Projects Can Fund Activity, but Systems Sustain Performance
In the first weeks of 2025, a policy decision made in Washington reached health facilities thousands of miles away, and some of those facilities went quiet.
The United States had ordered a 90-day pause on foreign assistance while it reviewed the alignment of aid programs with its foreign-policy priorities. Although lifesaving HIV treatment later received a limited waiver, the disruption had already moved through the institutions that delivered care. Payments stopped or arrived late. Awards were terminated. Health workers lost their positions. Supply chains weakened. Prevention, testing, outreach, and community-based services contracted sharply.1,2
By July 2026, an amfAR-led study of 166 organizations operating in 46 countries had documented the closure of 1,714 HIV service sites and the termination of more than 16,000 full-time positions following delayed or canceled PEPFAR funding. The surveyed organizations represented approximately 23 percent of PEPFAR’s country-level implementing partners, meaning the documented totals capture only part of the implementing-partner universe.2
The funding pause was an exogenous shock that exposed a deeper weakness—the continuity of essential services still depended too heavily on decisions made outside the institutions expected to sustain them.
The disruption exposed three principal failures: donor continuity, recipient ownership, and development design. Durable programs require continuity architecture that assigns authority, finance, workforce, supply, performance, and transition responsibilities from the outset.
PEPFAR had operated for more than two decades and helped save more than 26 million lives.3 It financed clinics and laboratories, supported a trained workforce, and strengthened treatment protocols, information systems, procurement mechanisms, community networks, and relationships with national institutions.5 Those accomplishments were substantial and should remain part of any fair assessment.
That record matters because the 2025 disruption could easily be misread as evidence that these services were merely projects masquerading as a system.
They qualified as functioning delivery systems, though they had not yet become fully resilient national systems. Their continuity remained dependent on decisions, financing, personnel arrangements, and administrative mechanisms that domestic institutions did not fully control.
The services worked, and the capability mattered, but the architecture needed to sustain them through a major shock remained incomplete.
Delivery Is One Requirement of a System
A health system consists of more than a collection of visible activities. The World Health Organization describes health systems as a set of interconnected components, including governance, service delivery, financing, workforce, medical products and technologies, and information systems.4 PEPFAR strengthened many of those components and, in several countries, helped governments expand broader health capacity.5
An externally financed arrangement can still qualify as a system. Governments routinely combine domestic revenue, development assistance, insurance, private investment, and philanthropic support to finance public services. The institutional relationships that convert resources into reliable performance matter more than the source of financing itself.
The more important distinction lies between delivery capacity and continuity capacity.
Delivery capacity allows an institution to produce an outcome under existing conditions, while continuity capacity allows it to preserve essential performance when those conditions change.
A program may have excellent clinicians, accurate data, dependable medicines, effective outreach, and strong treatment outcomes yet remain vulnerable to the loss of a single external sponsor. The system works, but its survival depends on authorities and resources beyond the control of the institution expected to sustain it.
Those accomplishments remain real. The unfinished task is to build continuity into the system itself.
The Crisis Exposed Three Principal Failures
The donor decision failed the continuity test. An abrupt interruption to a lifesaving program is neither an orderly transition nor a responsible institutional withdrawal. A dependency that deepened over twenty years cannot safely be severed by a stop-work order. The speed and administrative disorder of the withdrawal compounded the harm.
A responsible transition would have protected essential services while progressively transferring functions, resources, and decision rights to permanent domestic institutions. It would have treated uninterrupted patient care as a binding design constraint throughout the political review.
Many recipient governments fell short on the ownership test. External priorities carry political risk. Elections, administrations, legislative coalitions, and strategic interests change. Economic crises further narrow what donor governments are willing or able to finance.
Two decades made the possibility of future contraction foreseeable, even if its timing and manner remained uncertain. During that period, recipient governments had opportunities to absorb greater responsibility for health-worker payrolls, procurement, commodities, data systems, laboratory infrastructure, prevention programs, and recurring expenditure.
The scale and pace of absorption would necessarily have varied according to fiscal capacity. Ownership never required an immediate replacement of every donor dollar. It required a deliberate trajectory toward greater domestic control of the functions on which continued performance depended.
The prevailing development model often failed the design test. Donors and governments both had incentives to prioritize measurable service delivery in the present.
Donors could report patients treated, clinics supported, tests conducted, and medicines distributed. Recipient governments could accept services their budgets were unable or unwilling to provide. Implementing partners could satisfy grant requirements by delivering the outputs for which they were contracted.
