Malawi: A Path Forward

The aftermath of USAID cuts

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1:09For more than 60 years, the U.S. Agency for International Development, or USAID, provided medical care and other vital humanitarian aid to countries around the world. When the Trump administration abruptly dissolved the agency in 2025, that assistance ended, stripping tens of millions of people of basic health care and thrusting providers and their patients into an uncertain future. One of the countries most impacted

1:41has been the African country of Malawi, where foreign aid cuts have plunged the country into a health crisis. Global health experts and countries are becoming aware that this is going to be a longer-term shift in the aid landscape. Welcome to Big Picture Science. I'm Molly Bentley. In this, the first of a special series supported by the Pulitzer Center and in collaboration with Science Magazine, we provide an on-the-ground look at the impact of USAID defunding on health services in key spots around the globe.

2:11In this episode, we go to Malawi, where health care workers have created makeshift health clinics and are fighting to protect fragile gains in maternal health and where the country is rethinking its relationship to foreign aid. This episode is Malawi, A Path Forward.

Visiting Katenji health post

2:29It's a lively scene in the village of Katenji in central Malawi. Animals and young children are milling outside a small makeshift health clinic that provides basic care to children and women. It was here that reporter Catherine Offord began her story for Science Magazine and where Big Picture Science joined her. It was one trip out of four planned by the magazine

3:01to key spots around the world to report on the aftermath of the USAID cuts. Catherine, thank you for joining us. Let's begin with an overview of the series. And then could you explain how your goal for this trip differs from the reporting you did about the cuts about a year ago? Yes, so Science Magazine covered the USAID cuts in quite a lot of detail last year when they started in early 2025. And most of our coverage at the beginning was, of course, focusing on those immediate impacts.

3:33Obviously, it's been quite a long time since those cuts were first announced. And so we really wanted to look now at how countries that were affected by the USAID cuts have been responding and adapting to those cuts. It's become clear that the U.S. cuts are not a sort of isolated phenomenon. There have also been other cuts by countries like the United Kingdom, for example. And I think a lot of global health experts and countries are becoming aware that this is going to be a longer term shift in the aid landscape. So these news stories are really looking at that adaptation and how those things are going.

4:05And your series begins, as does ours, in Malawi. And why did you decide to focus on Malawi in particular? So Malawi is well known to be one of the most aid-dependent countries in the world. And that's particularly true when it comes to the health sector. So for many years now, more than half of the country's health spending has come from external donors. And USAID and the U.S. government more generally was a really big contributor to the health sector.

4:37Malawi is a long, thin country in sub-Saharan Africa. It's got a population of around 22 million people. And one of the striking things about it is just how rural that population is. So more than 80% of people in Malawi live in these rural areas away from cities. And you can imagine that that obviously has quite a big impact on the country's health services. Malawi's health infrastructure includes different kinds of health facilities. At the most basic are village health posts, which provide services like malnutrition screening and childhood vaccinations.

5:11Many communities have primary health care centres that can handle uncomplicated births and some minor surgeries. But when patients need serious medical care, they may need to travel to one of the country's district hospitals. Catherine started her journey in Katenji with a small health post, which is the result of community members stepping in to provide health care, as support from the government of Malawi has fallen short. So Katenji for us was a really interesting example of a community that is trying to some extent build its own services where those services are lacking.

5:45So their response to that, which they started working on a couple of years ago, was to try and crowdfund their own clinics so that they would be able to have their own centre where they needed it. And to us, this was an interesting example of a local group putting together a homegrown effort independently of aid. And I think this has perhaps taken on some new importance since the USAID cuts, because the USAID cuts, as well as cuts by other countries, have really illustrated the dangers of relying on external help. So describe the scene as you pulled into Katenji.

6:16I believe a number of you were piled into a jeep. That's right. There were about five of us in the car most of the time. So that was me, the photographer, Toko, who was working with Science Magazine. And then there was also Lesayu from the NGO AMREF Health Africa that helped facilitate some of our visits in the community. And the driver, Wales, as well as Shannon from Big Picture Science. Our very own Shannon Geary.

6:44Katenji Health Post is just off the road that goes through the town. So it's a relatively smooth road. And then you turn off onto this little dust track and you come to a clearing where the Katenji Health Post is being built. So on the Tuesday morning when we went there, they were hosting a nutrition screening where kids are essentially checked for malnutrition. And so we arrived just before the children did. And we were sort of standing by this clinic. And you could hear these little voices from across the clearing.

