Should global health initiatives have sunset strategies?

Over the past two decades, the U.S. President's Emergency Plan for AIDS Relief, or PEPFAR, has helped save 26 million lives and become the largest international donor to the global HIV and AIDS response. But it was never meant to run forever. In recent months, U.S. government funding cuts posed a real existential threat to the program. PEPFAR-funded activities have been massively limited, leading to a public outcry. A New York Times report also exposed a State Department plan to shut the program down in the coming years. The plan is under discussion, but experts Devex spoke to said it’s far from final. Other global health initiatives, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the Vaccine Alliance, were also forced to slash grants, cut back on their workforce, and revisit their priorities as a result of reductions in donor funding. Amid funding uncertainties and mounting calls for reform in the global health landscape, some experts have started advocating for changes, including transitions and sunset strategies. Some argue these changes are long overdue. While many global health initiatives have helped save lives, they have also received criticism for perpetuating aid dependency in many countries. But previous calls for changes have never really gained traction. “The fact that it's happening now is really only because we have no choice, which says a lot about human nature, which is that we tend not to make hard decisions, unless we have to,” said one global health expert who chose to remain anonymous, as they are not authorized to speak publicly on such matters. But some caution against abrupt transitions and random end dates. “I think randomly saying every organization should sunset within five years makes no sense,” Dr. Mark Dybul, who has led both PEPFAR and the Global Fund, told Devex, suggesting instead phased reductions with clear benchmarks on an annual basis. Nothing is forever Architects of some of the big global health initiatives say they never really discussed a timeline for how long the initiatives would continue. Anders Nordström, who served as the Global Fund’s first interim executive director in 2002, told Devex there was a lot of urgency then, especially in response to HIV and AIDS. “People just wanted things to get up and running as quickly and as efficiently as possible … [but] they didn't want a U.N. organization. They wanted something different. And that was why we also designed the Global Fund as we did, but there was no discussion about [sunset timelines] at that time,” he said. But these initiatives were never meant to exist indefinitely or operate at the same level for a long period. During its first decade of operation, PEPFAR started partnership frameworks — multiyear agreements with individual countries with clear goals and plans for governments to take more ownership of their HIV response. But while some countries are now funding a larger portion of their HIV response — for example, South Africa now covers 75.2% of its HIV response through domestic public resources — they have not yet fully transitioned out of PEPFAR support. Others such as Tanzania remain heavily reliant on PEPFAR support, which covers 90% or more of the country’s response. The Global Fund and Gavi also have policies that transition countries or disease components out of their support. Gavi has a co-financing requirement for countries, and those that reach a certain gross national income are placed on accelerated transition, meaning the countries fund a greater share of their vaccination needs over a period of eight years. After that, they are expected to be fully self-financing and are no longer able to access Gavi funding. As of 2022, 19 countries had fully transitioned from Gavi support. Global Fund also has an eligibility policy based on income level and disease burden, as well as a sustainability, transition and co-financing, or STC, policy. The latter was first approved in 2016 and revised in 2024. Unlike Gavi, Global Fund transitions happen per disease. For example, a country certified malaria-free can no longer receive Global Fund funding for malaria, but may still be eligible for funding for HIV or TB, especially if they have a high burden of these diseases. “We recognize that we need to be working increasingly with countries to support transition away from external financing. That's why we revised the Sustainability, Transition and Co-financing (STC) policy in 2024. That’s why we put in the STC policy the provisions to strengthen co-financing, transition planning, and the ability to set more clear [transition] timelines with countries,” Matt MacGregor, head of the health finance department at the Global Fund, told Devex. However, he said “there are still a lot of places where abrupt or too quick transitions would have really challenging impacts on the massive progress that we've made, and so this is why we've got to really focus on supporting countries to move towards self-reliance, but do that in a way that's tailored to each country's context. This is not a switch. It’s a journey.” However, when it comes to a sunset strategy for the organization itself, a Global Fund spokesperson wrote to Devex: “We don’t set arbitrary exit timelines. Instead, transitions are guided by countries’ readiness, not fixed dates or financial thresholds.” But Nordström said discussions should also take place on what happens to the organizations themselves, and if and how some of their important functions built over time can be preserved. He thinks the time is ripe for such conversations. Noncommunicable diseases, such as heart disease and stroke, are now the top causes of death in many countries, including low-income countries. And while foreign aid declines, the economies of some countries that receive aid have grown over the years. Several African leaders are also asserting independence. The recent Accra Initiative declaration called for governments to take responsibility for their own health systems and to mobilize domestic resources for health amid declining external aid. “I think generally one should talk about sunsetting. You should have a reasonable time perspective [for that],” Nordström said. And while he thinks what the U.S. did was “brutal,” he said discussions about transitions and sunsetting were bound to happen at some point. “Did we speak about sunsetting when we established the Global Fund almost 25 years ago? No. 