Boom and Bust
How Sierra Leone lost faith in foreign aid.
APRIL 8, 2025
In 2015, to support “post-Ebola recovery” efforts in West Africa in the wake of the world’s largest Ebola outbreak, I was hired as a policy adviser by Partners in Health, a global health nongovernmental organization headquartered in Boston. My job was to support an ambitious plan to double Sierra Leone’s Community Health Worker (CHW) program to include nearly 15,000 people. Community Health Workers are lay people who are trained in basic disease detection, education and support: helping people with HIV regularly access their medicine, for example, or giving information to new mothers about how to keep their newborn healthy. By this time, West Africa’s Ebola outbreak, which had infected nearly 29,000 people, killed more than 11,000 and threatened to spread far beyond the region if left unchecked, was finally waning. The region’s governments, supported by international donors such as the World Bank and USAID, wanted to use the devastating moment as a catalyst for change. CHWs had been essential during the outbreak; expanding their workforce would be essential in rebuilding the country, too.
In Sierra Leone, the virus had spread so quickly, and killed so many people, in large part because the country’s health care system was so under-resourced. There weren’t nearly enough health care workers, laboratories or basic materials like beds and medicines. As a result, international organizations led much of the Ebola response. Different NGOs and funders took on different parts: Doctors Without Borders, the World Health Organization and other organizations ran treatment centers; the United Nations’ World Food Program delivered food rations to quarantined families; the Red Cross oversaw burials.
The Global Fund wanted HIV to be a central component while U.N. programs stressed maternal and child health. There was disagreement across all parties about whether CHWs should get a stipend, and if so, how much.
At the time of my arrival in Sierra Leone, with Ebola case counts finally declining, there was the sense that this was a historic, fleeting moment in which to turn things around, after more than a year of chaos and horror. Government plans, backed by foreign donors and foreign NGOs, went beyond simply getting Sierra Leone’s health system up and running again. Doing so would be inadequate and short-sighted, given that, according to a U.N.-led report, “what was considered ‘normal’ before the crisis [is] unsustainable over the long term.” Across the region, donors pledged billions to support competent, comprehensive national health systems that “deliver safe, efficient and quality health care services,” with no drug stockouts, no health care worker shortage, no clinics without water — all within two years.
A large part of my job was coordinating between Sierra Leone’s health ministry, which was responsible for drafting policies and programs such as the expanded Community Health Worker effort, and the donors. (Outside of a crisis like Ebola, roughly half of the country’s health budget is funded by donors.) Even as funders such as the Global Fund to Fight HIV, TB and Malaria (the world’s largest multilateral funder of global health grants in low- and middle-income countries), the United States government, the World Bank and U.N. agencies insisted that the government of Sierra Leone be in the driver’s seat, they each had their own idea of what should be included in the CHW program. The Global Fund wanted HIV to be a central component while U.N. programs stressed maternal and child health. There was disagreement across all parties about whether CHWs should get a stipend, and if so, how much. To get the policy approved, my colleagues at the health ministry and I had to get other government programs on board, and then each of their external partners on board, too.
I was tasked with speaking to one government director in particular, a well-respected doctor who had worked with the health ministry for decades. For weeks, I tried to set up a meeting. His secretary said that he was busy, then traveling. When I found myself near his office I decided to pop by, and found that he was in after all, seated at a broad wooden desk, a folder open before him. He invited me in, but didn’t seem interested in speaking about the CHW program. Instead, he pointed to a map on the wall. It depicted the number of primary health care clinics across Sierra Leone: around 1,000.
The clinics’ decrepitude was regularly mentioned in health ministry meetings. In fundraising efforts by NGOs, donors, and the government itself, the government’s inability to ensure that these clinics were well-resourced was offered as an example of why the country needed so much outside support.
The director asked if I knew where that number came from. I said I didn’t. In the early 1980s, he explained, a consultant from the World Health Organization came to Sierra Leone, considered the country’s size, geography and population, and determined that, given new, ambitious international standards that declared primary health care a universal right, the country needed around 800 local health clinics to meet this goal. The clinics would be placed in every corner of the country, so that even Sierra Leoneans in the most remote areas would be able to receive health care within just a few miles of their home.
Soon after the WHO consultant made the map, he left. In the proceeding four decades, the government had been able to build, staff and resource some of the clinics. Others have been supported by NGOs or foreign donors. As the population expanded, the number grew, with villages demanding that politicians build more clinics, which had come to be seen as essential infrastructure. By the time I arrived the country had well over 1,000.
Fully staffing and resourcing more than 1,000 clinics, particularly those in hard-to-reach areas, has proven difficult. Health care workers didn’t want to live in the jungle. Trucks carrying malaria medicines got stuck in the mud on washed out roads. Forty years later, many of the clinics remained grossly under-resourced, lacking running water, trained staff, even basic medicines like Tylenol. The clinics’ decrepitude was regularly mentioned in health ministry meetings. In fundraising efforts by NGOs, donors, and the government itself, the government’s inability to ensure that these clinics were well-resourced was offered as an example of why the country needed so much outside support. Indeed, stories of their stunning inadequacies, from news outlets, NGOs, and foreign funders, helped to contextualize the Ebola outbreak, as well as the need for such a dramatic international response.