7:15And suddenly from behind these houses, this group of several dozen little children between, well, under five is the group, so toddlers, I would say, sort of coming across from this clearing, some of them holding hands, some of them being carried by carers. And they all sort of filed into this clearing and sat down just outside the building. Catherine, who is the gentleman speaking to the children? His name is Feniso Cementi. He does just go by Cementi to everyone who knows him.

7:46And he's been a health worker for many, many years. I think he had been in Katenji for around four years. And he'd received training from NGOs such as Almref Health Africa. So before we went into the building, Cementi gave a talk to the people who were there.

8:02And he was essentially trying to explain the importance of this kind of screening, the idea that you don't want to wait until you see some sort of problem arise necessarily. You need to go and have regular checkups so that you can detect any problems before they become serious. So Molly, even before the loss of foreign aid, people in Katenji were already struggling with getting access to medical care because the nearest government-run health facility is actually quite a long way away. So the community began crowdfunding for this health outpost around a year before the USAID cuts came in.

8:34And that was to provide healthcare services where those government services had fallen short. The building isn't complete yet, but it's already being used as a sheltered space for services like immunizations. And that actually made some of the younger children we saw hesitant to enter when we were there.

8:49He's saying that they're cranked because they think they're going to get jabbed with shots, but he's telling them that it's no immunization today. It's just screening for nutrition. I see some have lollipops. I wonder if lollipops are... Incentive. Yes, an incentive.

9:06The building is very much unfinished. When you go in through the wooden door, you come into a sort of relatively large room, which doesn't currently have any paving, so the ground is sort of the same dust that you'd find outside. And off to the side, off to the left, there's a little corridor that goes to four smaller patient rooms. So these children filed into this building, and Cementi had a weighing scale set up, hanging from the middle of the room. And mothers or carers would bring their children over and hang them in this cloth that's known as a chitenge,

9:37which is what they use to carry babies on their back. And so they would hang these babies or toddlers in the chitenge from these weighing scales, and Cementi would take down their weight. And then he'd take them over to a little chair where he had one of these measuring tapes, known as the MUAC tape, which is essentially a piece of tape with multiple different colors. It's got a red, a yellow, and a green stripe. And you wrap it around the upper arm of these children, and depending on the color, you can tell whether they're malnourished or not. So this one, the MUAC indicator shows red.

10:08Got it. So not gating enough, like, muscle in that tissue. Yeah, yeah, yeah, yeah, yeah. Which means he's not getting much food, so we need to supplement. Yeah.

10:18And the MUAC tape, or the MUAC system, it has been used in countries for decades, so it's striking that health monitoring, in this case for the children, is relying on something that is rudimentary and many decades old. Yes, I mean, the tape is certainly a sort of staple of rural health and relatively reliable way of diagnosing malnutrition quickly. So Sementi was telling us that some of the challenges they faced before they had this building related to, say, the weather.

10:49He used to provide immunizations and counseling outside under a tree in the clearing, but, of course, in really hot weather, that becomes absolutely unbearable. So this was really a sort of homegrown attempt to build something physical sooner in order to have a place where they could offer health services more quickly. Now we are happy because we are doing inside the structure because, you know, during the learning, we cannot conduct such services, but, you know, this structure provides us privacy and also the shade.

11:20People cannot feel hot. We can do our services free and fair. And more consistently, I imagine, you were saying that sometimes you'd have to cancel meetings because of the rain. Exactly, yeah.

11:34And Sementi told me that they have raised around $12,000. So it's a long way off what they need to complete the clinic, but it's still a fair bit for a community to be able to put towards their own health center. But already people were telling us that just having this shelter where you can go and be out of the sun or the rain or whatever it is and just receive services in a cleaner space and in a place where there's a bit of privacy made a real difference already. Plans for Sementi's outpost

12:14were already underway when the Trump administration abruptly cut USAID funding in January 2025. One of the casualties was the Momentum Project that supported maternal and child health across 40 countries globally, including an $80 million investment in Malawi. And for years, Momentum partnered with local NGOs to provide maternal and newborn care. Then the funding was cut and almost overnight, many of those services disappeared. Catherine told us that the health outpost in Katenji

12:46is an example of Malawians trying to build more self-sufficiency into their health care system. But it also shows just how fragile health care remains in many parts of the country. Some communities that were relying on USAID are looking to what's happening in Katenji as a model for how they might begin filling the gaps themselves.

Rural care in Chidongo

13:06After leaving the town, Catherine traveled through this changed health care landscape. Her next stop was the village of Chidongo, where the loss of funding from USAID has hit especially hard. We've come to Chidongo, which is a locality to the northwest of Katsungu. And we've come here because this was one of the sites that was receiving mobile outreach clinics thanks to the Momentum program that was funded by USAID.

