VIEWPOINT SERIES: FIGHT FOR RIGHTS

Beatrice Were and Vanessa Okumu-McCarron

Uganda has been a pioneer in combating HIV, spearheading a multi-sectoral response coordinated by the Uganda AIDS Commission.[1] Between 1990 and 1995, through its AIDS Control Program and collaboration across ministries, civil society, and communities of people living with HIV, Uganda achieved significant progress, reducing HIV prevalence among pregnant women from 30% to 15%.[2] This established Uganda as a global benchmark, and the success attracted more development partnerships. Today, 95% of people living with HIV in Uganda—including over 90% of pregnant women—receive life-saving antiretroviral treatment.[3] These accomplishments are a testament to Uganda’s unwavering courage in the face of an existential threat.

While celebrating these achievements, Uganda must address a critical vulnerability: its heavy reliance on foreign aid for health financing. According to the World Bank, donor aid constitutes over half of Uganda’s annual health budget; meanwhile, the government of Uganda contributes only 8%, private community-based insurance schemes cover another 8%, and households are left to cover the remaining 33% through out-of-pocket payments.[4] Donor funding accounts for 85% of HIV financing and over 90% of the malaria budget, starkly contradicting the country’s Abuja Declaration pledge to allocate 15% of its annual national budget to health.[5] By outsourcing health financing to external actors, Uganda is abdicating its obligation to ensure the right to health for its people, treating health as a charity or privilege rather than a fundamental human right.

The perils of dependency

“Give someone the power to feed you, you give them the power to starve you.”

—African proverb 

For decades, foreign aid has been crucial in financing life-saving treatment and prevention efforts. However, the Trump administration’s recent freeze on foreign aid has exposed the fragility of this dependence. The unpredictability of such aid leaves critical programs vulnerable, destabilizing communities that depend entirely on them. Without immediate action in Uganda, decades of progress are at risk of unraveling, potentially triggering a national crisis whereby millions are exposed to increased infections and mortality.

AIDS: Ghost of the 1990s is knocking at the door

The US President’s Emergency Plan for AIDS Relief (PEPFAR) and the United States Agency for International Development fund HIV prevention, testing, and sexual and reproductive health programs, including antenatal care, early infant diagnosis, and treatment. As reported by PEPFAR, as of September 2022, nearly all 1.3 million people living with HIV in Uganda were receiving PEPFAR-supported antiretroviral therapy. This averted approximately 500,000 HIV infections, including among 230,000 infants, and prevented 600,000 HIV-related deaths.[6]

The Trump administration’s abrupt freeze on foreign aid represents a reckless abdication of international obligations. By reneging on commitments, the United States undermines decades of global health progress, disregarding principles of shared responsibility underpinning global health security. The cuts are especially alarming given the interconnected nature of health, where epidemics can rapidly escalate into global crises, as seen with COVID-19. These actions erode trust in international partnerships and set a dangerous precedent for abandoning critical health initiatives, consequently undermining the very foundations of international cooperation. US leadership in global health is both a moral and a strategic imperative, vital to safeguarding lives and global stability, as emphasized in the United Nations General Assembly Special Session on HIV/AIDS Declaration of Commitment on HIV/AIDS.[7]

Between 2010 and 2022, the mother-to-child transmission rate in Uganda dropped by 77%, a milestone now in danger.[8] Uganda is systemically ill-equipped to make up the loss of funding, risking a resurgence of new infections due to shortages in antiretroviral medications and human resources, and risking the emergence of drug-resistant HIV, which is five to ten times costlier to treat. Heavy dependence on now-suspended external financing jeopardizes Uganda’s ability to fulfill its people’s right to health.

Interruptions in antiretroviral therapy heighten the risk of AIDS-related complications for HIV-positive pregnant and breastfeeding women and are likely to cause a resurgence in mother-to-child transmission. This could heighten Uganda’s rates of AIDS-related infant mortality, reawakening the anguish of the 1990s.

