What happens when U.S. international aid funding for immunization disappears? R4D’s new assessment reveals on-the-ground impacts and implications for programs in the DRC, Madagascar and Nigeria.
The challenge: Impacts of U.S. funding cuts on immunization systems
In early 2025, major budget cuts by the new U.S. presidential administration led to drastic reductions in funding for the U.S. Agency for International Development (USAID). As of March 2025, approximately 83% of USAID programs had been terminated (KFF, 2025). Before these cuts, USAID played a critical role in supporting immunization systems by funding vaccine procurement and introduction, training health workers, supporting outreach and community engagement, improving supply chains, and providing technical assistance to Ministries of Health (US Department of State, 2018, Dahl et al., 2024). Given the scale of budget reductions, concerns emerged about a “worst-case scenario” for effects on routine immunization, health worker support, vaccine supply chains and outreach programs. These impacts were hypothesized to be most severe in countries heavily reliant on international support with little domestic fiscal space to absorb new costs and at the “last-mile,” in facilities and communities where service delivery is already fragile. However, there is little to no information available about how funding cuts are translating to and impacting vaccination programs and coverage at the facility or subnational level.
The opportunity: Generating evidence to guide immunization recovery
While the threats to immunization programs due to reductions in US funding are clear, their real-world effects – particularly at the facility and sub-national level – are largely unknown and undocumented. This gap in knowledge limits the ability of governments, donors and implementing partners to respond effectively and target remaining resources to the highest-impact activities.
To address this gap, GiveWell – a nonprofit that researches and directs funding to global health and development programs, with an extensive history of supporting immunization programs and more than $190m USD disbursed in vaccine-related grants over the last decade – partnered with R4D to design a qualitative assessment focused on three priority countries: the Democratic Republic of Congo (DRC), Madagascar, and Nigeria.
Together, GiveWell and R4D developed key learning questions for the assessment to explore:
- How are vaccinators and other frontline health workers affected by funding cuts (e.g., workload, staffing, incentives, remuneration)?
- What new vaccine supply chain issues are emerging at the facility and district levels (e.g., stockouts, procurement delays, cold chain)?
- How are fixed-site and outreach vaccination sessions being maintained or reduced, and which populations are at increased risk of being missed?
- What gaps have newly emerged in the collection and use of immunization data?
- How are district and national actors adjusting planning, budgeting, and coordination to respond to new financial constraints (including how plans for new vaccine introductions are being affected)?
By addressing these questions, R4D aimed to generate rapid, actionable insights on “on-the-ground” impacts, expand GiveWell’s evidence base, and inform their grantmaking strategies to maintain impact amid shifting aid flows. Examining trends across diverse contexts may also shed light on dynamics and challenges emerging in other countries that previously relied on U.S. support for their immunization programs.
R4D’s work: Rapid assessment of immunization service disruptions
With support from GiveWell, R4D conducted a rapid, qualitative assessment to identify the impacts of U.S. funding cuts on immunization programs and last-mile service delivery in DRC, Madagascar and Nigeria. Specifically, the work included:
- Collaboration with local partners, including the University of Kinshasa, Department of Tropical Medicine in DRC; TA4ID, an international consulting group with a local presence in Madagascar; and a team of consultants, led by Dr. Mariya Saleh, in Nigeria
- Development and execution of key informant interview (KII) and focus group discussion (FGD) guides, adapted for different types of stakeholders and country contexts, with more than 200 stakeholders including vaccinators, facility managers, district/provincial officials, and national stakeholders
- Translation, coding and thematic analysis according to key domains of interest and site characteristics within and across countries
- Identification of actionable findings and recommendations for governments, donors and implementing partners
As of November 2025, the results of R4D’s rapid assessment are publicly available here and being broadly disseminated to country-level stakeholders, donors and key partners.
