Elie Hassenfeld: [00:00:00] Hey everyone, this is Elie Hassenfeld, GiveWell's co-founder and CEO, and I'm joined today by Alex Cohen, a principal researcher at GiveWell. We're gonna be talking about the work we've done to generate forecasts about the aid cuts and what it could mean for global health funding going forward, what it could mean for the needs that programs will have going forward, and what it could mean for GiveWell's work.

In these conversations that we've been having, we've been toggling between more zoomed out conversations and more specific conversations on particular grants. And this one is going to be particularly zoomed out and potentially fairly abstract, because we've been trying to get a better handle on what aid funding could look like in 2026 and in 2027. It is very hard to know and very hard to predict what things will look like. So, we are gonna try to go through that today.

Some of the questions we're gonna try to talk through are how large do we [00:01:00] expect aid cuts to be? To what extent do we think these aid cuts will preserve the most cost effective programs that exist? How do we think other actors, other governments private actors, local country governments, will respond. Today we're sitting in June of 2025, when will we know more about the answers to these questions? And then finally, what does this all mean for GiveWell's work? How could we respond differentially depending on which future scenario we end up in, and how are we thinking about that today?

Just to set this up a little bit, in aggregate, there's about $60 billion worth of global health funding every year, and the United States provides about 20% to 25% of that, so approximately $12 to $15 billion per year in funding in 2024. And so what we're gonna talk about is trying to understand what the US might do and then what that means for global health funding overall.

So I'm here with Alex. Before we dive in though Alex can you just briefly introduce yourself?

Alex Cohen: Glad to join. My name is Alex Cohen. [00:02:00] I've been at GiveWell about five years, I'm a principal researcher. In terms of background, I got my PhD in economics, focusing on development economics.

Before GiveWell, worked at a private foundation for about three years using research and evidence to guide their grant making. At GiveWell, I lead our crosscutting team. So while most of GiveWell's research team focuses on making grants and doing research questions related to those grants, we're looking kind of across the board ways to improve our research and decision making.

This includes a few things. Red teaming our research to poke holes, see where we could be wrong. Includes looking for methodological improvements. So, not just new ways to model cost effectiveness, but also ways to incorporate more local insights from places where we fund programs, and ways to improve our legibility.

My work also includes looking into research questions that apply across different grant making areas, including this question that we're talking about today, how should these big cuts to foreign aid that are being discussed influence GiveWell's grant [00:03:00] making?

Elie Hassenfeld: Thanks for joining me and having this conversation. You know, one of the big questions that we've just been struggling with in the last few months is what will global health funding look like in the future? We've done a couple projects on this, so we worked with people who are professional forecasters and have done some of our own work. And recently published a page about the forecast on US global health funding. Can you just walk through what we did to forecast aid cuts and what you take away from all that, your bottom line of where you think we might end up.

Alex Cohen: So this is obviously a really, really challenging question. Trying to predict the future is difficult in general. I think especially with this question on foreign aid so many things are up in the air, so we tried to take multiple different perspectives here.

First is, we tried to reach out to people that do forecasting for a living or do a lot of this. So The Good Judgment Project, their super forecasters are trained at trying to predict, highly uncertain things. So we made a grant with Open [00:04:00] Philanthropy to solicit forecast from several of their super forecasters.

Also worked with groups like Metaculus, which is a forecasting platform, to get their forecast as well. We also reached out to a ton of experts, people that know about different parts of this foreign aid decision making process. So this includes folks either currently or formally in the US government, people that are working on policy advocacy, people working at think tanks or other policy research groups. Talking to the charities and the other organizations that we fund. Talking to GiveWell staff that have been having lots and lots of these conversations, trying to get their forecast too.

Goal was to get lots of different perspectives on this and really try to pin people down and say, okay, quantitatively, what do you expect? We were hearing a lot of, yeah, there are gonna be big cuts or there are gonna be moderate cuts. But it was really useful, I think, to try and get people to say, okay, quantitatively, should we be thinking 20% cuts, 80% [00:05:00] cuts, somewhere in between.

