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- [00:05]
A
Welcome to Into Africa, a podcast where we explore Africa's geopolitical landscape, its evolving global role and the challenges and opportunities shaping the continent's future. I'm your host, Oge Onobogu, Senior Fellow and Director of the Africa Program at the center for Strategic and International Studies Foreign. 2025. The landscape for global health changed forever. The United States officially rolled out its America First Global Health strategy, moving away from large scale multilateral funding towards targeted bilateral deals for African countries. This isn't just a change in policy, it is a disruption of the healthcare ecosystem with several aid dependent programs facing significant pressures. But this policy shift is also triggering a new era of African led health sovereignty with several African nations pushing for and investing in their own health infrastructure. On today's episode we will look at how the America First Global Health Strategy is reshaping health partnerships across Africa. Our two guests will break down what this policy shift means for the future of global health, how African countries are adapting, and the power dynamics between Washington and their African counterparts. Dr. Doris Macharya is the President of the Elizabeth Glaser Pediatric AIDS Foundation. She is a global health leader and physician with frontline and executive experience advancing HIV care and health equity across Africa and globally. My colleague, Dr. Steve Morrison is a Senior Vice President and Director of the Global Health Policy center at the center for Strategic and International Studies. Through several high level commissions, Steve has shaped decisions in the US Congress and across different US Administrations on hiv, aids, reproductive health and health security, including pandemic preparedness. Doris Steve, thanks for joining me in the studio today. Doris, let me start with you. Let us take stock. It's been one year since we saw a significant overhaul in the US Development assistance architecture, resulting in a far more constrained and unpredictable global health financing landscape. In your assessment, what has been the impact of this shifting or reduction in the foreign assistance to existing global health programs in African nations? And how are African governments adapting?
- [02:51]
B
Thank you so much for having me. Across Africa, you know we've seen extraordinary progress, especially in the area of child and maternal mortality. This is as a result of expanding access to HIV treatment testing as well and ensuring that the whole continuum of care from testing to treatment to obviously virus suppression is maintained. Let me give some examples. Over the last 20 years we've seen a rapid decline in children's death related to HIV. In the year 2000 we were at about 380,000 and that has dropped by 80%. The same is also we see it in new HIV infections among children. So tremendous, tremendous progress. A good example. We work as Eggpath in Lesotho. And we've seen vertical transmission, also what we refer to as mother to child transmission, also dropping from 17% sometime in 2010 to 5% in 2024. So great progress. But today those gains are really under threat, primarily because the funding was cut abruptly, governments were ill prepared and a lot of the activities and programs that are tied to ensuring that continuum of care were no longer there. But we have to remember, behind every statistic is a child, a child whose future depends on uninterrupted treatment. And that's very important. We always talk about the first two years in the life of a child. If they don't have antiretroviral treatment, if they are HIV infected, they are likely to die. But we also have to remember there's also another 50% that are living and require services and require this support ongoing. So that is, I think, helps us to sort of understand the gravity of the funding cuts that we experienced last year. We also have to remember health programs are not just about systems. They're not individual services. HIV programs are very much interlinked. For instance, you come for a test, your specimen has to be sent to the lab, the lab has to send back your results to the provider. You get your results, you get an antiretroviral treatment, for instance, et cetera. It really is dependent and that is important. So when we are finding the activities and programs were disrupted, it was just not the antiretroviral treatment or the HIV test. It was a whole ecosystem. So if one piece of that system is disrupted, the entire pathway breaks down. So what we need is really about stability, stability in funding, stability in resources, stability in support, as well as sustained investment and, and strong partnerships. And this is something that is going to be important even as we are seeing the new agreements that are playing out that we'll talk to in a little while.
- [05:43]
A
Thank you so much for that, Doris. And picking up on the points you made on stability, Steve, let me turn to you. So, as we've already said, the US has overhauled its approach to global health, focusing on bilateral deals tied to the America First Global Health strategy that it unveiled last year. So can you break this down for us? What is this America First Global Health strategy and how does it fundamentally differ from previous Africa focused U.S. global health programs?
