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Claudia García-Vaz (1), Madiha Shekhani (1), Laura Agúndez (1), Hugo Santa (2), Núria Botella (2), Davide Rasella (2) and Gonzalo Fanjul (1). *
Information about authors
1- Policy & Development department, Translation & Impact area, Barcelona Institute for Global Health (ISGlobal).
2- IMPACThealth: Global Health Impact Assessment and Evaluation Group, Barcelona Institute for Global Health (ISGlobal).
*All statistical and epidemiological analyses and results have been provided by IMPACThealth: The Global Health Impact Assessment and Evaluation Group, at ISGlobal.
*Published by ISGlobal with the valuable support of Focus2030
May 2026
France, a historical leader in development cooperation, is now facing a shift in direction marked by successive budget cuts. Based on original research, this report quantifies the human cost of this retreat. By abandoning its leadership in global health, the country not only risks its prestige and credibility among partners but also cedes vital influence at a time of maximum pressure on international governance.
France has long been an indispensable pillar of the global fight against poverty and disease. For over a decade it stood among the world’s top donors, championing multilateralism and driving major gains against AIDS, tuberculosis and malaria. Its innovative solidarity taxes, its €1.6 billion pledge to the Global Fund in 2022, and a landmark 2021 development law signalled a country determined to reach 0.7% of GNI in aid and to lead by example. But this political momentum has collided with fiscal and political headwinds. Public debt has soared, parliamentary and societal support has eroded, and development cooperation has become an easy target for repeated budget cuts.
The consequences are already visible. Between 2022 and 2024 France’s ODA fell by $2.3 billion. The 2026 budget includes more than €800 million in additional cuts —disproportionately affecting multilateral aid— while defence spending accelerates. Priority countries are no longer prioritised; only one appeared among France’s top ten recipients in 2022. A growing share of bilateral aid is provided as loans, heightening debt stress in countries already struggling to fund essential health services.
This paper, based on original research, provides the starkest measure of what these shifts mean for human lives. Using mortality risk estimates adapted from previous USAID analyses, we model the global impact of French reductions across 124 low- and middle-income countries. Under the hypothesis of similar effectiveness between US and French aid, including multilateral flows, expected averted deaths associated with French aid per capita fall from nearly 11.7 million to 8.2 million between 2023 and 2030 due to aid cuts —a loss of more than 3.5 million people who might otherwise survive. While these staggering numbers rely heavily on the aforementioned premise, they are consistent with estimations by other organisations.
The message is unambiguous: French aid saves lives, and cutting it costs them. And the damage extends beyond the human toll. By dismantling a policy tradition that made it a cornerstone of global health leadership, France risks eroding its international prestige, weakening its credibility among partners, and surrendering influence at a moment when global governance is already under severe strain.
1. France, an Indispensable Donor
It’s difficult to understand the recent progress of the international community against poverty —and, particularly, in the field of global health— without acknowledging France’s remarkable contribution. For more than a decade, the country has ranked among the five largest donor countries in the OECD’s Development Assistance Committee (DAC).1 Not only is France a founding member of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, but has also been its largest European donor and the second largest globally, only surpassed by the United States. To date, it has contributed a total of USD 7.2 billion.2 During the seventh Global Fund replenishment, held in 2022, France committed a record €1.6 billion for the 2023-25 period, a 23% increase compared to its previous contribution. This allocation positioned global health as a priority for French cooperation, a commitment also reflected in the French Global Health Strategy 2023-27.3 While France has played a significant role for many years, its leadership throughout the last decade has positioned it as a global benchmark. Following the 2017 elections, Emmanuel Macron’s government committed to giving a major political push in the field of cooperation, resulting in the French Parliament’s approval of the Law No. 2021-1031 on programming related to solidarity-based development and the fight against global inequalities in 2021. Through this law,4 the country committed to reaching the target of 0.7% of its Gross National Income (GNI) dedicated to Official Development Assistance (ODA) by 2025, with at least 70% of that aid provided in the form of grants instead of loans.
