Financially independent from the United States (US), Médecins Sans Frontières has abruptly discovered its autonomy is merely an illusion. Drastic cuts in US aid have revealed systemic interdependence, from vaccines to humanitarian flights and health staff. According to the author, the organisation has now realised it has been an integral part of a system it has legitimately criticised for decades.
When, on 29 January 2025, the first administrative chainsaw was wielded in the form of stop-work orders for all humanitarian programmes funded by the United States Agency for International Development (USAID), the immediate public response from Médecins Sans Frontières (MSF) was – with a pinch of smugness – that “MSF does not accept US government funding and our programmes will not be directly affected”, but that “the massive role that the United States government plays in funding international aid cannot be rapidly filled by others”.[1]Médecins Sans Frontières, Freezing US foreign aid will result in humanitarian disaster, 2 February 2025, https://www.msf.org/freezing-us-foreign-aid-will-result-humanitarian-disaster These were both factually correct statements, but they sounded like MSF was saying “we are fine, but others beware!”, consistent with decades of public positioning where MSF has talked about the failings of the aid system as if it were not part of it.
The limits of independence from US funding
However, reality hit home very quickly as MSF project teams around the world, working closely with and within this aid system, started to raise the alarm that this time it was different. Many of the partners they were working with on the ground were financed by USAID and were telling the MSF teams they were no longer certain if many of the services MSF relied on would still be there in the next days or weeks. MSF hospitals and clinics may have been shielded from the cuts, but they formed part of a wider system that was not. Medical supplies and, crucially, medical staff often came through US-funded mechanisms of local health ministries. MSF health facilities relied on the ability to refer patients to other clinics that other US-funded organisations were managing. This interdependence was also true for the wider humanitarian ecosystem, as noted early on by Devex, using Oxfam as an example:
“Humanitarian aid and global development function as a network – or, as Grisgraber termed it, an ecosystem – made up of players ranging from philanthropic funders to international NGOs to community-based organizations. Oxfam America may not take USAID funding, but that funding remains crucial to many of the organizations it partners with to carry out its work. When one of the organisms in an ecosystem suddenly vanishes – or finds itself defunded, as the case may be – the ripple effects are significant.”[2]Lauren Evans, The fall of USAID changed everything – even for those it didn’t fund, Devex, 13 March 2025, … Continue reading
It turns out that MSF’s financial independence – reducing the level of government funding to less than 2% of its annual €2.36 billion budget in 2024 – does not translate so easily into actual operational or medical independence. The wider government-funded aid system, also led by the United Nations (UN), was crucial to keep MSF programmes running.
Immediate consequences for MSF projects
As the dust settled on the first panic about the stop-work orders, MSF conducted an analysis on the immediate consequences of the cuts for its projects. A sector analysis concluded that the most immediate bombshells were expected in specific countries, as USAID funding priorities and MSF operational priorities appeared to be largely similar. Countries with high USAID dependency (Afghanistan, South Sudan, Democratic Republic of the Congo [DRC], Sudan, Uganda, Nigeria, Haiti and Somalia) overlapped with MSF’s top fifteen priority countries, where roughly 1 billion of the total 1.5 billion operational budget for 2023 was spent. Except for Yemen, all other countries were countries where US funding accounted for between 45% and 85% of total humanitarian assistance. The effects of this are expected to accelerate towards the end of 2025 as more US-funded services close, increasing the number of patients in remaining MSF facilities.
