The Global Health Integration Moment Has Arrived
The next phase will be shaped not in donor capitals, but in national planning rooms. I outline five core questions to guide that work - and our attention!
Much has already been written about the promise and risks of the new America First Global Health Strategy. This scrutiny is appropriate. The restructuring of long-standing partnerships, the shift to bilateral agreements, and the redefinition of technical assistance have generated uncertainty across ministries, implementing partners, and affected communities. In some settings, these changes have already corresponded with staffing losses and service disruptions that carry real consequences for people who rely on uninterrupted access to prevention and treatment.
At the same time, the strategy contains elements that deserve recognition. I have noted myself that the document’s emphasis on sustaining progress toward 95-95-95, on integrating services into broader national health systems, and on universal health coverage aligns with priorities many countries have been advancing for years. These goals reflect a shared vision in which health services are not siloed, but embedded within stronger, more resilient national systems. They also reflect a broader shift across the African continent toward health system sovereignty, domestic financing, and regional coordination in regulation and manufacturing.
Both of these realities exist at once: there is promise here, and there is risk. And the pace of implementation is not theoretical. It is my understanding that the State Department is prioritizing negotiations on approximately a dozen or more MOUs by mid-December, with additional agreements to follow. In other words, the transition is already moving.
One of the most notable features of this moment is that, in principle, the United States and many partner governments are now pointing toward the same long-term objective: stronger national health systems that are domestically led, sustainably financed, and accountable to national institutions rather than external actors. This direction did not originate with Washington. It aligns with developments that have been shaping health policy on the African continent for more than a decade.
Recent commitments such as African Union leadership on pooled procurement, national insurance expansion, and local manufacturing — reflected in the Accra Accord — reinforce a broader movement toward regionally coordinated health systems with greater sovereign control over pricing, market access, and supply chain decision-making. Similar trends are visible in the Africa CDC’s regulatory harmonization agenda, South Africa’s manufacturing expansion, and Nigeria and Kenya’s ongoing domestic financing reforms. The United States is stepping into a trajectory that was already forming.
However, alignment at the level of strategy does not guarantee alignment at the point of execution. Execution is where gains can be maintained or lost. Whether the current transition strengthens systems or creates new vulnerabilities will depend on decisions made in national planning rooms, procurement agencies, and civil society coalitions over the next weeks and months.
For those engaged in negotiation, oversight, or system strengthening, the following five questions may be especially relevant. They build on recent analyses circulating in the global health community, but place greater emphasis on national planning, domestic governance, and country-level alignment.
Here are the five questions that matter now.
1. Are core health system elements costed, and are financing gaps clearly identified?
Costing is often treated as an administrative step. In practice, it is foundational. Many national strategic plans describe goals for service delivery, but fewer have fully costed operational budgets that cover system components: health workforce salaries, laboratory networks, supply chains, community delivery platforms, data systems, and supervision. As donor roles shift, the absence of shared costing can result in unplanned gaps.
A structured costing exercise, jointly reviewed by Health and Finance ministries, supports realistic sequencing of domestic resource mobilization and co-financing. Parliamentary and civil society oversight can ensure transparency, so tradeoffs are visible rather than implicit.
2. How will all populations remain included in service delivery during transition into national systems?
Integration may improve system coherence, but it does not automatically secure equity. In past transitions, services for key populations declined when targeted programs were absorbed into general delivery without explicit protections. In legal and social environments where stigma or criminalization is present, this risk is heightened.
Sustaining access may require:
Formal roles for key population–led organizations in planning and coordination
Targeted financing lines to prevent dilution into broader budgets
Differentiated service delivery models matched to community needs
Operational non-discrimination standards, not only policy statements
Without these measures, incidence may rise even if treatment availability remains stable.
About 1.3 million people acquired HIV worldwide last year, and roughly 9.2 million people living with HIV are still not on treatment — a reminder that the epidemic is not over (UNAIDS 2024).
