Death in Mozambique after US funding cuts — a health system crumbles

Daily Maverick

2 days ago

After the abrupt termination of American aid, the health system in central Mozambique descended into chaos. In part one of this special series, Spotlight and GroundUp explained how children with HIV had been abandoned by US-funded case workers. Now in part two, we describe how the funding cuts affected hospitals, where key staff were dismissed and deliveries of new medicines were halted. In the ensuing turmoil, children died.
On the hilly outskirts of Manica town in central Mozambique, Costancia Maherepa sits on a reed mat beside her mudbrick home and weeps over the death of her 11-year-old daughter, Paciencia.
For years, their family depended on the support of a US-funded organisation called ANDA (the National Association for Self-Sustained Development). It employed a network of case workers and health staff to care for vulnerable children living with HIV. Paciencia had been one of them.
'When the programme was running, all the kids in this area were healthy and taking their medication,' says Costancia. But now, everything has changed. The American aid that once financed ANDA's work is gone and Costancia's family has suffered the consequences.
Paciencia had a difficult life. Her father died six years ago, and Costancia struggled to grow enough food to keep her well fed. Around 2021, a case worker employed by ANDA saw that Paciencia was malnourished and took her for an HIV test. It came back positive.
But despite this, Costancia says her daughter was calm and resourceful. When Costancia was out farming, it was Paciencia who acted as household head, cleaning and cooking for her younger sister, aged nine. When facing hunger, it was Paciencia who came up with a way to find food for the family, often by reaching out to neighbours.
And with the help of the case worker from ANDA, Paciencia started antiretroviral (ARV) treatment and began to recover. She put on weight and even improved her marks at school.
At the beginning of this year she was getting ready to start Grade 6.
But at the same time, an election was taking place thousands of kilometres away from Pacienca's mud hut in Manica. A new US president was sworn in, and a slew of executive orders were issued.
Shortly after, the institutions that had kept Paciencia alive would crumble.
Children given the 'wrong medicines'
Mozambique is an overwhelmingly aid-dependent country. Its ARV medication is procured by the Global Fund to Fight Aids, Tuberculosis and Malaria, an international organisation. Until a few months ago, the distribution of these drugs to Mozambique's hospitals was heavily financed by US aid agencies, as was the transport of blood samples and specimens to the country's labs.
US-funded organisations also employed much of the workforce at government health facilities, as well as the case workers who operate within communities.
When US President Donald Trump decided in January to suspend the US government's global aid programmes, the health system in central Mozambique was upended.
Most of ANDA's staff lost their jobs, including Ivone Mupacocha, the case worker who had been helping Paciencia. But Mupacocha continued occasionally checking up on the children she once supported. When she reached Pacienca's home some time after the funding cuts began, she found that the child had fallen ill.
The cause was clear, according to Mupacocha. When the 11-year-old went to the health facility, she had been administered the wrong ARVs, and her body was reacting badly.
Others in the town of Manica told me similar stories.
HIV patients arrived at health facilities following the US funding cuts to find that everything had changed. Many of the health workers they knew were gone, and the queues stretched endlessly. After hours of waiting, they were handed drugs that differed from their usual prescription or were given much smaller doses of their medication than usual.
For instance, elsewhere in the town, another mother told me that her HIV-positive child was given a different regimen of medication after the funding cuts, and the new drugs made him feel ill.
The technical director of ANDA, Prince Mulondo, says that because US money funded the transport of drugs to health facilities, many hospitals in the region faced medicine stockouts following the aid suspension. Among the drugs that ran out were some ARVs. So health workers used alternatives that they still had in stock or simply began rationing people's medication.
In other cases, it appears that hospital staff simply didn't know what drugs patients had been on. The data capturers that managed patient files were overwhelmingly US-funded and many were now gone, as were facilitators who acted as the first point of contact for vulnerable children like Paciencia.
Within a month after she was put on a different treatment regimen, Paciencia grew increasingly ill. On 10 March she was admitted to hospital, where she stayed for more than three weeks. On 3 April, the 11-year-old, who had successfully jumped over so many hurdles in her short life, died in hospital.
She was not the only one.
HIV patients forced to ration medicines
A few kilometres from Costancia's mud hut is the neighbourhood of Pesanhota Bairro, where a steep dirt road snakes past earthen homes, occasionally fortified by bits of corrugated iron.
There, a former ANDA case worker, Cecilia Cláudio, sits on a plastic chair and ruminates about a family she once supported. The family included a single mother and two children, aged five and seven. The mother and the older child were HIV positive and for years Cláudio helped make sure they had the drugs they needed.
After the funding was stopped in January, Cláudio was largely gone from their lives. But she later found out what happened to the family. The story is as follows.
