‘What’s in’ and ‘what’s out’ in USAID’s global health programming

In the wake of the dismantling of the U.S. Agency for International Development, the agency’s leadership sent country missions abroad some insight into what will be considered acceptable global health programming under the Trump administration — and what won’t. The administration has slashed the majority of USAID’s global programming, but some of it will continue under the leadership of the U.S. State Department. USAID leadership sent out an Excel sheet and a PowerPoint dated April 8th — of which Devex obtained a copy — which highlighted 24 “central awards to support global health programming” that will continue under the agency’s “narrower focus.” It framed the awards as “What’s In” and “What’s Out”— detailing how the Trump administration envisions the future of foreign aid in the health space. The prioritized activities fall within four baskets: direct health service delivery; procurement of essential health commodities and supply chain management; emergency response to infectious disease outbreaks; and data analytics, monitoring, and evaluation to ensure accountability for results, cost effectiveness, and efficiency. Some of the programs fall solely in one basket, while others overlap. What’s now “deprioritized,” according to the PowerPoint, are awards with a focus on “broad and stand alone behavior change, health systems strengthening, knowledge management, broad research, and technical assistance (not directly tied to lifesaving service delivery activities).” Beyond companies and NGOs, the spreadsheet also lists active awards for public international organizations, including the Global Fund to Fight AIDS, Tuberculosis and Malaria; CEPI; the World Bank’s Pandemic Fund — as well as Ebola programming from UNICEF and the International Organization for Migration. The U.S. State Department did not respond to Devex’s request for comment. The PowerPoint noted that due to current “operational constraints” such as staffing levels at USAID and implementing partners, there will need to be “initial prioritization even within the lifesaving focus.” The agency’s global staff have been told they will lose their jobs in the coming months, with some still working but many already on administrative leave. And as USAID staff work to terminate awards in the final months of the agency’s existence, before the hand off to the State Department, they were asked to “limit the costs” incurred by the projects as they close out. The Trump administration’s decisions to terminate and reinstate programming have been in flux in recent weeks — so the presence of programs on this list does not indicate that there have not since been terminations — or won’t be in the future — nor that this list is exhaustive. Direct service delivery Programs that USAID leadership considers “in” — and plans to maintain — for direct service delivery include lifesaving services for HIV, malaria, tuberculosis, maternal and child health care, and nutrition in areas such as diagnosis, treatment, screening, and case management at community and facility levels. This includes laboratory systems, diagnostic networks, supervision, and on-the-job training. One example of a direct service delivery award that is spared is the U.S. President’s Malaria Initiative REACH. It works at the facility and community level, and can include other program areas — such as maternal and child health, as well as nutrition — as long as malaria is part of the package. The primary grant holder is PATH, with a handful of sub-grantees and countries where they operate. The project is slated to end in September 2028. Another is Adolescents and Children HIV incidence reduction, Empowerment & Virus Elimination, or ACHIEVE, which is an HIV-plus program for pregnant and breastfeeding women, as well as children. The prime contract holder is Pact, with a variety of partners in five countries. It runs through the end of 2026. While it includes direct services, it can also include integrated case management of co-infections and nutritional support. Other project awards maintained in this area include Reaching Impact Saturation and Epidemic Control, or RISE; The U.S. President’s Malaria Initiative Evolve project; MOMENTUM Country and Global Leadership; MOMENTUM Integrated Health Resilience; TB Implementation Framework Agreement; Global Health Supply Chain – Procurement and Supply Management, or GHSC-PSM; Core Group Partners Project; Meeting Targets and Maintaining Epidemic Control, or EpiC; United Nations Office for Project Services/Stop TB Partnership; and Long-Term Exceptional Technical Assistance Project, or LEAP Global. On the other hand, broad health system strengthening and capacity strengthening are “out.” Broad community-based HIV testing, voluntary medical male circumcision, and the DREAMS program, which is aimed at helping adolescent girls become “Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe” women are also out. The PowerPoint notes that funding in areas such as staff attending large meetings