Also, whilst the 2% level of government funding represents direct financial contributions (largely from three remaining funder countries: Japan, Switzerland and Canada), MSF also receives many in-kind goods and services on project level that are, in turn, financed by the US or other governments’ official development assistance (ODA) budgets. Medical commodities include donations of vaccines, Plumpy’Nut, tuberculosis (TB) medication, human immunodeficiency viruses (HIV) medication, cholera kits and malaria nets, donated through local health ministries or directly to MSF by the United Nations International Children’s Emergency Fund (UNICEF), the World Health Organization (WHO) or global health funding organisations such as the US President’s Emergency Plan for Acquired Immunodeficiency Syndrome (AIDS) Relief (PEPFAR), the Global Fund or the Global Alliance for Vaccines and Immunisation (GAVI). Exact figures are still hard to extract on a global level, but the estimate so far is that MSF received between €10 and €30 million worth of in-kind donations annually. A less obvious form of dependence spotted early on was MSF’s reliance on the ODA/US-funded United Nations Humanitarian Air Service (UNHAS) to run projects in hard-to-reach places. These flights are often the only way to reach critical projects, offering highly subsidised rates for humanitarian staff and cargo. This MSF dependence amounts to around 20,000 seats (pax) for MSF staff and 180 metric tons of supplies annually, concentrated in highly inaccessible places in Afghanistan, Haiti, Chad and Nigeria. If MSF has to fully finance these air movements, it would cost roughly €30 million annually. However, in practice, many routes remain, so initial cuts will probably only add a few million to the MSF budget. Clearly, even the maximum budget risk of 60 million does not present an extinction-level event for the current MSF operational budget of around 1.8 billion, but just having the money is often not an immediate fix. Many of the commodities are either highly restricted (such as vaccines) or highly regulated (such as flight operating licenses), where it can take time for MSF to create the legal and logistic expertise to replace these.
Moreover, the outsized role US funding played in the bilateral financing of national health ministries is expected to have a high impact for MSF – not just from USAID, but also other US State Department mechanisms and other funding and technical support through the US Department of Health and Human Services (HHS – the US health ministry) and the US Centers for Disease Control and Prevention (CDC). Few of the affected ministries have raised the alarm publicly, but privately acknowledged the severity of the funding with a major funding cliff expected by mid-2026. Most affected are services for HIV/AIDS, malaria, TB, immunisation, and health workforce development. They are now revising budgets, focusing on direct patient care and cutting “lower-priority” services such as prevention and surveillance. Many staff previously funded by the US have been laid off. MSF estimates that 70% of its projects are in collaboration with health ministries, especially relying on seconded health ministry staff to populate health facilities. Furthermore, the expected cuts in prevention activities could lead to an increase in patients and cuts in surveillance could mean response to disease outbreaks will be later and larger. So far, MSF has already increased budgets to cover emergency orders of therapeutic food and essential medicines in Mali, Niger and South Sudan and malaria commodities in DRC. MSF has also taken over water delivery in Haiti and some health services in Burkina Faso, DRC and Yemen, as US-funded organisations were forced to close.
An aid system built on Western funding
These USAID brutal and immediate cuts shocked the aid system, but it was a system already in decline as many European funder countries had already reduced their aid budgets in 2024, before the US did so in 2025.
On the US side, on 10 March, Secretary of State Marco Rubio announced that out of 6,200 USAID programmes worth $120 billion, around 1,000 contracts would remain, just 17% of all contracts, including nearly all grants to Yemen and Afghanistan.[3]Humeyra Pamuk, “Trump administration scraps over 80% of USAID programs, top diplomat Rubio says”, Reuters, 10 March 2025, … Continue reading Details were sparse at that time, with many waivers announced shortly after. The final tally showed, according to the New York Times,[4]The New York Times, “What remains of USAID after DOGE’s budget cuts?”, 22 June 2025. that 891 contracts remained, as of 7 May, totalling $69 billion. So, although in terms of number of contracts, USAID has been almost completely dismantled, in terms of budget, the cuts are more in line with the long-term ODA trend: 51 billion, or 42.5% of the budget, was cut. These cuts have disproportionately affected the health sector. The Lancet quantified the impact of specifically USAID health funding on mortality rates in the last two decades before the cuts, to get an idea of the impact of defunding USAID:
“We calculated the associations between different levels of USAID funding per capita and decreases in mortality by group of causes […]. The strongest association was found for HIV/AIDS with a 65% reduction, followed by malaria with 51%, and neglected tropical diseases with 50%. Strong associations were also found for diarrhoeal diseases, nutritional deficiencies, lower respiratory infections, maternal mortality, and tuberculosis.”[5]Daniella Medeiros Cavalcanti, Lucas de Oliveira Ferreira de Sales, Andrea Ferreira da Silva et al., “Evaluating the impact of two decades of USAID interventions and projecting the effects of … Continue reading
The current US government’s intentions for wider ODA cuts became clearer when, on 30 May, the State Department published its budget request for Congress[6]United States Department of State, Foreign Operations, and Related Programs, Congressional Budget Justification, Fiscal year 2026, August 2025, … Continue reading for the next US fiscal year, running from October 2025 to September 2026. This budget asks for $3.8 billion for global health programmes, down from $10 billion requested in 2024, and $4 billion for international humanitarian aid, down from $9 billion in 2025. The proposal eliminates funding for family planning and reproductive health, neglected tropical diseases, and non-emergency nutrition, and massive reductions for malaria, TB, and maternal and child health. The PEPFAR would shrink from $4.73 billion to $2.91 billion, a cut of roughly 40% again. US contributions to GAVI would drop to zero. And the US contribution to the Global Fund (to fight AIDS, TB and Malaria) has not been yet specified, but indications suggest a significant reduction is to be expected.
