GFO Issue 467, Article Number: 7
ABSTRACT
This article analyzes the new U.S. Global Health Strategy, titled “America First Global Health Strategy,” which marks a decisive shift toward transactional, results-based, and security-driven global health policy. The strategy links aid to national interests - focusing on outbreak detection, bilateral compacts, and co-financing agreements that require recipient governments to progressively fund frontline health costs. It prioritizes cost efficiency, local ownership, and direct government-to-government partnerships. Though it promises stronger surveillance systems and faster outbreak responses, critics warn of risks to equity, climate resilience, and multilateral cooperation. The approach could yield more efficient, country-led systems- but only if implemented with fairness, transparency, and local inclusion
The United States published its new global health strategy, ‘America First,’ last September. It is unapologetically transactional, thick with performance targets, and framed through a hard-power lens that links aid to national security, commercial advantage, and competition with China. For an ecosystem used to PEPFAR’s moral clarity and USAID’s convening instincts, the shift is jarring. But it is also coherent. The strategy promises to protect the homeland by detecting outbreaks in seven days; to lock in multi-year, country-to-country compacts that finance “100% of frontline costs” (commodities and health workers) while rapidly shrinking technical assistance; to require co-investment and measurable results before releasing future U.S. funds; and to leverage foreign assistance to expand markets for U.S. health innovations-from diagnostics to long-acting HIV prevention. The signal to multilaterals is unmistakable: bilateral deals first; pooled platforms and global norms only where they add capabilities the U.S. cannot obtain bilaterally.
The strategy’s operating logic: cost discipline, compacts, and co-financing
At the center of the document is a diagnosis many practitioners-quietly-share: too much money has been trapped in overhead and parallel systems for too long. The strategy asserts that only ~40% of U.S. global health funds reach commodities and frontline staff, with the rest swallowed by training, program management, and layers of implementing partners-“57 prime partners and 300+ sub-recipients” in one country, it notes, with executive compensation at some organizations crossing $1 million. Whether one sees this as overdue discipline or ideological pruning, the policy remedy is sweeping: maintain and even guarantee commodity pipelines and salaries for nurses, community health workers, and lab techs in FY2026; then require governments to absorb these costs progressively, pegged to income level, and tie annual U.S. disbursements to a few hard indicators-service volumes, epidemiology, supply-chain integrity, and country co-financing. It is the old “country ownership” agenda, but with teeth-and with a brisk timetable (agreements signed by December 31, 2025; implementation from April 2026).
Geopolitics and the pivot to bilateral leverage
This is not just accounting reform; it’s a geopolitical repositioning. The strategy is explicit that health assistance is now a “strategic mechanism” to strengthen bilateral relationships in places that matter most to the United States-particularly in Africa, where demographics, minerals, and security concerns converge-and to counter China’s influence (Figure 1). The critique of Beijing’s loans-heavy model is familiar. But what’s new is Washington’s decision to translate its health footprint into structured compacts: synchronized procurement (including pooled mechanisms that still accommodate U.S. products), integrated lab and data platforms across diseases, and a pivot to government-to-government (G2G) implementation wherever feasible. The examples chosen are telling. In Zambia, shifting HIV service delivery from U.S. implementing partners to provincial governments reportedly reduced per-patient support costs by 44% while increasing treatment coverage and viral suppression by 31%. In Kenya, moving technical assistance to county staff cut TA costs by 70% while more than quintupling the number of people on treatment. These are not isolated successes; they are the proof points for a model that wants to scale.
Figure 1: China and U.S Development Finance Breakdown
Outbreak security and the surveillance backbone
The security logic is equally clear. If COVID-19 was globalization’s worst-case stress test, this strategy is the insulation: assign U.S. health staff to every mission, weight staffing toward epidemiological hot spots, fuse vertical disease investments into a single surveillance-laboratory-data backbone, and mobilize within 72 hours when an outbreak threatens the U.S. That urgency is not theoretical. The document spotlights 2025 responses to Ebola in Uganda and Marburg in Tanzania, asserting that quick diagnostics, border screening, and therapeutics-often layered onto PEPFAR-built infrastructure-contained events with “zero cases” reaching U.S. shores. The “seven-day detection” goal is ambitious, but the general direction-fewer projects; more sensors-is right for a world where zoonoses are colliding with rapid urbanization and climate volatility.