13:36And we met a woman called Emily Mavula, who had prior to the cuts, she had been receiving prenatal counseling thanks to those outreach clinics run by Momentum. Can you tell me a little bit about your family? Are you from this area? How old are your children?

14:07So she has three kids. The first born was born in 2007, the second born in 2017, and the last born in 2025, and her name is Leticia. Hello, Leticia. How is Leticia? One, one, two. One, two, three, three, three, three, three, four. Okay, so Leticia is doing well. She's fine. Si como Leticia. Si como Leticia.

14:36After the cuts, which happened in early 2025 and before she'd had her third child, Leticia, she suddenly found that those services had been removed and she was having to travel to Katsungu District Hospital, which was extremely expensive. She was saying that it could cost up to $9, to travel on the back of a motorbike, for example, to get to the hospital. It's, I believe, around 15 kilometers. The road is pretty rough. It's not a particularly easy journey, so you can easily imagine it just taking an entire day to get there and back. And what sort of services were the mobile outreach clinics

15:07providing that were crucial for an expectant mother, for example? So one of the services they provided was prenatal counseling, where they would essentially check for any obvious complications in the mother and make sure that if they had any complications, they got to a health center fast enough that they could be addressed. And they'd also help mothers basically plan for their births, because one of the real challenges in Malawi is that people perhaps don't know when they need to go and seek healthcare services. So mothers are often arriving to health centers late, perhaps once problems have already started,

15:38and it becomes an emergency very fast, of course, during a birth, if the baby is stuck or if the mother needs a blood transfusion, for example. These are really life and death situations. So part of the prenatal counseling involves trying to help women plan how they're going to get to the hospital, when they're going to get there, and what to look out for should anything go wrong. We spoke to people in primary health care centers who were telling us about some of the challenges of getting women from these rural areas to district hospitals, for example.

16:12Fuel shortages, partly thanks to the conflict in Iran, have become a really serious problem. We also visited Makayoni Health Center, which is a health center in the district of Salima, and this is one of these health centers that is catering to a really large population. It supports some 30,000 people. If you look at our geographical location here, it's a bit high, and during the rain season, it becomes very difficult for a laboring mother to report to the facility. Even as of now, the roads are impassable.

16:43So it's a bit difficult. So one of the big challenges they have there is transport, because there's very little fuel. The district is running low on ambulances, and getting mothers in an emergency, either from the rural community to the primary health center in Makayoni, or from Makayoni to Salima District Hospital, is a massive challenge. While we were there, we spoke with the nursing officer overseeing the maternity ward, who's Esau Omar Nix. Three or four days ago, we had some issues whereby a woman's labor admitted here,

17:16and the labor went wrong, and we were supposed to refer the mother to the high level, and unfortunately, we had no transport to transport that laboring mother to the district. Sometimes you may call the ambulance, and you may find that the ambulance is not around. It's far from here. So it's a big challenge. So the NGOs might come to assist us in terms of, like, transport and the other things that we are lacking at the facility, which is far from the district hospital.

17:48So officially, NGOs funded by USAID didn't necessarily provide transport for women in an emergency, but in reality, having these NGOs available with cars, with ambulances, with fuel, meant that often, if there was this kind of emergency, you could, as a backup, call an NGO and get them to help you transport people in an emergency. So even though, you know, on paper, this wasn't something that they were obviously doing, the staff at Makioni Health Centre and some of the other centres we visited

18:19said that this was, in reality, one of the things that had happened, that they actually had fewer backups now, and so this transport problem had become more of an issue. We tried to transfer quickly. Unfortunately, there was no immediate transport. Nix told us that the lack of reliable transportation can create a huge amount of risk for women who need emergency care, and he thinks this played a role in the case he mentioned earlier when he and his colleagues had to transfer a woman in labour to the district hospital. The ambulance came, but after two hours,

18:50which was also difficult. Hours? Yes, after two hours, when the ambulance arrived here and the mother was taken to the district hospital. And do you know if she was OK? Unfortunately, the mother passed away two days ago. Yeah.

19:10As we continue this episode in our special series supported by the Pulitzer Center about the impact of USAID defunding on health services in key spots around the globe, Science Magazine reporter Catherine Offord speaks with health care workers at the Macchione Health Centre who are scrambling to provide maternal care in the wake of the cuts.

19:41The biggest challenge, number one, is lack of supplies. Second problem is the challenge of distance.