The mother arrived at the health facility following the funding cuts, where she was told that very little of her medication was left in stock. She was given a small bottle – much less than her usual refill. She went home and rationed the drugs, taking them on some days and skipping others. Her condition quickly deteriorated, and in March she died.
The two children she left behind went to stay with their grandmother. When the older child was taken to the hospital to collect his own ARVs, there was no one left who knew what drugs he was on. The facilitator was gone. The data clerks were gone. His mother was gone.
Cláudio has not been able to reach the family in a while due to the long distance between her home and theirs, but she was told that the child has not been well.
An uptick in deaths
After the health system was torn apart, ANDA began compiling a record of the dead. One of the main provinces they have focused on is Manica (where the town of the same name is located).
Among the vulnerable people that ANDA case workers had been protecting in this province, 22 have perished since January. Of that number, 16 are children. The figure is almost certainly a huge undercount since it only includes those who have died in four of Manica's nine districts.
ANDA doesn't yet have precise data on mortality figures in previous periods, but according to Mulondo, this is much higher than what they ordinarily see.
Government data also shows that HIV treatment efforts have stalled in Manica province compared with previous years.
At the headquarters of the Sofala provincial government in Beira I was given access to a government dashboard which displays HIV treatment figures for each province. It showed that between April and December 2024 there had been 1,500 to 1,900 people starting ARVs in Manica each month. (In most months the figure had been closer to the upper end of this range).
But after Trump's executive order in January this figure declined. In March (the most recent month for which there is data) only 1,308 people are recorded as having started treatment.
Provincial health officials say that not only are they seeing fewer people starting treatment, they are also observing an uptick in the number of HIV patients who are stopping their medication. Previously, the case workers had followed up with patients who failed to collect their ARV refills on time. Now, those people simply become lost to the system.
Indeed, the government dashboard shows that in Manica there were fewer people on ARV treatment in March than there had been at the beginning of the year.
Food shortage
The impact of the sudden removal of US-funded case workers in this region extends far beyond the prevention and treatment of infectious diseases. For many people, the case workers had been the only sources of stability in an otherwise extremely volatile context.
The rural village of Makurungu is 270km from Manica town. Here, homes are largely made of unplastered mud walls, topped with roofs of iron sheeting or thatch.
The village is in the province of Sofala, where a different US-funded organisation, ComuSanas, has been responsible for hiring case workers. Much like ANDA, the organisation lost its funding in January, and its case workers were laid off.
In Makurungu, this has often led to a deep sense of fear and abandonment.
One resident who had been a beneficiary of the programme explains that before the aid cuts took place there was a period when many people in this area were close to starving. But case workers from ComuSanas had organised food baskets for those in need.
Now that the programme is gone she doesn't know who will come to their aid the next time there is a food shortage. 'The future is dark,' she says.
Elsewhere, another resident, Amelia Waston, says she is deeply saddened by the loss of her case worker, whom she had come to view as a member of her own family. For years the case worker had been a consistent source of support for her and her children, but since January they hardly see her. No one had told Waston why she stopped coming.
Makurungu case worker makes Rubio an offer
Near Waston's home I sit with a group of former case workers from ComuSanas, where I hear yet another story about an HIV-positive child who died in the past month, possibly because of the funding cuts. This time it is a 14-year-old girl.
US Secretary of State Marco Rubio and the former Doge point man, Elon Musk, have both asserted that 'no one has died' as a result of the aid cuts. I tell the case workers about Rubio's assertion and ask them what they think.
An older man, Faustino Samuel, answers. Until that point in the interview, Samuel had spoken only in Portuguese, the lingua franca in Mozambique. But in response to that question he begins speaking in a local language, Ndau.
'It isn't true,' he says. 'If he could come here, we could show him the evidence.'
According to the local translator I was travelling with, the man switched to his native tongue for a very particular reason. He wanted to transmit this message as clearly as possible, the translator said. He wanted people to know what is happening here. DM
If you'd like to find out how you can support ComuSanas, you can contact their director, Virgilio Mubai by email: [email protected]. If you'd like to find out how you can help ANDA, you can contact their technical director, Prince Mulondo, by email: [email protected].
Note: Most of our interviews were in Portuguese and were mediated by a local translator. We subsequently transcribed and translated the recordings of these interviews using AI-based software, including Descript and ChatGPT. Where there was a significant mismatch between the interpretations of the translator and the software, we contacted the interviewee or got third parties to help translate the recordings. All parents and guardians gave permission to use the photos of children in this article. All people photographed understood that their photos would be published in news media. The cost of travel, accommodation and the journalist's remuneration was shared between Spotlight and GroundUp.