- [06:15]
C
Thank you. Thank you very much, Oge. And it's great to be here with Doris. As we heard, you know, organizations like Elizabeth Glaser Pediatric AIDS foundation, you know, a vitally important partner in HIV AIDS delivery across Africa and elsewhere, particularly Particularly for children. When the event started, February, March, accelerating into the summer, it was that he was a huge rupture. It was a demolition of many of these programs. And particularly with USAID disappearing then the administration began to pivot at the end of the summer into September on a very hurried basis to define this America First Global Health strategy, which they issued in the third week of September. They wrote it very rapidly. Brad Smith came in as a lead figure within the State Department, working with many of the career people in the Bureau of Global Health, Security and Diplomacy. And they began to define a new model. And that new model is saying it's overwhelmingly bilateral, although it's using the Global Fund as a key partner. And that's a very important thing to keep in mind. And that was a big surprise that the US stayed with the Global Fund and identified the Global Fund as one of its lead implementing partners. But it was calling for compacts. Government to government negotiated compacts that would set co investment requirements, that would come forward and say, we'll put X amount of money into these sectors. You're going to be committed up front to make these co investment commitments, putting in place performance metrics, lowering the role of international NGOs. And this is something that had deep implications for Egg Path and for others. Big focus on commodities and support of health workers. Big focus on integration. Rather than having a TB program, a HIV program, a maternal and child health program, a global health security program, they were attempting to wrap these into a unified or integrated package. And they were shifting the control and responsibility for data onto the national governments, whereas the data collection and coordination had been the responsibility of implementing NGOs for the large part in many contexts. So there was a race in the fall to get these compacts concluded. There's now 24 have been signed. They bring forward a total package of about $20 billion, of which the partner countries are accounting for 37% of that 20 billion. So roughly almost 40% in those compacts is what the governments themselves have to bring forward and then 63% what the US government. It's meant to be a transition to graduation. This is a very important thing. These are three to five year. They make distinctions among the partner countries. Some are seen as primary partners, large amounts of money. Nigeria, Uganda, Rwanda. Several countries are major partners that are going to be longer term. Some are ones that you can expect will graduate in a shorter period of time. I think Botswana is likely to be in that category. Others are fragile countries, DRC and others, which are going to stay on over a longer period. Of time. So these have been concluded. There's controversies in some of these and we'll talk about data, data specimen sharing, mineral deal making, conditionalities and the like. We'll have a few more signed this week that'll bring that number up. There's about 10 in the works, many of them in Asia, Vietnam, Philippines, Thailand, Indonesia. I want to add Also of those 24, it includes Guatemala, it includes Salvador, it includes Dominican Republic, Salvador, Dominican Republic, Panama. And so they are trying to make these globalized in terms of bringing in not just the African partners, but bringing in Asian and Central American partners. I think I'll pause there. There's a lot to unpack and talk about. As to the issues that have come forward, this is just the first phase. We now move into implementation. What the State Department did was organized three teams that went out to these countries and furiously put these things together on pretty rapid pace. And I think a lot of the issues that were most sensitive and complicated didn't get adequate attention. The data privacy and national sovereign sensitivities, the specimen sharing, these are very sensitive issues in some instances are now getting re litigated or renegotiated in some respects. We can talk more about that.
- [11:01]
A
Yeah, we'll come back to that in more detail. But Doris, you know, picking up on the on this point on the African continent, we see more than a dozen African countries have already signed on to this new U.S. bilateral health agreement. How is this shifting the landscape of public health policy on the continent?
- [11:21]
B
There's been definitely a shift and as Stephen was saying, we currently have 24 of these compacts that have been signed as of last week, March 3rd, and more to be signed. And majority of this, as you've said, okay, are African countries. This is actually the most significant restructuring of US Global health assistance since pepfa. PEPFA was large, massive, really impactful. But this is by far, I think the sort of the one that is really significant.