19:48This episode of Big Picture Science is Malawi, a path forward. Eva Longoria here, cookbook connoisseur, sports team tycoon, founder of a foundation. I've basically done it all. So when Lenovo asked me to lend an ear to small business owners, I cleared my incredibly busy schedule. Dial 1-855-CALL-EVA

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Maternal health challenges

20:42Funding for maternal health in Malawi is one of the areas that has been a priority of donors such as USAID. Malawi has often been held up as an example of a country in sub-Saharan Africa that has made substantial progress in improving its state of maternal health care. 30 years ago, it had one of the highest reported maternal mortality rates in the world, with more than 1,000 maternal deaths per 100,000 live births. That number has dropped significantly to 224 deaths, according to recent estimates,

21:14an improvement that is greatly credited to the influence of foreign donations, including programs like USAID Momentum. Our producer, Shannon Geary, traveled with Catherine Offer to Malawi to report for this episode, and we continue with their visit to the Macchione Health Centre, where Catherine talks with health care workers who are fighting to protect those fragile gains in maternal health. Macchione Health Centre is a sort of complex of small buildings in a sort of wooded area

21:44that we drove to from Salime. And when we arrived, we parked under a tree and we met a lot of the health staff who were working there, particularly from the maternity ward because we were interested in some of the challenges in maternal health. This is visitors' book. Yeah, you are supposed to sign. And they brought out a guest book for us to sign that they ask all visitors to sign in to. Today's date is the 20th? Yeah, 20. So we put down our names and, you know, countries of origin, etc.,

22:15and spoke to some of the staff who were working there about some of the challenges they'd seen in the past 18 months. I'm Aaron Nkata, medical technician. One of the first people we met was a man in a white lab coat who was called Aaron Nkata, who was the medical clinician overseeing the facility. And he told us about some of the challenges that the facility was facing, both in general and also in terms of the challenges that had been introduced since the USAID cuts came in. The biggest challenge, number one,

22:45is lack of supplies. As we have said, we're close to the border with other districts. So most people come from those districts which are not planned in the... When we're planning for services, they are not planned. So it just influx and we will deplete our resources very quickly. Second problem is the challenge of distance. So Makioni Health Centre is situated a very long way away from Salima District Hospital. So Salima District Hospital is the next level up in the healthcare system.

23:16And so when they receive patients who have challenges, they need to get those patients from that centre to the district hospital. So that's a really big challenge. And the district is short on ambulances. Often it means that you might have to wait quite a long time for transport to come and pick up patients. And that's really the big problem they face. They also face challenges with distance, getting to the communities they oversee. So this health centre actually is responsible, if you like, for a very large population. Typically health centres

23:47would look after 5,000 to 10,000 people ideally, but this centre looks after more than 30,000. So that's just a lot of patients that they need to be aware of, that might need to get from their remote community to this health centre to receive services. So it's a constant challenge. With Momentum, they are helping us to have outreach clinics where we could go with all our services here to the outreach clinic right there. But since Momentum phased out, we have stopped. And so since Momentum finished,

24:19what are you able to provide in the communities that you're serving? It's mainly vaccinations, but not to the maximum. The same challenges are transportation. And so these are the vaccines that are being transported by bicycle to individual communities. We have a number of vaccines

Vaccine cold chain storage

24:38in these CCEs. So we were shown around the health centre by some of the staff working there and by some of the staff who had come with us from Salima District Hospital. And that latter group included Flywell Ernesto, who was a cold chain technician. So somebody tasked with making sure that transport of cold medicines like vaccines is working properly. We have Benda, we have Corio, we have TD, we have BCG, we have MMR,

25:09which is measles, and Rubera vaccine. And he took us through some of the facilities they had at the health centre where they keep the vaccines that are used for community immunisations. IPV, inactivated polio vaccines, all these vaccines are kept in these CCEs. So it's my understanding from your piece, Catherine, that vaccinations have mostly continued at the Macchione Health Centre, but things like family planning and prenatal care have been severely cut. I think that's fair, yes.

25:40So there's been a real effort to maintain immunisations and so for the most part these vaccines are still being transported normally once a month to these communities that need to have these children vaccinated. But things like family planning, prenatal counselling, those kinds of services that were being heavily supported by NGOs and by Momentum have really fallen off just because there isn't the funding or the support to get staff out to these communities to provide these clinics, these so-called integrated health clinics they were called.

26:12What about antenatal care, family planning, these services? I've completely stopped that one. I wasn't providing it here at the facility, but then the community one I've completely stopped. And do you think that means a lot fewer people are accessing those services? Yeah, likely. Yeah, likely. Yeah. So previously when they were able or other staff were able to visit the communities, they'd be able to sort of keep an eye on some of the problems that pregnant women were having. They'd be able to recognize, for example, if women had issues like anemia

26:43or other things that might need to be watched during pregnancy. Now that those outreach clinics have stopped, they said that they were particularly concerned about the people they weren't seeing. Sometimes on paper it might look quite good because you're not seeing as many people with problems, but in reality what that means is that you're just not diagnosing those problems early enough. So it just takes out a buffer essentially in those healthcare services. It means that everything's a little more precarious and a little more likely to go wrong because you haven't had that time beforehand to see how people are doing.