Multilaterals in a bilateral age
The multilateral world will read these pages with a mix of relief and heartburn. Relief, because Washington still wants pooled procurement where it lowers prices and unlocks innovation; and heartburn, because the center of gravity is shifting decisively to bilateralism at the same moment the rules-based architecture has scored a rare win. In May 2025, WHO Member States adopted a legally binding pandemic agreement that sets out systems for sharing pathogens and benefits, diversifying research, and strengthening supply chains-passed with 124 votes in favor. The U.S., however, did not participate, having withdrawn from WHO earlier in the year; health experts warned that absence from the treaty’s equity mechanisms could complicate data, sample-sharing, and access to countermeasures in future crises. That dissonance-America doubling down on disease security while stepping back from the premier venue for health security norm-setting-will reverberate. It creates a two-track world in which U.S. outbreak control leans on bespoke country compacts and CDC cooperation, while most countries pursue treaty-enabled reciprocity through Geneva.
Financing politics: Global Fund, Pandemic Fund, and UNGA drumbeats
Financing politics are also shifting fast. The Global Fund launched its Eighth Replenishment this year, with early public and private pledges in September and a drumbeat of announcements on the sidelines of UNGA. The campaign’s shape is visible: a crowded calendar, a bigger role for private capital, and more overt alignment with pandemic preparedness and resilient systems for health. Whether the U.S. continues to be the anchor donor-and at what level-will influence not just grant envelopes but also the Fund’s leverage with suppliers and its co-financing expectations of countries. Meanwhile, the World Bank-hosted Pandemic Fund has quietly become one of the fastest-moving PPR platforms, awarding US$885 million across its first two rounds and catalyzing more than US$6 billion in co-financing across 75 countries; by August 2025 it reported an overall portfolio approaching US$7 billion. That makes it the multilateral instrument best aligned with Washington’s emphasis on detection, labs, and “no-regrets” capacities-if the U.S. chooses to use it.
PEPFAR at the crossroads
PEPFAR sits at the epicenter of the domestic politics that surround all of this. The program entered 2025 with a short-term authorization set to lapse in March; reauthorization expired on March 25, prompting a wave of analyses about whether PEPFAR could continue under permanent authorities and what reform would look like. The broader debate-about cost structures, local ownership, and culture-war skirmishes-cuts to PEPFAR’s identity. Supporters warn that destabilizing HIV platforms would be self-defeating for epidemic control and for outbreak response; critics of the status quo argue that the incentives around technical assistance and implementing partners dulled the transition to national systems. Both things can be true. The new U.S. strategy, with its guarantee of commodities and salaries, could preserve the backbone that matters while forcing the long-promised shift to government financing and integrated delivery-if executed with rigor and political sensitivity.
Country realities and delivery models
Country realities will decide whether this works in practice. Consider Uganda-nine Ebola outbreaks in 25 years, a vibrant but stretched health system, and a long history of U.S. collaboration. The strategy’s envisioned compact-frontline staff protected; diagnostics and therapeutics financed; surveillance integrated into national data systems; performance benchmarks agreed and verified-maps onto known capacities. It would also formalize joint accountability for stopping the next spillover at source, which benefits both Ugandans and Americans. Or look at Zambia’s and Kenya’s transitions away from parallel HIV delivery toward provincial and county implementation: success hinged on aligning salaries to local scales, using faith-based providers to extend reach, and investing in data that actually serve government decision-making. Those features-especially the role of faith-based networks that already deliver 40–50% of care in several countries-are center stage in the new strategy. The Circle of Hope model in Zambia, with decentralized “Community Posts,” higher viral suppression, and partial government absorption of costs, is precisely the kind of low-overhead, high-trust, scalable platform the document wants to replicate.
Figure 2 : Global Goals that US Health Foreign Assistant Will Contribute Towards
What’s missing: climate and equity
Two omissions deserve scrutiny. First, climate. Around the world, ministries of health are confronting heat, flooding, shifting malaria ecologies, and supply-chain disruptions. COP28 created a dedicated Health Day and a global declaration endorsed by over a hundred countries to build climate-resilient, low-carbon health systems; WHO and partners have since pushed to mainstream health across the climate agenda. Yet climate appears in the U.S. strategy mostly by implication-via zoonotic risk and calls for integrated surveillance-rather than as a core programmatic pillar with financing and metrics. That’s a missed opportunity. If surveillance is the new organizing logic, climate-health early warning (heat, air quality, vector suitability) and climate-ready primary care should be part of the bilateral compacts, not an afterthought. Second, equity. The strategy promises to “end mother-to-child HIV transmission in several high-burden countries by the end of the term,” but offers little on how gender, key populations, or marginalized communities will be protected in an era of tighter conditionality and contested social norms. That gap is not merely ethical; it is epidemiological. Programs without inclusive design tend to miss the people who drive transmission.
