It has been almost a year since the State Department unveiled its America First Global Health Strategy, a document that envisions major changes to US global health engagement. But despite an ambitious timeline outlined in the strategy, officials are still working to put the 30-plus agreements signed with partner countries into practice. Rebuilding and reorienting US international health assistance is no small endeavor—and there are big questions on the table about how precisely the State Department will structure the transition of health service delivery, commodity procurement, and workforce support to partner country governments.
In recent decades, the United States has allocated only a modest share of its aid directly to governments for health and development outcomes, but there’s an important opportunity to learn from past experience—including that of other donors— providing direct assistance to governments to advance health outcomes.
New case studies from Phillip Palmer and Deborah Cook Kaliel—formerly of USAID, each with years of experience in G2G programming—spotlight important lessons for the Department of State as it works to operationalize its new global health agreements. Each of the three case studies examines an arrangement involving direct, performance-based assistance for health, across nine areas: goals and objectives; design; risk management; indicators and disbursement; flow of funds; data monitoring, reporting, and verification; sustainability and co-financing; staffing, management, and technical assistance; results.
- Using its Program-for-Results instrument, the World Bank provided a financing package to Ethiopia, supporting maternal and child health services under the Ethiopian government’s national plan. This model operated through a pooled donor fund, linked disbursements to a narrow set of indicators, and used many of the government’s existing systems instead of creating parallel structures.
- The Global Fund shifted its portfolio in Rwanda toward a performance-based approach that disbursed funds linked to performance indicators on a sliding scale, aimed at facilitating accountability and flexibility. Given Rwanda’s strong governance and data systems, the program has relied on Rwanda’s Auditor General and national health information management system, allowing for a small donor staffing footprint.
- USAID provided direct assistance to the government of Jordan in support to the Jordan Health Fund for Refugees, a pooled donor fund, and incentivized policy reform while strengthening systems and facilitating country contributions to refugee health programming.
These examples showcase how design decisions matter and fundamentally shape donor capacity, oversight, and impact. Among the core takeaways:
- funding a national plan (or part of one), rather than developing a parallel program, yields greater country ownership and sustainability;
- systems strengthening is essential—programs can’t just pay for outcomes or services;
- while political pressure can add complexity, simple program designs and monitoring schemes are often the easiest to manage and the most effective.
It is harder than it looks (and it looks pretty tough!)
Notably, the governments profiled in the case studies have relatively high state capacity in the health sector and were committed to improving health outcomes. To effectively implement G2G programming, the State Department will need to assess which countries are strong candidates for direct assistance—those with strong financial management systems, independent audit institutions, and an established national health plan. The donor institutions in the case studies benefited from longstanding relationships with country governments, established staffing and management models, and existing assessments of fiduciary and programmatic risk—all of which the State Department will need to build in the wake of USAID's dissolution.
Even with only a few country governments poised to receive direct assistance from the start, the State Department has far fewer staff than USAID to manage health programming. With limited capacity, we hope State can learn from others as it pilots G2G approaches and ensure sufficient resources are made available to evaluate and learn from these partnerships.
The administration’s vision, as described in the America First Global Health Strategy, seeks to fundamentally alter how the United States has traditionally programmed health assistance. On paper, this direction—working more closely with partner governments to facilitate transition—has real merit. And operationalizing that vision would be a challenge under any circumstances. These new case studies provide insights we hope the State Department will take on board as it advances its ambitious strategy to help inform any future government-to-government partnership.