Not only is France a founding member of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, but has also been its largest European donor and the second largest globally, only surpassed by the United States.
France has also pioneered innovative mechanisms for financing aid. In 2005, it introduced a solidarity tax on airline tickets, and in 2012 it implemented a tax on financial transactions. For years, a fraction of the revenue from these taxes —over 700 million euros per year— was channelled through its Development Solidarity Fund to support multilateral initiatives in global health and climate. These measures generated almost immediate, tangible results. French ODA surpassed 0.55% of GNI in 2022 —with a record high of USD 17.3 billion going to ODA— and was steadily approaching the 0.7% target. However, in the summer of 2023, the government pushed back the deadline for achieving this goal to 2030. Between 2022 and 2024, ODA fell by more than USD 2.3 billion.
Today, France’s ability to fulfil its ambitions for development cooperation is being compromised by budgetary realities: the country maintains one of the highest levels of public debt in the EU, nearly doubling the limit set by Brussels. In its October 2025 draft, the government intended to cut €40 billion from the 2026 budget in order to tackle the deficit. These proposed cuts were highly unpopular, sparking protests and strikes, particularly against the pension reform, which has been postponed until the next presidential elections. Parliamentary polarisation and low government approval ratings reflect a climate of voter discontent and legislative deadlock that undermines political stability. After months of negotiations, on 2 February 2026 the final bill was passed, resulting in cuts of €803 million to the ODA budget ,5 making it the second most defunded budget line in both absolute and relative terms. These mark four consecutive years of aid cuts for the country and could reduce aid to its lowest level in a decade:6 0.38% of its Gross National Income (GNI), dealing yet another blow to the progressive multilateral architecture to which France has long been a major defender.
Understanding recent trends in French development cooperation and the impact they will have on health outcomes in recipient countries is essential. This document aims to achieve that.
2. France’s Historic Commitment Faces a Wall of Reality
The most recent period of successful French cooperation was linked to a time of political stability, with a presidential majority in Parliament and, according to specialised French organisations,7 a Foreign Affairs Minister who successfully engaged his administration on the issue. The reality in 2026 is very different. In the 2025 finance law, solidarity taxes were separated from the Development Solidarity Fund and redirected to the general budget, putting an end to a successful and innovative funding mechanism. In the 2026 budget, more than half of the €803 million in cuts correspond to multilateral aid, which sees a 42% decline, losing €476 million.5 In contrast, there is an expected increase in spending on defence and security of €6.5 billion by 2027.8
Despite its historic support for the Global Fund, a French news outlet9 has reported that the government plans to slash its commitment for the 2026-2028 period by almost 60%, tragically dropping from €1.6 billion to €660 million. This contribution is now more vital than ever, given that the Fund came out of its replenishment summit USD 5.4 billion short of its target.10 If confirmed, this unprecedented cut would have devastating consequences for global health.
While the reasons behind the French government's decision to take drastic budgetary measures are related to public debt, it is important to note that this shift follows a series of technical and narrative failures in the field of development cooperation.
While the reasons behind the French government's decision to take drastic budgetary measures are related to public debt, it is important to note that this shift follows a series of technical and narrative failures in the field of development cooperation. For instance, a recent study commissioned by the French NGO platform Coordination SUD found that less than one-third of the provisions of the 2021 law have actually been implemented since its adoption.6 The same study indicated that in 2022, only one of the 19 countries listed as priorities by the Interministerial Committee for International Cooperation and Development (CICID) actually appeared among the top ten recipients. In fact, less than 20% of the total funds distributed bilaterally was allocated to priority countries. From 2018 to 2022, around 25% of this bilateral ODA was not distributed to the intended recipient countries. This was because it was earmarked for scholarships and to cover the costs associated with refugees within France.11 Furthermore, France has relied heavily on loans in its cooperation strategies, which accounted for 19% of bilateral aid in 2023 —significantly above the 4% DAC average. This could exacerbate the fiscal pressures already experienced by many recipient countries, where rising debt burdens limit investment in health and other public services. As debt service consumes a growing share of public revenues, governments have less scope to strengthen health systems. This perpetuates a cycle of fragility and dependence, hindering sustainable improvements in health outcomes.12 It is a fact that African countries are spending up to five times more on debt servicing than on health investment.13 Some of the largest recipients of French development loans, such as Morocco and Senegal, are already at risk of debt distress.
