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

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 91 839 663 (95% CI 85 690 135–98 291 626) all-age deaths, including 30 391 980 (26 023 132–35 482 636) 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 14 051 750 (uncertainty interval 8 475 990–19 662 191) additional all-age deaths, including 4 537 157 (3 124 796–5 910 791) in children younger than age 5 years, by 2030.