The looming plight threatens the achievement of the 95–95–95 global targets for testing, treatment, and viral suppression—a roadmap for ending AIDS by 2030. Notably, UNAIDS reported in 2023 that by 2021, Uganda was nearing these goals, with 89% of people living with HIV aware of their status, over 92% on antiretroviral therapy, and 95% of those on treatment virally suppressed.[9]

Tuberculosis: A silent reaper poised to strike

Insufficient health funding also risks propelling tuberculosis—already the leading cause of death among people living with HIV—into a crisis of drug resistance, further burdening Uganda’s fragile health system. The World Health Organization estimates that 91,000 Ugandans contract tuberculosis annually, that 2% have multidrug-resistant tuberculosis (MDR-TB), and that more than half of tuberculosis-related deaths occur among people living with HIV.[10] Untreated tuberculosis accelerates the progression of HIV into AIDS. The United States funds tuberculosis prevention and treatment programs. Disruption caused by the freeze will lead to a lack of medicines, leaving many people untreated and enabling them to spread tuberculosis to others, causing a surge in new infections. Additionally, those already on treatment may miss their doses, increasing the risk of developing resistance to first-line drugs. These individuals can then spread drug-resistant strains to the public, exacerbating the crisis. This cycle of non-adherence and drug resistance will further strain Uganda’s health care system and undermine global efforts to combat tuberculosis. This exposes the public to MDR-TB, which costs 20 times more to treat than drug-susceptible tuberculosis. Uganda lacks the capacity to manage MDR-TB outbreaks, increasing the likelihood of a public health crisis. Donor funding enables 90% of tuberculosis patients to be tested for HIV, and vice versa. The freeze will decimate this synergy and undermine the investments made in prevention, treatment, and care.

Malaria: A prolific serial killer on the loose

Malaria, Uganda’s leading cause of death, endangers nearly the entire population: it accounts for 30%–50% of outpatient visits and 15%–20% of hospital admissions, primarily affecting children under five and pregnant women.[11] Malaria in pregnancy increases risks of fetal complications and maternal mortality, hindering progress toward Sustainable Development Goal 3.[12] With nearly 90% of the country’s malaria budget reliant on foreign aid, prevention and treatment programs now face potential disruption. Without this aid, households will bear the full out-of-pocket costs of malaria treatment, deepening the crisis as stockouts occur and families struggle to afford care.[13]

Inadequate investment has exacerbated disparities, with households covering approximately 70% of the cost of malaria treatment and management regardless of their socioeconomic status. The funding freeze intensifies this inequity, shifting the entire burden onto the public. This contravenes World Health Organization standards on universal health coverage and the International Covenant on Economic, Social and Cultural Rights, which mandates equitable and affordable health care as a fundamental human right.[14]

A system in collapse

Uganda’s health system is already overwhelmed, with infrastructure crumbling and communities being ravaged by preventable, treatable, and manageable diseases such as HIV, as well as curable ones such as tuberculosis and malaria. The COVID-19 pandemic exposed critical gaps in the health system’s infrastructure, demonstrating the urgent need for transformative investment. The freeze will compel an ill-equipped Uganda to fight a tripartite pandemic (HIV, tuberculosis, and malaria), reversing decades of progress toward epidemic control.  

Without urgent action, the consequences could surpass those of the 1990s epidemic, exacerbated by drug-resistant strains. Uganda cannot withstand the human and socioeconomic toll of such a catastrophe.

Persistent underinvestment in health grossly contravenes Uganda’s obligation to uphold the right to health as enshrined in national, regional, and international frameworks.[15] This perpetuates systemic violations of the population’s rights to health, life, and dignity.

Call to action

Averting this crisis demands a robust strategy by the Ugandan government to resolve the glaring systemic shortfalls and to create a resilient and self-sustaining health system:

• Prioritization of health financing: Reallocate components of the national budget toward an immediate contingency plan to manage this state of emergency.
• Domestic financing: Urgently mobilize funds to offset the freeze and sustain life-saving HIV, tuberculosis, and malaria programs. Explore innovative financing mechanisms, such as the AIDS Trust Fund and national health insurance, to reduce household out-of-pocket costs.
• Access to essential medicines: Invest in local pharmaceutical production to reduce external reliance and prevent stockouts.
• Accountability: Publish real-time data on the rapid response strategy for transparency and the meaningful participation of the public, civil society, and private.

The cost of inaction is immense—not only in terms of lives lost but also because it will perpetuate a cycle of epidemics and a crumbling health system, deepening the country’s reliance on donor aid. This crisis has potential to escalate into a regional catastrophe, similar to other pandemics such as Ebola and COVID-19.