3. Are national systems prepared to evaluate, introduce, finance, and sustain new health technologies and products?
Regulatory approval is necessary, but insufficient on its own. The next phase of the response is likely to include long-acting HIV prevention and treatment, biosimilars, digital adherence platforms, and regionally manufactured diagnostics. Whether these technologies reach users will depend on:
Health technology assessment to evaluate benefit and cost-effectiveness
Financing and coverage decisions that determine who pays
Procurement and forecasting adapted to long-acting delivery cycles
Provider training and updated clinical guidance to support adoption
Community literacy and demand shaping to establish trust and uptake
Data systems to track utilization and outcomes
Where these enabling conditions are weak, access may lag even when authorization exists. AVAC recently published Gears of Lenacapavir for PrEP Rollout, a concise framework outlining the system components required for equitable and effective introduction of long-acting injectable PrEP.
4. What domestic financing mechanisms are being mobilized, and how will they be sequenced?
Sustainable systems require predictable financing, negotiated across fiscal cycles. This often involves coordination between ministries of health and finance, legislatures, and—where applicable—insurance funds or procurement authorities. Tools may include tax reforms, national insurance expansion, strategic purchasing, pooled procurement, or sovereign health funds.
Health-for-debt swaps are another potential instrument. In these arrangements, a portion of external debt service is reduced or restructured in exchange for documented improvements in defined health outcomes. For example, a government could use fiscal space generated through a swap to support the rollout of long-acting HIV prevention, such as lenacapavir, with performance metrics tied to increased PrEP initiation, improved retention, and reduced new infections among priority populations.
Evidence suggests (see paper here) that transitions are most stable where domestic financing is planned transparently and accompanied by system reforms that enable funds to actually flow to service delivery, rather than remain on paper. Transitions focused only on replacing donor money—without adjusting the systems that manage budgets, procurement, and reporting—are associated with service interruptions. By contrast, transitions characterized by joint planning and capacity strengthening tend to preserve health outcomes.
5. How will bilateral agreements align with Global Fund, Gavi, World Bank, and regional mechanisms?
IIf bilateral planning occurs in isolation, system fragmentation may increase. This can result in parallel procurement arrangements, overlapping reporting systems, and duplicated supervisory structures — all of which raise administrative burden and weaken service continuity. Previously, multilateral platforms and donor coordination groups often played a central convening role in aligning these systems. Under the current approach, the U.S. is placing greater emphasis on direct bilateral agreements and is not prioritizing multilateral coordination in the same way.
This shifts the responsibility for coherence toward national governments, who now may need to take a more active role in coordinating investment flows across multiple partners. Aligning MOU commitments with Global Fund grants, Gavi transition timelines, World Bank financing windows, and regional pooled procurement mechanisms will likely require government-led planning forums, shared implementation calendars, and clear internal decision-making structures.
Visibility for civil society and affected communities in these processes remains important — not only for accountability, but because community actors often see early signals of service disruption before they appear in routine data. Strong coordination can help preserve continuity of care, reduce duplication of effort, and ensure that shifts in financing do not unintentionally reverse progress on access or equity.
Implications for Private Sector, Foundations, and Technical Partners
The roles of private sector actors, foundations, and implementing partners are unlikely to disappear, but the basis of engagement is changing. The emphasis is moving from operating parallel delivery systems to strengthening national institutions and supporting system functions such as procurement, regulation, forecasting, supply chain management, training, supervision, evaluation, and community-led monitoring. This may represent a shift from “doing” to enabling, governed through national planning cycles and accountability structures.
The transition underway is neither a crisis nor a victory on its own. It is a structural pivot that will require intention, patience, and clarity. The policies are written; the principles are widely shared. What matters now are the decisions made in budget rooms, procurement units, regulatory authorities, and community forums. I have seen what is possible when national leadership, donor partnership, and community voice move in alignment. I have also seen how quickly progress unravels when systems are left to absorb change without support. The next phase of global health will not be defined by what Washington announces, but by what countries build. The responsibility is shared — and the opportunity is real.
Thoughtful piece. Delivery for impact, which unfortunately has been downgraded by WHO, could be very useful to countries at this pivotal moment. https://www.who.int/teams/delivery-for-impact