Stories from the maternity ward

27:12My name is Sungeni Tole, Nurse Midwife Technician. When we visited the maternity ward we spoke to Nurse Midwife Technician Sungeni Tole and he was explaining a bit about some of the challenges they see as a result of outreach services to communities having ended. So although it's difficult to collect concrete data on the impact of these kind of service cuts it is possible to say that you have less visibility in the community

27:42and as a result he was telling us that it just means that they're not seeing potential complications in time. So it could be that a woman arrives to give birth and she has some complication, perhaps anemia, she's at risk of postpartum bleeding, perhaps she's going to have difficulty in labour and would need a c-section and those problems are things that just you have to deal with in the moment because you maybe haven't seen that mother before. So he was saying that unlike before when they would perhaps see people for all of these prenatal appointments now they're seeing people who come to give birth and they've never seen them before because they just

28:14weren't on their register they weren't being picked up by these clinics. And maybe those women were just lucky enough not to have any complications and they arrive at the health centre and they give birth and everything goes well but in an ideal situation they would have had doctor's appointments and seen doctors up until that moment when they were giving birth. Exactly. So there's just the concern that without being able to have those checks up until birth you're just putting everyone at higher risk. Most of the mothers some of them they deliver during

28:44on transit on the way they are coming here because of the distance you find that they have been already delivered on their way to the hospital so that's another challenge. And another challenge is that these mothers if we see them during antenatal we give them advices what to do when they are preparing for birth. So because of this that they are not coming to the hospital to seek these services most of them they are just coming in. So when they come here

29:15most of them they have more complications you find out there are complications that we cannot deal with as a health centre. What if you find during labour somebody requires say a c-section or other sorts of medical assistance?

29:29Yeah we sent her to the main district hospital but the issue is the same it's a challenge of transport so sometimes we call the district hospital to send us an ambulance but the response there they always say no we don't have a fuel at all the ambulance is not working so we normally use we normally tell the guardians to prepare for the patient so that they can go to district hospital in good time in order for us

30:00to protect the baby and the mother but with the cutting of this funding to us is a big challenge most of these things we just leave in the hands of the patient the situation here is it's like this we have tried our best so it is useful for you to look for the transport the maternity ward was lacking funds for some repairs that they were hoping to do at the time we visited in May and the ceilings of that ward have holes in them they were being powered by solar

30:31powered lights but of course those lights don't always last through the night our hospital as of now we don't have electricity that bagger electricity we are using only solar electricity but during the night we find that in the server there's no power again so normally we work using the torches hence a challenge for us to conduct delivery services part of the

Direct facility financing

31:07Malawian government's long-term plans to create sustainable health care financing is an initiative called direct facility financing first piloted in 2023 through this initiative health centres like Macchione submit funding requests directly to the national government in order to reduce administrative delays and give facilities more ownership over their own budgets but health centres have discovered that direct financing is not always so direct so last year the health centre

31:38had requested around twenty thousand dollars from the government to make necessary repairs from the maternity ward but also elsewhere and they found out that they had been allocated a small fraction of that around four thousand dollars but they also had trouble accessing that money for many months so even though they had been told that they would get that money they weren't able to use it until after we left actually I found out from them in late June that they finally received the money and were able to start using it and again it's not enough for what they want to do so they're really trying to support

32:08this very large population and to care for patients in this facility with minimal resources and they've come up with all sorts of creative measures to try to fill that funding gap I wonder if you could just give us an overview one of them is something called selling a health passport book what is that and what are some of the other methods that they've turned to so like staff in Katengi some of the people working at Makayoni health center told us that they were trying to come up with their own ways to raise money to support the health services for the community

32:39so one of the things that they were doing according to staff at the maternity ward is selling these health passports they're known as essentially these are little immunization cards if you like little booklets which really track the health of a particular patient and are useful so that both doctors and patients can monitor the health services they've received etc they're selling those wouldn't that be something that you would get automatically when you go to a health clinic a little book that tracks your health record yes this is indeed a little bit of a controversial

