“We are going to die”: The frontline costs of Uganda’s new US health agreement

On an early morning in February, 23-year-old Suzan Akello was found lying dead on a veranda outside a house she had visited in Namataala, Mbale town, in eastern Uganda. Friends said she could not afford a clinic and had taken herbal medicine to terminate a pregnancy. By the time Akello needed urgent care, it was too late.

Post-abortion care services (PAC) are legal in Uganda, secured through years of advocacy and government-NGO collaboration, some under US-supported programmes. But health workers, activists, and patients told The New Humanitarian that in recent months, post-abortion care and critical HIV/AIDS services are increasingly caught in the fallout of a new $2.3 billion health agreement between Uganda and the United States, one that is integrating donor-funded programmes into Uganda’s public health system while reducing reliance on NGOs.

A US State Department spokesperson said the deal is a joint commitment to sustain lifesaving programmes while building national capacity. Under the agreement, Uganda has pledged to increase domestic health funding by about $50 million annually, more than $500 million over five years, while the United States foots the rest of the bill through a phased transition.

Framed as a step towards “health sovereignty” and national ownership, the deal is one of more than 20 similar agreements signed across Africa, now expanding into Latin America. It follows President Donald Trump’s revision of USAID programmes worldwide, which triggered “stop work” orders early last year and withdrew billions in health funding globally, including in Uganda.

Funding for frontline health workers and medical commodities will be maintained in full in the first year, the State Department said, with responsibility shifting gradually based on readiness assessments. Transitions will be “case-by-case, multi-year, jointly planned” to ensure continuity of care.

But for many working within Uganda’s health system, that continuity is already fraying.

Undoing years of local progress

By mid-2025, months before the memorandum was signed, the shift was already underway. Hundreds of support staff working under US-funded programmes were called into meetings across Uganda and – in documents seen by this reporter – asked to sign compliance agreements aligning with US abortion restrictions.

Contract addendums barred them from “performing, promoting, or referrals” for abortion-related services “even where legal” and discouraged public discussion of the policy. While abortion is generally criminalised in Uganda, post-abortion care remains legal.

Months after those meetings, only a fraction of those support health workers still hold active contracts. Cuts to USAID funding have sharply reduced staff deployment, particularly those working alongside NGOs at government health facilities.

On paper, the memorandum contains elements that public health experts broadly support. Nakibuuka Noor, deputy at the Coalition to Stop Maternal Mortality Due to Unsafe Abortion (CSMMUA), points to its provisions on joint reviews and commitments to increasing health funding within Uganda’s national budget.

“These are things we have always asked for,” she said. “A government that takes responsibility for its health system.”

Ugandan NGOs, alongside the health ministry, negotiated a national PAC package in 2025 intended to standardise and expand lifesaving care for women suffering complications from unsafe abortions. But according to Noor, the memorandum sidelines this progress.

A 2010 report by the health ministry said 8% of all maternal deaths were due to unsafe abortions, but safe abortion advocates say the health system is poorly equipped to even measure its impact. Noor notes that maternal death notification forms do not include a specific category for deaths resulting from unsafe abortion complications, making data incomplete and unreliable.

Richard Mugahi, the ministry of health commissioner for reproductive health, insisted to The New Humanitarian that Uganda has the capacity to finance its share of the health budget, and that the memorandum does not violate national health policy.

On post-abortion care, he maintained there is “no violation” of Uganda’s guidelines, even as he has acknowledged constraints, stating at one point that PAC “has no budget”.

That tension between policy assurances and the realities on the front line is increasingly visible.

Coupled with reinforced US restrictions, health workers report being under growing pressure to turn away women showing signs of a terminated pregnancy. “We are not even allowed to probe to find out details about such cases,” said one in Mbale, who asked not to be named. “We are expected to stay silent.”

Two other support staff in eastern and western Uganda said they have been forced to either risk their jobs to help patients or turn away dozens in need of critical post-abortion care.

A system losing its intermediaries

The memorandum’s emphasis on “mainstreaming” donor-funded programmes is also reshaping how care is delivered. Thousands of peer educators, outreach workers, and specialised staff are being absorbed, reassigned, or lost altogether.