The wider picture of ODA contributions is more mixed, with some countries maintaining their ODA budgets, a few even increasing, but overall there has been a reduction from the 2023 peak. The seven European funder countries that have already confirmed cuts (France, Germany, Italy, Switzerland, Belgium, the Netherlands and the United Kingdom) show an overall curve of reductions, in billions of euros, from 85.5 in 2024 to 77.8 in 2025 (a 9% cut) and to 70.9 in 2026 (another 9% cut). According to the ALNAP Global Humanitarian Assistance report 2025:
“Deeper cuts in 2025 could see humanitarian assistance from government donors drop by nearly a half (45%) by the end of the [year] 2025 compared to the peak reached in 2023. […] The optimistic scenario is that funding will fall by over a third (34%) by the end of 2025.”[7]Mike Pearson, Fran Girling-Morris, Suzanna Nelson-Pollard et al., Global Humanitarian Assistance 2025, ALNAP, 19 June 2025, … Continue reading
The UN aid architecture is particularly hard hit, UN so far confirming budget reductions for OCHA (20%), the UN World Food Programme (40%), the UN High Commissioner for Refugees (30%), the International Organization for Migration (30%), WHO (45%) and UNICEF (25%).
We are the international community
As ODA funding for the UN and the wider traditional aid system largely comes from the Global North, appeals to the so-called “international community” are largely understood in the Global South as appeals to Europe, Japan and the parts of Europe that forcibly replaced populations in North America (the US and Canada) and the Pacific (Australia and New Zealand). This revealed another crucial interdependence of MSF, as its public advocacy relied heavily on these types of appeals to the “international community”. Looking at MSF’s public advocacy messages of the last two decades, they can be summarised in just five urgent calls: breach of international law (usually IHL with a focus on respect for medical missions), lack of humanitarian access to populations, lack of access of populations to healthcare, using humanitarian aid for political or military purposes, and, finally, the most common one: unrecognised urgent medical and humanitarian needs.
“This leaves MSF with a dilemma. Who are we appealing to now?”
These alerts about unrecognised or under-serviced medical humanitarian needs are then followed by so-called “calls to action”, usually asking other organisations (meaning the UN and Western humanitarian organisations) to do more and asking state funders of aid (in practice, in the Global North) to give more money to these other organisations (as MSF does not accept money from most of them). These common and almost habitual calls for others to do more became outdated overnight. Most of the other organisations (the UN and largely Western-based private international humanitarian organisations) have announced major cuts to their budgets, workforce and the closure of many projects, and most of these state funders have announced significant cuts – the US being now in front. So, asking them to do more and pay more now sounds out of touch and naïve. As MSF experienced in its projects that these cuts are, in fact, its cuts as well, it was clear that this Western aid community was our partner all along. As these partners and their traditional Western-led aid system are today in financial – and possibly moral – decline, this leaves MSF with a dilemma. Who are we appealing to now? Are we calling on non-Western funders – countries often involved in conflicts or linking aid to cynical military or political objectives – to step in? Are we rejecting this for the same reasons why MSF rejected money from the US and, later, the whole European Union and its member states?