- [11:49]
A
And for pepfa, for some of our listeners that might not know what President
- [11:53]
B
thank you for that. The President's Emergency Fund for AIDS Relief that started around 2004. It was initiative by President George Bush. Going back to these compacts, what does this actually mean for African countries? I think firstly is there's support for government sovereignty and greater ownership. That is excellent. I think this is something that we've been advocating for those of us who've been working in global health for a very long time. But there's a bit of skepticism. There's also anxiety. How will this be executed? And the timelines are pretty brutal and also, you know, quite unclear. Second thing is really about the transition away from donor led support and donor led service delivery to more government taking ownership of programs of services and being at the forefront of driving those. I think that is very much welcome. The current compacts are certainly more conditional performance based funding which is complex and quite new in our African continent and very unfamiliar. I think we'll need to get some new muscle to pull and to stretch so that we can really be able to know how to manage and work within this performance based funding. I think the fourth is, as Stephen was saying, data and surveillance obligations. That is big and that's new as well. And what we've seen is really a consolidation of, of this bilateral engagement. But they provide an opportunity, they provide an opportunity for less fragmentation of African solidarity. And we saw this believe that was I think the month of August or September, the Accra Reset. That was a really excellent initiative by President John Mahama of Ghana. Really great because it brought African leaders together to sort of say they are taking control and taking charge of their sovereignty. And we have to guard and support that even as these compacts are being implemented. Second thing for me is domestic financing for a very long time. I recall the Abuja Declaration, very aspirational, was really excellent, right? But the Accra Reset was not born out of aspiration, it's born out of a crisis. And that's good. It forces governments to commit to their at least 15%. Right now, on average most African countries are 7 to 8% of total GDP, which is well below. So there is something, and there is a lot that our African governments can do to sort of meet the moment and be able to provide more for their own people. Thirdly, and lastly for me is really around partnerships. I think of PEPFAR. Even in the last 20 plus years, countries that have been mentioned, Mozambique and Mlawi and others remain very much dependent on this donor funding. And it's going to take them time to transition. And we need to think how are we going to support them. We as EGPAF and other organizations, Elizabeth Glaser Pediatric AIDS foundation as well as others have been working very closely hand in hand with government. We need to think about how we're going to strengthen those partnerships in this particular moment to be able to learn, to be able to know we are going to partner in a different way, still be there. We don't want to abandon the African governments because we've been working very closely with them for many, many years and especially after last year, knowing that our own Assistance and our own support will look different in this new era of global health, but certainly needed. So stronger partnerships are going to really be key in terms of the short term, the medium term, as well as the long term for these compacts to work.
- [15:46]
A
Okay, well, thank you so much, Doris. And we'll come back to that point on domestic financing and partnership. But, Steve, let me turn to you. Why do you think that some African countries, such as Zimbabwe, have rejected these US Bilateral health agreements while some other African countries have signed onto them?
- [16:04]
C
Well, I think there's some specific issues at play here in the US Zimbabwe relationship that are happening. The US Relationship with Zimbabwe is in pretty bad shape. There's not a lot of trust. We have sanctions against the government. It's a much more difficult environment in trying to negotiate these compacts. Not a lot of trust right there on either side. And, you know, the Zimbabwe government, President Managua took a pretty strong stand in saying we're going to exit, we're going to terminate. The Trump administration's approach has been to kind of lay low and be patient and hope and see what happens. There's been some recent internal developments within Zimbabwe that make very clear that the cancellation or termination of current programs would have huge consequences for the population served. There's another debate going on among Zimbabweans about what's the wisdom of this. The objections around data sharing, specimen sharing, mineral conditionalities, these are part of the Accra reset in a way. I mean, what has happened Here is the 25 year golden era of global health has ended. There was a rupture, there was a cataclysmic set of events. Trump led the way, other governments retreated. At the same time, there was a 30 to 40% drop in ODA and overseas development assistance going towards health had huge consequences for the countries we're talking about in Africa in particular. And now we're in a reset happening. And the Accra reset came forward in August 4th in Accra when President Matama Muhammad pulled together several others. And there's been several subsequent summits that have happened. And it's interesting because really with this change, the rupture, it exposed the deep dependence that so many African countries had upon external sources for their health. And so a lot of leaders, not just health ministers, but state leaders, finance ministers, are asking themselves, you know, we're putting the fate of our citizens in the hands of, of decision makers a long way away from us, and maybe we need to think hard about this. And so a good deal of the Accra reset is a lot of soul Searching and a new set of commitments emerging around health sovereignty. That African leadership needs to make a higher political commitment, a higher financial commitment on their own in order to stand on their own, but also define more clearly two external partners, what are their priorities. So we have a surge of this Bakar reset and health sovereignty coming into collision with an America first populist vision. And that's what's playing out in the negotiations. To get to your point, it's most extreme in Zimbabwe, Zambia, there's some redeliberation going on. But you know, the reality is that most of the countries are moving forward. DRC just recently, it