What's included in the USAID global health waiver

As the global freeze on U.S. foreign aid continues, a limited set of lifesaving health programs are being granted exceptions — but with significant restrictions and unanswered questions about how they’ll be implemented. Last week, some programming under the U.S. President’s Emergency Relief for Aids Relief, or PEPFAR, which provides lifesaving HIV medication, was granted a waiver. Devex obtained a copy of waiver guidance for other types of global health programming, including for tuberculosis, malaria, acute risks of maternal and child mortality, severe acute malnutrition, and other life-threatening diseases and health conditions. The memo sent by Nicholas Enrich, acting assistant administrator for the Bureau for Global Health, to the agency’s chief of staff and deputy staff, stated that the bureau is “taking steps to resume or continue activities” deemed lifesaving. But Enrich added this only includes a “limited subset” of lifesaving humanitarian assistance. But even as these exceptions are made, USAID announced that nearly all direct hire staff globally will be placed on administrative leave, sparing over 600 individuals, down from more than 13,000 just three weeks ago. This has left many questioning who will oversee these programs on the ground. USAID staffers have told Devex that disbursements to implementing partners have not gone out so that partners can implement lifesaving programming approved by waivers. “Leaving behind just a few people in countries overseas to manage these very complex grants and awards is completely irresponsible. USAID has extremely tight financial management systems that require highly trained personnel and use of airtight grants management and disbursement systems that also involves extensive oversight of the recipients,” a USAID employee in the global health bureau who has been told that they will be placed on administrative leave told Devex. “Decimating Usaid’s staff and at the same time expecting them to deliver the resources for these minimal life-saving services is a recipe for disaster,” this person added. What’s included According to Enrich’s memo — which was dated Feb. 4th, but “cleared by email” on Feb. 6th — only the following activities will be resumed during the 90-day pause: The provision of lifesaving services related to preventing, diagnosing, and treating tuberculosis, malaria, acute risks of maternal and child mortality, and severe acute malnutrition, among other life-threatening diseases and health conditions. But only if their absence could “lead to mortality in women, newborns, and children under five.” Antenatal care and post-partum services for women are included “to address acute complications before, during, and after delivery, which require lifesaving treatments such as safe Cesarean section, safe blood supplies, oxytocin for post-partum hemorrhage, antibiotics, and access to lifesaving commodities,” he wrote. Essential newborn care is also included for preterm, low-birthweight, small and sick newborns, essential immunizations to prevent “imminent mortality,” treatment of acute child illness with antibiotics, oxygen therapy for pneumonia, and oral rehydration solution and zinc for acute diarrhea. It also includes the management of severe acute malnutrition with ready-to-use therapeutic food for children under five. Essential screening, testing, and treatment for tuberculosis are included, such as providing and monitoring lab services, drug susceptibility testing, clinical visits, and dispensing of essential medicines to “avert near-term mortality and spread of infection.” Essential services for malaria are included, such as diagnosis, treatment, and prevention through the distribution of nets and indoor residual spraying targeting highest-burden areas, where children are at risk of dying from malaria within 48 hours, and lifesaving malaria medicines for pregnant women and children. Rapid emergency response is included to help contain infectious disease outbreaks of pathogens with “high pandemic potential” that pose a national security risk to U.S. citizens such as Ebola, Marburg, mpox, and highly pathogenic avian influenza. This includes detection, prevention, and containment efforts, risk information for affected populations, active surveillance, infection prevention and control, support for testing, case management and treatment, and supply of medical countermeasures. Procurement, warehousing, and distribution of essential lifesaving medicines and health products are included, as well as support of laboratory systems for diagnosis and treatment, and targeted supply chain management. He wrote that implementing partner administrative costs “strictly necessary” to deliver this aid are included. He emphasized that this waiver doesn’t allow for activities related to abortion services, family planning, conferences, transgender surgeries, and administrative costs “outside the scope outlined.” It also noted that programs can’t be centered on gender, diversity, or equity. He wrote that final approval for activities rests with the bureau’s acting assistant administrator and for bilateral awards for USAID missions, it lies with the regional bureau and mission leadership. He noted activities must “resume or continue in the next 30 days” in order to “prevent imminent mortality among USAID beneficiaries."