In terms of the narrative, France is shifting towards a discourse that is gaining traction in many European countries, following a path first opened by the United States. The new donor euphemism dictionary presents the concept of 'cuts' as a means of 'reducing dependence', which is clearly a departure from a terminology that emphasises cooperation. While it is difficult to pinpoint a single cause for this trend, it is worth noting the recent criticisms of ODA by some politicians, particularly with regard to multilateral aid, which they accuse of directing funds to China.14
3. The French Retreat Strikes an Already Weakened Global Health Landscape
As a donor, France is committed to maintaining control over its resources. According to OECD data, in 2023 almost two thirds of French ODA was channelled bilaterally, whereas one third was directed as contributions to multilateral institutions. Nevertheless, when taking into consideration French ODA directed at the health sector, 60% of it was channeled multilaterally in 2023. For this reason, the impact on global health initiatives could be dramatic. As an example, the expected drop in support for the Global Fund to Fight AIDS, Tuberculosis and Malaria, of almost €1 billion, could result in failing to prevent more than 710,000 deaths and 13 million combined infections of all three diseases worldwide up to 2028, according to recent estimations.15 Current trends in ODA financing suggest a particularly concerning future for the diseases supported by the Fund. Overall funding cuts have the potential to result in 4 to 10 million new HIV cases16 over the next five years, as well as more than half a million additional deaths from tuberculosis17 by 2035. In light of these circumstances, the weakening of France’s long time commitment and support will prove devastating.
Recent changes in the top 20 recipients of French bilateral aid, with Sahel region countries and former colonies like Mali, Burkina Faso and Niger leaving the top, coincide with a period of scrutiny from West and Central African countries towards France’s military presence in the region.
In 2023, France allocated a total of USD 11.1 billion to bilateral aid. Only one of the ten main recipients of French ODA that year, Senegal, is on the United Nations list of Least Developed Countries (LDCs), despite the government's explicit designation of these countries as geographic priorities.18 However, if we consider only concessional funds —excluding the non-concessional portion of loans— other LDCs, such as Chad and Ethiopia, would also be among the top ten implementing countries. Figures 1 and 2 show recent changes in the top 20 recipients of French bilateral aid, with Sahel region countries and former colonies like Mali, Burkina Faso and Niger leaving the top. These changes coincide with a period of scrutiny from West and Central African countries towards France’s military presence in the region, deepening instability and conflict in the Democratic Republic of Congo, as well as the start of the Ukraine war.
Figure 1: Top 20 French ODA recipient countries in 2019.
Figure 2: Top 20 French ODA recipient countries in 2024.
While the vast majority of French bilateral aid recipients are not among the LDCs, this does not make them invulnerable to the cuts. Côte d'Ivoire is a good case study in this regard, as it has consistently been among France’s top aid recipient countries. In 2024, French bilateral ODA to Côte d'Ivoire accounted for approximately one-fifth of all aid received by the country, reaching up to one-third in previous years. Multilateral organisations have also had a strong presence in Côte d'Ivoire, accounting for roughly half of the assistance received in recent years. Collectively, French and multilateral ODA constitute three-quarters of the country's total gross aid. This situation highlights the country's vulnerability in the face of budgetary changes, particularly in light of the recent shift in policies on cooperation and global health by the United States, the other primary donor.
