03863nas a2200361   4500000000100000008004100001260001600042653001000058653002000068653001800088653002200106653002000128100001800148700003600166700001600202700001600218700001100234700001200245700001400257700001300271700001000284700001200294700001300306700001300319700001400332700001400346700001400360245018800374856007500562300000700637520284300644022001403487       2025                            d  bElsevier BV10aUSAID10aChild mortality10aGlobal health10aImpact evaluation10aDevelopment aid1 aCavalcanti DM1 ade Oliveira Ferreira de Sales L1 ada Silva AF1 aBasterra EL1 aPena D1 aMonti C1 aBarreix G1 aSilva NJ1 aVaz P1 aSaute F1 aFanjul G1 aBassat Q1 aNaniche D1 aMacinko J1 aRasella D00aEvaluating 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  uhttps://www.thelancet.com/action/showPdf?pii=S0140-6736%2825%2901186-9  a113 a<p><strong>Summary</strong> Background The US Agency for International Development (USAID) is the largest funding agency for humanitarian and development aid worldwide. The aim of this study is to comprehensively evaluate the effect of all USAID funding on adult and child mortality over the past two decades and forecast the future effect of its defunding.</p>

<p><strong>Methods</strong> In this retrospective impact evaluation integrated with forecasting analysis, we used panel data from 133 countries and territories— including all low-income and middle-income countries (LMICs)—with USAID support ranging from none to very high. First, we used fixed-effects multivariable Poisson models with robust SEs adjusted for demographic, socioeconomic, and health-care factors to estimate the impact of USAID funding on all-age and allcause mortality from 2001 to 2021. Second, we evaluated its effects by age-specific, sex-specific, and cause-specific groups. Third, we did several sensitivity and triangulation analyses. Lastly, we integrated the retrospective evaluation with validated dynamic microsimulation models to estimate effects up to 2030.</p>

<p><strong>Findings</strong> Higher levels of USAID funding—primarily directed toward LMICs, particularly African countries—were associated with a 15% reduction in age-standardised all-cause mortality (risk ratio [RR] 0·85, 95% CI 0·78–0·93) and a 32% reduction in under-five mortality (RR 0·68, 0·57–0·80). This finding indicates that 91839663 (95% CI 85 690 135–98291626) all-age deaths, including 30391980 (26023132–35482636) in children younger than 5 years, were prevented by USAID funding over the 21-year study period. USAID funding was associated with a 65% reduction (RR 0·35, 0·29-0·42) in mortality from HIV/AIDS (representing 25·5 million deaths), 51% (RR 0·49, 0·39–0·61) from malaria (8·0 million deaths), and 50% (RR 0·50, 0·40–0·62) from neglected tropical diseases (8·9 million deaths). Significant decreases were also observed in mortality from tuberculosis, nutritional deficiencies, diarrhoeal diseases, lower respiratory infections, and maternal and perinatal conditions. Forecasting models predicted that the current steep funding cuts could result in more than 14051750 (uncertainty interval 8475990–19662191) additional all-age deaths, including 4537157 (3124796–5910791) in children younger than age 5 years, by 2030.</p>

<p><strong>Interpretation</strong> USAID funding has significantly contributed to the reduction in adult and child mortality across lowincome and middle-income countries over the past two decades. Our estimates show that, unless the abrupt funding cuts announced and implemented in the first half of 2025 are reversed, a staggering number of avoidable deaths could occur by 2030.</p>
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