Poetry rhymes

The State Department’s new global health addendums are familiar. Here are four new things to look for anyway.

I love Star Wars. I was a kid in the 1980s and to a kid there’s nothing better than laser swords and spaceships. While talking about the prequel trilogy, George Lucas once said: “It's like poetry, they rhyme. Every stanza kind of rhymes with the last one.”  This quote was mocked heavily at the time. Especially once my generation decided in our 20s that the prequel trilogy was bad, actually.

Yet, the kids that saw the prequel trilogy in the theatre were filled with wonder; they grew up and loved a part of the franchise that didn’t speak to me anymore. And that was…fine.

Last week, we finally saw the future of US-backed bilateral global health assistance as the Department of State released addendums in Nigeria, Uganda, and Malawi. And, as George Lucas would say, they rhyme. There’s a lot familiar here: digital health, supply chain, sustainability, localization, G2G, even health center electrification!

But rhyming is not copying. There are distinct differences between the “original trilogy” and what comes next. Let’s talk about four of them.

Faith- and community-based services

Going back to my work at the beginning of PEPFAR, I have a strong affinity for faith-based community and health services, not because I believe that faith inherently produces better results, but because it’s a natural builder of community and trust. The FBOs that I’ve worked with have been well organized, community grounded, and capable delivery partners. Secular organizations can build community; it’s just an order of magnitude more difficult. Unironically, there’s a similar dynamic with gay rights organizations.

Faith-based services are embedded in the program design in a way that I’ve not seen before, even under the second Bush administration. In Uganda, three of the eight objectives address FBOs, including financial sustainability and institutional capacity. The Nigeria addendum specifically EXCLUDES support to government-run facilities, rather faith-based hospitals and clinics are the delivery mechanism. Malawi's guiding principles name FBO and community stakeholders as priority implementation partners.

This shift represents both opportunities and threats. The APS mechanism, the number of anticipated awards, and the ability to bid on only one objective in all three countries clearly signals that the State Department will issue more and smaller awards, which allows local faith-based and community-based organizations to compete as primes.

While USAID’s procurement architecture historically rewarded large primes with global compliance infrastructure, these addendums reward organizations with embedded community trust, existing service delivery networks, and governance structures capable of absorbing direct financing.  It remains to be seen if the DOS will follow through on this thinking with flexible contract terms and financing, cost-reimbursable mechanisms have always been a challenge for local organizations.

Finally, given their limited staffing on oversight, management, and contracting functions, I don't know if the Department of State can execute and manage the number of anticipated awards under this mechanism.

Transition is the program, not a principle

These awards will be explicitly measured based on the ability of grantees to transition support to non-USG-financed mechanisms by 2030. For example, Nigeria specifies a 25% annual reduction in USG salary support beginning 2027, with full GON absorption by 2030.

That is not something a grantee can control. I've often used the example of the blood bank in Kenya, where USG tried to transition control and financing to the Kenyan government, gave them ample warning, and still the blood bank collapsed when it was transitioned, costing innumerable lives.

And anyway, governments like Nigeria have a more basic set of concerns. One thing I learned from my time working on governance projects: the most important function of a state is to have a monopoly on violence. The Nigerian government certainly does not, especially in the north. In many ways, they are better off spending more money on guns than butter, so good luck convincing them to pay for more nurses.

Until this sort of rapid transition from USG or other donor support happens in real life, and not a budget line here or $80,000 there, I’m skeptical that it’s possible.

The addendums also disqualify interventions that create parallel structures (hint hint HIV implementers). Rather than this being a vague guiding principle, this is a review criterion.  Transition is easier to say than do, but it is, at least, directionally correct to embed more fully in program design than implementers scrambling for sustainability in the last year of a five year award.

The APS rewards innovation

The APS mechanism is not one that we've seen very often in global health. At least not one that I've seen. I've only worked on a few APSs in my career.  In my experience, USAID used them mostly to engage local organizations, to identify new players, and to get applicant-driven design. It signals that the State Department didn't really know what it wanted yet. But…it's also entirely possible they just used the APS mechanism because they didn't have the capacity to issue a bunch of NOFOs.

This provides a new set of benefits and drawbacks. For organizations that have operated at the margins of USG funding, who might understand how USG operates but have had trouble designing programs that specifically address every nook and cranny of a USAID NOFO, this mechanism presents an enormous opportunity to present new and interesting ideas. (This was exactly the premise of the Unlock AID consortium.)

For organizations that are used to a compliance-first mentality, where you must hit every single objective and guiding principle in a five-page concept note via keywords signaling, this is a new way of thinking and operating. That approach should be left in the past.

The goal of your SOI isn’t to win funding, it’s to move onto the next round. You move onto the next round by catching the reviewers' attention while remaining credible. I often say compliance first, then be compelling, but I think that way of thinking is backwards for these addendums. When I've done concept notes in the past, there was always a tension between trying to be comprehensive versus trying to be interesting. And we almost always leaned toward comprehensive. My advice: Be interesting.

The challenge, of course, is that genuinely novel approaches have significant implementation risk, especially over a five-year timeline with a hard transition deadline. SOIs will have to thread that needle by proposing approaches new enough to stand out and proven enough to survive transition by 2030.

AFGHS is the subtext, not the text

Do you notice four words missing from the addendums? "Safer, stronger, more prosperous."

The overviews, executive summaries, and program descriptions are quite technocratic. They talk about outcomes and specific diseases. They talk about government partnerships and MOUs.  They talk about transition and country ownership.

This, I believe, will be a major sticking point.  It's easy to think of these addendums as being business as usual, with more focus on FBOs and transition, based on the objectives and guiding principles. I think that’s a misreading. Remember that these decisions will not be made by career staff. They will be made by political appointees. Winning proposals must highlight America First Global Health Strategies fluently, not just repeat the words. That’s true, despite them not being explicitly named in the addendums.

The upshot

For the most part, this is less money spread across more awards than pre-2025. Nigeria, for example, is getting $200 million, but the Palladium-led IDIQ that it's replacing was $500 million. Some of that gap is in G2G awards. Some of it is just less available funding generally.

These addendums are not built for the big implementers. The barrier to entry is low. The awards will be small. The competition will be significant. Compliance is less important than compelling, at least at the SOI stage.

Rhyming is not copying. While these addenda may look familiar to anyone who's worked in health systems and services, the thinking behind them is not the same. There’s a lot new in here. Business as usual won’t work and the days of spending $200,000 worth of staff time on a five-page concept note are over.

As Admiral Ackbar would say, “It’s a trap!” If we use fresh eyes to review these addendums, rather than leaning too heavily on our vast USAID experience, we may be able to see our way out of the trap.