The majority of the United States’ funding allocated to Côte d'Ivoire has been directed towards the fight against HIV, with the money being channelled through PEPFAR, the President's Emergency Plan for AIDS Relief.19 These efforts, implemented in collaboration with the Global Fund and the Ivorian government, have enabled significant progress towards controlling the disease. However, the ongoing trend of aid cuts poses a significant threat to these gains, underscoring the critical importance of maintaining strong partnerships. France has already demonstrated its commitment to supporting strategic sectors in Côte d'Ivoire with the signing of a third "Debt Reduction-Development Contract" (C2D) for €137 million this year.20 Two of the three projects included in the agreement focus on sexual and reproductive health, and on university-level scientific education —both key areas for the fight against HIV. It is vital that the partnership between the two countries is maintained, as well as French support for the Global Fund, in order to ensure Côte d'Ivoire's resilience in the face of the withdrawal of U.S. funding.
4. The Impact of French ODA: Estimating the Human Cost of Aid Cuts
Côte d’Ivoire is an illustrative example of the importance of French leadership in the global health ecosystem, but many other countries will also pay the toll of aid cuts. To provide a sense of the magnitudes involved, the IMPACThealth research group at ISGlobal conducted an analysis based on the potential lives that could be saved each year between 2023 —when the defunding started— and 2030 in 124 low- and middle-income countries (LMICs) that receive French ODA, and how aid reductions would affect this figure. In the absence of empirical evidence on the specific impact of French aid on mortality, the study relied on impact measures obtained from a previous study21 analysing the effect of different levels of per-capita funding from the U.S. Agency for International Development (USAID) in LMICs. While the structure and sectoral composition of French ODA differ from that of USAID, both countries operate as major actors in the cooperation ecosystem. The estimated rate ratios derived from USAID cuts are here used as a pragmatic, though imperfect, proxy for estimating the potential impact of changes in French ODA funding on mortality. In order to make the estimates more reflective of reality, while the study on USAID exclusively took into account funds channeled through the agency, for the French estimates we took into account multilateral contributions based on per-country funding imputed by the ONE campaign, given the relative importance of health multilateral organisations as a component of French aid. While no causality can be drawn from this analysis, working under the assumption that French and US aid can be similarly effective serves the purpose of showing potential changes in mortality rates derived from changes in ODA funding.
According to estimates by analysts at SEEK Development22 —as consulted at the time of the analysis in December 2025; current figures might differ as projections are dynamic—, French ODA declined by 13.2% between 2022 and 2024, followed by a 16.7% drop in 2025 and an additional 7.3% expected for 2026. Based on these figures, our analysis (detailed in Annex 1) takes these cuts into account, which cumulatively amount to a 30% drop between 2022 and 2026, and assumes French ODA remains at 2026 levels up to 2030.
For this scenario analysis, we started with the assumption that French aid is as effective as US aid and, therefore, modifications in French ODA would impact mortality in a similar way. Using the USAID impact analyses as reference, we calculated the expected lives saved between 2023 and 2030 for each recipient country under the reported percentual reduction in French aid flows.23 We then compared these figures with a scenario where aid flows would have remained constant from 2022.
Under this hypothesis of similar effectiveness between French and US aid, 8,188,891 deaths would be averted in 124 countries between 2023 and 2030 under the 30% overall drop in ODA scenario. However, if aid flows had remained at 2022 levels, an additional 3,577,766 deaths could have been averted through this eight year period. As all estimates are subject to an inherent degree of uncertainty, the corresponding 95% confidence intervals24 are shown in Annex 1.
These estimates offer one fundamental lesson. Under the assumption that French ODA per capita has an impact on mortality similar to that of USAID, the drop in funding seen since 2023 may result in substantial changes in expected mortality, failing to prevent more than 3.5 million deaths over eight years in 124 countries. While averted deaths change by year according to the expected reductions, for the whole period this would equal roughly 447,000 deaths not being avoided in each of those years. This would undoubtedly be a heavy toll to pay. The potential health impacts would be heavily felt in countries which have historically relied on French assistance, but also in settings where multilateral organisations such as The Global Fund or Gavi are doing indispensable work. While the exact number of deaths in our analysis is an estimate based on the theoretical scenario of US and French aid having similar effectiveness in terms of mortality prevention, it does give an order of magnitude on the impact of these abrupt drops in funding.
