Recommended
When the 120th Congress gavels in this January, it will oversee a US global health system undergoing one of its most sweeping transformations in decades. As part of its overhaul of global health assistance, the Trump administration has signed bilateral health agreements and introduced new funding mechanisms. But the ambitious pace of the changes, coupled with limited capacity at the State Department to implement them, puts essential health services and decades of global health gains at risk.
To make matters worse, Congress—and the public—have little visibility into fundamental questions: who is receiving funding, how it is being spent, and how results are being tracked. The administration has a record of sidestepping congressional directives, so beyond prioritizing oversight questions, the more difficult task will be to make those requests yield real accountability.
Capitol Hill will have an important role to play in examining the dismantling of USAID and its devastating consequences, as well as shaping the longer-term future of US global health engagement. But there is also a more immediate task: ensuring that billions of dollars in assistance now being programmed by the State Department deliver health services where they are needed most, with results that can be verified.
Through its oversight, appropriations, and legislative authorities, Congress can help mitigate the risks of the new approach and support its responsible implementation by backing demands with leverage.
Here are six areas that warrant Congress’ attention, why they matter, and what lawmakers can do.
1. How is congressionally appropriated funding translating into programs?
Congress appropriated $9.4 billion for global health in FY26, keeping funding relatively flat with FY24 levels. But the system for turning those dollars into programs has changed dramatically. The State Department is now relying on bilateral memoranda of understanding (MOUs) with partner governments, an Annual Program Statement (APS) to fund implementing partners, and direct awards, including through its new Innovation Fund (see below).
The State Department has signed 36 bilateral health agreements, committing more than $16.1 billion over five years. Yet implementation plans remain unpublished, and it is unclear how much funding is moving under these agreements, and how much will specifically flow through government systems versus implementing partners. Despite the ambitious vision outlined in its health strategy, the State Department has said only a handful of countries will receive government-to-government funding in the near term.
The APS, with up to $4.5 billion in potential funding, raises additional questions about how awards will complement bilateral agreements and whether the partner pool will look much different from USAID's rolodex. The first awards only appeared in September, and while they are posted on USAspending.gov, State has not published a list of recipients, leaving analysts to piece it together.
Looking ahead, the administration has proposed major cuts to global health programs for FY27, while the draft House bill would provide a relatively steady $8.9 billion. With Democrats controlling both chambers, another formal rescission package is unlikely to pass. But the administration’s previous pocket rescission and attempt to divert $2 billion in global health funds for USAID closeout costs show it is willing to work around congressional intent.
The FY26 spending law, passed by a Republican-controlled Congress, established important new reporting requirements for global health funding and the MOUs. While it is unclear if and when we'll get a full FY27 appropriations package, future appropriations could build on these requirements and strengthen oversight of new funding mechanisms.
Options for Congress: Use new spending packages to require State to publish MOU implementation plans, along with regular public reporting of APS awards, including recipients, amounts, and their role in filling potential implementation gaps. Congress could also establish clearer eligibility and oversight requirements for government-to-government assistance. Consider extending the availability of global health funds.
2. Can the State Department accelerate country ownership through the bilateral agreements without jeopardizing access to life-saving health services?
Advancing country ownership through direct funding models, greater domestic financing, and results-based assistance is a long-overdue goal. But a one-size-fits-all approach is unlikely to work across countries with vastly different fiscal realities, health system capacities, and disease burdens. Some may be positioned to assume greater responsibility for financing and delivery within a few years, while others will need a longer runway or sustained US engagement (see our Tough Times, Tough Choices brief on PEPFAR).
A poorly managed transition risks disrupting essential services and undermining health outcomes. Timely and reliable data is essential to assess whether services are being maintained, especially where funding is tied to performance. Yet transparency on results is moving in the opposite direction. PEPFAR historically published detailed quarterly service delivery data, but the State Department has publicly released data for only one quarter for FY25 and FY26. With the reported shift to annual reporting under the bilateral agreements, how will the State Department monitor the overall transition and identify risks before disruptions occur? What safeguards are in place if new arrangements fall short?
Fragile or conflict-affected countries, in particular, may lack the capacity to negotiate bilateral agreements, even as health needs remain acute. What is the administration’s plan to support vulnerable populations in these settings where sustained US assistance remains necessary to save lives? Ultimately, progress toward country ownership should be measured by improved health outcomes, not by the speed of US withdrawal.
Options for Congress: Press the State Department for country-specific transition plans, regular reporting on service delivery and health outcomes that builds on PEPFAR’s reporting model, and contingency arrangements to protect services if new delivery models fall short. Consider requiring a system of benchmarks, as others have recommended, that signals when a transition is putting lifesaving services at risk, backed by a dedicated reserve fund that State can use to surge support when those benchmarks are triggered. The funds shouldn’t expire, and the reserve could include a provision requiring transfer to a partner already delivering lifesaving services on the ground if State doesn’t move the money within a fixed window.
3. How is the State Department ensuring that changes to procurement don’t disrupt access to critical health supplies?
Buying and delivering medicines and other essential health supplies account for a significant share of US global health assistance. But the bilateral agreements are being rolled out alongside major changes to how these products reach patients. A poorly managed handover risks stockouts and treatment interruptions, undermining US investments in lifesaving products if they never reach patients.
The State Department has granted no-cost extensions through November 2027 to two existing Global Health Supply Chain – Procurement and Supply Management contracts to avert disruptions to HIV, malaria, and maternal and child health products. But questions remain about the planned shift to the Global Fund’s Wambo.org platform. For example, it remains unclear whether broader supply chain functions currently supported under existing contracts, including warehousing and in-country distribution, will be financed and maintained under the new arrangements.
