Making global health aid transition work while sustaining progress against AIDS, tuberculosis and malaria

Initial suggestions for the 120th Congress from Friends of the Global Fight Against AIDS, Tuberculosis and Malaria

October 23, 2026

Responsible transition of U.S. global health assistance to greater country leadership should be a positive next step in America’s legacy of achievement against infectious disease. Done right, transition will center decision making with partner governments and communities, drive increased domestic health investment and respond to growing calls from African leaders for health sovereignty.  Done hastily and without safeguards, it risks backsliding on 20 years of progress.

In June 2026 Secretary of State Rubio said in congressional testimony, “…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.” Following two years of program disruption and significant policy change, the 120th Congress will have the opportunity to review the initial results of the America First Global Health Strategy and recalibrate the response as necessary to keep the results – and the legacy of American leadership – on track.

Below are some ideas for potential Congressional action.  Please let us know if we can provide further information on these or other topics. Thank you for your consideration.  Other good – and consistent – suggestions for global health transition come from joint statements organized by 1) the Bush Center, here, and 2) a group of PEPFAR advocates, here.  (Friends was engaged in both projects.)

1. Include priority programs in the bill with dedicated funding.  Include programming directives coupled with dedicated funding levels in appropriations bills (in addition to report language) for priorities like those outlined in this memo, perhaps including population-level surveillance, data validation, and reporting; staffing levels; community-based services; malaria-specific priorities given the particular risk of resurgence; and services to reach adolescent girls and young women and other vulnerable populations.
   • This dedicated funding could be through an earmark in the bill and/or tables in the Joint Explanatory Statement (JES) tables for the Global Health Programs (GHP) account, both of which are legally binding. Such binding language may help allay concerns with government-to-government arrangements.

2. Insist on robust, validated surveillance and reporting.  A bipartisan hallmark of successful health assistance has been evidence of impact.  Without quality data and reporting aid transition is flying blind: the risk of undetected disease resurgence is magnified and the chance to make mid-course corrections is lost. Population-based data is needed alongside program-level data to understand disease trends. 
   • Congress could tie surveillance data to the health areas in the GHP lines as evidence of impact.  Currently, the MOUs will largely rely on national systems for these results even though they are at varying degrees of maturity and readiness.
   • The Bush Institute has encouraged the State Department bureau of Global Health Security and Diplomacy (GHSD) to develop “next-generation” targets. Congress should require robust surveillance, and disaggregation by age, sex, location, vulnerability and other factors, as well as reporting on service delivery priorities such as treatment, prevention, reaching the most vulnerable (including children, adolescent girls and young women and key populations) and scaling of innovations. 
   • Congress could earmark funds for surveillance and validation activities such as population level surveys like the Population-based HIV Impact Assessments (PHIA) that have not been done in several years.  Alternately, hybrid surveys could combine targeted population sampling with routine data.
   • Congress could request a report on the metrics, methods and validation approaches the State Department is utilizing.
   • To advance transparency and the focus on tracking results, data on services and outcomes, as well as the MOUs and Implementation plans, should be made publicly available.

3. Require a benchmark/adjustment system to keep transition on course.  A new expert analysis on global health integration and transition from the National Academies of Sciences (NAS) – commissioned by the State Department – urges policy makers to “Monitor, learn, and adapt” as they implement transition.  The report observes: “Trigger indicators can help countries and partners decide when to continue, pause, slow, or adjust sequencing if transition appears to affect quality, retention, commodity availability, disease-specific outcomes, and access for priority populations.”  In line with NAS recommendations, Congress should consider requiring establishment of a system of benchmarks or triggers that indicate potential disease resurgence or other concerns requiring adjustment in transition timelines and planning.  Establishing such a system requires quality data, including drawing on the expertise of CDC for technical support.  Adjustments could include, for example, pausing funding reductions, investing to scale effective innovations or providing enhanced support in particular health systems areas.  
   • A related option is to commission an independent evaluation of transition through the NAS or another entity.

4. Declare that public health results are the priority.  Send the message in communications and authorizing and appropriations language that U.S. global health leadership and programming is intended to achieve positive public health results including ending epidemics, not primarily non-health diplomatic or economic interests.  Make it clear that aid transition must be managed in a way to maintain and increase progress and not squander gains following two decades of American investment.  Proceeding without a focus on prevention or pursuing strategies that leave those most at risk behind puts hard won gains at serious risk.    

5. Maintain appropriations levels and ensure all funds are spent in a timely manner.  Appropriation levels should reflect the priority of sustaining progress toward ending these diseases, not pre-set levels in MOUs. Appropriations levels should be at least maintained for the Global Fund, bilateral global health programs and CDC global health programming (to support disease surveillance, tracking, and implementation of services and technical advice to countries taking on responsibilities).  In addition, appropriations should be sufficient to seize strategic opportunities and scale innovations to accelerate transition.

6. Invest in the Global Fund as a driver of successful aid transition. The Global Fund is the leading edge of aid transition, propelling domestic investment, strengthening health systems, pooling procurement to reduce costs, coordinating with US bilateral programs, engaging multiple stakeholders (not just governments) and achieving year on year results.  Congress should consider the maximum possible appropriations to the Global Fund – at minimum $1.533 billion in FY27 and FY28, one-third of the US $4.6 billion 8th replenishment pledge.  

7. Invest in community service systems and protect the most vulnerable. Community service organizations are trusted, front line responders and are particularly important for reaching the most stigmatized, vulnerable populations. Yet publicly available documents from GHSD do not detail how community services will be protected. And many governments do not yet have “social contracting” policies in place that allow them to invest in community systems.  With the significant reduction in PEPFAR’s DREAMS services for adolescent girls and young women, it is important that transition plans specify how the multiple needs of this population, as well as other vulnerable groups, will be met.   Congress should ensure that country implementation plans protect community-based services or, failing that, a dedicated funding stream is established for community-based services.  Congress should stipulate that the health needs of most vulnerable must be protected in aid transition.

8. Require strategy for scaling highly effective innovations. This includes two American-made interventions – lenacapavir for HIV prevention and spatial emanators for mosquito control – for which the administration has wisely set up partnerships with the Global Fund and companies. A clear, ambitious plan for financing and delivering these and other innovations and a defined operational approach for the State Department’s new Innovation Fund is needed to drive the necessary speed and scale.   

More information:  Chris Collins [email protected]  Mark Lagon [email protected]