April 30, 2025

Global health is at a critical juncture: Will we let the moment pass by?

History shows that institutions often change not gradually but through sharp disruptions—critical junctures. These are moments of profound uncertainty and instability, when the usual path is interrupted and a new direction becomes possible—even mandatory. The choices made during such periods by countries, governments, and communities can set trajectories that last for decades.

In January 2025, global health entered such a moment. Stop work orders were issued for PEPFAR-funded activities and other U.S. global health programs across multiple countries, abruptly halting life-saving HIV prevention and treatment services. Some activities have been reinstated in the weeks since, but many have not. A persistent lack of clarity about the future of PEPFAR and the role national systems will play in navigating this uncertainty remains.

This disruption exposed the structural dependencies that continue to shape many health systems, not only financial, but operational and strategic, and often rooted in colonial legacies. It also raised urgent questions for PEPFAR-supported countries: Have national governments begun planning for a future where external support is no longer guaranteed? LMICs must move deliberately toward self-determination and sustainability, rather than awaiting the next external decision.

In a newly published article in PLOS Global Public Health titled “A Critical Juncture in Global Health: Leveraging Historical Institutionalism to Examine PEPFAR Dependency and Inform the Development of Self-Reliant Public Health Systems,” the authors frame the recent disruption not simply as a policy breakdown but as a critical juncture: an opportunity to confront longstanding structural dependencies and reorient global health systems. The authors call for deliberate action by LMIC governments to reduce aid dependency, strengthen national ownership, and build self-reliant public health systems.

This moment must not be met with inertia. The article argues that LMICs must use this rupture to challenge the status quo, disrupt historical path dependencies, and take strategic steps toward institutional transformation. This includes prioritizing domestic leadership, investing in resilient systems, and building policy frameworks that are not donor-contingent.

PEPFAR’s contributions remain significant, but legacy alone cannot chart the path forward. The future of equitable and sustainable HIV responses depends on intentional, nationally driven leadership that reclaims agency and sets new trajectories.

Read more: A Critical juncture in global health.