The US government’s new global health strategy calls for shifting 270,000 frontline health-care workers from US-funded NGO programs to recipient government payrolls. But this could cause an exodus from the profession, undermining the disease-surveillance system and putting American lives at risk.
BOSTON – Last December, while visiting Nairobi for a global health workshop, I met a group of community health workers, the frontline professionals who play a vital role in providing HIV, tuberculosis, and maternal health services across Africa. They talked about navigating informal settlements to reach patients who missed appointments; building trust one conversation at a time; and knowing the ins and outs of their catchment area, including which children are orphaned, which traditional healers collaborate on referrals, and which patients struggle with adherence.
Their expertise was largely developed in programs funded by the President’s Emergency Plan for AIDS Relief (PEPFAR), which US President George W. Bush launched in 2003. By training and supporting community health workers, the program has helped strengthen the continent’s health-care systems. But these workers do more than deliver health care: they also function as an early-warning system for the next pandemic – a crucial role that directly benefits the United States.
But US policymakers seem to have overlooked this, at least judging by the America First Global Health Strategy that the US Department of State released in September. It sets the ambitious goal of achieving the 95-95-95 targets (whereby 95% of HIV-infected people know their status, 95% of those who know are in treatment, and 95% of those being treated are virally suppressed). The strategy also aims to reduce both tuberculosis mortality and malaria mortality by 90% by 2030, and to detect epidemic outbreaks within seven days and mobilize a response within 72 hours of detection.
At the same time, to end the system’s “inefficiencies, waste, and dependency” (a major theme in the current US administration, which has already eliminated billions of dollars in foreign aid), the strategy calls for shifting 270,000 frontline health-care workers from US-funded NGO programs to recipient government payrolls starting in 2027. The problem is that PEPFAR-funded health-care workers typically earn significantly more than their government counterparts, often requiring salary harmonization when transitioning to government employment. In Malawi, nurses with international NGOs that are supported by PEPFAR have long earned a notably higher median salary than nurses with local NGOs. In South Africa, absorbing 24,264 PEPFAR-funded workers would cost the government R2.82 billion ($167 million) – and even that represents only 63% of what PEPFAR currently spends on salaries, illustrating the compensation gap workers face during transition.
When faced with deep salary cuts, workers are likely to flee rural public health for better-paying jobs in urban clinics or other NGOs. This reveals a fundamental tension in the strategy: it seeks to maintain robust disease surveillance while effectively dismantling the workforce responsible for it.
The section on pandemic preparedness, correctly identified as a core national interest, is telling. It touts the US government’s proactive efforts to stop significant outbreaks of Ebola in Uganda and Marburg in Tanzania, celebrating that “zero cases reached American shores.” But there is no discussion of how this system works, particularly its dependence on the health workers now at risk.
PEPFAR infrastructure was essential to the rapid containment of Uganda’s Ebola outbreak in 2022-23: the program’s transport system for HIV samples was repurposed for hemorrhagic fever samples, while local partners leveraged their relationships with clinics to educate more people about infection prevention and control. Likewise, during the COVID-19 pandemic, PEPFAR-supported laboratory sites across Africa performed testing, and community health workers applied their strategies for HIV contact tracing to surveillance of the outbreak.
The 208,800 community health workers who are the PEPFAR program’s eyes and ears are the first to notice unusual disease patterns, report unexplained illness clusters, and relay community signals to national surveillance teams. Lose them and America’s early-warning capacity collapses.
Responding to outbreaks where they originate is cheaper and safer than waiting until they reach America. COVID-19, after all, cost the US economy trillions of dollars and killed more than one million Americans. In view of this, PEPFAR’s annual budget of around $6 billion is hardly excessive; rather, it is a high-return investment in national security.
The US strategy aims to complete bilateral agreements by December 31 and begin implementation by April, giving policymakers a three-month window. But government employment processes typically require two years to navigate budget approvals, create positions, recruit competitive candidates, and set salaries. Uganda’s successful health-worker transition followed a similar timeline. Rushing the handover risks triggering a mass exodus.
The US government has promised to employ dedicated staff members in each country to focus on validating and auditing surveillance data. But without community health workers to conduct contact tracing during disease outbreaks and maintain the community trust required for rapid case identification, there will be no data to process.
To be sure, the strategy identifies a major problem: less than 40% of PEPFAR funding goes to frontline supplies and health-care workers. Reforms are clearly needed. But there is a difference between a thoughtful transition and a rapid dismantling. Continuity of institutional knowledge is crucial, and Congress should require the State Department to set realistic timelines that match administrative realities and develop comprehensive workforce transition plans that include terms for retention bonuses and severance packages. Bilateral agreements should include binding commitments from recipient governments to maintain pandemic-surveillance capacity regardless of domestic political pressures.
Most importantly, policymakers must understand that 270,000 health-care workers are more than a line item; they are the backbone of the disease-surveillance system protecting American lives. The same community health workers testing for HIV today will test for tomorrow’s novel pathogen. The trust they build with marginalized populations now will be essential for vaccine uptake during the next outbreak. Funding the people who help keep Americans safe should not be seen as charity, but rather as spending that serves Americans’ own interest in staying healthy.