33:09idea some of the officials we spoke to in Salima district said that this wasn't the only centre that does something like this so it's not unheard of for centres to solicit a small fee essentially that they then put back into the health centre itself the fee the fee is around 1,000 Malawi kwacha so that's about 60 cents and the staff at the maternity ward in Makayoni were adamant that they only request this fee for people who can afford it so anyone who can't pay that gets these booklets for free but yes certainly that is something that is

33:40not a universally accepted idea because these booklets are necessary for people to track their health and they're 60 cents I suppose you're translating that into US dollars about 60 cents per book that's right that is such a modest amount I'm almost speechless that certainly can't raise that much that much money and in fact I think you say that over two years maybe 450 dollars were raised so that's in combination with another initiative that the maternity ward had started so they had also

34:11in the last year or so started a small garden they were growing potatoes and selling those so those initiatives combined had raised around 450 dollars and of course this isn't a huge amount the staff were saying that they'd used it to purchase some drugs that they needed to buy cleaning supplies to buy stationery for sort of the day-to-day running of the centre and the ward but for major issues of course this is a drop in the ocean next we

National funding solutions

34:51consider the large-scale funding solutions being proposed in Malawi to address cuts to foreign aid and why some officials are touting the prospect of self-sufficiency all of Africa we need to graduate from depending on donors we continue our special series supported by the Pulitzer Center about the impact of the abrupt USAID defunding on health services in key spots around the globe this episode in the series is Malawi a path forward

35:49or surviving the parts nobody puts on the press release I'm working with Lenovo to back every business standard call and data charges may apply terms and conditions at call even out dot com some say that the evidence of USAID's ability to make a difference in Malawi is the health care crisis that has unfolded since the funds were abruptly cut off in 2025 Catherine

36:20offered reporting to Malawi for Science Magazine included researching the role that all foreign aid including that from NGOs such as AMRF played in strengthening the country's health care system we asked her what the evidence was that the USAID momentum project in particular had helped improve the country's health outcomes this is a very challenging question I think for a lot of international development projects it's very hard to say what exact effect a particular project was having because they typically

36:51operate on the ground among a lot of other things that are going on they're trying to integrate their services with what's currently there they might be affected by other policies or other crises that are going on in the country at the time so it's very difficult to scientifically measure how a particular project improves or doesn't health services in a particular country there have been some efforts to measure the impacts of momentum so there was a study by some of the people involved in the project that looked at uptake of things like family planning services and teenage pregnancies and they did find

37:22that in the districts where the project was operating they found a decrease in teenage pregnancies and an increase in family planning services so you know that's suggestive of a positive impact but as I was saying it's not hugely scientific it's quite a short monitoring period and they're not really able to compare this with other groups that didn't receive the services in a scientific way to say that this was the impact I believe that you reported that about half of Malawi's money for health care comes from external donors what have the other

37:53sources outside of USAID momentum been there are several major country donors to Malawi so historically the UK has been a big donor Norway gives a lot of money to Malawi China and Japan give some money to Malawi US through USAID but also through CDC for example and then beyond that there are these big sort of international organisations or consortia if you like that also give money so those are things like the Global Fund for example Gavi other organisations that represent

38:23often particular priorities in health and then you might get philanthropists so the Bill and Melinda Gates Foundation for example the Beginnings Fund is something that they set up recently to support child and maternal health in countries such as Malawi and beyond that you might have some private investors for example who might not be giving aid exactly but they might want to invest in the healthcare

38:50Yeah that's a really interesting point because I think it illustrates a little bit how sort of interdependent all of these funding sources are so it's true that no one has quite taken the route of USAID to just sort of shut off the funding as abruptly as all that but the US cuts have had impacts on other funds in various ways so for example they've been withdrawing or threatening to withdraw from various organisations that also provide health funding so they have reduced their involvement in say the World Health Organisation

39:22the Global Fund UNICEF is also struggling so there has been sort of an indirect impact of USAID cuts or US cuts that way additionally there are also other countries that for their own reasons are reducing their funding so the really big one in the past year has been the UK which gives

39:45and actually just recently they put out their country by country estimates for how that would affect individual countries around the world and it's projected that Malawi will lose about 90% of the funding that it currently gets from the UK over the next five years or so so what your reporting has done is dispel this notion that this is a simple equation it's very tempting for people to consider these cases of foreign aid and health care in countries around the world in say black and white terms very stark terms and what you're revealing

40:16to us is that it's just a much more complicated equation than one would think at first glance I think so I think it's complicated and I think you have to keep two points separate one is that the money was reduced or disappeared in some cases and

40:37degrees has been incredibly destructive both in terms of the impact on the communities who were benefiting in some way from that funding but also just in terms of relations between countries people think it's been a disaster on many levels if you put that aside and you look just purely at the idea that that kind of aid so this idea of money going to NGOs to implement health services within a country if you look purely at that and you talk about the reduction in that funding I think the opinions are much more nuanced so you know we

