When I asked one global health expert whether major health initiatives should have sunset timelines, I was told that if I had asked the question last year, people would have thought I was crazy. Back then, even the idea of consolidating organizations was viewed as absurd.
But things have changed remarkably over the last seven months. The United States decided to abruptly halt and then terminate billions of dollars in lifesaving assistance and cut back funding for many global health initiatives, including the global HIV/AIDS initiative PEPFAR. And as other donors also shrink their aid budgets, calls for transition plans and sunset strategies have begun to emerge.
Most global health initiatives were created in response to a crisis. PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria were set up to help turn the tide against epidemics, which were killing millions of people in the early 2000s, and Gavi, the Vaccine Alliance aimed to help reduce child mortality by vaccinating against preventable diseases. And these organizations have largely been successful in achieving what they set out to do: Deaths from HIV and AIDS have declined significantly over the years, and efforts to boost child immunization have saved millions of lives.
However, as disease epidemiology, country demands, and expectations change — and long-term funding becomes uncertain — how much longer should or could these organizations continue to operate, at least at the same level as they currently do? After all, their architects have confirmed that they were never meant to run forever.
In my conversations with experts, it’s clear that the questions need to be asked. But the answers will be varied and complex.
Hundreds of thousands of people still die from HIV-related illnesses today, and many of them are vulnerable members of the population who are criminalized or stigmatized by their own communities. Millions of people with HIV remain reliant on these initiatives to continue accessing lifesaving medications, such as a twice-yearly injectable to prevent HIV infection — the latest scientific breakthrough that experts describe as the next best thing to an HIV vaccine — which PEPFAR can offer. In addition, millions of children are still missing out on critical vaccinations.
Some experts say what’s needed are carefully structured transitions based on a solid understanding of a country’s current capabilities and vulnerabilities — and after that, perhaps reasonable sunsets with safety clauses can be made. Still, some challenge the idea of a complete organizational sunset. The Global Fund and Gavi already have transition policies for countries or disease programs they fund, although they don’t have clear exit timelines as organizations.
But there are those who feel a clear sunset timeline is needed now, to help organizations focus their efforts and prevent lifelong donor commitments.
“Did we speak about sunsetting when we established the Global Fund almost 25 years ago? No,” Anders Nordström, who served as the fund’s first interim executive director in 2002, tells me. “Would it have been reasonable to do that? No. But over time, when you begin to see success, and when you begin to see that things are changing, yes.”
Read: Should global health initiatives have sunset strategies? (Pro)
Related: What should a responsible PEPFAR transition look like? (Pro)
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Malawi is the fourth poorest country in the world, with 70% of its population living on less than $2.15 a day, according to the World Bank. It had made great strides in fighting HIV infection, thanks to a focus on prevention. But in 2024, 98.9% of its HIV response was externally funded, and a large portion of that came from PEPFAR.
So when the USAID shutdown came — and with it a pause in support for most HIV prevention globally — services that had been working to slow HIV infections came to a virtual standstill in Malawi. The provision of the oral and injectable pre-exposure prophylaxis, or PrEP, was suspended as the government prioritized treatment for people living with HIV in the immediate aftermath.
Eventually, some PrEP services were able to resume. But without sufficient funding, the massive progress made on fighting HIV in Malawi may not be able to continue. My colleague Andrew Green traveled to Malawi to report and found that most programs are still not functioning as they used to. Even government-run centers are not operating at full capacity, and several drop-in centers for those most at risk of acquiring HIV remain shuttered.
Health workers reported a decline in clients picking up condoms, lubricants, and oral PrEP — and fear it will lead to a rise in new HIV infections.
Read: In Malawi, the fight to get HIV services back on track post-USAID cuts
It’s not a cruel summer for Taylor Swift, who just announced her engagement to her professional football player boyfriend, Travis Kelce. But her hit song applies to this season for the World Health Organization headquarters in Geneva, where Director-General Tedros Adhanom Ghebreyesus recently wrote to staff that he anticipates losing 600 staff members as the United Nations health agency faces a 21% reduction in its budget for 2026-2027.
Staff anxiety at WHO has been high since the U.S. withdrawal announcement in January. Even after cutting back on travel and other spending, WHO still faced a gaping hole in its budget, and Tedros told member states in May that the agency expects a salary gap of more than $500 million in the next two years.
Its fiscal situation forced WHO to make some hard decisions, starting with reducing senior leadership and director positions. Some contracts were also not renewed. But with more reductions coming, some staff are questioning the fairness of the process for choosing who stays and who goes. And it could get even worse: Regional offices have yet to disclose how many staff they’re losing as part of the whole agency restructuring.
Read: WHO anticipates losing some 600 staff in Geneva
“While the prospect of an AI and automated future is grandiose, what if Africa’s next economic catalyst was far simpler? When it comes to health and prosperity, so much starts with and comes back to the humble toilet.”
— Kinya Seto, president and CEO, LIXILIn places such as Nigeria and Tanzania, toilets aren’t readily available to many people, creating health hazards. Seto — head of the Japanese manufacturer behind the low-cost toilet pan SATO — writes in an opinion piece for Devex that several African countries have set ambitious targets to improve sanitation access for their populations. Tanzania aims to be open defecation free by the end of this year and have universal access to safely managed sanitation by 2030.
That will require the installation of nearly 10 million latrines and the employment of at least 2,300 masons to install them over the next five years, he writes. And apart from the thousands of jobs it will create, it will also improve people’s health and dignity, he adds.
Opinion: How a humble toilet can help accelerate growth in Africa
A rural health center in Zambia is now powered by solar energy as part of a pilot project by Gavi to expand people’s access to health services, including immunization and clean water.
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Switzerland
The Health Facility Solar Electrification program aims to deploy solar photovoltaic systems and cold chain equipment in 1,277 health facilities across four countries, including Ethiopia, Pakistan, Uganda, and Zambia. Gavi estimates it will benefit 25 million people living in the vicinity of these health facilities.
Why is this important? More than half of health facilities in sub-Saharan Africa have unreliable or no access at all to electricity, according to WHO data. If the pilot is successful, “it could unlock co-investment and long-term government support for maintenance, ensuring sustainability,” according to a news release. The program is also “designed as a learning agenda” for Gavi to “inform future investments in sustainable energy solutions for health systems.”
From the archives: Turning health clinics into appealing customers to the energy sector
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Israel bombed Nasser Hospital in the Gaza Strip, killing at least 21 people — including journalists, medics, and rescue workers. [Al Jazeera]