was a hesitant. It just recently signed Uganda. We can go through the long list. The majority of countries are signing on. Some are raising some objections which are totally valid and which require more discussion and to reach some sort of resolution. This is the era of the pandemic treaty negotiations around these matters of specimen sharing and data privacy concerns and sovereign concerns. I think a lot of leaders don't want to abandon that agenda just because they're entering a bilateral agreement with the United States. US has just withdrawn from who. WHO is terribly important to African ministers of health and beyond. I mean, it's the African health sector and leadership of health sector are a major constituency for who. And so we're in a strange period right now. And I think there's a lot of tension on the risk side of this. Just a couple key points from the standpoint of African leadership. What are the risks they're assuming right now they're risking unilateral U.S. withdrawal. Right. We've seen that with South Africa around the Africana issue, around the ICC and Gaza issue. South Africa is frozen out right now. The unilateral for reasons that had nothing to do with health, they have to do with other matters. Right. So there's that risk, there's the risk of inadequate finances. The timelines may be unrealistic and many of these countries may not have the actual fiscal leeway aptitude to meet these obligations. There's excessive debt hangover right now and there's really a lot of discussion around the need for a renewed effort around debt relief and restructuring like we saw 25 years ago with the HIPC program. So there's a risk that the governments themselves, who are now being asked to take responsibility for data and for oversight, will not do so well. And then if we have a deterioration in quality of data, we won't know what we're achieving in terms of health outcomes. And so I think there's a lot of goodwill going into this, but a lot of obvious recognition that there are risks for both sides in entering these bilateral agreements. And we're only so far along. The implementation plans are where they're going to spell out the performance based financing and the way in which auditing and oversight's gonna be. And those are gonna be difficult negotiations. And those still lie ahead.
- [21:55]
A
Yeah. So given these valid concerns you've highlighted about data protection and African autonomy, how can African nations really balance their need for US funding or international funding with the goal of African led health security?
- [22:12]
B
I think firstly, I think the recognition that dependency is not even across Africa. And we've just been discussing that when we're looking at countries like Mozambique or Malawi or Zimbabwe heavily dependent on US funding for their HIV programs, then on this other hand you have countries like South Africa, Kenya, Botswana, Namibia who are about, maybe less than 25% of their funding was coming from the US government. So we can't treat them all in the same way. We have to have a more targeted approach in terms of how we look at how we can balance, how we balance how countries can sort of look at their own funding and see how we can eventually reach Africa led health security. First and foremost is to remember also that as we saw these funding cuts, it meant health workers didn't have a salary. Orphanages. And I was just actually speaking to the Malawi, our Malawi team in EGPAF a couple of days ago, we were seeing more orphanages which were almost getting to be a thing of the past filling up because where do those children go? Who is going to take care of them? Where are they going to get food from? We've also seen some reports coming out of Uganda as well, how health workers are really going far and beyond to try and provide services. It is difficult and it is very, very difficult. So African nations, in my opinion, and as we think about it in eGpav, we need to navigate this a little bit more responsibly. For me, I think being an African like myself, I think of how can we build African institutions first and foremost? Africa Union comes first in mind, at least for me in terms of it's an opportunity for, for them to really be able to show up to lead the way to help secure domestic funding through pooled procurements and other mechanisms. Also the African Medicine Agency as well, and as well as nepad. Recently, I think after the International Women's Day, I was very surprised to see an announcement from South Africa indicating that they're looking for vendors who will support manufacturing of local Lena Kapavir that is amazing. And that's what we want. We want more African manufacturing. African institutions must be supported. So it's not just about supporting programs, but supporting institutions that actually get the job done and actually get it and do the work that is supposed to be done. So it's also reframing also the role of organizations such as Eggpath, organizations such as other in the global health space that have been supporting the African governments is making sure that we are also providing support where the need is rather than fulfilling any other need that might be there. For me, those are important. And then lastly, Oge, as we were talking earlier on, is domestic financing. We've seen a lot of this and we know that African governments can do more to meet their 15% commitment. We are collecting and I think we'll talk about it in more detail, seen taxes in countries, whether it is Ethiopia, in South Africa, in Kenya, in Rwanda, sugar tax, tobacco tax. Where is all that tax going? It's being all pulled into, you know, what the treasury is providing in each of the countries and being provided as you know, as financing for even non health programs. So how can we provide support and what do we need to do to ensure that the those taxes that are collected for health related issues, for sin taxes can eventually find their way into health programs, into health services. So that is going to be key and that might help also in terms of bridging the 15% again. And then of course, of course is diversifying the donor base. And Stephen talked about this earlier. Not only the US Government, Global Fund, the EU and many other donors that are there that need to come to the table and provide resources to be able to support the global health and their national health priorities. I think in full. I think the more that African governments are less dependent on one particular donor, I think that's just the way to go. And that's what I think will help us to sort of get to this sort of next step of this compact, the implementation and more sustainability at the end of the day.
