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In this powerful conversation, Ramona Godbole, former Deputy Director of Policy Planning and Programs at USAID’s Global Health Bureau, takes us inside the chaotic dismantling of America’s global health infrastructure—and the critical memo that became her final act of public service.Ramona led the development of USAID’s first-ever comprehensive global health policy, a document designed to sunset the need for foreign aid by building sustainable, equitable health systems worldwide. Just months after its release in January 2025, she watched as a new administration took a different approach: sunsetting the aid itself, prioritizing rapid withdrawal over long-term impact.What does it mean when the goal shifts from ending disease to ending assistance? When payment systems freeze even for programs labeled “lifesaving”? When the data that tracks millions of lives suddenly goes dark?Ramona shares what she witnessed during those first chaotic weeks, why she wrote the most important memo of her career, and what happened next. She explains the difference between development and humanitarian assistance—and why conflating them has consequences that ripple far beyond foreign policy. And she reveals where critical health data has gone, what the lack of transparency means for accountability, and why this moment sets a precedent that extends well beyond USAID.This isn’t just a story about foreign aid. It’s about what happens when expertise is sidelined, when transparency vanishes, and when documenting the truth becomes an act of moral courage.Below, you can read the USAID Global Health Policy that Ramona and her team developed—the strategic vision that was released in January 2025, just weeks before the agency’s dismantling began.Policy for Global Health Development: Advancing Life Expectancy and Well-BeingTABLE OF CONTENTEXECUTIVE SUMMARYINTRODUCTIONBACKGROUNDVISIONPRINCIPLES* Equitable, Inclusive, and Person-Centered* Evidence-Based and Adaptable* Locally Led Development and Country Ownership* Collaboration and Diverse PartnershipsPOLICY INTO PRACTICE* The Primary Health Care Approach* Strengthen Systems to Deliver Health Services* Enable Resilient and Sustainable Health Ecosystems* Advance Research and Innovation for HealthLEARNINGCONCLUSIONGLOSSARY (OF TERMS USED THROUGHOUT)ANNEX: GLOBAL HEALTH SUB-SECTOR POLICIES, STRATEGIES, AND GUIDING DOCUMENTSEXECUTIVE SUMMARYIn today’s world, the demand for a robust policy to guide USAID’s global health development work has never been more urgent. We are confronted by a landscape where emerging infectious diseases, persistent health disparities, and the sweeping consequences of climate change intersect. The COVID-19 pandemic starkly revealed these vulnerabilities, exposing significant gaps in health systems and access to services worldwide and emphasizing the necessity for a coordinated and strategic response. It underscored how intricately linked our health is to economic, environmental, and social factors, reinforcing the importance of strengthening resilience capacity—not just for the crises we anticipate, but for those we cannot predict.Through decades of USAID work, it has become increasingly clear that global health outcomes are best achieved when we work across technical areas focusing on strategic, coordinated programming and strengthening cross-cutting systems. This policy provides a new and uniting vision to guide all USAID global health development programming and defines new pathways that connect every aspect of our work. This policy institutionalizes a commitment to intentionally work across all of our health programming toward equitably and sustainably advancing life expectancy and well-being.For the first time, this policy lays out the crucial role of primary health care (PHC) in the Agency’s global health development work and how it is essential to achieving this cross-sectoral vision. This comprehensive, community-based approach helps make services supported through USAID global health programs accessible to all, including individuals from marginalized groups. With a PHC approach, health service delivery is based on a model of integrated and coordinated people-centered care, both within health facilities and in the community. Strengthening PHC is key to building health system resiliency for the future and is foundational to pandemic preparedness.This new framing of USAID’s global health development work and operations are guided by four core principles:* Equitable, Inclusive, and Person-Centered: We believe that all individuals deserve access to health services that respect and respond to their unique needs. This means addressing the barriers that prevent equitable, high-quality care; supporting health services that are both accessible and comprehensive; and putting people at the heart of everything that we do.* Evidence-Based and Adaptable: We are committed to using data and evidence both to design our programming and to foster continuous learning and monitoring and evaluation. This approach allows for effective programming and nimble responses to overcome new challenges and seize emerging opportunities.* Locally Led Development and Country Ownership: We recognize that sustainable health outcomes are best achieved when local governments and communities take the lead. By prioritizing local partnerships and emphasizing local ownership, local actors are able to strengthen health systems and services from within.