and conferences, multisectoral policy or strategy development, economic and finance-related activities, such as in health financing, household economic and education, and stand-alone mental health services, will also be excluded. Emergency response to infectious disease Under the emergency response to infectious disease umbrella, community-based surveillance and systems capacity for detecting “priority” diseases, as well as data systems for monitoring, analyzing, and reporting threats, are “in.” The government will also continue to fund infection prevention and control, including purchasing commodities that help assist with this, as well as programming on water and sanitation, emergency operation centers, point of entry screening, risk communication, and laboratory systems. For example, an award with IMO that runs through 2030 has been spared. It’s currently only approved for responding to the Ebola outbreak in Uganda. The agreement enables USAID to partner with IOM across the world when outbreaks occur — and aims to strengthen disease surveillance and outbreak response for populations on the move, including health screenings at borders. Other awards maintained in this area include STRengthening Infectious disease DEtection Systems, or STRIDES; The U.S. President’s Malaria Initiative Evolve project; GHSC-PSM; Core Group Partners Project; RISE; EpiC; MOMENTUM Country and Global Leadership; and MOMENTUM Integrated Health Resilience. But global health systems workforce development not specific to outbreak response or lifesaving activities, as well as social and behavior change not related to a current outbreak or priority threat, will not be covered. Programs around preventing antimicrobial resistance, which is when pathogens become resistant to treatment, general global health systems policy, strategy, and coordination work; zoonotic disease research, including spillover risk assessment; and work around market access investments and innovative finance are also out. Supply chain for health commodities What USAID leadership considers “in” for supply chains for health commodities for lifesaving responses to HIV, malaria, tuberculosis, maternal and child health care, nutrition, and global health security, include: ensuring quality, delivery, duty waiver processing, customs clearance, in-country warehousing, and distribution. It can also include campaign and supply planning, distribution, forecasting, and supply chain-related data systems. One example of an award that was spared is USAID’s GHSC-PSM Task Order project, which works to procure and deliver medicine and commodities — and has done so to over 70 countries. The end date is November 2026. This includes supplying products to the U.S. President’s Emergency Plan for AIDS Relief, the U.S. President’s Malaria Initiative, USAID’s maternal and child health and nutrition programs, and for other health threats such as Ebola and Zika. The prime grant holder is Chemonics International, with a variety of sub-grantees and countries receiving support. Another program includes the GHSC-PSM RTK. Remote Medical International holds the primary grant for procuring HIV rapid test kits, such as self-tests. It ends in November 2026. Other awards maintained in this area include Qualifying Testing, Issuing, or QTI; NextGen Comprehensive Technical Assistance for Health Supply Chain and Pharmaceutical Management, or CompTA; EpiC; RISE; UNOPS/Stop TB Partnership/Global Development Fellows; and MOMENTUM Country and Global Leadership. But the procurement of commodities for non-supported activities, such as voluntary medical male circumcision, and systems strengthening not directly related to operational support, are all considered “out.” Data analytics, monitoring, and evaluation What’s “in” for data analytics, monitoring, and evaluation includes these programs for supply chain-related systems, service delivery, reporting, accountability; and routine facility and community information systems for case reporting, surveillance, and impact measurement. It also includes insecticide and drug resistance monitoring to guide malaria procurements. One program that remains is Data for Implementation, or Data.FI, which has Palladium as the prime partner and runs through the end of this year. It focuses on digital health for client care, using data for decision-making around interventions, data analytics that find inefficiencies, and data standards. It also includes data sharing with governments. Other awards maintained in this area include STRIDES; LEAP Global; Support, Mobilizing, and Accelerating Research for Tuberculosis Elimination, SMART4TB; TB Alliance; GHSC-PSM ; CompTA; RISE; REACH; EpiC; The U.S. President’s Malaria Initiative Evolve project; MOMENTUM Country and Global Leadership; and MOMENTUM Integrated Health Resilience. But what’s considered “out” is expanding current data systems of development of new systems; research, trials, surveys, evaluations, community-led monitoring; tuberculosis prevalence and drug resistance surveys; and tuberculosis infection surveys.