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Claudia García-Vaz (1), Madiha Shekhani (1), Laura Agúndez (1), Clara Marín (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 original analyses and results have been provided by IMPACThealth: The Global Health Impact Assessment and Evaluation Group at ISGlobal.
*Published by ISGlobal with the valued support of Focus2030
May 2026
In 2025, Germany briefly became the world’s largest provider of Official Development Assistance (ODA) in absolute terms, filling a leadership vacuum created by the dismantling of US aid. Yet in reality, Germany’s potential for leadership had already begun to unravel in 2023.
Between 2022 and 2026, German ODA is projected to have fallen by nearly 37%, returning to levels last seen more than a decade ago. Aid as a share of Gross National Income has already dropped from 0.85% in 2022 to 0.67% in 2024 and is expected to fall to 0.52% in 2026, with further declines anticipated. The Federal Ministry for Economic Cooperation and Development (BMZ) has seen its budget reduced by almost 30% since 2022, while humanitarian assistance was cut by nearly half in 2025 —at a time of record global need.
These reductions are not abstract accounting decisions. They carry measurable human consequences. According to analyses conducted by ISGlobal’s IMPACThealth group, if German aid continues on its current trajectory, an estimated 2.9 million deaths would cease to be averted between 2023 and 2030 —nearly 361,000 per year— compared to a scenario in which 2022 funding levels had been maintained. Cuts of just €642 million to major multilateral health institutions —equivalent to 0.06% of the federal draft budgets— could contribute to over 650,000 preventable deaths by 2029 and leave 2.8 million children unvaccinated.
Germany’s retreat has been described as an exercise of ‘recalibration’, but this turnaround represents more than fiscal consolidation. It signals a fracture in the political consensus that positioned the country as a stability anchor in global development and multilateral cooperation. The contradiction is stark: while defence spending surges, preventive instruments that reduce instability at far lower cost are being hollowed out.
This report argues that Germany’s recent moves risk undermining both global health gains and its own long-term strategic interests. To safeguard its international standing and protect vulnerable populations, Germany’s integration of aid as a strategic security pillar involves defining a roadmap to regain the 0.7% GNI target. It is critical to align multilateral health ambitions with stable financial commitments, as the mandate to "achieve more with less" becomes a contradiction in terms at this scale of defunding.
1. Germany’s Historical Presence in Development Cooperation
Following the dismantling of the United States’ development cooperation programs, policies, and budget in early 2025, Germany emerged as the world’s largest provider of Official Development Assistance (ODA) in absolute terms. The country’s position as a leading donor dates back decades: its development cooperation agenda —focused on conflict prevention, climate and environmental protection, global health and food security— has been continuously supported by the country’s consensus-based politics, which kept the development budget expanding even through global shifts.
While Germany was already positioned as a significant contributor to the development ecosystem, its aid budget surged after 2014 due to a combination of geopolitical crises, domestic policy shifts, and a commitment to international targets. In 2015, the Syrian civil war saw Germany receiving over one million asylum seekers and migrants in a short period of time. While this spawned social debate, it also led the federal government to increase its aid budget, aiming to address the root causes of displacement. While in-donor refugee costs rose to 27% of the country’s ODA in 2016, driving part of the budget growth, this effort also helped Germany achieve the UN-recommended target of 0.7% of Gross National Income (GNI) directed to ODA.[1] It also positioned Germany as the second largest donor to both the UN Refugee Agency (UNHCR) and the World Food Program (WFP) in 2017.
