Many commentators anticipated a downturn in the fortunes of the United States Agency of International Development (USAID) after the re-election of President Trump. Nonetheless, its abrupt demise has sent shockwaves through low- and middle-income countries (LMICs). Optimists may hope that this is a Trumpian flash in the pan, which will be quickly reversed with a change in government.

However, overseas development assistance (ODA) cuts announced by the British, French and German governments suggest that this is an inflection point for global health. In the short term, affected LMICs will need to respond to substantial budget cuts. This may necessitate the withdrawal of effective services — an unpopular move, which risks political difficulty for local and national governments, further sowing global instability.

In the medium term, multilateral institutions are due for funding replenishment in the next 1–2 years. The USA has historically provided around one-sixth of total funding to Gavi, the Vaccine Alliance1, and one-third of pledges to the Global Fund to Fight AIDS, Tuberculosis and Malaria2. Without prompt action to meet anticipated funding gaps, an extra 14.9 million malaria cases and 107,000 deaths could occur in 2025 alone3.

Countless vaccine-preventable childhood deaths are estimated to follow in the next decade.