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,” he added. Dr. Sania Nishtar, CEO of Gavi, said one of the flaws in the current global health architecture is that most global health institutions — including Gavi — do not have sunset clauses. “The global health system needs to embrace a new reality in which international institutions have a clear understanding of their mandates and their lifespans,” she wrote in an opinion article for The Lancet. She acknowledged that “will require difficult conversations and some tough choices about the form, function, and, in some cases, the continuity of some institutions going forward.” A flaw in the system But Dr. Githinji Gitahi, group CEO of Amref Health Africa, believes sunset dates should not be institutional but instead based on country or population, and rely on the human development index, which measures a country’s development based on its people’s health, education, and standard of living, and not just their economic growth. He advocates for a nuanced approach where organizations gradually transition responsibilities to countries, and align with national development priorities, allowing countries to have “program sovereignty.” “It’s not about where the money comes from. It's about where the money goes,” he said. He said if organizations such as Gavi had gradually sourced vaccines and medical commodities from African manufacturers over the past two decades, it would make transition much easier for countries “because those would have caused development, plus capacity building.” But he challenges the idea of a complete organizational sunset, arguing that equity will always be a global necessity. “Aid is not a bad thing. By saying they must all sunset, we are saying there is a time that will come when there are no people who need equity [and] that’s not true,” he said. What sunset timelines can offer One benefit of having a timeline is that it helps institutions focus on the problem they’re trying to solve and achieve it in the fastest way possible. The Gates Foundation’s announcement that it will sunset on Dec. 31, 2045, for example, allows them to focus on what to do for the next 20 years, said Ramanan Laxminarayan, founder and president of the One Health Trust, a public health research organization. “I think the focus that sunsetting brings is always very helpful, because … you can see what do I want to have achieved at the end of the sunset period, and then work backwards to say, what do I need to do in order to get to that situation,” he told Devex. But Laxminarayan is of the view that sunsetting based on the eradication of a disease can be very difficult. A more feasible benchmark could be bringing a problem to a very low level and then allowing countries to take care of it themselves, he said. “The curse of smallpox is that it has set up the belief that it can be done again and again when it might be really quite hard,” he added. Another benefit of having a sunset clause or timeline is that it creates a time-bound commitment for donors up front, as opposed to a lifelong commitment for decades. “We've been living in this, I don't know, fantasy Disneyland, which is a remarkable dream that health care services can be financed by a foreign entity, initially during an emergency phase, and 20 years later, still financing it,” the expert who spoke anonymously said. “Diamonds are forever, but I don't know if PEPFAR was supposed to be forever.” A thoughtful transition But sunsetting without a proper transition plan could lead to the loss of lives. This was the case with the sudden U.S. funding freeze. Some also fear that vulnerable populations, such as members of the LGBTQ community who are criminalized in several countries, would lose access to treatments and services if funding from external sources dries up. People would also lose their jobs. With the funding cuts this year, many global and local aid organizations have had to let go of thousands of staff. “I think the most difficult [thing] is uncertainty. [But] if you know what's going to happen, then you can plan,” Nordström said, adding that it’s important for organizations to be open and transparent to their staff. Dybul, who’s called for carefully structured transitions, said there needs to be an understanding of where countries are now to determine what a reasonable transition would look like. And that takes time. After that, “maybe you would be able to set reasonable sunsets with safety clauses based on stability, geopolitics, things like that,” he said. But he also cautioned that there can be unforeseen crises that could impact these efforts. He recalls how Côte d'Ivoire was in a position to begin to transition out of PEPFAR support, only for that to be derailed by the country’s civil war. The transitions aren’t just about reducing financial support, however, but about reimagining relationships between countries. “Africa's been asking for something different for 20 years,” Dybul said, including trade and technology exchange. “If we had been doing what we should have been doing the last 20 years, we wouldn't be in this position,” he said.