Within its diverse development cooperation trajectory, Germany has also established itself as a central actor in international climate finance, consistently ranked among the largest bilateral providers of climate-related development finance. Successive federal governments have committed to scaling up international climate finance toward a €6 billion annual benchmark, positioning climate funding as a core development and foreign policy priority.2
The country’s position as a leading donor dates back decades: its development cooperation agenda —focused on conflict prevention, climate and environmental protection, global health and food security— has been continuously supported by the country’s consensus-based politics, which kept the development budget expanding even through global shifts
In 2020 the importance of international cooperation became more apparent than ever during the COVID-19 pandemic. This experience fueled the German Federal Ministry for Economic Cooperation and Development (BMZ, by its German acronym) to develop and introduce the “BMZ 2030” reform,3 aimed at making its cooperation efforts more strategic. This reform established the policy framework that positions development cooperation as a cornerstone of Germany’s first National Security Strategy, treating international solidarity and national security as 'two sides of the same coin,' and asserting that every euro invested in global peace and stability directly promotes security. Another major event, the war in Ukraine, also fueled Germany’s expenditure on assistance. By 2022, the country’s aid reached a record figure of 0.85% of GNI for development, with almost USD 40 billion net disbursements for that year.
This period consolidated Germany’s position as one of the few major donors consistently prioritising development at scale, while it also saw a strengthening in its commitment to global health initiatives. The country’s pledge to the Global Fund to Fight AIDS, Tuberculosis and Malaria reached a record €1.3 billion for the 2023-2025 period, following a total of €1.47 billion provided in 2020-2022 (which included €465 million for emergency COVID-19 response).4 This trajectory has recently shifted with an acute 23% drop in the €1 billion pledge to the Fund’s Eight Replenishment (2026-2028), a concerning sign coming from the Fund’s fourth major public donor. In terms of leadership, Germany was one of the first donors to announce its pledge, which provided much needed momentum for the Replenishment. However, this also acted as a double-edge sword, as the steep reduction set a concerningly low ceiling for other countries, further confirming the retreat from development assistance in favor of domestic fiscal consolidation.
2. Contradiction at the Heart of Germany’s Retreat from Development Cooperation
While the decrease in economic support for the Global Fund might be the most recent sign of Germany’s retreat as a main development actor, the country had already entered a marked downward trajectory in 2023. Total ODA fell from USD 37.9 billion in 2023 to USD 31.4 billion in 2024, a decline of approximately 17% in just one year, accompanied by a fall in ODA as a share of GNI from 0.82% to 0.67%, just below target. Budget projections confirm that this downward trend will continue, in the context of the continuous economic downturn the country has been facing since 2022.
Under the 2026 draft budget, ODA is expected to fall further to 0.52% of GNI, with the Finance Ministry’s Secretary of State forecasting a decline to 0.43% by 2029.5 These are levels last seen in 2014, effectively erasing more than a decade of progress and damaging Germany’s hard-earned strategic position in the development ecosystem. The BMZ budget has also been declining consistently. Currently at approximately €10 billion —almost 30% lower than in 2022—, the budget is projected to drop further until 2029, thereby falling below 2% of the federal budget, the lowest the country has seen in 15 years.6 This reduced budget proposal was published shortly after Germany reaffirmed its commitment to the 0.7% target at the 4th International Conference on Financing for Development (FfD4) in July 2025, making the policy reversal particularly stark and weakening the credibility of such international commitments and multilateral platforms.
Under the 2026 draft budget, ODA is expected to fall further to 0.52% of GNI, with the Finance Ministry’s Secretary of State forecasting a decline to 0.43% by 2029. These are levels last seen in 2014, effectively erasing more than a decade of progress and damaging Germany’s hard-earned strategic position in the development ecosystem
Although the rise in German ODA —similar to other countries— was driven by exceptional expenditures linked to the unprecedented inflow of refugees from Syria, the COVID-19 pandemic and the war in Ukraine, it reinforced Germany’s soft power and credibility as a central pillar of development cooperation. By contrast, while some of the recent decline can be attributed to a decrease in such needs, the scale, speed and accompanying political narratives of the current cuts suggest a more fundamental political shift.