* Collaboration and Diverse Partnerships: We know that no single entity can tackle global health challenges alone. Our commitment to building partnerships across sectors and with a diverse range of stakeholders allows us to harness collective action, share knowledge, and increase our impact.These principles underpin every aspect of USAID’s health development programming across three pathways through which we work to achieve our health goals, all of which are supported by the scaffolding of PHC:* Strengthen Systems to Deliver Health Services: Strengthening health systems and improving service delivery are mutually reinforcing; effective health systems support better service delivery, and high-quality services enhance the performance and sustainability of health systems.* Enable Resilient and Sustainable Health Ecosystems: Health is influenced by myriad factors as part of a broader health ecosystem, encompassing the social, economic, environmental, political, and legal elements affecting health. Building and strengthening health systems, including service delivery, that are resilient and adaptable to shocks and stresses—such as those from economic downturns, natural disasters, or pandemics—requires consideration of this health ecosystem and cross-sectoral work so that they remain sustainable over the long term.* Advance Research and Innovation for Health: Innovation drives progress. We support the development of and incorporation of new technologies, data systems, diagnostic tools, approaches, treatments, and vaccines into our programs. By fostering research partnerships and promoting local innovations, we help scientific advancements benefit all communities, including people in the most vulnerable situations.At USAID, we aim to continue to foster enduring improvements in global health. As we navigate an increasingly complex and evolving global health landscape, we must sustain the gains made while moving forward with an approach that is both adaptive and strategic and incorporates the most recent advances in innovation and research. This policy is not only a response to immediate needs but also an opportunity to build and strengthen systems that are sustainable and resilient to future shocks and stresses, while enabling the delivery of high-quality and equitable health services.Further, global health development does not exist in a vacuum. Our work in health is part of a larger, multisectoral approach that spans education, food security, economic growth, environment, climate, humanitarian response, and democracy and governance. Progress in health leads to better development outcomes; and USAID’s development work, in turn, improves health.Through this policy, we continue our investments in USAID’s flagship global health programs and unite all global health development priorities around our shared vision to partner with communities and countries to equitably and sustainably advance life expectancy and well-being.INTRODUCTIONFrom its earliest days, USAID’s global health development efforts have focused on reducing the glaring gaps in survival between the richest and the poorest and improving global health security. In partnership with countries around the world—and alongside local actors, other U.S. government agencies, and multilateral organizations—USAID has committed to equitably increasing access to high-quality health care.USAID’s work to save and improve lives takes many shapes: delivering lifesaving vaccines and promoting child health and development; increasing access to HIV/AIDS treatment and prevention options; helping individuals and couples exercise their right to decide whether and when to have children and how many children to have; supporting individuals to give birth safely; and working toward control and elimination of malaria, tuberculosis (TB), and many other neglected and emerging infectious diseases. USAID complements these efforts with bolstering local health systems not just to achieve, but to sustain, progress. And, by demonstrating a steadfast commitment to respecting, protecting, and fulfilling the right to health, USAID has committed to improving health outcomes equitably.USAID’s health programming not only addresses immediate health needs but also contributes to the Agency’s broader development, national security, and diplomacy goals—reinforcing U.S. leadership in creating a healthier, safer world. As the world’s largest bilateral donor for health, USAID is uniquely positioned to use a development diplomacy approach to bring together our collective expertise, convening power, influence, and programs to tackle the health challenges of today and tomorrow while simultaneously addressing interconnected development issues.With this Policy for Global Health Development, the first in more than a decade, USAID reaffirms its commitment to a strategic and integrated approach that will drive future progress in advancing life expectancy and well-being across our health development programs. This policy calls for continued strategic investments in USAID’s flagship global health programs, which not only work to achieve specific health outcomes but can also be designed to advance integrated health systems. This policy also