Financing the Right to Health: How the Destruction of Foreign Aid Reveals Deeper, Systemic Problems

The new U.S. Administration has carried out an unprecedented attack on foreign aid during its first 100 days, destabilizing decades of progress in global health and undermining access to care around the world—including in many of the places where Partners In Health (PIH) works.  

This situation is dire for countless people around the world and raises a number of challenging and important questions for the movement for global health equity, such as:  

• What can be done immediately to minimize the unnecessary and significant harm these attacks are causing?
• What modifications to the aid infrastructure might help reduce harm in the near future?
• What meaningful structural transformations, beyond aid, are needed to address the roots of global health inequity?      

At PIH, our focus is on forging a world where everyone has the right to health. To fully realize this vision, we must aspire beyond the reinstatement of U.S. aid, which by itself has never been enough to guarantee health as a human right. While getting U.S. aid funding back out the door is essential to reduce the unnecessary suffering caused by its reckless and poorly planned removal, the current system of aid is insufficient to halt the unnecessary suffering inflicted by centuries of colonialism and the current unequal economic world order.

Reducing Harm Immediately

The rapid, uncoordinated, and unstable withdrawal of U.S. foreign aid has caused immense destabilization worldwide. Consequently, experts project unconscionable harm, predicting 200,000 cases of paralytic polio a year, 310,000 deaths from tuberculosis in the next year, and up to 166,000 additional annual deaths from malaria—all of which aid funding could help prevent. Each of these statistics is made up of individual patients who are losing access to essential medicines and treatment, facing preventable suffering and death due to forces far beyond their control.

PIH continues to work alongside partners and supporters to reduce this cruel and unnecessary harm. The PIH advocacy team has magnified constituent voices by supporting calls, emails, and meetings with more than 500 congressional offices—including every U.S. senator—asking for a reinstatement of foreign aid cuts.

Meanwhile, ongoing lawsuits are challenging the legality of the administration’s actions. Removing congressionally directed funding by executive decree violates the very premise of separation of powers enshrined in the U.S. Constitution, bypassing bipartisan support for global health funding.

While this pushback is critical towards reducing some of the unprecedented damage occurring around the world, PIH Co-Founder Ophelia Dahl would describe the attacks on foreign aid as an “acute-on-chronic" problem. The acute situation—the rapid removal of aid that has limited access to care for patients around the world—must be addressed. But we cannot ignore the underlying chronic issues: that the current aid infrastructure forces dependency on foreign funding and obscures the larger systems at play that produce a need for aid in the first place.  

Rethinking Foreign Aid

It’s important to note that aid has been essential to a dramatic reduction in global illness and death over the past several decades, with programs like PEPFAR and the Global Fund to Fight AIDS, Tuberculosis, and Malaria achieving remarkable advances in treatment, delivered to the poorest and sickest people in the world. Yet much of the world’s aid still doesn’t contribute towards strengthening public health systems, which are critical to establishing lasting, reliable care infrastructure for patients.

As Dr. Paul Farmer, PIH’s late co-founder, put it: “The aspiration to improve the lives of those living in extreme poverty through better public health, public education, and public works by definition requires public-sector capacity.”  

Health care initiatives can’t be brought to scale without a strong public sector to support them. This is why PIH’s accompaniment model focuses on providing long-term support to governments, seeking to align external funding with national health plans and priorities. Ultimately, PIH’s goal is to become irrelevant in this equation, leaving local governments with the economic sovereignty they need to support and strengthen their own public health sectors. Overreliance on aid is both a product of poor countries’ lack of autonomy and an obstacle that continues to prevent them from obtaining it.  

PIH’s accompaniment model inspired the Paul Farmer Memorial Resolution, a bicameral resolution introduced in the U.S. Congress in 2022 to support a bold global health strategy for the U.S. government—offering us a roadmap for how to respond to today’s crisis. The resolution calls for a massive increase in bilateral financing from the U.S. government to poor countries and presses for that money to be used wisely to support crucial public health sector strengthening. But the resolution also takes a look at the deeper systems that perpetuate much of the preventable suffering in today’s world.  

Structural Transformation

Ultimately, even a 10-fold increase in dedicated health foreign aid wouldn’t be enough to close the current Universal Health Care financing gap, which is estimated at over $400 billion. This is due to the enormous outflow of resources from Global South countries to the Global North.

Countries in the Global North—like the U.S., Canada, and almost all European countries—often tout the generosity of their aid. And it's worth noting that in 2022, global official development assistance for health was $36 billion, much of which is providing critical health system inputs. But this narrative of generosity obscures the broader reality.  

If you look at all financial flows—including exports, imports, interest payments, debt servicing, illicit financial flows, remittances, and more—the numbers show a different story: the Global South’s net transfer of wealth to the Global North is at least $3 trillion every year. This reality flips the development narrative on its head. Poor countries are actually financing richer countries to the tune of $3 trillion a year, not the other way around. These outflows are colonial in origin and include excessive interest payments on debt, trade mis-invoicing, tax evasion and avoidance, and patent licensing fees.

Illicit financial flows are unrecorded outflows extracted via the international trade system. Corporations may report false prices on their trade invoices to siphon money out of Global South countries, directing it into tax havens and secrecy jurisdictions. Many countries lose five to 10 times as much as their annual health budgets to these illicit financial flows.

Additionally, exorbitant debt payments also take priority over—and come at the expense of—addressing basic human rights and needs, including health care. Many countries are locked into vicious cycles of debt and interest payments. Currently, over 45 countries now spend more on interest alone than they do on health care.  

And then there’s the World Trade Organization's (WTO’s) Trade-Related Aspects of Intellectual Property Rights (TRIPS), which sets minimum standards around intellectual property, including essential medicines, through the WTO. Developed and directed by high income countries, TRIPS advantages private interests over public access, and costs developing countries $60 billion per year in extra patent licensing fees.

These outflows are examples of the man-made, structural violence that must be eliminated if poor countries are to achieve the fiscal space necessary to finance robust public services like quality health care. To get to the root of global health inequity, PIH advocates for structural financing solutions beyond aid. The Paul Farmer Memorial resolution calls for financial reparations for colonial harms, the advancement of the United Nations Framework Convention on International Tax Cooperation to address illicit financial flows and other unfair tax practices, and the cancellation of unjust debt burdens.  

With decades of experience partnering with governments to strengthen health systems and partnering with civil society to build a movement for global health equity, PIH is standing up to lead a reimagined, more equitable approach to international health financing.

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