Mulanje and Lilongwe, Malawi — Irene Makata sits on a weathered bench in a clinic in Malawi’s southern Mulanje district, wearing a white nursing uniform.
The facility, one of 13 in the district, is located in a predominantly semi-nomadic farming community near the Mulanje Mountains, 65 kilometers east of Malawi’s commercial capital Blantyre.
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Painted beige, it stands out from the dozens of red brick and thatched huts that surround it. To the right of the main entrance is a supply room with dwindling medical supplies. On the other side is an ambulance, which Makata says is rarely used now.
These medical posts were established to serve remote communities and reduce the burden on district hospitals. These were critical in providing basic medical care, antenatal care, family planning, and vaccines to communities.
Mulanje’s clinic used to see dozens of women a day and provide maternal care, including helping women give birth, dispensing medicines, and transporting women to hospitals when necessary. But now, with funding cut, the facility is only open about once every two weeks, stretching supplies as long as possible and unable to regularly transport visiting health workers.
Such health facilities are facing closure after the Trump administration cut funding to the United States Agency for International Development (USAID) in February, with 20 already closed nationwide. This has forced the country’s health system to suspend critical services, further straining hospitals and leaving thousands of women and children without the care they need in areas struggling with poverty and long distances to hospitals.
Makata is a nursing staff who specializes in maternal and newborn care, and she usually works at a district hospital, where she visits her post two or three times a week. Now she comes in rarely and no longer sees most of the patients she used to care for.
“Most of the women who relied on this post now feel that it is too far to go to the district hospital,” she told Al Jazeera.
Traveling along the bumpy dirt roads of Mulanje district, it will take you a good portion of the day to get there. The long visits “take them away from the daily activities that bring them income and food,” she explains.
Many people can’t afford to do that and now go without any care.
“They don’t have access to ideal antenatal care services, especially in the first trimester,” Makata said.
“The baby and mother are at risk.”
USAID funding was comprehensive. It provided funding for remote medical hubs, covering everything from training new staff to providing medicine and essentials to pregnant women and gas for ambulances.
The U.S. government provided nearly 32 percent of Malawi’s total health budget before the cuts.
Starting in 2022, USAID will provide funding to health facilities in 14 of Malawi’s 28 districts through a program called MOMENTUM to help strengthen existing clinics and establish new clinics. As of 2024, there are 249 posts. The program also provided medical assistance to the community and medical equipment. Washington had invested about $80 million in the program.
Earlier this year, President Donald Trump issued a stop-work order for USAID-funded programs as part of an executive order to suspend and reevaluate foreign aid.
This move resulted in MOMENTUM being shelved, resulting in the closure of 20 mobile posts. Doctors in training were left at a loss, and life-saving equipment was sold off at a fire sale by the Washington government.
Although the United Nations Population Fund (UNFPA) still provides technical and financial support for maternal and child health in some remote areas, available resources are not sufficient to cover the MOMENTUM-funded sites. There are concerns that UNFPA sites will run out of resources and supplies in the coming months.
In the wake of President Trump’s funding cuts, health experts in Malawi have expressed urgent concern that new mothers and babies could face the greatest impact, resulting in many lives lost.
Makata has set up a WhatsApp group for women to voice their concerns and questions, but she is frustrated that she can’t work like she used to.
“We went where people lived and provided permanent, long-term care,” she said, referring to the post. “This is not easy for me to understand. We can’t help the people who need our services the most.”
Massitive Matekenya, a leader of the Musa community in Mulanje district, wears a black blazer and an oversized green plaid tie at a vacant Mulanje health post.
These days, he says, it’s hard to put on a brave face for the people he represents.
“Women in our area are currently giving birth on the way to the county hospital because it is very far away,” Matekenya says. “The mother could then bleed, putting the baby and mother at risk.”
Matekenya has struggled to boost morale, constantly facing community anger over the fact that medical assistance has ended.
He said a 40-year-old woman in his community recently died of malaria. “Due to transportation issues, she could not be immediately referred to the nearest medical facility,” Matekenya said, noting that the community contacted a politician, but his help came too late.
“I’m worried,” he says. “With family planning services no longer available, a surge in pregnancies is expected and maternal deaths are also expected to increase.”
Impact on fistula treatment
A woman dressed in black and wearing a golden brooch shuffles from hall to hall at a clinic in Malawi’s capital Lilongwe. Margaret Moyo carries out her day-to-day responsibilities as the lead coordinator of the Bwaira Fistula Center.
