Soita Khatondi Wepukhulu is an award-winning investigative journalist reporting on global health, governance, and human rights in Africa. This article was originally published by the New Humanitarian here
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.
“We are not even allowed to probe to find out details about such cases. We are expected to stay silent.” 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…
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