strives to align our programming to collectively focus on strengthening a primary health care (PHC) approach, which combines multi-sectoral policy and action, community empowerment, and integrated health services. This person-centered approach focuses on proactive care—health promotion, disease prevention, diagnosis, and treatment—delivered equitably by multidisciplinary teams as close as possible to people’s everyday environments, reducing morbidity and mortality across the lifespan.This policy will build on and support the Agency’s development vision for “progress beyond programs” outlined in USAID’s Policy Framework; which prioritizes reversing the decline in global life expectancy that occurred during the COVID-19 pandemic, bolstering global health security, and improving PHC. The policy also relies on, connects, and amplifies the many existing global health policies and strategies that guide our work within specific health priorities (see Annex) to provide a united vision for optimizing USAID’s significant global health impact.BACKGROUNDSince 1961, USAID has partnered with countries around the world to improve health, mitigate disease, and increase global health security. Over the past five decades, global health outcomes have improved considerably as illustrated by a dramatic reduction in deaths from diarrheal illness; the eradication of smallpox; substantial strides in preventing and treating HIV, TB, and malaria; the development of new tools; and a remarkable increase in global lifespan. Investments in creating an expanded and more capable health workforce, strengthened health systems, and innovations to adapt to new and existing challenges have also been critical in contributing to this unprecedented progress.Moving forward, USAID programs must sustain the gains made and continue to adapt to the evolving global health landscape, which includes new and emerging challenges. The COVID-19 pandemic stalled or reversed decades of public health progress; highlighted financial, structural, cultural, and attitudinal barriers to health; increased gender-based violence; and accelerated information manipulation related to health. Additionally, the rise of noncommunicable diseases, mental health conditions, and antimicrobial resistance further complicates the global health agenda. Increasing crises due to conflict and migration are straining health systems and heightening health threats. Climate change is also threatening progress, including changing the location, timing, and intensity of disease outbreaks; undermining nutrition; and causing heat-related illness and death. Biodiversity loss and environmental degradation further compound global health challenges, including disruptions to food and water security and increased risk of infectious diseases. USAID global health programs increasingly operate in complex environments and will need to continue to navigate the challenges of frequent and protracted emergencies. Further, the rise in democratic backsliding and global threats to human rights have profound implications for health. Many countries face rising sovereign debt and constrained health budgets, food insecurity, climate catastrophes, and other crises, which not only jeopardize health, but also pose a risk to global health security. The effect of these compounding crises is stark: after seven decades of uninterrupted progress, global life expectancy declined in 2020 and again in 2021.Nevertheless, new opportunities are emerging. Many countries in which we work have growing economies, leading to rising incomes and reductions in poverty. This also creates opportunities to increase tax bases and grow health investments. While these populations continue to need support, it is crucial that assistance aligns with evolving contexts, underscoring USAID’s adaptability. The improvement of educational attainment, involvement of the world’s largest generation of young people, and the establishment of formal community health systems present additional opportunities. Further, the digital transformation of health systems—alongside increased digital connectivity and emerging technologies such as artificial intelligence—can increase access to health care services and address health disparities, although potential risks must also be acknowledged and mitigated.In our global health work, there is also the opportunity for better health outcomes to have a pronounced impact on broader development goals (see Fig 1). Countries simply cannot achieve prosperity, peace, and stability if their people are not healthy enough or cannot live long enough to build it. By promoting health equity, access to health services, and robust health systems worldwide, USAID’s global health efforts help to stabilize communities, foster economic growth, and build resilient societies.VISIONThis policy articulates USAID’s vision to partner with communities and countries to equitably and sustainably advance global life expectancy and well-being. Increasing life expectancy by reducing deaths before age 50, and enhancing well-being by contributing to quality of life, are both influenced by access to health care, promotion of health, supportive social structures, and favorable economic and environmental conditions. Within global health development programming we cont…
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