August 7, 2026
A Guide for Getting Global Health Transition Right
By Chris Collins
The debate in Washington is no longer about whether U.S. global health assistance should transition toward greater country leadership and greater service integration. Secretary of State Marco Rubio has articulated that vision, the Administration’s America First Global Health Strategy has set it in motion, and many partner governments have embraced the goal. The real question is whether this transition will be remembered as the moment countries took charge of ending AIDS, tuberculosis and malaria as public health threats — or the moment when decades of American investment and leadership unraveled into epidemic resurgence.
That is why a new expert consultation from the National Academies of Sciences, Engineering and Medicine, sponsored by the State Department, deserves close attention from policymakers. The report, “Approaches for Transitioning from Disease-Specific Programs to Integrated, Country-Led Health Care Systems,” is the closest thing we have to an evidence-based guide for getting this moment right. Its central insight is deceptively simple: transition should be a deliberate process rather than a single handoff. Success is determined by whether countries sustain or improve health outcomes — not by how quickly programs are integrated or handed over.
In other words, follow the results. This echoes Secretary Rubio’s own comments to Congress in June: “…we don’t want aid to solely be judged by how much you spend; we want it to be judged by what its results are.” The National Academies’ framework makes evidence-informed points that should guide transition of global health assistance. Four priorities jump out:
First, tailor transitions to each country’s reality. The experts call for readiness assessments, phased implementation, flexible timelines and clear indicators that signal when to pause, slow or reverse a transition step. Countries differ enormously in fiscal capacity, debt burdens and conflict, and with combined U.S. and Global Fund support projected to decline roughly 24% through 2029, one-size-fits-all deadlines are a recipe for backsliding. As Secretary Rubio said of aid transition before Congress, “Some countries, that may take five years; some countries, it may take 15.” For guidance, look to the Global Fund, which gives countries considerable warning before funds are reduced, and which works with countries to strengthen the systems needed for success.
Second, protect the data. The report insists that quality data is critical to success. Data collection should be adequate to monitor disease outcomes, drug stock-outs, loss to follow-up, referral completion and disaggregated information on sub-populations. As U.S.-supported data infrastructure shifts to national systems, we cannot manage what we no longer measure, and we cannot catch a resurgence we cannot see. Global health advocates have raised concerns about U.S.-led bilateral health agreements that require far less detail on populations and programming, the kind of data that has been a cornerstone of PEPFAR’s success.
Third, keep communities at the center. The National Academies report finds that trusted community partnerships and support for community health workers and community providers are decisive for success, and that their loss undermines service continuity. This suggests the U.S. should be insisting community services are supported and helping partners in setting up social contracting rules that enable governments to maintain this support. The NAS report also emphasizes the need to preserve services designed to reach the most vulnerable groups—something at which community providers excel.
Fourth, be transparent about money. The experts are blunt that integration “is not a substitute for adequate investment” and warn against unfunded mandates that shift costs onto patients. That means co-finance requirements on countries should account for fiscal space, debt, conflict and other challenges, and there should be room for adjustment of funding timelines. It also means ensuring appropriated funds are obligated and spent as intended by Congress.
The report has implications for Congressional oversight, such as closely monitoring outcomes and early warning signs of resurgence; setting trigger points for reassessing timelines and strategies; tracking the quality of data systems; ensuring scale up of game changing innovations; and calling for a formal midpoint review of transition implementation in 2027.
For decades, the public health and HIV communities have called for careful integration of disease-specific programs into country-led health systems as well as country leadership of health programming. This is an important shift, and the Administration deserves credit for putting real political weight behind it. But ambition must now be matched by evidence: the measure of success will not be how quickly programs transition, but whether countries sustain and improve health outcomes.
Chris Collins is President & CEO of Friends of the Global Fight Against AIDS, Tuberculosis and Malaria