When we did that, I think high level takeaway is we got a variety of answers. This is really challenging to predict. I don't put a ton of stock in a specific point estimate, but if we take rough averages here, what we're hearing is something like 50% cuts in the US and substantial, but maybe not as severe cuts beyond the US. So thinking about other bilateral funders in UK, Europe, other places. So maybe rough, very directional guess is maybe drop of global health funding by a third per year over the next few years. But again, I think these things are really uncertain so don't wanna put a lot of weight on a specific point estimate here.

Elie Hassenfeld: So let's try to put that all together. So basically, we've been sitting in this situation where a big question we have is, what will global health funding be in the future? And often when you're talking to people or reading reporting, people will use just words like there could be massive cuts. And [00:06:00] it's very hard to know what to do with language like that and what that means for the future.

And so we went out and tried to gather more quantitative estimates of what the future could look like. And it gave us this very wide range of outcomes. Folks wanna go to the page that this public on our site, you can see more about the details here. But very roughly, I guess it gave us this central estimate of 50% cuts to US health funding, which then would imply about a one third cut to health funding globally, which is a function both of just the size of the US health funding itself, but also the expectation that some other countries will be reducing aid as well.

Is that right? We have been focused so much on the US cuts and that's the specific thing that we ask people to forecast, but it's not just the US right? Some of what we're looking at is cuts in other funding as well.

Alex Cohen: That's right. Yeah, I think it's fair to say that we've applied the most scrutiny to US funding cuts. We've had the most conversations with people on [00:07:00] that, we've had the most visibility on that. We're estimating 50% cuts, but there are other funders too. So like you said, US is maybe 20, 25% of total funding. The rest of that is coming from other bilaterals like the UK, Germany, France, other countries. And also some private donors as well.

Initially, I think we were hoping they might step up and increase their funding in response to cuts from the US. That may happen in some countries, but especially in looking at bigger funders like the UK and Germany, they've both at least made some indications of planning to scale back their funding too. But I think by and large, looking across all these groups we're expecting roughly a 35% or so cut to total funding.

Elie Hassenfeld: To put that into numerical terms, we started with this baseline of $60 billion. And our best guess is that when you take the US, which we're estimating at 50%, and then others, it would be a total drop of a third, which is $20 billion of aid cut. [00:08:00] $20 billion a year is a huge amount of funding. As a reminder, we directed last year, nearly $350 million. So, you know, really just a minuscule fraction of the total cut that we're expecting. Like Alex said at the beginning, obviously we don't know whether or not this will come to fruition. But that's a $20 billion hole in health funding relative to what was there before.

That sort of leads to the next question, which is presumably, you know, a large amount of the aid that's being cut is really cost effective. There are programs that the US government supports, other government funders support via GAVI, which is the Vaccine Alliance, the Global Fund, which focuses on HIV, TB, and malaria, so supporting all of these important programs where it'd be a shame to see them cut.

I guess the question is like, how much of the programming that could be cut is cost effective? If governments do a great job prioritizing the cuts according to cost effectness, maybe the resulting needs won't be as great. And on the other hand, if they do a poor job or just allocate the cuts randomly across that $20 billion there could be a huge hole. [00:09:00] So, to what extent will the most cost effective programs be preserved? What do we know about that? And what's your bottom line?

Alex Cohen: Yeah, two questions we need to answer there are, what share of that initial funding, that initial $60 billion do we think is highly cost effective by GiveWell standards. And then how targeted do we think those cuts are? The optimistic case is yeah, there are cuts, but it's concentrated in programs that we think are much less cost effective, or cuts to countries where there's less burden of disease.

So on the first piece we've done some very rough cuts to try to understand how cost effective current global health spending is. This is based on using current cost effectiveness estimates that we've done for programs like insecticide treated bed nets, seasonal malaria chemoprevention, malaria treatment, these areas that we know well. And then making some very rough extrapolations to other areas outside of malaria. I think a lot more uncertainty once we get outside [00:10:00] of malaria.

But I'd say at a high level, we think roughly 10% of this global health funding is in the most cost effective programs. So in our terms, this is 20 times as cost effective as our benchmark. Our current bar is 10 times our benchmark, and so 20 x that is programs that are really cost effective. So maybe 5 to 10% of that $60 billion is these highly cost effective programs.