Leaning over his desk, the director considered the magnitude of providing resources to the clinics the WHO man had told Sierra Leone to build and support. He explained he didn’t disagree with the objective of primary health care for all. For that matter, he wasn’t against CHWs, or doubling their workforce. He wasn’t against external support; he was grateful to the foreign NGOs and donors that funded the Ebola response. But he was frustrated that the country was given specific directives by foreigners who had little local context and who set lofty goals without spelling out how they could be achieved. He was frustrated, too, that such unfulfilled goals were then held up as an example of the country’s ineptitude.
At the time, I considered health ministry staffers like this director unambitious, even accepting of the status quo. Energized by the optimism that characterized the “post-Ebola recovery period,” I had missed the fact that a boom-and-bust cycle, marked by spectacular commitments followed by scaled-down support, was the status quo. No wonder such staffers were reluctant to champion big promises and flashy goals.
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Since a devastating civil war ended in 2002, Sierra Leone has seen a cycle of waxing and waning interest from foreign donors and organizations who are compelled to act during a major crisis — the aftermath of war, the world’s largest Ebola outbreak — and then shrink their commitments as the crisis wanes. Today Sierra Leone and other countries reliant on foreign aid for basic services like health care and education are facing another bust, this one potentially catastrophic, with Donald Trump and Elon Musk’s dismantling of U.S. foreign aid.
In the period immediately after Sierra Leone’s civil war, aid efforts largely focused on humanitarian relief: things like food, refugee rehabilitation and health care. Within a few years, nearly 70 percent of the country’s health care was supported by donors. “Without them,” one Sierra Leonean doctor said at the time, “the health system would collapse.” By 2009, according to the Sierra Leonean government, aid made up approximately 18 percent of the country’s GDP. Nearly 80 percent of these funds flowed at least in part through NGOs, circumventing the government.
A doctor who spent his career working with the health ministry told me what he remembered from the postwar period, a relatively flush time. (He asked that I not use his name, given sensitivities around discussions about foreign aid and perceived government criticism.) He recalled being thrilled when TERRA TECH, a German NGO, provided things like medicine and vehicles and constructed wells in the southern district of Moyamba, where he practiced. The NGO set up a private medical supply chain, separate from the government’s; it also offered some clinicians a salary top-up if they performed surgeries. “Had it not been for … NGOs it would have been very difficult for the ordinary citizen to [manage] after the war,” the doctor told me. “There was just so much destruction.”
But a few years later, after the doctor had taken a new post in the country’s capital, Freetown, TERRA TECH scaled down its efforts in Moyamba. Its funding, from the German government, had been short-term, focused on immediate postwar rebuilding. “We had a lot of NGOs, we were brought a lot of things,” the doctor said. “If we had been able to continue with them, we would have had an advanced state.”
The health ministry had taken its time training the workers; donor staff complained that the rollout was slow and messy, eating up precious time in a short, two-year “post-Ebola” funding blitz.
Other funders also shrank their commitments. For example, the U.S. government had pledged $74.5 million to Sierra Leone in 2001, as the war was ending — almost all of it for humanitarian aid. By 2008, that figure had dipped to just $18.6 million; instead of direct service delivery, the majority of funding went to promoting democracy and “good governance.” U.S. funding rose a bit over the next few years — $28.9 million in 2010, $32.7 million in 2011 — as the U.S. government gave millions to help put alleged war criminals on trial as part of Sierra Leone’s U.N.-led justice and reconciliation process. In 2014, before the Ebola outbreak began in May of that year, the U.S. government had pledged $29 million to Sierra Leone. Funds focused on agriculture, sustainable livelihoods, women leadership and development, military training and education, and programs to strengthen the private sector, along with, curiously, just over $11 million to support nonproliferation of nuclear, chemical and biological weapons. (Sierra Leone has none of these.) According to a U.S. government website, that $11 million was implemented and managed by the U.S. Department of Defense. It could not be spent on Sierra Leone’s government priorities, such as health and education.
Total foreign aid, from the U.S. and others, picked up again when the Ebola outbreak began. Global aid for the country more than doubled, from $449 million in 2013, to $914 million in 2014. It was amid this spree that I pushed the CHW plan. I helped to raise millions for the expanded program, with funding from USAID, the Global Fund, the World Bank, and U.N. agencies. At the end of 2016, with Ebola beginning to recede into the rearview, I left the position, and in early 2018 I left the country.
The next bust happened soon after that. When I returned to Sierra Leone for a reporting trip later in 2018, I learned that the CHW program was being rewritten again. The health ministry had taken its time training the workers; donor staff complained that the rollout was slow and messy, eating up precious time in a short, two-year “post-Ebola” funding blitz. Despite the U.N. having warned “the international community needs to remain committed” to rebuilding the country’s health system, total aid went from nearly $1 billion in 2015, at the height of the outbreak, to $508 million in 2018 — just a bit higher than what had been given in 2013, before the outbreak began.
