The aid era won’t end evenly, as Vietnam is finding out

The 2025 US administration’s freeze on foreign aid blocked $4.1 billion in global health funding. Donor nations redirect funds domestically, while low- and middle-income countries face debt crises that limit health investments. As medical research specialists put it (Opens in new window), the cuts mean “the golden age of global health is over.

External financing for HIV and tuberculosis is contracting across the developing world, and countries that built their responses on donor money now face one question: whether anything was built to outlast it.

If there is one country that began answering that question early, it could be Vietnam.

Vietnam is a recently reclassified upper-middle-income country with a growing economy and a double burden: non-communicable disease is a leading cause of death, yet prominent communicable disease remains a serious challenge.

Its tuberculosis rate is among the world’s 30 highest (Opens in new window), and it ranks 10th for multidrug-resistant TB. Its HIV epidemic is concentrated among key populations. The responses to both diseases were historically donor-built, with external funds covering roughly 70% (Opens in new window) of the HIV response.

Vietnam folded TB and HIV into its own social health insurance to absorb the cost of treatment for both (Opens in new window). Antiretroviral therapy moved onto insurance from around 2015; tuberculosis treatment followed in 2022. While a donor grant can be withdrawn, a domestic insurance benefit is harder to cut. Vietnam converted the first into the second.

The timing shows this was not accidental. A 2016 Prime Minister's Decision set a target of full insurance coverage for people living with HIV by 2020. Coverage rose (Opens in new window) from 40% in 2014 to over 85% by 2018. Domestic resources financed 30% of the HIV response in 2015 and reached 49% by 2022, rising about 3.5% a year. The replacement financing took place while donors were still present and the outcomes held through the transition (Opens in new window). A cohort of over 2,200 patients in northern Vietnam maintained viral suppression above 90% and retention above 87% across the switch to insurance. An early survey (Opens in new window) found 0.1% of antiretroviral patients incurred catastrophic HIV-related payments. Treatment survived the move.

The regional comparison shows why this matters for allocation decisions. Measured against the treatment element of the UNAIDS 95-95-95 targets (Opens in new window), the gradient across the Indo-Pacific is wide. In 2024 (Opens in new window), an estimated 31% of people living with HIV in Indonesia and 43% in the Philippines were on antiretroviral therapy, both below half; in Fiji, where new infections have risen roughly tenfold in a decade and the government declared an HIV outbreak in January 2025, coverage was 28%. Thailand, by contrast, treats almost all diagnosed people, with over 97% of those on treatment virally suppressed in 2025. Vietnam sits with the stronger performers on treatment coverage, and has done more than most to secure that position with domestic money. This is a straightforward lesson for donors.

The transition is most complete where the task was easiest. Treatment is a discrete clinical service an insurer can pay for, and it has been domesticated. What remains a challenge is prevention and case-finding: both are diffuse and cannot readily be billed to insurance.

Vietnam detects an estimated 57% of its tuberculosis cases; the remainder are undiagnosed, and finding them is not a function insurance funds. Nearly one in ten people living with HIV remains uninsured, most often the undocumented and marginalised whom a residence-based card reaches least well. A national study (Opens in new window) found a quarter of tuberculosis patients could not enrol even with active support, for lack of documentation, and that 63% of TB-affected households had faced catastrophic costs under the previous model.

This could define donors’ future decisions. Domestic insurance will carry the patient who is already diagnosed and documented. It will not, on its own, find undiagnosed cases, reach criminalised populations, or fund the prevention that stops the next infection. Treatment support can taper as insurance absorbs it, but prevention and case-finding financing cannot be handed to a domestic insurer, and cutting them first is where new infections return.

For governments, the corresponding task is to build a home for prevention that does not depend on an insurer: a ring-fenced budget line for case-finding and key-population outreach, and formal domestic funding for the community organisations that currently run on donor grants. Vietnam has begun this through social contracting, but it remains the least-secured part of its transition.

The transferable action is to fund the construction of the domestic financing mechanism while still present, and to hold prevention financing longest, because it is the function no insurance scheme inherits. Whether it can build the equivalent sustenance for prevention, before the money is gone is the open question. With the golden age over (Opens in new window), what follows will be determined by which functions were secured domestically before the transition, and which were left to a donor now leaving.