The current budget trajectory reveals tensions between Germany’s stated development priorities, political commitments and corresponding fiscal allocations. While the 2026 Development Reform Policy describes development as a “central pillar” of Germany’s security and peace policy, key areas such as humanitarian aid and climate finance remain underfunded.7 Humanitarian assistance was cut by nearly 50% in 2025,6 reaching its lowest level in a decade, with no planned increase despite the Federal Foreign Office’s commitment in the Strategy for Humanitarian Assistance Abroad 2024.8 This comes at a time of record global humanitarian need and insecurity, and at the expense of Germany’s long standing reputation as one of the largest humanitarian donors. A similar pattern is visible in climate finance. Although Germany has long been a leading contributor to international climate funding, the country will likely fall short of the committed €6 billion annual benchmark due to budget cuts.9 Thereby, weakening both its climate justice commitments and its credibility in multilateral negotiations ahead of key forums such as COP30 and at a moment when climate finance is central to global equity, security and stability.
While government representatives continue to emphasise the development–security nexus, funding for preventive instruments —essential for addressing root causes of instability, such as humanitarian aid and climate financing— is declining, whereas defence spending is surging. Between 2024 and 2026, the BMZ budget is set to fall by over 11%, while the defence budget will increase by nearly 15%.10 This increase is supported by taking on substantial new debt of over €180 billion.11 Yet evidence consistently shows that prevention is cost-effective: an analysis by ONE estimates that every dollar invested in conflict prevention can save up to $103 in future crisis response costs.12 Redirecting resources away from development cooperation toward military expenditure risks proving counterproductive.
At the same time, funding appears increasingly concentrated on crises perceived to have a direct European security dimension, such as Ukraine, while engagement in parts of Latin America and Asia is being scaled back.13 This recalibration reflects a narrower interpretation of strategic interest and risks overlooking how instability in distant regions can ultimately affect European security. Reducing preventive investments in certain fragile contexts may ultimately generate higher costs —financial and political— through increased instability, displacement and the politicization of conflicts.
Government officials acknowledge the strain of the cuts while attempting to frame them as manageable within a broader strategic context. Development Minister Reem Alabali Radovan has acknowledged that while the reduced budgets are far less than what is needed, she stressed that German development policy will “remain effective” and is still far from the scale of cuts seen in the United States —framing the shift as a recalibration rather than a withdrawal.14 Meanwhile, actors on the far right are calling for even more drastic reductions. However, opposition figures and humanitarian organisations have criticised the cuts as unprecedented in scale, warning that they undermine Germany’s longstanding commitment to international solidarity and risk “militarising” development policy.15 These contrasting perspectives underscore the growing concern that the consequences of the reductions will not be confined to budget lines, but will be felt concretely in partner countries and vulnerable communities.
The new reform plan for development policy16 published by the Federal Ministry of Economic Cooperation and Development in January 2026 serves as confirmation of what they seek to achieve with this shift: effectiveness and efficiency. With it, the government intends to increase its focus on underfunded countries, especially the Least Developed Countries (LDCs), where aid can achieve the biggest impacts. Evidence-based implementation is also at the core of this new reform, aiming to prioritise the most impactful interventions and rolling back those less effective. While both measures are definitely the way forward in general terms, it is worth questioning whether they will be enough to soften the blow of such a steep defunding.
3. The Human Toll: Quantifying the Health Impacts of Funding Shortfalls
The effects of these reductions have begun to reverberate through the entire development cooperation ecosystem, and especially through communities and lives previously supported through German aid. In the humanitarian sphere, the nearly 50% cut between 2024 and 2025 is projected to leave around 4 million people worldwide without access to food assistance, alongside reduced access to clean drinking water in fragile and crisis-affected settings.14
Germany’s reductions in funding to major multilateral health institutions are expected to generate disproportionately large consequences relative to the limited fiscal savings achieved. According to analysis by ONE, the cumulative cuts of approximately €642 million to the Global Fund, GPEI, IDA, and UNFPA represent just 0.06% of the federal draft budgets for 2025 and 2026, yet could contribute to over 650,000 preventable deaths by 2029, leave 2.8 million children unvaccinated, and place tens of thousands more lives at risk.10 Beyond the human toll, the erosion of access to basic healthcare also implies the loss of billions of euros in potential economic returns, underscoring the strategic and economic costs of short-term fiscal retrenchment.