One afternoon on this 2018 trip, I found a former health ministry colleague sitting in a corner office, looking exhausted. She was meticulously combing through the CHW policy we had written just over two years before, deciding what to keep and what to cull and how to pull it all off. (This staffer also asked that I not use her name as she is currently negotiating with the program’s funders amid the USAID fallout.) One major U.N. funder had agreed to cover training costs and supplies but wouldn’t cover CHWs’ stipends. Another funder only wanted to cover districts that were “hard to reach” because it fit with their focus on rural areas. Some funders gave money for one year, others for two or three.
My former colleague was trying to create a quilt out of these disparate pieces. When I met her, she was sitting with her head in her hands, massaging her temples, her glasses on the table. She told me there was only funding for 8,000 CHWs around the country — just half of the expanded, ambitious post-Ebola goal. As a result of the reshuffling, thousands of CHWs were fired and then had to re-apply for their jobs. Those who were re-hired would make at most $25 a month — around $35 less than the government-mandated minimum wage at the time — and would have to undergo another training in yet another revised curriculum.
The recent USAID stop-work order and follow-on cuts, which the New York Times estimates amounts to $40 billion annually, has resulted in Sierra Leonean clinics shuttering, staff retrenchments and the suspension of essential services such as HIV testing, treatment and care. Even volunteers at U.S. supported sites have been told to stop working. One former staff member from a U.S. government funded program, not authorized to speak about an evolving situation, told me “Trump really wants to send people [to an] early grave.”
I asked if she had a backup plan. “No,” she said, with a half laugh. “We have no idea what’s going on.”
Before the cuts, U.S. government funding for Sierra Leone in 2024 included $53.3 million for USAID. The majority of that supported the health sector, including CHWs. But without a current crisis — no Ebola, no war — donors prioritized long-term reforms and programs, particularly economic ones. The Millennium Challenge Corporation, a separate U.S. agency focused not on health or humanitarian support but on “promoting economic growth, reducing poverty, and strengthening institutions,” allocated $40 million for Sierra Leone in 2024, mostly to support electricity and water projects. In September of that year, they announced a $480 million grant to be used for energy infrastructure over five years. By the time of the stop-work order, USAID covered CHWs in just three of the country’s 16 districts.
Now, in light of the Trump administration’s cuts, my former colleague may have to revise the CHW plan again. When we spoke in early February, she told me that as a result of the initial USAID stop-work order, CHWs in those three districts weren’t being paid, and no one was supervising them. I asked if she had a backup plan. “No,” she said, with a half laugh. “We have no idea what’s going on.” She had heard of another funder — the philanthropic arm of a major financial company, which had a lot of money but was relatively new to global health — that might be interested. Like everyone else, the funder has its own approach, namely that it doesn’t pay CHWs. Instead, workers are given microfinance loans, with which they are expected to build businesses and pay themselves. She also had preliminary conversations with the Global Fund about taking over the three USAID districts, but given that the U.S. government had pledged $6 billion to the fund for 2023-2025, it wasn’t clear how their own finances would be impacted. There was an anonymous donor that might be able to help, she said. “But this [would be] just for the short term. They’re leaving [Sierra Leone] at the end of this year.” A few weeks later she told me that donor’s budget had been reduced, too, so they wouldn’t be able to cover payments to CHWs.
About two weeks into the stop work order, I asked my former colleague how she thought the CHWs would feel about not getting paid while the Sierra Leonean government and its donors figured everything out. “Oh, they’re used to it,” she said. “You know, money from funders often comes late, this is normal. Hopefully they’ll get it eventually, even in two or three months from now.” When we spoke again in late February, she sounded more pessimistic. “We’re now thinking that we’ll have to [cut] 1,500 CHWs, so then we would have about 7,000 for the whole country.” Even though payment for the three USAID-supported districts still hadn’t come through, “all the CHWs are still working, for now.” She wasn’t sure how long they would hold out. “The future is bleak for them.”
I checked in again a few weeks after that. My former colleague said she was still worried by the gap left by the withdrawal of USAID funds. Then she went quiet. During that time, the New York Times reported that the U.S. would curtail much of its financial support for GAVI, a global vaccine fund on which Sierra Leone relies for routine immunizations and support in battling an outbreak of mpox. (The Global Fund was spared.) I heard from friends who found themselves out of work and unhopeful about finding new positions amid the cuts.
I hesitated every time I picked up the phone to call my former colleague. It felt cruel to ask “how are things going” when it seemed clear the answer wouldn’t be good.
Then, on April 1, I saw a message on my phone. “Hello Mara. We have some good news,” my former colleague wrote. The stipends to CHWs “will continue.” Amid the gutting of U.S. funding, $3.3 billion for the President’s Malaria Initiative, which oversees USAID’s spending on CHWs in Sierra Leone, has been retained. It is unclear how USAID, now run by the State Department, decided what funding to maintain; decisions were made without the required Congressional approval. Funding for 80 U.N. programs was cut, for example, but a $1,500 contract for internet access for Madagascar’s financial intelligence unit was spared. It was “good news” for Sierra Leone’s CHWs — but only for now.
✺ Published in “Issue 27: Promises” of The Dial