Institutional transfer offered fewer immediate rewards. It was slower, politically difficult, administratively complex, and harder to capture on a dashboard. Payroll integration, procurement reform, domestic revenue mobilization, civil-service adjustment, and the transfer of decision rights rarely produced the visibility associated with a new clinic or national launch.
The dominant incentives within the prevailing development model rewarded immediately measurable performance more consistently than institutional transfer. Donor incentives were one cause among several, alongside domestic political choices and fiscal constraints.6
The unfinished work was the design of the political, fiscal, and institutional architecture through which lifesaving activity becomes a nationally owned capability.
Six Questions Define Continuity Architecture
Every long-horizon, externally supported service-delivery program should carry a continuity architecture from its first day. That architecture must answer six questions.
1. Authority: Which permanent domestic institution possesses the legal mandate and decision rights required to continue the function? A ministry that participates in a program without controlling its critical decisions does not yet own the capability. Authority must include the ability to allocate resources, direct personnel, enforce standards, and correct failure.
2. Finance: Which recurring financing mix will sustain essential costs as any single external source declines? Sustainable financing may combine national or subnational budgets, insurance arrangements, earmarked revenue, private-sector participation, pooled international support, and other dependable mechanisms.
3. Workforce: Which personnel and payroll system will retain the people who perform the work? Training workers creates little institutional resilience when their employment ends with the grant. A continuity plan must address recruitment authority, compensation, career structures, supervision, professional development, and eventual integration into sustainable employment arrangements.
4. Supply: Which institution will procure, store, and distribute the essential inputs? Medicines and diagnostic materials must move through supply chains capable of functioning after foreign contractors depart. That requires procurement competence, quality control, warehousing, transportation, inventory visibility, and sufficient authority to correct shortages.
5. Performance: Which information and accountability system will detect failure and compel correction? Performance requires data connected to timely decisions, corrective authority, and accountability. The responsible institution must know which indicators matter, receive information in time to act, possess the authority to intervene, and face consequences when persistent failure goes unaddressed.
6. Transition: Which milestones will progressively reduce single-source dependency and govern any planned reduction or withdrawal? A transition strategy requires demonstrated milestones beyond an exit date: personnel absorbed, budgets executed, commodities procured, data systems operated, decisions made, and performance sustained under domestic leadership.
Together, the six questions give sustainability concrete institutional requirements.
Nigeria Is Living Both Sides of the Lesson
Nigeria illustrates the depth of the earlier dependency and the beginning of a forced transition.
Before the 2025 disruption, the United States financed approximately 90 percent of Nigeria’s HIV treatment costs and supported significant portions of the workforce delivering services. The pause in aid worsened access to treatment. In Makurdi, all ten treatment centers reportedly closed for approximately one month. Patients who had previously received six-month supplies of medicine sometimes received only one or two weeks’ worth. Community volunteers subsequently helped reconnect thousands of patients to treatment, and the Nigerian government announced emergency health funding. By the end of 2025, 1.7 million Nigerians were receiving treatment, slightly above the 1.6 million reported in 2024.7
Prevention, however, was hit harder, and testing declined sharply. The number of Nigerians accessing pre-exposure prophylaxis fell from approximately 43,000 in November 2024 to fewer than 6,000 by April 2025. Male-condom distribution fell 55 percent between December 2024 and March 2025, and more than one million fewer people were reportedly tested for HIV in 2025 than in 2024.8
Nigeria has since begun constructing elements of the ownership architecture that the crisis exposed as incomplete. At the June 2026 launch of Nigeria’s National Strategic Plan for the HIV response, NACA described the 2026–2030 framework as a roadmap for a sustainable, integrated, and resilient response and said its launch reaffirmed Nigeria’s commitment to a country-led response. NACA also stressed domestic ownership and coordinated action as conditions for successful implementation, while a panel discussion examined domestic financing, resource mobilization, and private-sector participation. The government has separately committed $346 million in 2026 co-financing across HIV, tuberculosis, and malaria, while a new bilateral health agreement anticipates progressively greater Nigerian financial responsibility.9
Nigeria’s response marks a necessary shift under conditions that make the transition harder and riskier than it needed to be.
Had the transfer begun while the system was stable, institutions could have sequenced reforms, tested new arrangements, protected services, and corrected weaknesses before external support declined. Nigeria is instead building ownership while trying to prevent service failure.
The Missing Design Partner
The six continuity questions also expose a recurring institutional gap.
Donors bring grant administrators and program specialists; governments rely on ministry officials; implementing organizations field technical experts to deliver contracted outputs. Responsibility for the transition itself, however, remains fragmented. No single participant is usually responsible for advancing the whole process from externally supported performance to durable domestic capability.