Implications for the Global Fund, Gavi, and the Pandemic Fund
What are the implications for multilateral institutions? For the Global Fund, expect tougher co-financing negotiations: if the U.S. is tying bilateral disbursements to domestic outlays and inventory integrity, it will want the Fund’s grant conditions to mirror that discipline. Early signals from the Eighth Replenishment-private sector pledges topping US$1 billion during UNGA week, followed by European pledges-show the Fund leaning into innovation and diversified financing to stay relevant. If Washington shifts a larger share of dollars into bilateral pools, the Fund’s comparative advantage will be price discovery, market shaping, and grant management where Government-to-Government (G2G) is not feasible-along with anchoring TB and malaria where bilateral disease diplomacy buys less leverage. For Gavi, whose 2026–2030 strategy was approved last year and emphasizes health security, new vaccines (including mpox stockpiles), and sustainability, alignment with U.S. priorities should be straightforward-if Gavi can keep delivery costs low and channel country demand into co-financed, system-strengthening investments. For the Pandemic Fund, this is a moment to function as the multilateral arm of the U.S. surveillance agenda, co-financing the same labs, workforce, and regional networks the bilateral deals will rely on-and thereby smoothing the edges of Washington’s partial exit from WHO norm-setting.
Industrial policy, IP, and local manufacturing
The hard question is whether the strategy’s industrial policy-explicitly promoting U.S. products through pooled procurement and commercial diplomacy-can be squared with affordability and local manufacturing ambitions in Africa and Asia. The document argues that pre-market commitments (it cites the U.S.-backed rollout of long-acting lenacapavir for HIV prevention) help scale innovation and save lives. That can be true. But unless the bilateral compacts protect space for regional regulators, ALM (African-located manufacturing), and technology transfer where feasible, partner governments will perceive a double standard: “local ownership” of costs, globalized ownership of IP. The best defense against that narrative is transparent price-volume deals, clear timelines for generic or biosimilar entry, and co-investment in African regulatory harmonization (e.g., the African Medicines Agency) that lowers transaction costs for everyone.
PEPFAR’s legacy-if the strategy stays pragmatic
Where does this leave PEPFAR? Surprisingly well-if the policy follows its own logic. Guaranteeing commodities and salaries stabilizes the backbone that made PEPFAR the world’s most successful disease program; integrating platforms across HIV, TB, and malaria reduces duplication; and shifting TA into ministries and faith-based networks cuts costs without cutting outcomes. But the politics still bite. Reauthorization turbulence, program audits, and culture-war narratives have real consequences for confidence and country planning. The surest way to preserve PEPFAR’s legacy is ruthless focus on results that matter to patients (viral suppression, TB cure, malaria mortality) paired with simple, auditable metrics for co-financing and supply-chain integrity. That is the one language that can still command bipartisan respect.
Conclusion
This strategy is not a return to isolation; it is a bet on a different kind of interdependence. The U.S. will be more present in the field and less present in Geneva; more interested in performance contracts and less interested in consensus statements; more comfortable using health aid to build commercial corridors and less comfortable funding process-heavy TA. The risk is fragmentation and backlash if countries feel they are being strong-armed into absorbing costs on political timetables, or if civil society and key populations are sidelined in service of “efficiency.” The opportunity, however, is real: a cleaner cost base; durable, government-run delivery; and faster, smarter surveillance embedded in everyday care. If Washington marries that discipline with the humility to co-design with countries, support regional manufacturing, and plug back into global rules where it counts, the “America First” strategy could still deliver a global public good.
A piece of advice for those involved in the global health ecosystem: follow the money and the metrics. Watch the bilateral compacts for their co-financing ramps, transition triggers, and product lists; watch the Global Fund’s replenishment for whether Washington doubles down or trims its multilateral bet; and watch whether the Pandemic Fund becomes the connective tissue that keeps U.S. bilaterals aligned with regional and global preparedness. Above all, watch the clinics. If a nurse in Nairobi or Yaoundé can refill ART, screen for TB, distribute an ITN, give PrEP, and send a sputum sample to a functioning lab-because the data system is simple, the supply chain is clean, and the salary is paid-then the strategy’s hard edges will have been worth it. If not, the cost of getting lean will be borne by the people least able to afford it.
