UK aid cuts will put global health systems at risk

The United Kingdom is a major provider of foreign aid, and is the world’s second largest bilateral health aid donor after the United States. The UK is also a major donor to the global health multilateral agencies. However, the UK government recently announced it will only supply bilateral aid to 34 countries, thereby eliminating the aid budget for 102 previously supported countries. The consequences of this sudden departure will affect health systems globally. 

On 7 June 2021, the UK’s foreign secretary Dominic Raab wrote a letter to the International Development Committee—a parliamentary committee that scrutinizes the use of UK foreign aidannouncing that only 34 countries would receive UK bilateral foreign aid in 2021-2022. This means that 102 countries or territories that received aid in the previous year will no longer receive bilateral UK aid. 

The UK has recently implemented major changes to the way it organizes and manages its aid portfolio. In 2020, the Department for International Development (DFID), the primary agency responsible for overseeing and disbursing foreign aid, merged with the Foreign & Commonwealth Office (FCO) to create a new agency called the Foreign Commonwealth & Development Office (FCDO). This move aligns with the UK prime minister Boris Johnson’s vision for spending aid in the national interest. 

Academics warned of the risks of this merger. Specifically, scholars flagged that a new agency may favour countries with strategic interests over the neediest (i.e., the poorest and most fragile.) Unfortunately, it seems that these concerns have been realized. 

Despite Raab’s previous statement that the newly formed agency would continue spending UK aid in the world’s poorest countries, less than half of the 34 countries who will continue to receive foreign aid are considered low-income. Wealthier countries, for examples China and Brazil, make up nearly a quarter of the countries. More than half of the 34 countries are in Sub-Saharan Africa (54%) followed by South and East Asia (23%), a clear reflection of the new agency’s geographic focus on the Indo-Pacific and East Africa. Although the letter clearly articulated FCDO’s geostrategic priorities, it is surprising to see five countries back on the recipient list (Burundi, China, India, Indonesia, South Africa) despite DFID previously withdrawing its bilateral support. 

In contrast, more than half of the 102 countries whose aid has been cut are either low- or lower-middle income and nearly a quarter are fragile or conflict-affected, a previously prioritized demographic for DFID. But there could be good reason for cutting many of these countries: they simply were not receiving much UK money in the first place. An analysis of UK official development assistance (ODA) data shows that in 2019, the 34 “budget safe” countries received nearly five times as much ODA as the 102 being cut. That proportion dramatically increases when we look at health aid: budget safe countries received over fifteen times as much ODA than the cut countries combined. 

While the loss of UK aid may not be felt strongly for some of the 102 countries or territories nixed from the UK budget, it will in others. For example, the Gambia, a low-income country in western Africa, received more than half (55%) of its health aid in 2019 from the UK.  This phenomenon of a country receiving most aid from one or a few donors, also referred to as donor concentration, leaves countries vulnerable in the face of sudden donor policy shifts. Not only is the Gambia’s donor environment very concentrated, but external aid makes up more than one-third of all health expenditures in the country, signalling donor dependency in its health sector.

When donors make sudden and unilateral decisions to cease funding to recipient countries, there is no opportunity to sustainably wind down aid programmes. An evaluation by the Independent Commission for Aid Impact found that even in countries where DFID began its transition out of aid in an intentional manner, they did not do so in a way that would “minimize the risk of development reversals and protect its past aid investments.” Other aid recipient countries have seen severe deterioration of health outcomes when funders exited without a transition plan in place. When the Global Fund left Romania in 2010, the HIV prevalence among people who inject drugs rose from only 1.1% at the time of exit to 53% by 2013. 

The 34 countries that are safe (for now) may have cause for concern if the UK has another sudden policy shift. Many of these countries have concentrated and dependent donor environments, leaving them vulnerable to transitions from foreign aid. For example, South Sudan funds nearly two-thirds of its health system from external donors. A third of its health aid in 2019 came from the UK.  

While the decision to withdraw bilateral support has already been made, the FCDO should learn from the past mistakes of other donors that withdrew aid without taking appropriate measures. Learning from evaluations of DFID’s approach is a worthwhile cause. Aid in the national interest should not be an excuse for irresponsible leadership.

Kaci Kennedy McDade, Policy Associate at the Center for Policy Impact in Global Health, Duke University.

Twitter: @kennedy_kaci

Wenhui Mao, Senior Research and Policy Associate at the Center for Policy Impact in Global Health, Duke University 

Twitter: @WenhuiMao

Competing interests: none declared

Acknowledgements: The authors would like to acknowledge Gavin Yamey and Osondu Ogbuoji for their feedback on early drafts of this piece.