- [26:46]
A
So let's expand on that a little bit more because this is mobilizing domestic resources part. That's a very interesting piece of this conversation here and we see that picking up on the continent too as well. So are there innovative financing models that can inform how African governments can move from the short term aid to sustainable long term financing in their healthcare systems?
- [27:12]
B
I think apart from syntaxes that we just talked a little bit a while ago is I was thinking about the national health insurance and these have taken off somewhat in Africa, Ghana was really, I think at the first forefront to sort of lead this way implementing a national insurance scheme. But we've seen in Rwanda also with community based financing and community based insurance financing schemes in Kenya as well in South Africa that will be key because again it's looking at how you can do payroll deductions of those who are paying, taking care of the indigent populations, but ensuring that everybody who needs health care services can get healthcare services without out of pocket expenses. That is going to be important. So that must be loaded and that must be supported and that must be supported with resources as well. I think two is I was thinking about a case like Zimbabwe. I think it's the only country which has a AIDS trust fund. So very interesting and it seems to be working. And remember, Zimbabwe is still the same country that is heavily donor dependent. So they have tried get away of figuring out how do they mobilize their own resources for the one problem that's given them a lot of headaches, which is HIV and aids. And they have done that successfully. That doesn't mean that it is an initiative that would maybe work in another country, but for sure in a place like Zimbabwe, it has worked and it probably would be the same in a similar sort of scenario, especially where countries have been heavily dependent on pepfar, for instance. So those could be some of the ways that we could look at this. There are obviously other ways of financing, but those are for me, I think low hanging fruit that we can easily mobilize. They're not new. We don't have to convince anyone we don't need more resources. We can move ahead. Most plans are already in place with the initiatives such as the national health Insurance as well, because that is going to be key in terms of not only covering HIV and aids, but also other health services. And I think that would be critical as well.
- [29:13]
A
So Steve, are there some examples that you have of innovative financing models, even if not from the continent, examples that have worked elsewhere that you could share that could probably apply in this context too as well.
- [29:26]
C
I just want to make a couple points on that. There is no magic bullet. This is a period in which finance ministers are joining with heads of state and health ministers across these countries for a new kind of conversation under a lot of pressure. And as Doris emphasized, there's a whole bunch of options on the table. Debt relief, taxes, insurance. You can point to certain countries that made a substantial commitment, Thailand, Vietnam, over extended periods of years and built up their capacity. Brazil and countries that have very, very well functioning systems right now. And their dependency on external donors is very low. So there are models and cases we can point to. In many of these instances, there's uncertainty around what the true capabilities are of the governments. Like in the Zimbabwe negotiations, you know, the US Side was of the opinion that Zimbabwe had much more financing capability than it was admitting and that it just wasn't willing to commit. It didn't have the political will to make the commitment versus oh yes, we're doing all these things. There was a sense of, come on, now's the moment. Because they had done an analysis of what they saw as the finances. The other thing that we have to bring into this is the difficult issue of corruption and accountability. The health sectors in many of these countries have been problematic. And why was it that we created all these parallel systems over the last 25 years? Well, it was a lack of trust or confidence in the existing health systems. Now we're changing out of that. But it brings back to the fore the issues of accountability and auditing and controls over corruption. And you're going to see a lot more of that in many of these compacts. And so what are the controls going to be in this period that will lead to higher confidence by the countries themselves that the dollars that they're now called upon to invest are going to achieve the results that they're looking for. Back to the US Approach here. These compacts were put together on the basis of the first budget presented by the Trump administration. And that was a budget dramatically reduced from the prior year budget. There's a lot of money that's being held back that's been appropriated in prior budgets. The Trump administration came forward and said, okay, we're going to do this and we're putting about 12 billion into this and asking for another 6 to 7 billion from the partner countries to move this forward. In the meantime, Congress came forward. Congress during the demolition and the events of 2025 was pretty weak and pretty inert in this period. Then Congress came back in February and passed a budget that was 6% less than the prior budget. There's a huge delta between that budget level that's funding these mouse versus what Congress has appropriated. There's a lot of money that has not been accounted for as to how it's going to be spent. And when you get down to that, well, what happens with those funds? Do they go towards health in Africa? Do they top up or supplement this? You don't get a clear answer from the administration, but you get a couple of answers. One answer is that that you get