That gap requires a standing design function—an actor capable of mapping mandates, clarifying decision rights, aligning budgets with responsibilities, sequencing institutional transfer, identifying critical dependencies, setting transition milestones, and ensuring that withdrawal follows demonstrated capability.
In development, that fragmented responsibility is the advisory gap.
Technical and administrative expertise can improve delivery and manage portfolios. They do not necessarily determine whether the capability will remain institutionally owned when funding, leadership, or political conditions change.
The disruption did not affect every country or program uniformly. Nigeria’s partial recovery and the uneven outcomes documented across PEPFAR-supported organizations illustrate that variation.2,7 The variation invites comparison of the institutional arrangements in place and the extent to which they helped some systems absorb the shock more effectively than others.
Ownership Can Include External Finance
Fiscal capacity limits how quickly ownership can deepen. Many low- and middle-income governments cannot absorb the full cost of internationally financed health programs without constraining other essential services. External financing may therefore remain economically necessary for years, especially for cross-border disease control and in states facing narrow tax bases, debt pressure, or acute competing needs.
A continuity architecture cannot assume rapid self-financing. Ownership can deepen even while some financing remains exogenous, provided that authority, responsibility, and the institutional capacities required for continuity become increasingly endogenous to the national system. Deeper ownership also requires progressively diversified financing, institutionalized workforce and supply arrangements, and a transition path calibrated to actual fiscal capacity. Domestic health financing has grown in many PEPFAR-supported countries, providing evidence that greater domestic financial contribution is achievable where fiscal space permits.10 Continuity ultimately depends on whether the government controls the decisions and maintains the trajectory required to preserve essential services as external financing changes.
From Performance to Resilience
PEPFAR’s record and its vulnerability must be read together. Millions of people are alive because the program existed. However, that achievement does not by itself establish that essential services could survive a major withdrawal of external support.
Projects can mobilize resources and organize expertise quickly, but sustained performance depends on institutions able to keep essential services running as funding, leadership, and political conditions change.
Therefore, long-horizon service-delivery programs have two jobs from the beginning—deliver the service while building the institution that will continue to deliver it after the original sponsor has gone.
The first protects people today; the second protects them tomorrow.
- Jennifer Kates, "The Status of President Trump’s Pause of Foreign Aid and Implications for PEPFAR and Other Global Health Programs," KFF, February 3, 2025, accessed August 6, 2026, https://www.kff.org/global-health-policy/the-status-of-president-trumps-pause-of-foreign-aid-and-implications-for-pepfar-and-other-global-health-programs/. The January 20, 2025 executive order imposed a 90-day pause on U.S. foreign development assistance; a limited waiver issued February 1, 2025 resumed urgent lifesaving HIV treatment services. ↩
- amfAR (Andelson Office of Public Policy), in partnership with the Johns Hopkins Bloomberg School of Public Health, Funders Concerned About AIDS, and Data Etc., Findings from the PEPFAR Pulse Study: Measuring the Global Impact of PEPFAR Disruptions (July 2026; date per the study’s public release rather than printed report metadata), https://www.amfar.org/wp-content/uploads/2026/07/PEPFAR-Pulse-Study_2448.pdf. The study surveyed 166 PEPFAR-funded organizations across 46 countries—about 23 percent of country-level implementing partners—and documented 1,714 closed service sites and more than 16,000 terminated full-time positions. It notes that local NGOs were overrepresented among respondents while national governments and international contractors were underrepresented, and that the most severely disrupted organizations may have been least likely to respond, so it characterizes the documented totals as likely understating the overall disruption. ↩
- amfAR, "Taking the Pulse of PEPFAR," July 21, 2026, accessed August 6, 2026, https://www.amfar.org/news/taking-the-pulse-of-pepfar/ (PEPFAR has helped save more than 26 million lives since 2003). ↩
- World Health Organization, Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and Their Measurement Strategies (Geneva: World Health Organization, 2010), 3, https://iris.who.int/handle/10665/258734. ↩
- Institute of Medicine, Committee on the Outcome and Impact Evaluation of Global HIV/AIDS Programs, "Strengthening Health Systems for an Effective HIV/AIDS Response," in Evaluation of PEPFAR (Washington, DC: National Academies Press, 2013), accessed August 6, 2026, https://www.ncbi.nlm.nih.gov/books/NBK207003/. The evaluation documents PEPFAR’s substantial contributions to laboratory capacity, health workforce, supply chains, and information systems in supported countries. ↩