Elie Hassenfeld: What we're trying to figure out is when funding is cut in the future, what will that mean for the kinds of needs that emerge that weren't there previously? We're just trying to start with this question of how much of that is extremely cost effective by our lights and the way that we're defining extremely cost effective right now in this conversation is, a program that's twice as cost effective as our current funding bar.

So current funding bar is 10 times our benchmark, twice as cost effective is 20 times our benchmark. And you're saying maybe, and of course this is a fairly, rough estimate, but maybe 10% of that total pool of funding, that $60 [00:11:00] billion, is in that category.

Alex Cohen: Yeah, that's right. When I'm thinking, about the 10% of that $60 billion that's really cost effective, 20 X our benchmark or twice as cost effective as our current bar for funding, I'm thinking of things like, malaria prevention programs that we support currently: insecticide treated bed nets, seasonal malaria chemoprevention. I'm thinking about malaria treatment, thinking about HIV treatment and prevention, so pre-exposure prophylaxis. These are areas that we've devoted less attention to, but we think are cost effective. I have in mind vaccination programs for childhood diseases, ready to use therapeutic food or the high calorie food that's given to kids with malnutrition.

These are some of the programs that I have in mind, but yeah, that's the high level overview.

Elie Hassenfeld: All the programs you just mentioned are some of the programs that I think would, at a high level be called, really evidence backed and cost effective.

And then there's always this question when we look at a program is how cost effective is it in [00:12:00] a particular context? Meaning how much does it cost to reach a person? And what are the challenges of delivering in a particular location? And so we don't know for sure, but we can look at the 30,000 foot view, and see that there's a large amount of funding going to support these very strongly evidence backed, cost-effective programs in areas where there's very high burden of the problem that they're addressing.

And so, we know that that funding is going to them today. Which then leads to this next question of, to what extent will the relevant decision makers preserve the most cost effective stuff in the cuts that take place in the future.

Alex Cohen: So at a high level, we think there are 35% cuts overall to global health funding. My best guess is something like 25% cuts to the most cost effective areas. So that means there's some prioritization of remaining funding to the most cost effective programs, malaria treatment and prevention, HIV treatment and prevention, and some prioritization of countries with the highest burden of disease. We [00:13:00] think those are gonna be places where this is most cost effective.

Reasons why I think there could be some prioritization are, we're seeing in discussions from the US government some extra protection of areas like malaria and HIV. Some suggestion there that cuts to those areas will be smaller than some other areas.

I think there could also be prioritization based on geography. So within malaria, making sure that West Africa is prioritized where there's an especially high burden of disease. I think that could happen, but I think less visibility on that.

Reasons to think it won't be perfect prioritization, there are other factors that are going into these decisions beyond burden of disease. There are questions about strategic interest too. There are forces pushing in both directions, which makes me think there'll be some prioritization to the most cost effective programs, but probably not complete prioritization.

Elie Hassenfeld: As you were talking that through like the thing that I was thinking about is what are the mechanisms through which we'd expect decision makers to preserve, and or, not preserve [00:14:00] the most cost effective programs? The programs that have strong evidence behind them and straightforwardly help people at prices where it's pretty cheap to reach people - preventative health programs, child health programs - those are programs that we generally think are more cost effective, and they seem to be the programs that are relatively more likely to be preserved in the scheme of things.

And then also, there's an understanding of where burden of disease is higher. And for example, we do think that other things equal, decision makers would be relatively more likely to preserve malaria programs in high malaria areas, than not. And so that's consistent with the expectation of some degree of preservation of more cost effective programs.

And then on the other hand, the lens that we evaluate the world through is a very focused, cost effectiveness one, and that's just a lens that is fairly rare and not one that we see applied elsewhere with other decision makers. They just have other priorities that are driving funding decisions, which will lead to some degree of cost-effective programs, being removed.

And we start with the [00:15:00] $60 billion of total global health funding. And of that, we think that 10% is extremely cost effective, so 20 times our benchmark. To just put numbers on that, that's $6 billion, relative to GiveWell's annual funding of $350 million.

So if a meaningful portion of that most cost effective $6 billion is cut, that would certainly mean that there are huge funding needs that are opened up that we would want to fill if we were able to. How do you think about the size of those cuts at that extremely cost effective level?

