Every day, millions of lives depend on effective global health programs – but delivering them is harder than it looks. This year, the State Department is stepping into a new role, directly managing more than a dozen bilateral global health agreements. This shift reflects a broader transformation in how the United States engages on global health, with a new focus on country ownership, co-financing, and direct bilateral partnerships. These health agreements could save lives, strengthen economies, and prevent future pandemics – but only if they work on the ground. Seven lessons from past experience offer a roadmap to turning these agreements into real-world impact.
On January 22, the Modernizing Foreign Assistance Network (MFAN) hosted a congressional briefing, as part of its ongoing aid reform series with the Congressional Caucus for Effective Foreign Assistance, to examine what it will take to make this transition successful. Framing the discussion, briefing moderator Sarah Rose, Director of Policy at The Share Trust – and a former Senior Advisor for Localization at USAID – put the central challenge plainly:
“There is a great deal of focus on the State Department's new bilateral global health agreements. As State shifts from developing to implementing these agreements, we need to understand what core capacities and functions they will need to take on this new role effectively and accountably.”
This transition is unfolding against the backdrop of sweeping change across U.S. global health and development, as responsibility for managing major health programs shifts from USAID to the State Department and long-standing foreign assistance structures are reshaped. Over the past year, major programs have been ended, USAID dismantled, development functions consolidated at State, and staffing reduced across agencies. Panelists were clear that this moment carries real risk – but also significant opportunity. As Tod Preston, MFAN’s Executive Director, noted:
“Amidst all this upheaval, there is an opportunity to embrace new models and approaches for U.S. assistance – to make global health and development investments even more impactful and transformational, and to help empower countries on a path of greater sovereignty and self-reliance.”
He added, “U.S. global health programs have saved tens of millions of lives – from HIV/AIDS to malaria – and they are vital to country stability, economic growth, and our first line of defense against future pandemics. As the U.S. moves to implement these new global health agreements, the scale of the task will require a State Department far better equipped than it is today. Significant gaps in staffing, strategic planning, monitoring and evaluation, technical expertise, and risk assessment must be addressed. Building a modern, high‑performing assistance architecture at the State Department is essential, and it’s a central focus for MFAN.”
Despite institutional disruption, global health remains a bipartisan priority on Capitol Hill. U.S. investments have strengthened economic stability in partner countries, and helped build the systems needed to prevent and respond to pandemics.
Congressional funding reflects that continued support. The final FY2026 appropriations bill includes $9.415 billion for global health programs. The State Department also released a Global Health Strategy last fall, signaling that global health remains a priority under the current administration – though it will be pursued through a different operational model.
Panelists emphasized that strong, bipartisan leadership and oversight in Congress will be critical to ensure these agreements are properly managed and implemented effectively.
Under the new strategy, the State Department plans to implement global health programs through bilateral agreements with partner governments. These agreements emphasize co-financing, data coordination, and increased country ownership. About 15 agreements in sub-Saharan Africa have already been signed, with many more expected. Implementation is scheduled to begin this year.
The scale of this shift is significant. For decades, the State Department played primarily a diplomatic and oversight role in global health programs. Now, it is moving rapidly into management and implementation – prompting a central question raised repeatedly during the briefing: does the Department have the systems, staff, and operational capacity to manage this work effectively?
Last fall, MFAN’s report “Operational Readiness: What the State Department Needs to Effectively Manage U.S. International Development and Humanitarian Assistance” raised concerns. Historically, only about two percent of the United States President’s Emergency Plan for AIDS Relief (PEPFAR) implementation was managed directly by the State Department. That share is growing quickly, even though the Department absorbed only five to 10 percent of former USAID global health staff, raising concerns about operational readiness.
Panelists highlighted weak financial and contracting systems, delays in bridge funding for partners, and limited implementation guidance as early warning signs. Several also flagged the continued reliance on post project audits rather than real-time monitoring, which makes it harder to identify problems early and adjust course.
One panelist, Anu Rajaraman, a former Senior Foreign Service member who served as the Mission Director for USAID in Colombia and Guatemala and led the Journey to Self-Reliance Strategy under the first Trump Administration – emphasized the central role of coordination and clarity in effective agreements:
“One of the most important lessons I learned over my time with USAID is that the strength of any agreement is a function of the quality of the joint planning and coordination that goes into developing that agreement. It should reflect a true partnership. Once signatories are ready to sign, both parties should already know what success looks like – including what systems and capabilities are needed, who is responsible for what, and the plan for mitigating risk while verifying performance.”
Design smart incentives: Agreements must encourage positive behaviors, or risk wasting money. Drawing on lessons from past bilateral agreements, panelists stressed that success depends on strong upfront planning. Cutting corners early can create major operational risks once programs move into implementation.
Incentives matter. Agreements shape behavior, and poorly designed incentives risk reinforcing weak systems or misdirecting scarce resources. From the outset, strong safeguards must be in place to verify results, track performance, and confirm that partner governments are meeting their co-financing commitments. Monitoring, evaluation, and learning systems must support continuous course correction – not just compliance reporting.