Meanwhile, the wider aid community was already forced by the cuts to suggest a direction for the new, reduced traditional aid system, the UN being in front with a proposal, in April this year, for what they call the “humanitarian reset”. The UN Inter-Agency Standing Committee (IASC) proposed to “prioritize saving lives based on greatest needs, consolidating mandates and services” and “make local participation and communication with affected communities standard practice”.[8]IASC, Recommendations: Reimagining the Humanitarian System, Deputies Group internal memo, 17 April 2025. Whilst presented as a more inclusive approach, it has a distinct feel it is mainly designed to be a cost-cutting exercise – fewer projects, merging overheads and implementation through (cheaper) local partners. Or, as described in The New Humanitarian:
“The reset process is run and overseen at the IASC principals level – essentially leaving the people who have the most power in the system with the task of reimagining it”[9]Irwin Loy, “The humanitarian ‘reset’ takes a step forward this week. But for many, the bigger question is: What comes next ?”, The New Humanitarian, 16 June 2025, … Continue reading [because] “the humanitarian sector undermines itself by a pervasive competitive mindset that incentivises institutional expansion over cooperation. The result is that power and resources are heavily concentrated with UN agencies and big INGOs. They are perpetually unwilling to substantively cede power and resources to local and national actors, whether affected populations, civil society, or states”.[10]Dustin Barber, Anita Kattakuzhy and Ruby Johnson, “Beyond the reset: Five priorities for genuine humanitarian transformation”, The New Humanitarian, 19 June 2025, … Continue reading
At the same time, the UN, as well as the wider international aid system, is scrambling to find alternative sources of income and wean itself off dependence on the US and the mainly Western ODA system, discovering that many alternative sources are already on the ground, choosing to operate outside the UN and UN-led funding mechanisms. One of the many reports published this year by various think tanks points out that “financial fluency beyond ODA remains limited”, using the example of capital flows through faith-based systems like the Islamic “zakat” (estimated worth 550 billion) and capital flows through diaspora-generated remittances (estimated worth 647 billion) in 2022. Both these figures are larger than the combined Western ODA. They also highlight that “low- and middle-income countries now have a wider range of options as governments including China, Russia, United Arab Emirates (UAE), Türkiye and Saudi Arabia offer alternative development and security partnerships”[11]Suleiman Abdullahi, Damian Lilly and Lydia Poole, Reckoning And Renewal: A Future-Ready Humanitarian System, ALNAP, June 2025, … Continue reading – bilateral arrangements bypassing UN system entirely.
Is MSF, or other actors, needed at all?
“After years of complaining we were stuck in the traffic, we suddenly realised we were the traffic.”
After years of complaining about an inadequate humanitarian aid system, including campaigns such as “Where is everyone?”,[12]Sean Healy and Sandrine Tiller, Where is everyone? Responding to emergencies in the most difficult places, Médecins Sans Frontières, 6 juillet 2014, https://www.msf.org/msf-report-where-everyone MSF was suddenly forced to look in the mirror. To use a metaphor, after years of complaining we were stuck in the traffic, we suddenly realised we were the traffic.
The “international community” – the Global North – has turned its back on the field of international solidarity and humanitarian aid as long as it does not meet their domestic needs like controlling migration, curtailing terrorism or keeping epidemics from their borders. Many in the Global South do not mourn the demise of a system that remained rooted in a post-colonial mindset and see this as a necessary change. They now demand taking the lead in the humanitarian response for their own communities.
If MSF can hold on to its private fundraising – still coming largely, albeit with increased competition, from a more cynical public in the Global North – it needs to decide how to navigate this contradiction: being part of, and reliant on, an outdated aid system it routinely criticised as ineffective and inappropriate, whilst claiming to speak on behalf of populations who reject this aid system and demanding agency in decisions on humanitarian response.
Specialised medical care will doubtless remain in demand, regardless of the politics. And in situations of conflict where civilians become the target, an international presence such as that of MSF will remain relevant and welcome. But now, who are those “others” who should do more? And how can agency in response and decision-making genuinely be that of affected people and communities? National governments can and do take more ownership, as do local civil societies and local businesses and foundations. But do they really need MSF to tell them to do more – or do they even need MSF to be the one that comes and does it?
Picture credit : © Embajada de EEUU en Argentina