Under the assumption that French ODA per capita has an impact on mortality similar to that of USAID, the drop in funding seen since 2023 may result in substantial changes in expected mortality, failing to prevent more than 3.5 million deaths over eight years in 124 countries.
While the potential loss of lives is the most serious and direct consequence of defunding development aid programs, the symbolic and strategic implications threaten to multiply the impact of these decisions. The recent and projected reductions in French ODA signal a departure from its historical role as one of Europe’s strongest advocates for multilateral management of shared challenges, starting with global health. These changes risk reversing years of symbolic leadership and reinforce the worrying deprioritisation of health within the global development agenda. Given France’s influence —both internationally and within the European Union— these actions have a significant impact. This trajectory mirrors similar movements by other donor governments, focusing on domestic agendas and thus weakening collective action in international cooperation. It also limits the ability of France, and Europe as a whole, to position itself as a strategic counterweight in response to the partial withdrawal of the United States from leadership in global health and development.
Box 1. Cascading effects: the indirect impacts of defunding French aid
Domino effect in funding cuts. With the US abruptly withdrawing as a major global health donor in early 2025, the lack of a counterbalance from big European actors like France has paved the way for many more countries to deprioritise global health and development aid.
Health security breaches. With the drop in ODA funding, weakened health systems and public health preparedness mechanisms in low- and middle-income countries can hinder collective response in the face of cross-border health emergencies.
Geopolitical risks. Humanitarian and development efforts can play a role in stabilising fragile contexts and preventing violence and its consequences. For France, the Sahel region has long been the centerpiece of a security-first strategy that is now widely seen as having failed.25 To avoid further destabilisation, France should consider a more pragmatic, less paternalistic approach that prioritises maintaining development aid and a diplomatic presence.
Forced displacement. Both conflict and climate change vulnerability are big factors that could result in the forced displacement of populations. At the same time, these populations are now at their most vulnerable. According to a report by UNHCR,26 following the 2025 aid cuts, up to 11.6 million displaced individuals risk losing access to direct humanitarian assistance, with $1.4 billion being cut from essential programs.
5. Conclusions and Recommendations: Development Aid as a Symbol of France’s Historical Crossroads
As with many other former global powers, France is facing a period of significant change and uncertainty. The military presence of the former colonial power in several African countries has been a subject of scrutiny by various governments in Central and West Africa in recent years. This has led to a gradual withdrawal process that was formally completed in July of last year with the handover of the last military bases in Senegal.27 During his second term, President Macron has continued to promote multilateralism and sought to renew France's partnerships with the African continent. In this new context, active participation in multilateral global health financing mechanisms (such as the Global Fund or Gavi) represents a more ethical and advanced way to maintain French cooperation with Africa.
Active participation in multilateral global health financing mechanisms (such as the Global Fund or Gavi) represents a more ethical and advanced way to maintain French cooperation in Africa.
When analysing Europe's declining influence on the global stage, it is important to consider the significance of soft power instruments such as development cooperation. France may encounter difficulties in garnering support from African nations for Ukraine, for instance, if other conflicts and humanitarian crises are not given a higher priority in the budgets of this major donor. A number of civil society organisations —including Oxfam, ONE, Action Santé Mondiale and Coordination SUD— have expressed their disapproval of the government's decision to reduce aid funding at a time when millions of people are facing food and security crises.28 Overall, civil society and some members of parliament are calling for ODA to be regarded as a central expression of fiscal justice, political coherence and France's universal values, rather than merely a "budgetary adjustment variable".