In the humanitarian sphere, the nearly 50% cut between 2024 and 2025 is projected to leave around 4 million people worldwide without access to food assistance, alongside reduced access to clean drinking water in fragile and crisis-affected settings
As a whole, the perspective of German ODA falling below 0.5% of GNI paints a grim picture for the future, and the impact will be felt in many countries. In order to better understand this toll, the IMPACThealth research group at ISGlobal has conducted an analysis based on the potential lives saved between 2023 —the year the decline started for German development assistance— and 2030 in 128 low- and middle-income countries (LMICs) that have received German ODA, and how would aid reductions affect this figure.
No empirical evidence has been published yet on the specific impact of German aid on mortality. Therefore, this study relied on impact measures obtained from a previous study17 analysing the effect of different levels of per-capita funding from the U.S. Agency for International Development (USAID) in LMICs. While German and American aid differ in scale, sectorial composition and channels, the leading role of Germany as a pillar for development cooperation makes this a viable comparison. 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 German ODA funding on mortality rates in recipient countries. In order to make the estimates more reflective of reality, while the study on USAID took into account exclusively funds channeled through the agency, for the German estimates we took into account multilateral contributions based on per-country funding imputed by the ONE campaign, given Germany’s multilateral presence and efforts. While no causality can be drawn from this analysis, working under the assumption that German and US aid can be similarly effective is useful to show how changes in ODA funding per capita could potentially impact mortality rates. While recognising that sector-specific allocation is relevant to assessing the effects of ODA on health, we have focused on overall ODA disbursements and assumed a direct effect on mortality. For this analysis, 2022 was used as a reference year since it was the year Germany achieved the landmark 0.85% of GNI for development, investing over USD 40 billion, later starting its downward trajectory the following year.
According to estimates by analysts at SEEK Development —as consulted at the time of the analysis in December 2025; current figures might differ as projections are dynamic—, German ODA was cut by USD 1 billion in 2023. While this is not a negligible figure, especially when contextualised among funding gaps of other donors and given the potential impact of this sum on the development ecosystem, it accounted for only a 2.6% cut on Germany’s development expenditure (from $40,2bn down to $39.2bn). Regrettably, 2024 saw it falling further by 16%, losing USD 6.3 billion in the process and dropping below the 0.7% of GNI target. Cutting didn’t stop there, as USD 5.8 billion were further slashed in 2025. Although future decreases are projected to happen at a slower pace, overall cuts will amount to almost 37% between 2022 and 2026. While the German Finance Ministry’s State Secretary has stated the intention to cut to 0.43% of GNI for development by 2029 —an additional loss of approximately USD 3 billion when compared to the expected 2026 expenditure—, in this study we opted to assume constant funding from 2027 onwards, as this might be subject to change.
For this scenario analysis, we started with the assumption that German aid is as effective as US aid and, therefore, modifications in Germany’s ODA funding flows 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 German aid flows.18 We then compared these figures with a scenario where aid flows would have remained constant from 2022.
Under this hypothesis of similar effectiveness between German and US aid, 9,384,027 deaths would be averted in 128 countries between 2023 and 2030 under the important reduction in ODA scenario. However, if aid flows had remained at 2022 levels, an additional 2,891,570 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 intervals19 are shown in Annex 1.
While these results are to be interpreted cautiously, they do provide an understanding of the implications of Germany’s budgetary 'recalibration'. Crucially, they expose the widening gaps between Berlin’s stated global commitments, its real fiscal commitment, and the actual effects in implementing countries. German aid had the potential to avert over 1.5 million deaths each year leading up to 2030, had the country maintained its leadership through sustaining the 0.85% of GNI milestone. A persistent defunding trend might hinder this potential, ceasing to avert over 361,000 deaths each year and almost 2.9 million for the eight-year period.