Alex Cohen: So yeah, we've got $6 billion that we think is really cost effective. My guess is there's 35% cuts in global health funding overall, maybe slightly smaller cuts to the most cost effective stuff, so let's say 25%. So, maybe $1 to $2 billion in really cost effective programs per year. You know, I think, again, these are very rough. You should be thinking of wide confidence intervals around those.

But I think maybe take home message is, there could be [00:16:00] these substantial gaps, more than GiveWell's annual grant making, in what we think are programs that avert to death very cheaply. And just to maybe put a finer point on that, when we're talking about programs that are 20 x our benchmark, we're thinking about programs that avert a death for $2,000 to $3,000 per death averted.

Elie Hassenfeld: Yeah. So I mean, I think in some ways the big takeaway is just how large the potential needs could be because huge funding flows that have been supporting extremely cost effective programs are going to reduce. And I think importantly, we don't expect it to be a 100% reduction. I think it certainly could happen, I hope it doesn't happen. But even taking the central estimate of what we expect, you know, maybe 25% of the most cost effective stuff being cut, it really leaves absolutely massive gaps for some of the largest needs in the world.

And then I guess the next question that is important for how this plays out is, what will other actors do to respond? There's the Gates Foundation, there's other private donors. There are [00:17:00] potentially country governments that are not planning to reduce their aid and local country governments increasing aid spending. So I'm curious how much we know about them, how much they might give, and how much they might prioritize cost effectiveness in directing funds, and to what extent that would offset some of the cuts that we're expecting.

Alex Cohen: Yeah, I think the big wild card, the big uncertainty in this analysis is how country governments will respond. So for example, back in February the government of Nigeria announced that it would commit $200 million to help fill gaps left over from cuts by the US government. I think it's an open question how Nigeria and other countries will step up and reallocate funding to health programs in the face of these gaps.

That's not something that I've looked into in depth yet. But yeah, I think there could be scope for some countries within Africa or other countries to fill some of these health gaps.

Elie Hassenfeld: Okay. So we've talked about [00:18:00] expectations for the nature of, and the size of the needs that could emerge. And probably have emphasized maybe too much how much uncertainty we have and how little we know even though we're trying to do our best to get some sense of it.

When are we gonna know more? Is there a point where this will become clearer? If so, when? Or is it something where it's gonna be following along slowly and it will just emerge as time passes and spendings out. Like what are the big milestones we should be watching out for where we'll actually get more certainty or confidence about what kind of future we'll be in?

Alex Cohen: I think my instinct is we're gonna be in a world where there is slow trickle of updates. There's not gonna be a discreet point where we know, okay, this is the amount that the US government is going to commit to global health.

So to focus on the US specifically, the White House and Congress are still figuring out the budget for fiscal year 2026. The deadline for that is the end of September, so ideally we would know by then this is the amount of the total US government budget, including the amount that's [00:19:00] allocated for global health and other foreign aid. It's possible that congress passes a budget, but it's also possible that there's a continuing resolution, which means that Congress can't agree to a budget and we revert back to previous year's numbers. I think in that case, we're kind of back where we are now.

Elie Hassenfeld: Got it, so several months from now we could have more information, but this is just gonna be something that we're gonna be watching. How are you staying up to date on this? Like is there a mechanism through which we're getting updated forecasts, or do you plan to do more work on this forecasting project to get a better handle of how things might play out?

Alex Cohen: Yeah, I think given that it seems unlikely, there's gonna be a key point where we have a ton more information, the best strategy seems like monthly check-ins on where we are. Concretely, that means talking to a lot of people and tracking updates. That includes partners in DC that have a good sense of conversations going on in the capitol, charities we fund and other major global health funders. Our grant making teams are talking to these groups on a pretty [00:20:00] regular basis. And then also talking to colleagues at places like Kaiser Family Foundation, Center for Global Development, and Open Philanthropy. These are groups that are having similar conversations, trying to keep an eye on what's going on.

So we have these conversations and then pull this information together and step back every few weeks to say, okay, what do we think now about what gaps are likely to emerge and how does this update our grant making strategy?