Obstetric fistulas occur when a hole forms between the birth canal and the bladder or rectum when labor is obstructed and prolonged. Women who do not seek medical treatment may remain incontinent.
Beyond the physical pain, women who suffer from obstetric fistulas also face social stigma due to constant leakage and are often ostracized from their communities.
The Bwaila Fistula Center receives more than 400 patients annually from all over the country and from neighboring regions of Mozambique. It has 45 beds, one doctor and 14 specialist nurses, and there were about 30 patients at the center when Al Jazeera visited in August.
Moyo argues that fewer resources could mean less frequent personal visits during pregnancy, meaning maternal health problems, such as an increase in fistulas, may go undetected. She also worries that discussions about prevention and education will take a backseat.
“Young women are often at the highest risk of fistulas, so there should be a focus on midwifery training, access to care and education, and on delaying pregnancy in young women,” says Moyo.
Before the USAID cuts, the Malawian government was already projecting a $23 million shortfall in reproductive, maternal and neonatal health funding in 2025 due to reduced foreign aid.
“I can help them.”
For the past five years, Moyo has been implementing what she calls an “ambassador” program at her facility. Patients who have successfully repaired their fistula and are reintegrated into the community are trained and released into the community.
To date, 120 fistula survivors have become patient ambassadors, inspiring new patients to seek treatment through community outreach.
One such ambassador is Alefa Jeffrey. Wearing a gray Fistula Free Foundation T-shirt, the 36-year-old mother of four, arms crossed and staring at the floor, talks about being ostracized after giving birth and developing fistula.
“I wasn’t even allowed to go to church because the other girls made fun of me and told me I smelled like urine and feces,” she says. “My family told me to go to a traditional healer, but he couldn’t help me.”
Although Jeffrey was able to cope with the physical pain, he struggled with negative relationships with friends and family.
“I got used to dealing with my fistula, but the most painful thing was what people said,” said Jeffrey, who has considered suicide.
But she began searching for answers, asking traditional healers and eventually meeting an ambassador who came to the community to talk to the women.
After successful treatments including surgery, patient follow-up, and educational care, Jeffrey now advocates for fistula education.
She set up a WhatsApp group for people to chat with her for information about the condition. She also brought 39 mothers from the area to the clinic.
“I’m an expert now. I can convince people to come, but it’s not easy,” Jeffrey says. “Some women have already given up because they have lived with a fistula for so long that they don’t believe it can be repaired. I can help them.”
Lessons from the past: “We didn’t panic”
Health experts are concerned about what the future holds for the system without USAID in a country where more than 70% of the population lives below the poverty line, but government leaders say they have been in this situation before.
Back in 2017, during his first presidency, Trump cut funding to UNFPA and several organizations that provide family planning. The Malawi government has approached NGOs and other countries to address the funding gap.
They believe that through community and grassroots innovation, they can weather the storm again.
“When we heard about the USAID cuts, we did not panic,” said Dr. Samson Mundoro, Malawi’s health secretary. “Instead, we looked at ways to be more efficient and get more services for your money.
“We looked at areas where we could make the most of our resources. For example, if a police officer goes into a community for vaccinations, they can now also provide family planning services on the same trip.”
Mundolo sits in his office behind an orderly desk in the Lilongwe City Council building, discussing challenges.
“As soon as the cease-and-desist orders were issued, we lost nearly 5,000 health care workers, the majority of whom are what we call HIV diagnostic assistants,” he said, referring to the fallout from USAID’s layoffs. “We are now moving toward a health system that is not necessarily hospital-based, but more community-based.” In such a system, doctors and health workers from central hospitals would be sent further into remote areas, where regular community outreach would become part of their mission, and they would be asked to perform a broader range of services.
Mundolo and his colleagues have set up online activities and WhatsApp chat groups to respond to questions from patients in remote areas. He remains optimistic about Malawi’s health system, saying the worst the country can do now is lose hope.
“Each crisis is an opportunity. This gives us the opportunity to strengthen our systems and retrain our workforce and digital health systems,” he says.
“We’re not naive. This will take time, but if we understand that as a nation, we can get better over time. That’s the opportunity we have.”
Despite this sense of security, people living in remote communities say they feel isolated.
Tendai Kausi, a 22-year-old mother from Musa community in Mulanje district, is still going to a remote clinic to seek help for her four-year-old son Saxton. But many women in her community don’t do that because of cutbacks and closures. She has seen new mothers become pregnant in isolated villages, far from medical care and without regular check-ups.
“This is not good for the development of our country,” she says.
“My children will also be affected because the services here will not improve,” Kaushi said. “I feel so sad for the community.”