Panelists also stressed the importance of building on existing technical expertise and country knowledge, particularly from USAID and long-standing partners, rather than attempting to recreate that capacity inside the State Department. Civil society participation ensures that agreements incentivize outcomes that truly benefit communities, not just meet bureaucratic metrics.
Panelist Jeff Bernson who serves as the Senior Vice President and Global General Manager for Mathematica, with extensive experience in global health and development across the Gates Foundation, USAID, the Millennium Challenge Corporation, and the World Health Organization, emphasized the role of accessible data and evidence to drive results:
“Data transparency and accessibility is enormously important for not just holding ourselves accountable but recognizing that to accelerate gains in global health, data needs to move faster than the speed of disease transmission.”
Several speakers noted renewed interest in government-to-government (G2G) approaches, which can strengthen country ownership, build public legitimacy, and support long-term sustainability when conditions are right. But they were equally clear that G2G is not a one-size-fits-all solution and reducing the role of civil society can undermine the agreements.
Panelist Daphne McCurdy who serves as the Vice President, Policy and Advocacy for Pact, and who served previously as a Deputy Assistant Administrator at USAID and as a Senior Advisor in the Department of State’s Office of China Coordination, underscored both the promise and limits of G2G approaches:
“Going through governments helps make host governments invested in their development pathways, builds public support and legitimacy, and can strengthen systems like financial management and democratic consultative mechanisms – creating muscle memory that lasts long after the project ends.”
These approaches require strong public financial management systems, transparency, and human rights protections.They also concentrate risk and limit partner diversification – an important tool for managing uncertainty. Civil society organizations, universities, and the private sector remain essential partners, particularly in contexts where government capacity or political will is uneven.
Global health agreements don’t succeed because they look good on paper – they succeed because people on the ground are able to make smart, timely decisions. While Washington sets strategy and guardrails, implementation lives with partner governments, civil society, communities, and U.S. embassies.
Accountability can’t be reduced to controls and audits alone. It depends on trust. Effective implementation requires space for honest reporting about challenges, supported by transparency, timely data, and meaningful engagement with civil society and other local stakeholders. When partners fear consequences for surfacing problems, issues tend to emerge late – when they are harder and more expensive to fix.
By contrast, partnerships built on trust and goodwill strengthen local systems, reinforce shared ownership, and make it easier to adapt as conditions change. In a model that places more responsibility with governments and country teams, trust isn’t a “nice to have” – it’s essential to delivering results.
Panelist Michael Ruffner, who is an independent consultant specializing in global health financing and sustainability, and was the former Deputy Coordinator, at the U.S. Office of the Global AIDS Coordinator and as Director of the U.S. Department of the Treasury’s Technical Assistance Program, emphasized the importance of institutional capacity and risk-aware leadership:
“Bureaucracies act in predictable ways, and there’s reticence to take risks. To make new agreements work, we need staff who can manage that system, take calculated risks, and push change forward without being blocked by the way the system normally operates.”
A consistent message from the briefing was that government-to-government models are more labor-intensive, not less. Moving away from implementing partners does not eliminate core functions such as compliance, monitoring, reporting, and technical support – rather they must now be absorbed into the State Department, host governments, or both.
Speakers underscored the need for a clear division of labor: Washington should set strategy, parameters, and guardrails, while embassies lead implementation and should have adequate time, resources and patience to consistently adapt. That requires staffing well beyond current levels, including technical global health experts, country-context specialists, and in-country legal and financial professionals who can negotiate complex agreements and ensure strong financial stewardship.
Panelists also raised concerns about whether co-financing expectations –ranging from 13 to 70 percent in some health agreements – are realistic, given broader fiscal constraints in many partner countries.
“As we shift more to government ownership, it’s not just about technical expertise in health. You need staff who can maintain relationships, understand country dynamics, and provide proper oversight—this is much more labor-intensive than just contracting services,” said Daphne McCurdy.
Panelists repeatedly highlighted the importance of ongoing monitoring and learning. Strong monitoring, evaluation, and learning systems must support continuous course correction, not just compliance reporting. Without mechanisms to adapt programs in real time, even well-designed strategies risk failing to deliver real-world impact.
Implementation is the central risk facing the State Department’s new global health agreements. With the right investments in people, systems, and data, these agreements could strengthen U.S. global health diplomacy and deliver tangible results. Without them, even the best-designed strategies may struggle to translate into impact.
“We don’t have to build the gold standard of monitoring and evaluation – we have to build one that’s fit for purpose in this new era, with the right people, systems, and data to verify results and ensure programs are rigorous and sustainable,” said Jeff Bernson.
With careful attention to planning, staffing, incentives, and learning, the U.S. can ensure these agreements not only succeed on paper, but save lives and strengthen partner countries for decades to come.