Remaining health workers said they received communication from the Ministry of Health since January, saying their positions will be advertised, and that their qualifications are currently being “validated” as part of a process to “mainstream” them into the national system. Many of them say they do not meet the academic qualifications the government has set for them to retain their jobs, even though they’ve worked effectively with marginalised communities for years.

Peter educators and outreach workers form an integral part of Uganda’s HIV/AIDS focused care.

Winnie Byanyima, the executive director of UNAIDS, cautioned that communities can not be ignored in HIV/AIDS care.

“Communities must remain at the heart of the response and all people living with or at risk of HIV need access to lifesaving medicines and services,” she told The New Humanitarian. “Recognising that is not a political statement; it’s an epidemiological fact.“

However, funding shifts also appear to be undoing years of progress on attitudes towards most at-risk populations secured by delicate community organising under NGOs.

According to Betty Balisalamu, executive director of Women with a Mission in eastern Mbale, the effects of a health model cutting out civil society are already visible in how local officials engage with marginalised communities.

“It sends a message,” she said. “The officials say if even our funders are stepping back, then the government should too.”

At Rukoki General Hospital in Kasese, in western Uganda, a laboratory technician described what that looks like in practice. Key population focal persons, like staff trained to support groups such as sex workers and LGBTIQ individuals, are no longer present.

“There is more stigma now,” the technician said. “People are afraid to come.”

Without those intermediaries, patients reported being shamed or turned away, widening gaps in HIV prevention.

In the fishing community of Kahendero near Lake Albert in western Uganda, outreach workers reported shortages of prevention tools so severe that some people are using polythene bags as condoms.

Hilda Kamuhangire, a former sex worker now working as a peer educator in Kahendero, said the disruption has been abrupt. “We used to go to the bars, talk to women, give them condoms, PrEP [pre-exposure prophylaxis] information,” she said. “Now many of those services are not there.”

“They tell you, ‘haven’t you heard about the Trump things?’”

At health facilities, she added, some workers now ask for payment or turn patients away, citing funding changes. “They tell you, ‘haven’t you heard about the Trump things?’”

The political framing of the agreement has further complicated its impact. US officials have linked funding restrictions to concerns about “gender ideology” – a narrative that has gained traction in Uganda. Activists say this framing misrepresents their work and undermines service delivery.

“We are fighting political and cultural wars,” Noor said. “Wars that are not ours.”

An LGBTIQ+ organiser told The New Humanitarian the US government’s narrative that NGOs spread “gender ideology” is reminiscent of the feverish anti-gay rhetoric that drummed up support for the 2023 Anti Homosexuality law, partly on the false belief that Ugandan NGOs “promote” homosexuality.

Steps back on HIV/AIDS

Uganda’s HIV response has long depended on US support, particularly through PEPFAR – the US President’s Emergency Plan for AIDS Relief – which helped place over a million Ugandans on treatment and financed prevention programmes targeting high-risk populations. About 1.4 million people are living with HIV, with tens of thousands of new infections each year.

LGBTIQ+ people and sex workers in Uganda face disproportionately high HIV risks compared to the general population, as stigma, criminalisation, and shrinking access to community-based services limit their ability to seek prevention and treatment.

For decades, much of US government response has been delivered through community-based networks that bridge the gap between formal health systems and marginalised populations.

In a response to The New Humanitarian, the State Department pointed to new data, it said, showing that the number of people receiving antiretroviral treatment in Uganda increased in late 2025 compared to the previous year, pointing to “the long-term resilience and adaptability” of Uganda’s HIV response.

However, health workers described how since last year they have sometimes been instructed by US government implementing partners, formally or informally, to prioritise certain groups – such as pregnant and breastfeeding women – for post-exposure prophylaxis (PEP), even as other high-risk populations struggle to access it.

“We cannot end AIDS by picking and choosing who can access medicines,” Byanyima said. The UNAIDS head also warned that the full impact of these disruptions may not yet be visible.

But for a health worker who has worked on HIV/AIDS prevention and treatment of LGBTIQ+ people for over 15 years, she had one urgent message for US policy makers; “We are going to die. Please have mercy.”