4. Conclusions and Recommendations: Pathways for Political Consensus on Aid Budgeting under Fiscal Constraints
The current erosion of German ODA represents more than a budgetary shift; it is a fracture in the long-standing political consensus that established Germany as a "stability anchor" in global development and multilateralism. The constant tension between expressed intentions and actual monetary commitments is starting to fracture the country’s credibility. The current Development Minister has consistently tried to distance Germany’s budgetary changes from those of the United States, declaring they are “a long way off American conditions —and that's how it should be”.14 In the meantime, the United States congress continues to push back against the cuts, while in Germany there is currently limited political opposition to this trajectory. With some labelling the arguments against the cuts as “alarmist”, and others pushing for even deeper defunding, NGOs and global health actors have a difficult fight ahead. At the same time, while public support for development cooperation in Germany has diminished in recent years (going from 68% in January 2020 to 54% in January 2025),20 the majority of the population still thinks the country should keep or increase its aid budget. Neglecting poverty reduction and global health should not be an electorally viable option.
The latest German development policy reform might have set a good foundation to move forward around the principles of effectiveness and efficiency. However, at this scale of reduction, the mandate to “achieve more with less” risks becoming mathematically impossible
The latest German development policy reform might have set a good foundation to move forward around the principles of effectiveness and efficiency. However, at this scale of reduction, the mandate to “achieve more with less” risks becoming mathematically impossible. The arguments presented in this document provide an understanding of the projected impact of current funding gaps. In order to safeguard Germany’s international standing and protect critical gains in global health, we issue the following policy recommendations:
- Uphold the 0.7% of GNI for ODA commitment. Germany’s historical adherence to the UN-mandated 0.7% target has been the cornerstone of its diplomatic influence and reliability. A gradual but binding annual increase —shielded from ad hoc fiscal adjustments— would restore predictability, protect Germany’s diplomatic credibility, and allow multi-year planning in partner countries and multilateral institutions.
- Ring-fence humanitarian aid and global health as core security instruments. Establishing a minimum budget floor or legal safeguard could serve to mitigate the impact of fiscal volatility on humanitarian assistance and global health funding. At a time of record global need, reducing preventive and stabilising instruments while increasing defence expenditure weakens Germany’s own security architecture. Development and defence must be understood as complementary, not competing, pillars of stability.
- Align multilateral ambition with financial commitments. The current development reform states that the BMZ’s activities in the health sector will be primarily implemented through multilateral cooperation. The strategic pivot toward multilateralism is only credible if supported by stable and sustained funding for core global health institutions. Current budgetary reductions to The Global Fund and Gavi create a gap that undermines the very architecture Germany claims to prioritise. Maintaining leadership within these platforms requires aligning multilateral engagement with predictable, multi-year pledges to support the operational capacity of these organisations.
- Ensure that efficiency does not become a pretext for structural defunding. The 2026 development reform rightly emphasises effectiveness and strategic focus, particularly in the Least Developed Countries, where funding is more critical. However, efficiency gains cannot compensate for such steep reductions in volume. The federal government should define minimum operational thresholds for priority sectors —health, climate, humanitarian response— to ensure that reform strengthens impact rather than legitimises retrenchment.
- Rebuild cross-party consensus on development as a pillar of both global solidarity and national security. Germany’s leadership in development cooperation rests on the understanding that moral responsibility and strategic interests are inseparable. The strength of this approach rested on the kind of broad political consensus that has characterised national politics up to this day. A structured parliamentary review process —engaging civil society, academic institutions, and implementing partners— should reassess the strategic role of development policy within Germany’s National Security Strategy, ensure better communication of historical development gains with society, and honour the country’s historical commitment to global solidarity.