The arguments presented in this document thus far help to contextualise the present and future of French ODA within a global health landscape undergoing major restructuring. The ability of France’s cooperation partners to withstand the pressure caused by the withdrawal of other donors will depend on the decisions taken during the current legislative term. The country's strategic position as a key actor in the future global health ecosystem will be contingent on the stance of the current government. Therefore, we are issuing the following recommendations:
- Maintaining the trajectory established by the 2021 Law would ensure that France remains a leader in development cooperation. While current fiscal constraints might require a prioritisation-based approach, upholding these commitments aligns with long-term strategic interests. Postponing or relinquishing the pursuit of these objectives should not be an option, especially as mounting evidence suggests that ODA remains a primary driver of improved health outcomes in implementing countries.
- France must sustain its political and economic leadership on global health programmes. In light of the prevailing circumstances, the nation's long-standing commitment to the Global Fund has never been more important. The necessity for leadership in this area is twofold: firstly, to mitigate the health impacts of declining funding, and secondly, to prevent a domino effect leading to further donor withdrawals. This leadership is required in the face of budget cuts from key donors, such as the United States.
- Global health should be a priority within the French G7 presidency in 2026. It is only through the convening of global leaders for deliberations on this matter, and the subsequent generation of political momentum, that the United States' position on its G20 presidency, which marginalises global health in the discourse and silences various nations, including South Africa, can be counterbalanced.
- Re-aligning the revenues from financial transaction and airline ticket taxes with the Development Solidarity Fund would add structural stability to French development financing. Ensuring continuity of these innovative fiscal instruments is fundamental to preventing further cuts to the development aid budget, but it must be accompanied by a commitment to restore the funds’ allocation to the Development Solidarity Fund or an equivalent mechanism.
- France should encourage initiatives aimed at mobilising domestic resources in implementing countries, and matching funds could be a way to go. As a counterpart for its commitments, France is in a unique position to promote schemes for domestic capital mobilisation. Initiatives like the UNFPA Match Fund have proven to be a solid strategy for advancing national health agendas. By providing a 2-to-1 match for every government dollar spent, the fund has successfully unlocked millions in additional domestic resources for reproductive health products since its launch in 2022.29 Applying the same co-investment principle to other health commodities such as vaccines, treatments, or diagnostics could be a game-changer for procurement in a constrained funding environment.
Annex 1. Methodology summary. Analysing the impact of France’s Official Development Assistance reduction on all-cause mortality in Low- and Middle-Income Countries 2023-2030.
Methods
We analysed data from low- and middle-income countries (LMICs) receiving French Official Development Assistance (ODA) funding, applying estimates of the Preventable Fraction of the Population (PFP) and the reported reductions of ODA.
The year 2022 was selected as the reference year for the analysis, as it corresponds to the peak in funding levels, represents the closest alignment with the GNI target, and precedes the onset of subsequent funding reductions. To ensure consistency across data sources, mortality and population data from 2022 were also used; this choice was supported by the comparability of estimates from the most recent available year (2023).
Data for mortality and population were obtained from the Global Burden of Disease Study (GBD-IHME). Data for France’s Official Development Assistance were obtained from the OECD Development Assistance Committee Creditor Reporting System (OECD-CRS), accessed via ONE Data. We have accounted for Total ODA Gross Flows, incorporating bilateral and multilateral contributions, the latter through imputation. Multilateral imputations by ONE Data are based on OECD DAC Creditor Reporting System and Providers’ Total Use of the Multilateral System. The funding reduction for the period 2023-2026 was calculated as projected by SEEK Development’s Donor Tracker and kept constant from 2027 to 2030, equating to the last expected reduction reported. 124 recipient countries were included in the analysis (see Supplementary Table).