The United States published its new global health strategy, ‘America First,’ last September. It is unapologetically transactional, thick with performance targets, and framed through a hard-power lens that links aid to national security, commercial advantage, and competition with China. For an ecosystem used to PEPFAR’s moral clarity and USAID’s convening instincts, the shift is jarring. But it is also coherent. The strategy promises to protect the homeland by detecting outbreaks in seven days; to lock in multi-year, country-to-country compacts that finance “100% of frontline costs” (commodities and health workers) while rapidly shrinking technical assistance; to require co-investment and measurable results before releasing future U.S. funds; and to leverage foreign assistance to expand markets for U.S. health innovations-from diagnostics to long-acting HIV prevention. The signal to multilaterals is unmistakable: bilateral deals first; pooled platforms and global norms only where they add capabilities the U.S. cannot obtain bilaterally.
The strategy’s operating logic: cost discipline, compacts, and co-financing
At the center of the document is a diagnosis many practitioners-quietly-share: too much money has been trapped in overhead and parallel systems for too long. The strategy asserts that only ~40% of U.S. global health funds reach commodities and frontline staff, with the rest swallowed by training, program management, and layers of implementing partners-“57 prime partners and 300+ sub-recipients” in one country, it notes, with executive compensation at some organizations crossing $1 million. Whether one sees this as overdue discipline or ideological pruning, the policy remedy is sweeping: maintain and even guarantee commodity pipelines and salaries for nurses, community health workers, and lab techs in FY2026; then require governments to absorb these costs progressively, pegged to income level, and tie annual U.S. disbursements to a few hard indicators-service volumes, epidemiology, supply-chain integrity, and country co-financing. It is the old “country ownership” agenda, but with teeth-and with a brisk timetable (agreements signed by December 31, 2025; implementation from April 2026).
Geopolitics and the pivot to bilateral leverage
This is not just accounting reform; it’s a geopolitical repositioning. The strategy is explicit that health assistance is now a “strategic mechanism” to strengthen bilateral relationships in places that matter most to the United States-particularly in Africa, where demographics, minerals, and security concerns converge-and to counter China’s influence (Figure 1). The critique of Beijing’s loans-heavy model is familiar. But what’s new is Washington’s decision to translate its health footprint into structured compacts: synchronized procurement (including pooled mechanisms that still accommodate U.S. products), integrated lab and data platforms across diseases, and a pivot to government-to-government (G2G) implementation wherever feasible. The examples chosen are telling. In Zambia, shifting HIV service delivery from U.S. implementing partners to provincial governments reportedly reduced per-patient support costs by 44% while increasing treatment coverage and viral suppression by 31%. In Kenya, moving technical assistance to county staff cut TA costs by 70% while more than quintupling the number of people on treatment. These are not isolated successes; they are the proof points for a model that wants to scale.
Figure 1: China and U.S Development Finance Breakdown
Outbreak security and the surveillance backbone
The security logic is equally clear. If COVID-19 was globalization’s worst-case stress test, this strategy is the insulation: assign U.S. health staff to every mission, weight staffing toward epidemiological hot spots, fuse vertical disease investments into a single surveillance-laboratory-data backbone, and mobilize within 72 hours when an outbreak threatens the U.S. That urgency is not theoretical. The document spotlights 2025 responses to Ebola in Uganda and Marburg in Tanzania, asserting that quick diagnostics, border screening, and therapeutics-often layered onto PEPFAR-built infrastructure-contained events with “zero cases” reaching U.S. shores. The “seven-day detection” goal is ambitious, but the general direction-fewer projects; more sensors-is right for a world where zoonoses are colliding with rapid urbanization and climate volatility.