41:07obviously are aware that a lot of countries and a lot of people in places like Malawi feel that aid has not been you know universally successful it's been controversial it kind of maintains a dependency on foreign donors it in some people's view prevents the country and from really taking ownership of its own health services it might mean that you are beholden to these priorities of foreign donors and when the foreign donors governments change then their priorities change and so you're not able to take control of your health care in a way

41:38that might be most beneficial for your citizens so a lot of people we spoke to in Malawi were really explaining that nuanced view that yes this has been damaging and there will certainly be short and perhaps medium term pain but that actually in the long term this might be an opportunity to really look at how Malawi funds its own health care and say can we find new sources of funding that are more reliable and also can we find ways of raising funding within our own country it's not going to be easy because there are lots of challenges that Malawi's economy faces already never mind all of the impacts of U.S. funding withdrawals but

42:08it's still seen as something that is worth doing and that potentially in the long term might actually lead to something more resilient We've heard about the regional efforts employed by health care workers on the ground to raise money to bridge funding gaps such as selling health passports and food from local gardens but officials in Malawi say that health care sustainability requires ambitious programs on the national level My name is Anthony Masamba Chair of the Parliamentary Committee on Health Malawi National Assembly So I was

42:39actually very pleased to be able to speak to Anthony Masamba because he's quite a sort of important figure in some of these discussions So Anthony Masamba is the Chair of the Parliamentary Health Committee and an MP in Malawi and his role is to chair this offers sort of advice and analysis to the government on matters of health and we interviewed him about some of the strategies that his group is proposing and that included the syntaxes so his group has been quite sort of pro the idea of syntaxes to go to

43:10provide money to go into a dedicated national health fund To cover the gaps as a committee we are pushing for the reforms so we are saying that perhaps we can push for the introduction of syntaxes so products like sugar products like salt products like alcohol He's also even suggested putting potentially toll booths on roads to sort of source money that way again that idea has been somewhat controversial because people feel like they're already paying enough and that you know

43:41if they're also going to have to pay money on roads that's going to become sort of unmanageable He was also in favour of a lot of the current proposals so things like paying wards for example we are standing in front of Salima District Hospital and this is the hospital that serves the district and we're standing in particular next to the paying ward of the hospital so several district hospitals in fact all of the district hospitals have been encouraged to introduce paying wards as a way to help subsidise some of the public services provided in

44:12the rest of the hospital there have been some reports of controversy about the concept of using a paying ward Catherine what exactly are paying wards basically the idea is that healthcare should be free at the point of access but that there are lots of people who potentially can afford to pay for healthcare services who may be getting these free services and don't need to or rather they could contribute to the healthcare system financially and they haven't been up until now so so the idea with these paying wards is that you know a hospital would

44:42have its public ward and then it would separately have a paying ward where the service quality should be the same but perhaps it's less crowded or you have more space and more privacy and so people who can afford to might opt to actually have that experience and therefore put some money into the hospital they've been somewhat controversial in Malawi because of course like the taxes there's a fear that this might actually penalize vulnerable citizens the hospitals we spoke to denied that this was a problem but it would be untrue to say there haven't been reports and concerns about it in the country what we are saying is while introducing

45:12the paying wings we also need to make sure that the most vulnerable are being taken care of because if we want to achieve universal health coverage what we also need to do is to ensure that there's affordable accessibility and availability to everyone without exposing anyone to financial burden so if you collect all these revenues and these revenues should be a channel towards a health sector so the introduction of national health fund is also one of the most critical issues that we are putting forward and

45:43that we are advancing as a committee and this is the story from all of Africa we need to graduate from depending on donors because essentially donors are withdrawing we need to come up with innovative way of mobilizing our resources and that's why we are saying apart from introducing these taxes we also need to have innovative way of generating our income

New US government agreements

46:04locally while officials like Anthony Massamba advocate for novel ways of generating health care funding domestically a new opportunity for Malawi to regain foreign funding has appeared perhaps something that people couldn't have predicted when the cuts came in last year is that the relationship between the US and Malawi and many other countries is certainly continuing but it looks very different now from what it was 18 months ago so in the past year the US has been signing these so-called memoranda of understanding

46:35with countries including Malawi and under these memoranda of understanding or MOUs the US is giving a lot of money to Malawi but it's a different kind of relationship from what they had before so instead of funding NGOs such as AMREF to perform particular programs on the ground they're giving money directly to the government and in return for that they are asking the government to commit to raising its own funds so in Malawi for example that looks like nearly $800 million from the US in return for Malawi increasing its health funding by nearly $150 million