from Russ vote and the omb, which is we didn't ask for these monies, we don't want these monies. We're spending too much on health. We may continue to engage in pocket rescissions that take those funds and put them back. That's one answer. A second answer is we want to take the excess, the delta and we want to put it into an innovation fund. We've got the Lena Capavir partnership, which was one of the first innovation partnerships that came up in this period. There's a zipline partnership. We will soon see a proposal come forward to Congress for an innovation fund that will account for some part of that delta of funding. There's also discussion around a rainy day fund for countries that get into unforeseen trouble, famine, flooding, political instability, that need a little bit of health for stabilizing. And then there's a third fund that they're talking about which is rewarding high performing countries. I don't think we're going to see those other two funds till next year, but we're going to see the Innovation Fund come forward here. The last thing I'd say, which is about how uncertain the situation is right now. Almost all of this work that we've seen has been dominated by the Department of State. HHS has been not at the table in this. CDC is going to play some role which is part of hhs. But HHS has been in its own way given responsibility for leading on the withdrawal and disengagement from WHO and the creation of a new alliance of partnerships to replace who. So you have the State Department with the MOUs and these compacts, but you have another part of our government that is talking about, well, we're out of WHO now. We need to create global health security alliances. And mostly they're talking about doing this in Asia and Latin America, not in Africa. And those plans are calling for 2 billion a year. So when you're looking at that Delta, the monies that have been appropriated, there may be pressures coming from OMB to take them back. There may be pressures to put them into Innovation Fund or into these to support the Africa things, or there may be pressures coming for let's create something new that builds partnerships principally in the Western Hemisphere and Latin America and in Asia on pandemic preparedness and response. It's a fractured and uncertain moment we're in right now in the big picture on where does this go and it's
- [35:33]
A
difficult to follow Steve picking up on that. I think even in this moment as we see this overhaul In US Global health strategy, I think it appears to signal a broader ambition on both sides, the US side and on the side of African nations to move from donor dependency to national ownership. And I believe all of us around this table also agree with that ambition. However, given some of the pushback that we've seen in the implementation or the rollout of the strategy, as you've said, we're going into the implementation phase next. Some of the pushback that we've seen with the rollout of this strategy. How can US partnership with African countries genuinely move beyond the donor recipient model to one that is more equitable and collaborative in order to achieve this proposed ambition?
- [36:27]
B
I think it's going to be a proactive adaptation. These particular compacts are really new, nothing like we've ever seen. We've been implementing HIV programs and others for years. We have to think about how do governments deliver value to their own citizenry, to the donors who are supporting them and resourcing them, but also how are we going to shape national health agendas going forward. So there is a short term and there is midterm and what I would call a sort of a long term way of looking at this. First and foremost is at least from our side, as egpaf, as Elizabeth Glaser Pediatric AIDS foundation is, we have to continue supporting people living with HIV and AIDS services across the board and support the Ministry of Health. That's first and foremost. Whatever the compact is, whatever we need to get done, I think that's important. That's going to be in the short term. And that's where we currently are. We are implementing programs, we are supporting, supporting the implementation plans, pulling those together. And that is, I think, remarkable. It's great and underscores the intention of the compacts. Secondly is in midterm, as we see how, as Stephen has said, how these compacts are going to evolve from the actual mouse to the implementation plan to the actual delivery of services. We need to make sure that there is successful transition. And successful transition will mean many things will ensure do governments have the right civil society partners, faith based organizations, international NGOs and other NGOs that should be there and available to support this successful transition as well as the financing mechanisms that we talked about that will be part and parcel of what will be key for success. In addition to that is also other donors beyond the US Government. That is going to be key, I think on a long term is ensuring how will the ministries of health, the ministries of finance deliver on these MOUs? That is going to be Critical and that's a big long term goal. These MOUs and the compacts are over five years so it's not a long time. 2030 and we've got this very ambitious 2030 goals. Right. Zero infections at least from egg PAF or pediatric HIV. We're asking ourselves how will we reach that? How do we countries from my perspective and if you can allow me is really to think about also what do we need to protect? What do ministries of health need to protect? From our standpoint as EGPAF1 is PMTCT prevention of mother to child transmission is a non negotiable. We must save children, we must save mothers lives and must be in the domestic budget line item, whatever financing we come up with, sin taxes, national health insurance bonds, social bonds, et cetera. That's going to be