Multilaterals in a bilateral age
The multilateral world will read these pages with a mix of relief and heartburn. Relief, because Washington still wants pooled procurement where it lowers prices and unlocks innovation; and heartburn, because the center of gravity is shifting decisively to bilateralism at the same moment the rules-based architecture has scored a rare win. In May 2025, WHO Member States adopted a legally binding pandemic agreement that sets out systems for sharing pathogens and benefits, diversifying research, and strengthening supply chains-passed with 124 votes in favor. The U.S., however, did not participate, having withdrawn from WHO earlier in the year; health experts warned that absence from the treaty’s equity mechanisms could complicate data, sample-sharing, and access to countermeasures in future crises. That dissonance-America doubling down on disease security while stepping back from the premier venue for health security norm-setting-will reverberate. It creates a two-track world in which U.S. outbreak control leans on bespoke country compacts and CDC cooperation, while most countries pursue treaty-enabled reciprocity through Geneva.
Financing politics: Global Fund, Pandemic Fund, and UNGA drumbeats
Financing politics are also shifting fast. The Global Fund launched its Eighth Replenishment this year, with early public and private pledges in September and a drumbeat of announcements on the sidelines of UNGA. The campaign’s shape is visible: a crowded calendar, a bigger role for private capital, and more overt alignment with pandemic preparedness and resilient systems for health. Whether the U.S. continues to be the anchor donor-and at what level-will influence not just grant envelopes but also the Fund’s leverage with suppliers and its co-financing expectations of countries. Meanwhile, the World Bank-hosted Pandemic Fund has quietly become one of the fastest-moving PPR platforms, awarding US$885 million across its first two rounds and catalyzing more than US$6 billion in co-financing across 75 countries; by August 2025 it reported an overall portfolio approaching US$7 billion. That makes it the multilateral instrument best aligned with Washington’s emphasis on detection, labs, and “no-regrets” capacities-if the U.S. chooses to use it.
PEPFAR at the crossroads
PEPFAR sits at the epicenter of the domestic politics that surround all of this. The program entered 2025 with a short-term authorization set to lapse in March; reauthorization expired on March 25, prompting a wave of analyses about whether PEPFAR could continue under permanent authorities and what reform would look like. The broader debate-about cost structures, local ownership, and culture-war skirmishes-cuts to PEPFAR’s identity. Supporters warn that destabilizing HIV platforms would be self-defeating for epidemic control and for outbreak response; critics of the status quo argue that the incentives around technical assistance and implementing partners dulled the transition to national systems. Both things can be true. The new U.S. strategy, with its guarantee of commodities and salaries, could preserve the backbone that matters while forcing the long-promised shift to government financing and integrated delivery-if executed with rigor and political sensitivity.
Country realities and delivery models
Country realities will decide whether this works in practice. Consider Uganda-nine Ebola outbreaks in 25 years, a vibrant but stretched health system, and a long history of U.S. collaboration. The strategy’s envisioned compact-frontline staff protected; diagnostics and therapeutics financed; surveillance integrated into national data systems; performance benchmarks agreed and verified-maps onto known capacities. It would also formalize joint accountability for stopping the next spillover at source, which benefits both Ugandans and Americans. Or look at Zambia’s and Kenya’s transitions away from parallel HIV delivery toward provincial and county implementation: success hinged on aligning salaries to local scales, using faith-based providers to extend reach, and investing in data that actually serve government decision-making. Those features-especially the role of faith-based networks that already deliver 40–50% of care in several countries-are center stage in the new strategy. The Circle of Hope model in Zambia, with decentralized “Community Posts,” higher viral suppression, and partial government absorption of costs, is precisely the kind of low-overhead, high-trust, scalable platform the document wants to replicate.
Figure 2 : Global Goals that US Health Foreign Assistant Will Contribute Towards
What’s missing: climate and equity
Two omissions deserve scrutiny. First, climate. Around the world, ministries of health are confronting heat, flooding, shifting malaria ecologies, and supply-chain disruptions. COP28 created a dedicated Health Day and a global declaration endorsed by over a hundred countries to build climate-resilient, low-carbon health systems; WHO and partners have since pushed to mainstream health across the climate agenda. Yet climate appears in the U.S. strategy mostly by implication-via zoonotic risk and calls for integrated surveillance-rather than as a core programmatic pillar with financing and metrics. That’s a missed opportunity. If surveillance is the new organizing logic, climate-health early warning (heat, air quality, vector suitability) and climate-ready primary care should be part of the bilateral compacts, not an afterthought. Second, equity. The strategy promises to “end mother-to-child HIV transmission in several high-burden countries by the end of the term,” but offers little on how gender, key populations, or marginalized communities will be protected in an era of tighter conditionality and contested social norms. That gap is not merely ethical; it is epidemiological. Programs without inclusive design tend to miss the people who drive transmission.