- Institutionalise accountability through annual impact reporting: To reconnect public support with policy decisions, the federal government should publish an annual balance sheet quantifying delivery, potential impact, and economic returns generated by German ODA. Making impact visible would strengthen democratic legitimacy and counter narratives that frame development cooperation as discretionary charity rather than strategic investment.
Annex 1. Methodology summary. Analysing the impact of Germany’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 German 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 corresponded to the peak in funding levels and preceded 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 Germany’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. 128 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.21 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.22 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 German ODA funding 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 128 countries.
Although the structure and sectoral composition of German 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 German 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* |
|---|---|---|---|---|
| 12 195 720 | 9 384 027 | 5 220 189 | 13 577 607 | 2 891 570 |
*Reported results are drawn from Monte Carlo simulations
Limitations
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 analyzed. Because Germany and other major donors’ ODA differ in structure, allocation mechanisms, and sectoral composition, the true rate ratios associated with German funding may differ, and the USAID-based estimates could mask the actual effect of Germany’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 German ODA at the time these analyses were developed. Further analyses, using specific models and estimates from Germany 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 | Cameroon | Central African Republic |
| Chad | China | East Timor | Ecuador |
| Egypt | El Salvador | Equatorial Guinea | Eritrea |
| Eswatini | Ethiopia | Federated States of Micronesia | Fiji |
| Gabon | Gambia | Georgia | Ghana |
| Grenada | Guatemala | Guinea | Guinea-Bissau |
| Guyana | Haiti | Honduras | India |
| Indonesia | Iran | Iraq | Ivory Coast |
| Lesotho | Libya | Macedonia | Madagascar |
| Malawi | Malaysia | Maldives | Mali |
| Marshall Islands | Mauritania | Mauritius | Mexico |
| Moldova | Mongolia | Montenegro | Morocco |
| Mozambique | Myanmar | Namibia | Niger |
| Saint Lucia | Senegal | Serbia | Sierra Leone |
| Solomon Islands | South Sudan | Sri Lanka | Sudan |
| Suriname | Syria | Tajikistan | Tanzania |
| Thailand | Togo | Tonga | Tunisia |
| Turkey | Turkmenistan | Uganda | Ukraine |
*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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13. Ahmed K. Sweden and Germany slash aid budgets to focus on Ukraine and defence spending. The Guardian; 21 Dec 2025. Available from: https://www.theguardian.com/global-development/2025/dec/21/sweden-and-germany-slash-aid-budgets-to-focus-on-ukraine-and-defence-spending
14. Fürstenau M. Germany slashes aid and development budget. Deutsche Welle (DW); 21 Sep 2025. Available from: https://www.dw.com/en/germany-slashes-aid-development-budget/a-74066633
15. DevelopmentAid. Germany’s aid cuts under fire. 12 Aug 2025. Available from: https://www.developmentaid.org/news-stream/post/198806/germanys-aid-cuts-under-fire
16. Federal Ministry for Economic Cooperation and Development (BMZ). Shaping the future together globally: reform plan. Bonn: BMZ; 2025. Available from: https://www.bmz.de/resource/blob/288188/reform-plan-shaping-the-future-together-globally.pdf
17. 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
18. This analysis is based on the Population Preventable Fraction (PPF): the proportion of cases of a disease or adverse event in a population that could be avoided if a specific risk factor was eliminated or an effective intervention was implemented.
19. 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.
20. Oh S. DEL Dashboard – Germany June 2025. London: Development Engagement Lab; Jun 2025. Available from: https://developmentengagementlab.org/wp-content/uploads/2025/06/Germany-Dashboard-June-2025.pdf
21. Strain T, Brage S, Sharp SJ, Richards J, Tainio M, Ding D, Kelly P. Use of the prevented fraction for the population to determine deaths averted by existing prevalence of physical activity: a descriptive study. The Lancet Global Health. 2020;8(7):e920-e930.
22. 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