important I think secondly is also how ensuring that we can close the gaps for children in terms of early infant diagnosis, critical for child survival beyond second and fifth birthday and as well as also protecting the pay of community health workers. And because this is something we saw last year as the funding cuts came and the foreign assistance was withdrawn, community health workers who are so vital in ensuring that community mothers and children for instance were connected to clinics and to other services beyond just testing treatment and viral load suppression. Getting a birth certificate for instance so that you can go to school, going for immunization as an example. So how do we protect those and make sure that community health workers get paid? I think for me the third and big investment would really want to make sure that it not only continues but is part of the successful transition is accelerating these new prevention tools that we talked about. Lena Kapavir and other prep interventions beyond just the 2 million making sure that pregnant and breastfeeding women, adolescent girls and other populations can be able to access them. That will be key because at the end of the day, after five years, the question is what really have to show that this has actually worked. It's a very short turnaround. We are already in the first year and it's going to finish very quickly. Yeah. So it's really to think about what are the key investments. And for us as EGPAF mothers and children come tops for the obvious reasons they've been left behind and we need to do more. And that's where we can show really important gains and really reach those zero infections and avat new infections for moms, for children and of course for the entire family. So it's a lot. But I think if we do it stepwise and we think about the priorities and look at it in terms of those three phases. I do think that we can get somewhere in terms of maintaining how we can secure the current investments that we have through these compacts.
- [41:06]
A
Thank you so much. I like the point you make about proactive adaptation and really thinking about this in stages from the short term to medium to long term. You know, moments of disruptions like this also create opportunities for learning. What lessons does this moment hold for global health policy and US Partnership with African nations? Steve, let me, let me turn to you. You've been working in this field for a very long time, and we're at this interesting moment now. What lessons do we get from this moment?
- [41:39]
C
We have to change, there's no question about this. There's no restoration of the status quo ante. We're in a new phase of great uncertainty. But as you point out, we've been talking for a long time about reforming programs, making them more efficient, making them more owned by the countries themselves. And now the change was enacted in a particularly disruptive and destructive way and harmful way, with huge consequences in terms of the lives of those impacted and the workers that were making their careers and committed to serving people. But we have to move forward. We have to find a way forward. What we're talking about here is an interesting model. It's got some very attractive aspects. It's got some troubling aspects. And we need to keep a focus on making sure that this works for the US Government. We need an assistant secretary. We need a nominee to lead this effort. We've had very competent and interim leadership, but we're in the second year of this administration. We need a nominee to come forward to lead this effort. We need more staffing in the State Department. State Department has now shifted to taking a lead role to replace what was done by AID before. And they need to recruit and build out. It's not going to be like it was before. We need the tensions between hhs, between Secretary Kennedy and Secretary Rubio around these big issues resolved. They're moving in, in opposite directions. There's huge tensions. We need a resolution of our own internal problems between OMB and State Department around is this money truly going to be appropriate or not? And Congress is part of that. So we need greater coherence, we need greater clarity of what is the vision. Because right now it's very uncertain and it's confusing. It's confusing to all of our African partners who look at this and go, wait a second. What is real and what is still in dispute are not clear And I think for African leadership, for elected leadership, for finance ministers or health ministers, for advocates, this is a huge moment, a huge test, and there's going to be a lot of attention and vigilance around what's the evidence of political will, high level political will, and financial commitment in this period that's going to get to the next step and building the capabilities that are on the table right now. We should have been building those capabilities 20 years ago. We're coming back to this challenge today. There are many different organizations that are coming back to the governments themselves, the African governments, to offer their help, Eggpath being one of them. I mean, what we've seen, this notion that the sources of expertise and technical assistance are now being banished is not entirely true. I mean, MSH and EggPath and PSI, they've all been scaled down significantly, but they're still players. And they've pivoted to creating these partnership arrangements with the African governments in a direct way. And many of the foundations are stepping forward and supporting them in trying to get them to help think through these financing options. We've had Gates foundation, we've had Wellcome Trust, we had others come forward, putting these teams together. And that, I think, is promising, that organizations like Egg Path and others are changing the way they operate and doing things that are very important and learning a lot.