Implications for the Global Fund, Gavi, and the Pandemic Fund
What are the implications for multilateral institutions? For the Global Fund, expect tougher co-financing negotiations: if the U.S. is tying bilateral disbursements to domestic outlays and inventory integrity, it will want the Fund’s grant conditions to mirror that discipline. Early signals from the Eighth Replenishment-private sector pledges topping US$1 billion during UNGA week, followed by European pledges-show the Fund leaning into innovation and diversified financing to stay relevant. If Washington shifts a larger share of dollars into bilateral pools, the Fund’s comparative advantage will be price discovery, market shaping, and grant management where Government-to-Government (G2G) is not feasible-along with anchoring TB and malaria where bilateral disease diplomacy buys less leverage. For Gavi, whose 2026–2030 strategy was approved last year and emphasizes health security, new vaccines (including mpox stockpiles), and sustainability, alignment with U.S. priorities should be straightforward-if Gavi can keep delivery costs low and channel country demand into co-financed, system-strengthening investments. For the Pandemic Fund, this is a moment to function as the multilateral arm of the U.S. surveillance agenda, co-financing the same labs, workforce, and regional networks the bilateral deals will rely on-and thereby smoothing the edges of Washington’s partial exit from WHO norm-setting.
Industrial policy, IP, and local manufacturing
The hard question is whether the strategy’s industrial policy-explicitly promoting U.S. products through pooled procurement and commercial diplomacy-can be squared with affordability and local manufacturing ambitions in Africa and Asia. The document argues that pre-market commitments (it cites the U.S.-backed rollout of long-acting lenacapavir for HIV prevention) help scale innovation and save lives. That can be true. But unless the bilateral compacts protect space for regional regulators, ALM (African-located manufacturing), and technology transfer where feasible, partner governments will perceive a double standard: “local ownership” of costs, globalized ownership of IP. The best defense against that narrative is transparent price-volume deals, clear timelines for generic or biosimilar entry, and co-investment in African regulatory harmonization (e.g., the African Medicines Agency) that lowers transaction costs for everyone.
PEPFAR’s legacy-if the strategy stays pragmatic
Where does this leave PEPFAR? Surprisingly well-if the policy follows its own logic. Guaranteeing commodities and salaries stabilizes the backbone that made PEPFAR the world’s most successful disease program; integrating platforms across HIV, TB, and malaria reduces duplication; and shifting TA into ministries and faith-based networks cuts costs without cutting outcomes. But the politics still bite. Reauthorization turbulence, program audits, and culture-war narratives have real consequences for confidence and country planning. The surest way to preserve PEPFAR’s legacy is ruthless focus on results that matter to patients (viral suppression, TB cure, malaria mortality) paired with simple, auditable metrics for co-financing and supply-chain integrity. That is the one language that can still command bipartisan respect.
Conclusion
This strategy is not a return to isolation; it is a bet on a different kind of interdependence. The U.S. will be more present in the field and less present in Geneva; more interested in performance contracts and less interested in consensus statements; more comfortable using health aid to build commercial corridors and less comfortable funding process-heavy TA. The risk is fragmentation and backlash if countries feel they are being strong-armed into absorbing costs on political timetables, or if civil society and key populations are sidelined in service of “efficiency.” The opportunity, however, is real: a cleaner cost base; durable, government-run delivery; and faster, smarter surveillance embedded in everyday care. If Washington marries that discipline with the humility to co-design with countries, support regional manufacturing, and plug back into global rules where it counts, the “America First” strategy could still deliver a global public good.
A piece of advice for those involved in the global health ecosystem: follow the money and the metrics. Watch the bilateral compacts for their co-financing ramps, transition triggers, and product lists; watch the Global Fund’s replenishment for whether Washington doubles down or trims its multilateral bet; and watch whether the Pandemic Fund becomes the connective tissue that keeps U.S. bilaterals aligned with regional and global preparedness. Above all, watch the clinics. If a nurse in Nairobi or Yaoundé can refill ART, screen for TB, distribute an ITN, give PrEP, and send a sputum sample to a functioning lab-because the data system is simple, the supply chain is clean, and the salary is paid-then the strategy’s hard edges will have been worth it. If not, the cost of getting lean will be borne by the people least able to afford it.