- The incentive dynamics described here—donor pressure to disburse visibly and on schedule over slower institutional strengthening, the resulting "capability trap," and assistance delivered as project-bound technical assistance—are documented in Laurence Chandy, "It’s Complicated: The Challenge of Implementing the Paris Declaration on Aid Effectiveness" (Washington, DC: Brookings Institution, 2011), https://www.brookings.edu/articles/its-complicated-the-challenge-of-implementing-the-paris-declaration-on-aid-effectiveness; Matt Andrews, Lant Pritchett, and Michael Woolcock, "Escaping Capability Traps through Problem-Driven Iterative Adaptation (PDIA)," World Development 51 (November 2013): 234–244, https://doi.org/10.1016/j.worlddev.2013.05.011; and Biniam Bedasso, "Rethinking Technical Assistance: What 900 African Officials Told Us" (Center for Global Development, October 15, 2025), https://www.cgdev.org/blog/rethinking-technical-assistance-what-900-african-officials-told-us. Incomplete ownership also reflects domestic political and fiscal factors; on the political-settlements account of why institutional performance tracks the distribution of power among organized interests, see Mushtaq H. Khan, "Political Settlements and the Analysis of Institutions," African Affairs 117, no. 469 (October 2018): 636–655. These mechanisms are examined at length in Wilson Ugah, "The Advisory Gap: Why African Institutions Need Design Partners" (Winning the Peace, July 22, 2026). ↩
- Ben Ezeamalu and Jennifer Rigby, "With US Aid Slashed, Nigerian HIV Volunteers Went Door-to-Door to Keep Patients Alive," Reuters, March 31, 2026, accessed August 6, 2026, https://www.reuters.com/business/healthcare-pharmaceuticals/with-us-aid-slashed-nigerian-hiv-volunteers-went-doortodoor-keep-patients-alive-2026-03-31/. U.S. support had covered roughly 90 percent of Nigeria’s HIV treatment costs; following the funding pause, all ten treatment centers in Makurdi reportedly closed for approximately one month and medicine-dispensing periods contracted from six months to one or two weeks. The same reporting documents community volunteers, coordinated through the Afrocab network, returning 3,356 people to care in Benue State—including 1,095 children and young people under twenty-four and 95 under five—between June and December 2025; a $200 million emergency health funding package announced by the Nigerian government; and roughly 1.7 million people on treatment by the end of 2025, up slightly from 1.6 million in 2024. ↩
- On pre-exposure prophylaxis, see UNAIDS, AIDS, Crisis and Power to Transform: Global AIDS Update 2025 (July 2025), https://www.unaids.org/sites/default/files/2025-07/2025-global-aids-update-JC3153_en.pdf (PrEP access fell from approximately 43,000 people in November 2024 to fewer than 6,000 by April 2025). On condom distribution, see UNAIDS, Overcoming Disruption, Transforming the AIDS Response (World AIDS Day 2025 report, November 25, 2025), https://www.unaids.org/sites/default/files/2025-11/2025-WAD-report_en.pdf (male-condom distribution in Nigeria fell 55 percent between December 2024 and March 2025). On more than one million fewer HIV tests recorded in 2025, see Ezeamalu and Rigby, "With US Aid Slashed." ↩
- National Agency for the Control of AIDS (NACA), "Building a Sustainable Future: NACA Launches National Strategic Plan 2026–2030," June 15, 2026, accessed August 6, 2026, https://naca.gov.ng/building-a-sustainable-future-naca-launches-national-strategic-plan-2026-2030/. This official NACA account reports the June 11, 2026 launch and describes the strategic direction and implementation priorities presented there; the underlying plan document was not available through the cited page. On the co-financing commitment, see Folasade Akpan, "Nigeria Commits $346m Co-Financing for Health, Unveils Lenacapavir," News Agency of Nigeria, March 25, 2026, reproduced by P.M. News, accessed August 6, 2026, https://pmnewsnigeria.com/2026/03/25/nigeria-commits-346m-co-financing-for-health-unveils-lenacapavir/. The $346 million is co-financing across HIV, tuberculosis, and malaria collectively, announced by Coordinating Minister of Health and Social Welfare Muhammad Ali Pate and directed for inclusion in the 2026 federal budget. On the bilateral arrangement under which Nigeria assumes increasing responsibility, see Ezeamalu and Rigby, "With US Aid Slashed." ↩
- amfAR, The Foundation for AIDS Research, "Domestic Funding Contributions to Health: Comparing Changes in Domestic Financing in PEPFAR and Non-PEPFAR Supported Countries," March 2025, accessed August 6, 2026, https://www.amfar.org/wp-content/uploads/2025/04/IB-World-Bank-Country-Analysis.pdf. Domestic health financing has grown substantially across PEPFAR-supported countries, providing evidence that greater domestic financial contribution is achievable where fiscal capacity allows. ↩
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