Elie Hassenfeld: I guess like the biggest thing that I've taken away from this work that you've done is we've already been finding in the last few years before any cuts, the you know, really cost-effective programs that are not being picked up by anyone else.

And now, we anticipate cuts of about a third, they're not gonna be perfectly prioritized against cost effectiveness. So they're just going to be much larger gaps, and gaps in areas that we haven't looked at before or haven't looked at in depth. And so, I'm curious to just talk for a second about ways we could respond.

I guess from my perspective, number one is making sure we're hiring and building [00:21:00] the capacity to look into areas so we can consider and understand areas like HIV/AIDS that just historically were so well covered by other funders that we didn't spend a lot of time looking at it.

I think the impact of additional funding will be greater than it was in the past. If the needs that are emerging are more cost effective. So it raises the priority of raising more funding and donors giving more. What are the other things that you've been thinking about from where you sit about how GiveWell should respond? You know, what should we be doing to have as much impact as possible going forward?

Alex Cohen: Yeah. So we've been spending this conversation talking about these specific numbers and gradually gotten to this bottom line of, okay, maybe there's $1 billion or $2 billion that could be opened up per year in these really cost-effective programs for GiveWell.

I don't put a ton of weight in that number, it doesn't make me think, okay, let's plug that into our model, that means we should raise our bar by this amount. You know, I think that's work that we should do. We should think about whether we raise our bar, meaning that we set a higher threshold for cost effective programs, knowing that [00:22:00] there's really cost effective things available.

But I think really the big takeaway for me is, there seems like a decent chance that there could be some really, really effective ways to use funding. We need to do what we can to find those areas. And that's a lot of the things that you mentioned it's getting more staff. The more capacity we have, the more we can learn about these areas that we've learned less about before, or figure out exactly where we can plug in and fill the most cost effective funding gaps.

It's trying to bone up our research on areas like HIV for example. If we think there are gonna be big gaps there, that's not an area that we've traditionally explored in the past, largely because it's been covered by PEPFAR. But if that opens up, it'll be important for us to be able to explore that and understand what the impact will be and have the same level of confidence that we have in other areas that we devote a lot of funding to.

So I think, yeah, this really is I don't know, call to action for us to make sure that we're doing what we can so that we can find these really great giving opportunities because there are opportunities here to avert a lot of deaths and have a big impact in the [00:23:00] world.

Elie Hassenfeld: And so how do you think about this question of, raising our cost effectiveness bar? The way we work is, currently our bar is 10 x our benchmark, and pretty reasonable prediction is that there'll be a billion and a half dollars of additional needs that are 20 x our benchmark. So, basically five times as much funding as we currently direct. That's, double the current cost effectiveness threshold that we use for decision making.

And so that, I think would, in a sort of simplistic way, imply, we should just be funding more cost effective things immediately. Like what are we doing? Why not just raise that bar and only support things that are 20 x if we expect those to emerge. When I've thought about this I find it to be a bit of a struggle because there's so much uncertainty about the future and even today, the needs are so great that you have a strong inclination to raise money and move it out the door to help people.

There's a certain power to that quantitative argument that, you know, in some ways comes through in this conversation about the size of the cuts. Yeah, I don't know, how are you thinking about that one?

Alex Cohen: Yeah, I think it's a good question. [00:24:00] So yeah, put it differently. If we think there's gonna be $1 billion per year at 20 times our benchmark. And our current bar for funding is 10 x our benchmark, we make roughly $350 million in grants per year. We could just raise our bar to 20 x and double our impact basically.

There are a few things pushing against doing that. First is, there's a lot of uncertainty here. So, there's a chance that these gaps are much lower than we expect. Maybe we look into these programs and realize they're not as cost effective as we thought or country governments step in and fill more of these gaps, or there is better prioritization of malaria programs and these other highly cost effective opportunities. So if that happens, we could be in a case where we decide to raise our bar and spend slightly less or potentially spend a lot less, and then we do more work and realize those programs aren't as good as we thought and we're kinda in a bad situation 'cause we spent less and missed out on some really cost effective [00:25:00] opportunities. That's one thing, pushing against that.

