Background <p>The withdrawal of the USA from the World Health Organization and the freeze on USAID are among the major events in the realm of U.S. foreign policy under the U.S. president. Within his broader “America First” policy, aimed at reducing the U.S.‘s international commitments and rethinking its role in global organizations and foreign aid, this review attempts to make a case for Africa by examining the implications of recent reductions in U.S. funding.</p> Methods <p>We conducted a comparative case study of Nigeria, Ghana, Zambia, and Rwanda, selected for their aid volume, exposure to disruption events, and availability of outcome data. Using process tracing and critical narrative synthesis, we analyzed policy documents, expenditure reports and peer-reviewed studies to assess how each country responded to aid disruptions and what structural factors shaped their resilience or fragility.</p> Findings <p>Three dominant patterns emerged: acute service interruptions (Nigeria, Zambia), structural fragmentation (Ghana), and resilient adaptation (Rwanda). Key drivers of vulnerability included overreliance on tied aid, SAP-era health system legacies, and underdeveloped domestic financing mechanisms. Rwanda’s ability to maintain high ART coverage and reduce malaria deaths by 88% during funding cuts reflects a deliberate break from aid dependency through community-based insurance, decentralized governance, and regional procurement strategies.</p> Conclusions <p>Donor transitions are not neutral events; they expose and exacerbate pre-existing structural weaknesses. Current models that frame aid withdrawal as empowerment risk, replicating past harm unless coupled with institutional reform and reciprocal accountability. This study suggests assessing transition readiness and reorienting global health partnerships toward equitable, resilient, and sovereign systems.</p>