Option for Congress: Request a procurement handover plan that identifies potential supply chain gaps and sets out safeguards against disruptions as existing contracts wind down.
4. What does "innovation" mean beyond buying American health products?
Procurement and distribution of US breakthroughs like lenacapavir in partnership with the Global Fund is a promising example. In May, State announced a similar deal to buy about 30 million Guardian spatial repellents for malaria. State plans to build on this momentum by spending hundreds of millions of dollars through a new Innovation Fund. But beyond purchasing American products or investing in individual partnerships like the Zipline deal, the broader strategy remains unclear and cost effectiveness questionable.
For Congress, the key questions are now about scope and transparency. Innovation at scale requires R&D pipelines, new delivery models, market shaping, and regional manufacturing, areas where State has a limited track record. Will the Innovation Fund support this broader agenda through a range of funding mechanisms, or primarily serve as a procurement vehicle for market-ready US products?
The Zipline deal suggests interest in innovative service delivery, not just commodities. Will that extend to include investments in digital health, supply chain systems, and community-based delivery models that help bring new technologies to patients?
Congress has signaled support for the administration’s direction of travel through the FY26 spending deal but mandated a briefing from State on the Innovation Fund. As new awards are made, the State Department should share information about the fund's governance, selection process, and spending.
Options for Congress: Require State to publish an innovation strategy, detailing investments across R&D, delivery innovation, market shaping, and manufacturing, along with a rationale for its funding mechanisms. Congress should also seek disclosure of the core terms of innovation deals and require an annual report on global health R&D, like the one USAID previously produced.
5. Where can multilaterals be a force multiplier for what State can't do alone?
The administration’s approach to global health multilaterals has been selective: withdrawing from the World Health Organization (WHO), deepening engagement with the Global Fund, and resuming support for Gavi, subject to new conditions.
But with the State Department now managing billions in global health assistance with a fraction of USAID's former capacity, the case for leveraging these institutions is stronger than ever. Congress should view multilateral institutions not simply as another funding channel, but as a critical lever to extend US global health reach and influence. That includes sustaining funding for key global health institutions, like Gavi, which remains a best buy in global health.
In countries without bilateral agreements, fragile and conflict-affected settings, and cross-border health emergencies, multilateral and regional institutions may be better positioned to sustain services or coordinate responses. The US withdrawal from WHO also raises questions about how essential functions, including surveillance and outbreak coordination, will be maintained or replaced.
Coordination with multilateral partners will also matter in countries with bilateral agreements. How is State ensuring that new commitments complement existing Global Fund, Gavi, and World Bank investments rather than creating duplication or competing domestic financing requirements?
Options for Congress: Beyond sustaining robust funding for global health multilaterals, press State to explain how it plans to engage multilateral and regional partners where bilateral mechanisms cannot deliver effectively, maintain essential international health functions, and coordinate bilateral and multilateral investments at the country level.
6. Are surveillance, preparedness, and countermeasure supply chains ready for the next outbreak?
The 2026 Ebola outbreak is the first major stress test of US response following the dismantling of USAID and post-WHO withdrawal. Congress should closely examine this unfolding emergency to understand whether the US has the capacity to respond effectively to future outbreaks.
The administration’s record here is mixed. Bilateral health agreements place a heavy emphasis on surveillance. Yet the administration also canceled and suspended global health security awards including contributions to CEPI and the Pandemic Fund. Its FY26 budget requested just $200 million for global health security, a 71 percent decrease from FY25, while the president’s FY27 request included no dedicated line item. Meanwhile, appropriators have continued to provide health security funding for bilateral health security efforts and expressed support for multilateral contributions.
The Ebola response underscores both the importance of these investments and questions about the capacity lost with USAID’s closure. As of late September, the State Department has provided upwards of $800 million in health and humanitarian assistance, with a $50 million contribution to CEPI to develop countermeasures targeting the Bundibugyo virus. But experts have pointed to delays in outbreak detection and mobilizing support, raising questions about the consequences of losing USAID’s field presence and coordination capacity.
Congress needs to know what capacity and expertise now exists to detect and contain outbreaks and develop and deliver medical countermeasures.
Options for Congress: Require a public accounting of the Ebola response, including funding sources, implementer partners, response timelines, and gaps. Congress should also require regular reporting on where and how appropriated global health security funds are being obligated, and how the State Department is coordinating with the CDC, multilateral partners, and regional organizations.
Priorities for the first 100 days
The first 100 days are a key window for setting an oversight agenda and shaping appropriations text. In that time, lawmakers should consider:
- Convening a hearing on the implementation of the bilateral health MOUs, with testimony from the State Department on country implementation plans, co-financing requirements, and how funds are flowing,
- Calling for an “after-action” review and hearing on the Ebola response to clarify how the administration is building outbreak response and preparedness capacity, including how it is coordinating with multilateral and regional bodies,
- Hosting experts—both American and from regional bodies and partner countries—to discuss the most promising game changers in global health and how the US can best support their development and deployment,
- Working across parties and committees to draft language that sets durable guardrails for the MOU model, such as continuity requirements for lifesaving assistance and protection for vulnerable populations and that requires public reporting on APS and Innovation Fund awards.
Congress has shown a bipartisan commitment to US leadership in global health, and lawmakers now have a chance to turn a period of upheaval into a stronger, more accountable model. Getting there will take more than reporting requirements alone. In today’s low-trust environment between Congress and the executive branch, those requirements carry less weight than they once did and are hard to enforce on their own, so lawmakers will likely need to pair them with real leverage, such as tying administrative funds to compliance.
DISCLAIMER & PERMISSIONS
CGD's publications reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions. You may use and disseminate CGD's publications under these conditions.