I think the other is, it takes time for us to investigate these programs ourselves. I think there's an argument for tolerating more risk and being a little bit more uncertain about programs. But we do wanna be able to investigate, what is the intervention and how does it work, and how does the implementer work, and how do they make sure that the drugs make it to kids? Ask all these skeptical questions that we ask. 'Cause I think that's really important for our work.

It takes time to understand whether these programs are gonna be built back up. So if we're talking about big cuts to malaria and HIV treatment, maybe it's possible that these gaps aren't there to be funded, the program isn't ready to go because there's been so much disruption that could cause delays in our funding.

So I think that kind of lends toward doing something in between, keeping our bar at 10 x or raising it to 20 x. And so I think that's where I stand on the bar discussion. But I think maybe the broader takeaway for us is just do as much as we can, add the capacity, do the research so that we can learn as quickly as possible where those really cost effective [00:26:00] gaps are so we can fill them.

Elie Hassenfeld: Couldn't agree more, Alex. Anything else you wanna add before we wrap up?

Alex Cohen: I guess one other thing is this is our understanding as of June 2025. Things are changing a lot these days. A lot of this could be out of date quickly, and we're gonna do our best to make sure that we're as up to date as we can.

Elie Hassenfeld: Thanks, Alex. This was really helpful. Thanks for talking this through with me.

Alex Cohen: Yeah, my pleasure.

Elie Hassenfeld: Hey everyone, it's Elie again.

The backdrop that I've had in mind throughout all these conversations and throughout the work we at GiveWell have been doing over the last few months, is that GiveWell was founded in 2007, and that means that for GiveWell's entire history up to the current year, we operated in an environment of high, certainly historically speaking, global health funding. Global health funding overall really ramped up from the early 2000s to about 2007, 2008.

And GiveWell's now operating in a government funding environment that's different from the one that we have ever operated in [00:27:00] before in our nearly 18 year history. And so that just raises these important questions. What should we be focused on going forward? Where do we expect needs to emerge? How will we identify the programs that can do the most good? These programs might be in areas that we don't know well in HIV/AIDS or data systems, family planning or primary healthcare.

You know, one of the questions that we're trying to answer is how do we expect that future to look? Because the different possible futures we could be in affect the decisions we make today, decisions we make today about where our staff focuses, you know, which areas they're looking into right now, what roles we try to hire for, how we set our cost effectiveness bar so we can decide what to fund.

And I think this conversation, while somewhat abstract and perhaps hard to sink your teeth into, is a good illustration of how GiveWell works. We're just trying to bring rigor, empirical data assessment, and transparency to these important questions, because we think that process will help us get the best answers we can, good answers to guide our own strategy making decisions about what areas to look [00:28:00] into and what roles to hire for. In the same way that we think that approach of rigorous truth seeking and transparency leads to better funding decisions that we make on a day-to-day basis.

But I think, like ultimately the bottom line of this conversation is that we expect there just will be even larger needs in the future for extremely cost effective programs than there were in the past.

And in my opinion, I think this is a time when GiveWell's value is even greater when the need for the kind of approach that we take is particularly needed, because in a moment of reduced resources, the need for prioritization is even greater. And so we see that there'll be these huge needs out there and just really focused on doing the best we can to direct those funds to the places they'll do the most good.

We expect there to be needs across a wide variety of areas. Areas that we've supported in the past, areas that we may not have and might support in the future. If you want to help, you can give to our Top Charities Fund, which supports four organizations working in areas that we expect to see cuts. If you wanna support the grant making [00:29:00] we do across all areas, more flexible grants, potentially areas we know much less about, you can do that via the All Grants Fund. Either way, we really appreciate the support, because now's the time when we expect donations to do even more and go further in helping people in need.

We've also been doing this podcast for a while now and would just love to hear what's working, what you like about it, what you think we could do differently or better. So if there are topics you'd like to see us cover or ways in which you'd like to see us adjust these conversations, please let us know. The best way to do that is shooting an email to info@givewell.org. If you send a message there, we'll see it and can help us make sure that these conversations are as helpful to you as we hope they can be.

Thanks again for listening and for your support of GiveWell and for caring about doing the most good we can altogether. We really appreciate it.