- [45:08]
A
You know, we always like to end the podcast on a hopeful note. We've had a lot that we've discussed here today. So really, to the both of you, what outcomes are you most hopeful for that could emerge in the global health policy landscape from this moment of disruption and uncertainty? What are you most hopeful for? And, you know, we always like to put a spin on this question, too. And we ask you, you know, to sort of recommend an African musician or a book by an African author that reflects this hope.
- [45:42]
B
Doris, you want to go ahead and start? I think I'm most hopeful even when I think of EGPAF and all that we've gone through as an organization and similar to what other organizations have gone through, is this is my theory, that if we sustain our commitment and protect the systems that have protected us, have supported us for years in the African continent, do you know we can get to a generation of zero pediatric HIV infections? That is amazing. And that can be done in the next five years. That would be amazing. And that's what we're working towards. And I think I'd like to end with that. But you've asked me about a writer. I was just thinking, I grew up with parents who were, you know, really, really African nationalist. And I could remember seeing Gogiwathiongo and Chinua Achebe and Y. Those are great. But I think more recently, what we're seeing a lot are really new voices like Farah and Di. I was just reading some of her work and I'm just really struck that even as we are having these discussions, it's about self reliance. It's about the journey to self reliance with, of course, with a different twist, with new energy, with a new voice. So that to me is one. And of course the other one is Ndambisa Moyo from Zambia, Amazing, amazing economist who has really lent her voice very unapologetically in terms of self reliance in the African continent, but really supporting African institutions to lead the way, African governments to lead the way, and the rest of us supporting that as well. So that's what I'd like to end with and to say those to me are the most inspiring. There are many others inspiring as well as singers. But I would just want to put a note on that one. Yeah. Thank you.
- [47:29]
A
Thank you so much, Doris.
- [47:31]
C
Steve, I think that for the subjects we're talking about right here, the people that I think deserve the greatest kudos are President Mahalakhana for pushing forward and bringing others along on the Accra reset. That is a very pivotal moment that has happened. I think Jean Kassea, head of Africa cdc, has been also out in front putting new ideas. The plan they put together on financing was a blended finance. And we talked a bit. It's not perfect, but it was a. It was bold and fast and creative, and that's what we need right now. We need fresh thinking, we need granularity, and we need political leadership coming forward. And those are the people that I think are providing that for us. The last point I'd make, which maybe we should have made earlier, is, yeah, the golden era is over. But the 25 years of the golden era created enormous expertise within Africa. And that expertise is there. And you're seeing it expressed. In the midst of this crisis and this transition into this new era, we are seeing experts come forward all across Africa with an enormous body of experience and expertise. I mean, yesterday you came, Doris, to the book event with Kevin De Kock. Kevin De Kock's not African, he's part Kenyan.
- [48:58]
B
He's African. He's African.
- [49:00]
C
I tried to make this point in the book event about he's a blended identity. I mean, he's very African in his mindset and his lived experience. And when you read that book. It's full of all of these stories about the amazing people that he worked with over many, many years. And I took that as the kind of proof of this. These centers of excellence that have emerged through this investment, they're not going away. And that's what gives me a lot of hope in this period.
- [49:33]
A
Well, thank you both so much for joining us on this episode. You know, as we say, in this moment of disruption and uncertainty, there's still a lot of opportunities and a lot for us to be hopeful for. So I thank you all so much and thank you. Looking forward to continuing working with you all on this topic.
- [49:50]
B
Thank you.
- [49:51]
C
Thank you.
- [49:54]
A
Thanks for listening to Into Africa. If you enjoyed this episode, please subscribe. Wherever you listen to your podcast. You can find more analysis from the Africa program on our website CSIS.org or find us on social media. Search for SISAfrica on X, LinkedIn and Instagram.