One year after the United States announced the withdrawal of its health support in January 2025, the ripple effects are quietly unfolding across Kenya’s public health system.
At the Comprehensive Care Center in Bungoma County Referral Hospital, the doors remain open, but the strain is unmistakable.
On a chilly Monday morning, the waiting bay is already full. Patients sit shoulder-to-shoulder on worn wooden benches, waiting for routine checkups before collecting life-sustaining medication. The atmosphere is tense but familiar, a daily ritual shaped by uncertainty.
Among them is Ruth Nekesa (not her real name). She pulls her cardigan closer as she waits to be called in, hoping to receive medication that will last her the next three to six months, depending on her condition. A widow who has lived with HIV/AIDS for two decades, Nekesa describes the facility as her lifeline.
When news broke that USAID, the American agency that had funded her treatment for years, was pulling out, her first thought was stark and immediate: death.
“The first thing I thought about was death,” she says, with her calming voice. “I knew I could no longer access the drugs.”
Ruth knows exactly what happens when the medicine stops.
Years ago, she walked away from her treatment for two years.
She says , “I watched my health deteriorate, but since resuming taking the drugs , I have found stability and life again.”
Duncan Wanyonyi (Not her real name) is haunted by a different kind of memory.
He is living with HIV, navigating life with his HIV-negative wife.
For him, the announcement of the funding cuts felt like a rewind to a time he thought Kenya had left behind.
He remembers the years between 2003 and 2005, the era before massive donor support made ARV’s free at the point of care. He says , during that time ,
“The first question was, how much I was going to pay?” he says “I am still not confident on what will happen in the future”, he adds.
The announcement did not have an impact on only Ruth and Duncan, but on many patients in Bungoma.
As the HIV coordinator Bungoma County Joy Nyarotso says , for weeks , they had to follow up with other patients to come for the drugs because the majority knew that they could no longer access the drugs .
“We had to follow up most patients to come for their checkups and drugs because of the information that drugs were no longer available , and there was no communication on way forward , “ she says
However, she adds that USAID did not just support giving of drugs, it supported counselling and follow ups assistance and structure.
Under Kenya’s devolved health system, the county is responsible for the Human Resources for Health (HRH) and the operational costs of health facilities.
However, the transition from donor to county responsibility has been a story of fiscal avoidance.
“The reluctance of county governments to absorb donor-funded staff has created a lethal gap in human resources,” notes Ignitius Nyukuri , a health budget advocate .
He adds , “ The biggest challenge is with the budget process , with most cases county governments failing to allocate relevant funds to important departments , and only focus on recurrent budgets instead .”
Despite years of warnings that donor support was not reliable, counties budget allocations have largely failed to secure funds for HIV continuity.
While Bungoma county’s Programme Based Budget (PBB) for FY 2024/25 lists millions for medical supplies and infrastructure the specific technical costs of maintaining a HIV program, such as reagents for viral load tests and transport for sample monitoring, often remain invisible or underfunded.
Hon. Benjamin Otsiula , Bungoma county’s chair of the budget committee, agrees that there is a lack of strategy for donor exit , both in the local and national government.
“You cannot set a ceiling and you want to factor in funds that you don’t have. You set ceilings according to, first of all, your own source revenue,” he says
Relating to the county governments 2024/2025 and 2025/2026 budgets , Otsiula attests that without donor funding in the health sector, it is not possible for the local governments to sustain themselves .
“The easiest thing, at least when the budget is being submitted, HIV related programs are supposed to be captured.It’s not difficult.” he adds
A report from Bajeti Hub’s County Budget Transparency Survey (CBTS) 2024 finds that while county transparency is improving, meaningful accountability is still blocked by gaps in detail and public participation reporting.
The survey reports an overall score of 64/100, with counties publishing 84% of the key budget documents assessed, yet still failing to provide 39% of the information required by law.
Nyukuri states that it is a violation of the spirit of the Public Finance Management (PFM) Act, which requires budgets to be credible and based on actual service needs.
According to the National and County Health Budget Analysis for the 2023-2024 financial year , Kenya’s health system depends heavily on foreign aid, which provides nearly a third of the national budget, amounting to about Ksh21.5 billion.
The 2025/2026 budget of Ksh4.29 trillion is below the Ksh643.5 billion recommended by the Abuja Declaration of 2001, in which governments were to scale health budgets to 15 per cent of total budgetary allocation.
The government allocates far less than needed for healthcare , with health economists and public health experts stating that the country has poorly funded public healthcare system spending only $38 (Ksh4,800) annually for each of its people a far from the recommended $86 (Ksh10,900) , resulting to persistent poor healthcare and unhealthy donor dependence
Timothy Kiprono , a public finance and governance expert at the Institute of Public finance the withdrawal of USAID funding did not create the crisis ,it exposed it.
“This is a case of healthcare not being just like any other sector,” he explains. “If you anchor a statutory obligation like healthcare on an unsustainable funding source, then you’re risking the lives of Kenyans.”
For years, donor funding, particularly through USAID, quietly carried critical parts of Kenya’s HIV response leading to distrengthening existing government systems,
“USAID showed clearly that we are delegating our responsibility as a country to well-wishers,” He adds “The impact was both financial but also capacity,“It’s not just that we don’t have money, but we also lost the system to deliver services.”
In December 2025 , Kenya and the US signed a major health partnership agreement investing $1.6 billion (Ksh 208 billion) over 5 years to make Kenya ‘s health system sufficient by 2031 .
Kenya will contribute about Ksh850 million over the five years, with the U.S. providing $1.6 billion, with money going directly to the government , bypassing non governmental organizations that were previously handling programs like HIV In Kenya.
Even after USAID’s withdrawal, Kenya continued to rely heavily on foreign aid.
In the 2025/2026 financial year, the largest commitments for healthcare development came from donors including the Susan Thompson Buffett Foundation, the Global Fund, and the Global Alliance for Vaccines and Immunization (GAVI).
With these donors showing inconsistent support in previous years , there are still concerns about sustainability of the programs.
For Bungoma, and counties like it, the lesson is urgent.
Healthcare cannot be sustained on temporary goodwill. Without deliberate planning, budgeting, and integration of donor support into national and county systems, each withdrawal risks becoming not just a funding gap but a public health crisis.
As Timothy puts it, the solution is not simply more money, but better systems.
He says “Donor support should build systems and transfer capacity so that when they leave, the government continues without disruption.”
Until then, the waiting bay at the CCC will continue to tell a story not just of illness but of a system struggling to stand on its own.
