Analysis by the Centre for Global Development (CGD), a think-tank based in Washington, DC and London, found that American aid is equivalent to 10% of the government’s health spending in 37 countries. In ten of them it is equivalent to more than half (see map). The Trump administration’s cuts highlight that many countries have become over-reliant on America and other aid donors to support basic health functions.

The CGD identified 26 countries that will suffer most, because of their reliance on American aid coupled with their low income levels and high risk of being unable to meet their financial obligations (see chart). In Afghanistan, for example, American health aid is the equivalent of almost 350% of the government’s health spending. As a poor country at high risk of debt distress, Afghanistan will struggle to replace American aid. A combination of political instability, poverty and low domestic health spending have created this dependency.

There are no obvious alternatives to replace American aid in full. European countries are also slashing foreign-aid budgets in order to boost defence spending. Philanthropic organisations don’t have enough cash to replace government aid budgets. China sees a “pretty big opportunity” to forge alliances, says Daniel Thornton, of the World Health Organisation. China’s vaccine diplomacy during the pandemic combined humanitarian goals with geopolitical ones. Providing finance for critical programmes that America has cut off could now give it another soft-power advantage. Still, China’s contributions to global health assistance are relatively small—at $783m in 2023 compared with America’s $12.4bn.

One clear message from the crisis is the need for countries to restructure their health systems so that they are less reliant on political whims abroad or the priorities of any single donor. Mr Thornton says there is also an opportunity to provide many services more cheaply than those that have been offered by American companies, which implement many of the country’s foreign-aid programmes. An old saying holds that from crisis comes opportunity. Unfortunately, a deadly period of adjustment will come first.