Given the time constraints and the policy window guiding this work, our analytical strategy followed the global-level PFP approach described in previous studies, which has been used to estimate the mortality impact of changes in population exposure when relative risks or rate ratios are not directly available.30 We adopted this approach by using the rate ratios reported in a prior study from our group, which estimated reductions in all-cause mortality associated with different levels of USAID per-capita funding. This study reported four exposure categories: Baseline (below USD 1.96), Low (USD 1.96–3.96), Intermediate (USD 3.96–7.06), and High (above USD 7.06). In that study, a rate ratio was empirically derived for each category. Using these same thresholds, we calculated French ODA funding31 per capita for each country and assigned the corresponding rate ratio from the USAID study. The ODA funding per capita was calculated, as in previous studies, by dividing the total disbursed amount (numerator, in monetary terms) by the total population (denominator) for each of the 124 countries.
Although the structure and sectoral composition of French ODA differ from those of USAID, both operate as major development assistance donors. On this basis, the rate ratios estimated for USAID can serve as a pragmatic, though imperfect, proxy for approximating the potential mortality impact of changes in French ODA, while acknowledging that differences between donors may introduce some degree of imprecision.
For calculating PFP and expected averted deaths, we implemented a counterfactual reconstruction approach, treating each country as an individual observational unit. Countries were classified into the four USAID funding categories. We estimated counterfactual and averted deaths, assuming the counterfactual was a situation without exposure to the corresponding level of ODA funding, in this case, the baseline level. A global PFP was calculated as the ratio of the sum of averted deaths to the sum of observed deaths across all countries. Uncertainty was quantified using 1,000 Monte Carlo simulations, drawing rate ratios from their published uncertainty ranges and recalculating averted deaths and PFP in each iteration. Expected mean averted deaths and uncertainty intervals for the period 2023-2030 are used for reporting. Uncertainty intervals were defined by the 2.5th and 97.5th percentiles of the simulated estimates.
To assess the impact of funding reductions, we compared each scenario to a reference case in which 2022 funding levels were maintained for all subsequent years. Under this assumption, averted deaths were held constant at 2022 levels. The difference in total averted deaths over the study period between the reference and reduced-funding scenarios was calculated, with the mean difference derived from Monte Carlo simulations.
Table 1. Expected averted deaths and 95% uncertainty limits following a counterfactual reconstruction approach.
| Assumed averted deaths if funding for peak ODA (2022) was maintained | Mean expected averted deaths under reported defunding 2023-2030* | Lower uncertainty limit* | Upper uncertainty limit* | Mean difference in expected averted deaths with the reference year* |
|---|---|---|---|---|
| 11 691 480 | 8 188 891 | 5 013 679 | 11 672 813 | 3 577 766 |
*Reported results are drawn from Monte Carlo simulations
Limits
Our analyses have several limitations. First, we assumed constant deaths and population structures for all years assessed, furthermore we have used the same death and population numbers from 2022. This assumption ignores demographic change and epidemiological transitions, which may independently influence mortality, regardless of funding levels. Nevertheless, the mortality and population figures for 2023 (the last year available in the GBD) were comparable to those in 2022, and, given the short time period assessed, the estimates may not change substantially. Further analyses considering the changes in deaths and population structure are guaranteed to provide more precise estimates.
Second, we assumed funding levels remained equally distributed for each recipient country for the subsequent years to 2022, which ignores specific internal changes in funding committed across the period assessed. In the case of multilateral funding, allocations were estimated using imputations based on assumed disbursement of multilateral bodies and may therefore not precisely capture the funding ultimately received by recipient countries. Similarly, some bilateral and multilateral funding may not have been specified or accounted for in the data obtained for the assessed countries. However, our analysis offers a snapshot of the situation prior to the implementation of reductions and may still be relevant for informing policy decisions.
Third, we assumed uniform exposure to ODA funding within each country, treating the entire national population as beneficiaries of the funding category in which their country was assigned. This ignores within-country variation in the reach of externally funded programs and may mask the estimated association. We have also assumed that overall ODA has a direct impact on mortality, while we have not assessed the impact of specific sectoral allocations. Similarly, we may not disentangle the effect of funding from other major ODA donors to the same recipient countries, which may impact mortality estimates.