In the 1990s, Uganda proved that political will, innovation, and multisectoral engagement could overcome the most daunting health challenges. Today, similar stewardship is urgently needed to galvanize a collective regional response and avert disaster. Prioritizing health funding by investing in people’s well-being is transformational and could again inspire other countries in the region.

Foreign aid, while invaluable, often comes with strings attached that promote donors’ agendas rather than Africa’s priorities. True sovereignty cannot coexist with overreliance on external support.

Recognizing health as a human right obligates governments to ensure available, accessible, acceptable, and high-quality prevention and treatment services, as articulated in article 15 of the International Covenant on Economic, Social and Cultural Rights.[16] The abrupt cessation of US funding is irresponsible; in response, Africa must accelerate a unified, robust, and sustainable health agenda rooted in equity and innovation.

Africa must build and resuscitate its health systems to make them resilient enough to ensure that the health of its people no longer hinges on the whims of foreign aid and where the phrase “African solutions to African problems” becomes a lived reality.

Beatrice Were, MA, is a policy, human rights, and AIDS advocate in Uganda.

Vanessa Okumu-McCarron, PMP, LLB, is a lawyer and project manager in New Hampshire, United States.

Please address correspondence to Beatrice Were. Email: beatrice.were@gmail.com.

Competing interests: None declared.

Copyright © 2025 Were and Okumu-McCarron. This is an open access article distributed under the terms of the Creative Commons Attribution-Noncommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

References

[1] G. Slutkin, S. Okware, W. Naamara, et al., “How Uganda Reversed Its HIV Epidemic,” AIDS Behavior 10/4 (2006).

[2] M. M. Alsan and D. M. Cutler, “Why Did HIV Decline in Uganda?,” National Bureau of Economic Research Working Paper 16171 (revised 2012). 

[3] UNICEF Data Warehouse, “Per Cent of Pregnant Women Living with HIV Receiving Effective ARVs for PMTCT (Excludes Single-Dose Nevirapine): Cross-Sector Indicators” (2023), https://sdmx.data.unicef.org/overview.html.

[4] G. Nangayi, “Surging Out-of-Pocket Health Spending Threatens to Cause Financial Ruin for Millions in Uganda,” Development Aid (September 24, 2024), https://www.developmentaid.org/news-stream/post/185061/surging-health-spending-in-uganda.

[5] Alliance for Health Policy and Systems Research and World Health Organization, Uganda: Transitioning from External Health Financing (Alliance for Health Policy and Systems Research an d World Health Organization, 2023).  

[6] Centers for Disease Control and Prevention, “Scale-Up of HIV Antiretroviral Therapy and Estimations of Averted Infections and HIV-Related Deaths: Uganda, 2004–2022,” Morbidity and Mortality Weekly Report 72/4 (2023).

[7] Declaration of Commitment on HIV/AIDS, G.A. Res. S-26/2 (2001).

[8] World Health Organization Africa Region, “Uganda Records Significant Reduction in New HIV Infections Among Newborns” November 30, 2023, https://www.afro.who.int/photo-story/uganda-records-significant-reduction-new-hiv-infections-among-newborns.

[9] UNAIDS, “Joint Statement by the Leaders of the Global Fund, UNAIDS and PEPFAR on Uganda’s Anti-Homosexuality Act 2023,” May 29, 2023, https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2023/may/20230529_uganda-anti-homosexuality-act.

[10] World Health Organization Uganda, “Uganda Government Reiterates Commitment to End TB by 2030,” March 24, 2023, https://www.afro.who.int/countries/uganda/news/uganda-government-reiterates-commitment-end-tb-2030.

[11] Target Malaria, https://targetmalaria.org/about-us/where-we-operate/uganda/.

[12] C. Mutesi, R. Migisha, L. Bulage, et al., “Trends and Distribution of Malaria in Pregnancy, Uganda: Analysis of Surveillance Data, 2015–2023,” Uganda National Institute of Public Health (2024).  

[13] K. Snyman, C. Pitt, A. Aturia, et al., “Who Pays to Treat Malaria and How Much? Analysis of the Cost of Illness, Equity and Economic Burden of Malaria in Uganda,” Health Policy and Planning 40/1 (2024), p. 63.

[14] International Covenant on Economic, Social and Cultural Rights, G.A. Res. 2200A (XXI) (1966).  

[15] Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases, OAU Doc. OAU/SPS/Abuja/3 (2001).

[16] International Covenant on Economic, Social and Cultural Rights (see note 14), art. 15.