 years ago. Yet inertia and vested interests made real transformation difficult.

Now, perhaps more than ever, this crisis creates an urgent imperative to do what we should have done all along.

I see three BIG opportunities, which we should have prioritized after COVID, but didn’t:

1. Prioritizing Holistic, People-centered, and Outcome-oriented Primary Care

The evidence is overwhelming - strong primary care systems deliver the best health outcomes per dollar spent. Look at Costa Rica: by investing in community-based care teams (EBAIS) that provide integrated services, they achieved stunning results:

• 90%+ reduction in deaths from communicable diseases, and 13% reduction in all-cause mortality!

• Life expectancy of 80-81 years (rivaling much richer countries)

• All while spending less on health (~7-8% of GDP) than the world average (10%)

Most importantly, their model reduced health inequalities. Between 1980-2000, premature mortality fell 48% among the poorest populations compared to 39% among the richest. By 2009, there was essentially no geographic disparity in infant mortality.

With aid funding shrinking, countries will need to focus resources where they get maximum value for money. The math clearly favors integrated primary care over fragmented disease-oriented programs. Governments and local actors will also have more autonomy to design locally relevant, people-centered systems rather than be perversely incentivized by lucrative aid dollars to prop up fragmented vertical programs. One promising early example of this is Nigeria, where the government stepped up to allocate $1B in funding in response to the USAID freeze, and geared it more towards health system reforms than vertical programs, earmarking significant portions for primary health care, workforce training, and maternal/child health.

There is yet another reason to invest in robust community-based primary care. As we start to face new and grave health challenges like anti-microbial resistance (AMR), chronic diseases (NCDs) and Climate Change, our natural knee-jerk response has been to allocate new verticals of funding to address these needs. Yet, I would argue that a robust PHC approach would treat these new challenges as opportunities to build systemic capacity, such as strengthening workforce capacity to do empanelment and proactive routine follow-ups, motivational interviewing (for lifestyle and behavior change), address heat strokes and vector-borne diseases, and institute/enforce rational antibiotic use. Costa Rica’s model is illustrative here as well — when dengue fever emerged as an issue, the EBAIS teams incorporated dengue control into their routine work. Now, as diabetes and hypertension rise, the teams are managing those by doing home visits for at-risk patients and emphasizing health education. The system adapts because it’s built to be comprehensive and locally relevant.

2. Leveraging Private Sector Infrastructure

One of my biggest and long-standing frustrations has been watching donors support the building of parallel and duplicative health infrastructure while ignoring existing and trusted community-based providers like drug shops completely. In Bangladesh, 70% of primary care happens through local pharmacies and informal providers. Instead of bypassing this vast cadre of providers, why not upgrade their capabilities and integrate them into the health system?

The funding crisis creates urgency to be more pragmatic. Private providers like pharmacies already have sustainable business models. With proper training/accreditation, oversight and incentive alignment, they could deliver many basic health services (there are numerous success stories from across the world spanning family planning, TB, immunizations, malaria, NCDs, etc.) more efficiently than building new facilities or cadres of providers.

There are also numerous social enterprises and non-profits —big and small— around the world that are trying to deliver high-quality, integrated care. Developing health financing models that reward these providers for population health outcomes they generate can be an effective model for building robust, decentralized and outcomes-oriented health systems that rely on local innovation and leverage private capital rather than external aid.

3. Using Technology to Achieve More with Less

As I wrote in my post on AI and healthcare, we're seeing breakthrough capabilities that could help bridge gaps in health workforce, digital literacy and care delivery. AI can now match or exceed the vast majority of human doctors in many diagnostic tasks. Multimodal language models can provide accurate, empathetic health guidance in local languages and even over voice.

These tools won't replace human providers, but they can dramatically extend their reach and capabilities. A community nurse in a rural clinic, supported by rapid diagnostic tools, AI clinical decision support and telemedicine, could handle a much wider range of cases. Community health workers armed with AI assistants could provide higher quality care to more people. Interoperable data standards and “digital public good” platforms can help make care delivery more transparent, accountable, efficient, and continuous. People could have 24/7 access to evidence-based triage and self-care advice from the comfort of their homes.

Above all, we need to stop treating digital technologies as their own silo of interventions, and bake them into the core fabric of future health systems. We need to be able to show that they improve outcomes, reduce cost, and enhance system efficiencies and capabilities.

The Path Forward

To reiterate — the USAID shutdown is incredibly disruptive in the short-term, and completely unnecessary. The human suffering it's causing alone is unconscionable. But it is equally true that the prevailing aid architecture was largely responsible for the brittleness, ‘top-down-ness’ and fragmentation of health systems globally.

Given the rise of right-wing, inward-looking politics across the world, I think it is fair to assume that significant reductions in aid are going to last at least a decade, if not more. I believe it is imperative we leverage this crisis as an opportunity to rebuild a better, more resilient system that is long overdue.

What might that look like? I envision health systems that:

• Center on strong community-based primary care

• Integrate services instead of fragmenting them by disease

• Leverage existing private infrastructure rather than duplicating it

• Use technology to amplify human capabilities

• Measure and reward actual health outcomes

• Build local ownership and sustainability

Most importantly, we need health systems that serve people's comprehensive needs, not donor priorities. The Alma-Ata Declaration was ahead of its time in 1978. In 2025, we have no excuse – we must turn that vision into reality. The freeze of old funding models might just be the thaw that lets something new grow: a health system that truly serves and survives.

What do you think? How are you seeing the impacts of the USAID freeze play out? What opportunities do you see to build back better? Let me know in the poll and comments section.