Fourth, starting in 2027, we assumed a constant funding scenario rather than a forecast. Developing studies with robust forecasting models that incorporate various funding scenarios and mortality projections is guaranteed to yield more precise estimates.
Finally, we relied on rate ratios derived from the most recent and country-comprehensive peer-reviewed study quantifying the mortality impact of USAID funding on the countries analysed. Because France and other major donors’ ODA differ in structure, allocation mechanisms, and sectoral composition, the true rate ratios associated with French funding may differ, and the USAID-based estimates could mask the actual effect of France’s ODA. Nevertheless, the consistency of findings across previous studies examining the health effects of development assistance suggests that the direction of association is robust, and the USAID estimates from the cited scientific article remain a sound proxy for the potential consequences of reductions of French ODA at the time these analyses were developed. Further analyses, using specific models and estimates from France and disentangling the effects of other major donors, are necessary to better understand the impact of ODA on mortality in LMICs.
Supplementary table. List of recipient countries included in the analysis.
| Afghanistan | Albania | Algeria | Angola |
| Argentina | Armenia | Azerbaijan | Bangladesh |
| Belarus | Belize | Benin | Bhutan |
| Bolivia | Bosnia and Herzegovina | Botswana | Brazil |
| Burkina Faso | Burundi | Cambodia | Cameroon |
| Cape Verde | Central African Republic | Chad | Colombia |
| Comoros | Congo | Costa Rica | Cuba |
| Democratic Republic of the Congo | Djibouti | Dominica | Dominican Republic |
| East Timor | Ecuador | Egypt | El Salvador |
| Equatorial Guinea | Eritrea | Eswatini | Ethiopia |
| Fiji | Gabon | Gambia | Georgia |
| Ghana | Grenada | Guatemala | Guinea |
| Guinea-Bissau | Guyana | Haiti | Honduras |
| India | Indonesia | Iran | Iraq |
| Ivory Coast | Jamaica | Jordan | Kazakhstan |
| Kenya | Kyrgyzstan | Laos | Lebanon |
| Lesotho | Liberia | Libya | Macedonia |
| Madagascar | Malawi | Malaysia | Maldives |
| Mali | Mauritania | Mauritius | Mexico |
| Moldova | Mongolia | Montenegro | Morocco |
| Mozambique | Myanmar | Namibia | Nepal |
| Nicaragua | Niger | Nigeria | Pakistan |
| Panama | Papua New Guinea | Paraguay | Peru |
| Philippines | Rwanda | Saint Lucia | Saint Vincent and the Grenadines |
| Sao Tome and Principe | Senegal | Serbia | Sierra Leone |
| Solomon Islands | South Africa | South Sudan | Sri Lanka |
| Sudan | Suriname | Syria | Tajikistan |
| Tanzania | Thailand | Togo | Tonga |
| Tunisia | Turkey | Turkmenistan | Uganda |
| Ukraine | Uzbekistan | Vanuatu | Venezuela |
| Vietnam | Yemen | Zambia | Zimbabwe |
*We excluded countries that did not receive bilateral aid for the reference year, even when assuming a small amount would have come from the multilateral system. As most of these countries corresponded to islands or countries with small population sizes, their contributions to the overall deaths were negligible.
References
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24. A 95% confidence interval (CI) is a range of values, calculated from sample data, that is likely to contain the true population parameter 95% of the time. It reflects the uncertainty inherent in using a sample to estimate a population value, providing a measure of precision around the estimate.
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29. Cavalcanti DM, De Oliveira Ferreira de Sales L, Da Silva AF, Basterra EL, Pena D, Monti C, et al. Evaluating the impact of two decades of USAID interventions and projecting the effects of defunding on mortality up to 2030: a retrospective impact evaluation and forecasting analysis. The Lancet. July 2025;406(10500):283-94. Available from: https://doi.org/10.1016/s0140-6736(25)01186-9