47:06over the next five years but also there are some sort of conditions that come with that money that are currently unknown that is to say that Malawi has not made the text of this deal public in other countries it's included things like access to national health data in recipient countries or access to rare minerals for example and these deals have been really controversial in other countries so it's interesting in a way that you know this deal has been signed in Malawi and the politicians we spoke to who had seen it were very positive about it and said it was the best thing for Malawi and that it provided needed

47:37funding and that it was a fair deal there's a little bit of disquiet about it in the country because people don't know exactly what they've signed up for so the US is continuing to support Malawi but it's just a very different relationship than what came before if the US if the US continues to give money to Malawi doesn't that undermine the self-sufficiency argument that the Malawi government is putting forth yes and no because I think that nobody in Malawi thinks that they're going to be able to switch off foreign support just like that it's been so important for

48:07such a long time you couldn't possibly make up the difference overnight so clearly foreign funding and external donors are going to be really important for the foreseeable future I think the question is more about how that money comes into the country and so there was the perception among many people including a government that having money come in via NGOs wasn't really building necessarily the resources that you would need long term within the country and that perhaps by having that money go directly to the government the government can then put in place systems and practices that can continue after that money has gone

48:37so the idea is that it's more sustainable and this is not just a Malawian government opinion this is what a lot of global health experts say that there are ways in which funding the government directly is cheaper you're not spending so much on overheads that NGOs have for example you're putting money directly into the country rather than something that might disappear after five years so there are ways in which that money could be more efficient I think it'll just remain to be seen if that's how it actually plays out and just a little more generally now obviously there's been a big shake up in the last year in the relationship I suppose between government and NGOs

49:07and external funders do you think this is going to lead to some long term change in the way services delivered in Malawi of course of course I think so what we're thinking is these areas will struggle will struggle when they say that donors have just pulled out and because there's that gap in funding okay we'll have poor health services but as we live with the reality that we no longer have donors I think people now have to accept that reality and accept the

49:38solution that we are suggesting like SIM taxes and other solutions so in so doing as years go by I think we'll be able to now begin to fund for our services and gradually I think we'll be able to have affordable and high quality medical care so Catherine

Future of Malawi healthcare

50:07it's been a while since you traveled to Malawi and given that where have your thoughts gone in terms of considering what the future of Malawi is and what the next steps are in terms of the country achieving some kind of self-sufficiency I think the strongest feeling I have after working on this is just how unsettled everything still is it's still so hard to look ahead and say you know is Malawi and other countries that find themselves in a similar situation are these countries going to be able to really make good

50:38on that promise are they going to really be able to take opportunity of this situation and put together these more sort of resilient health systems that potentially will be better for their citizens in the long run it's possible I think a lot of the people we spoke to thought that the opportunity was there but the challenges are also just so huge there's just so little money to go around I think we're going to have to wait years before we see the full impact of the cuts the full impact of the policies responding to those cuts and just to see what this kind of new landscape is going to look like it seems from what our reporting shows and what other people's reporting shows

51:08that this is a sort of fundamental shift we're not going to go back to this very sort of age-centric relationship between countries that came before so it seems like we're going to move to something new but I think what that new thing is is still kind of murky well Catherine Offord it has been such a privilege to talk to you about your reporting for Science Magazine thank you so much for joining us thank you very much for having me Catherine Offord is a journalist for Science Magazine her article An Uncertain Path

51:39part of the magazine series looking at the consequences of the cuts to USAID appeared in the July 2026 issue of the magazine Big Picture Science was able to join her on her Malawi reporting trip thanks to support from the Pulitzer Center In a future episode in our special series looking at the impact of USAID defunding and attempts to fill the gaps Catherine Offord's colleague John Cohen reports from South Africa

52:10where a breakthrough drug that could end the HIV epidemic now faces an uncertain future South Africa has 8 million people of the 40 million people in the world living with HIV that means they have the highest risk of transmission you could imagine they need more prevention tools This show is thanks to the talents of senior producer Gary Niederhoff assistant producer Brian Edwards and contributors Sikhan Akban and Roland Pease a special thanks

52:41to producer Shannon Rose Geary who oversaw the production of this episode and to Science Magazine reporter Catherine Offord for sharing her reporting from Malawi I'm the executive producer of Big Picture Science Molly Bentley also a big thanks to our listeners and our Patreon supporters the original music in the show is by Dewey DeLay and June Miyake and this episode of Big Picture Science the first in a special series supported by the Pulitzer Center and in collaboration with Science Magazine that looks at

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