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Coefficient Giving
September 18, 2026

Announcing the Health Aid Transition Fund

By Amanda Glassman and Jeremy Klemin

Aid is falling faster than at any point on record, and many governments in low- and middle-income countries are adjusting to financing and providing the full range of basic health programs themselves. While many governments that rely on foreign aid have long wanted a shift toward greater ownership of their health systems, they now face tough choices and tradeoffs. These countries have a critical window to get this transition right: Decisions made over the next few budget cycles will shape health systems for years to come. 

That’s why Coefficient Giving is launching the Health Aid Transition Fund: a $165 million initiative to help governments navigate the transition. 

We think philanthropy can play an outsized role over the next few years. Some governments are asking for support with technical work: deciding which programs to take on with fewer resources, and ensuring that the money they budget reaches clinics and suppliers. They also need bridge financing to keep critical programs running through the handover — and, in some cases, to unlock aid dollars that would otherwise go unspent. The Fund will build on nearly $18 million in grants made by Coefficient that have already helped governments reduce costs in existing programs and mobilize new funding to cover gaps left by aid cuts.

Earlier this month, Amanda Glassman joined Coefficient Giving to oversee the Health Aid Transition Fund, as well as the Global Aid Policy and Global Growth funds, in her role as Managing Director for Global Health and Development Policy. She has spent her career helping large institutions incorporate cost-effectiveness into their spending decisions, and will work closely with Noemi Schramm Ndao, the Fund’s new Senior Program Officer, to scale up the work and execute the Fund’s strategy. 

Amanda and I talked about the role technical assistance can play in this transition period, how the Fund corresponds with our ongoing work on global aid policy, and why the health systems that countries own and pay for themselves could prove more resilient than what they replace.

(This interview has been edited for style and clarity.)

Tell us about the current aid environment. How is it changing? 

For the past two decades, the U.S. and other external donors paid for the recurrent costs of basic global health programs, especially in HIV/AIDS and malaria, and largely ran them through contractors and NGOs that procured drugs and commodities, operated the supply chains and data systems, and handled other core functions of these programs. 

That arrangement is changing. Total assistance dropped over 20% from 2024 to 2025, with further cuts expected in many wealthy countries. The U.K., for example, is projecting a roughly 50% drop in its bilateral aid to the lowest-income countries. 

Replacing U.S. contributions is a set of agreements between the U.S. and individual countries, laid out in bilateral memorandums of understanding (MOUs). Those MOUs call on countries to co-finance about 40% of health funding on average. Given that most of these programs have historically run with no formal government cost-share at all, it’s a big leap from one budget year to the next. And this is often not the only co-financing ask — governments have concurrent and sometimes overlapping co-financing agreements with various partners. 

Low-income countries, especially in sub-Saharan Africa, rely heavily on external aid. Roughly 6.4% of their GDP came from aid in this space before the cuts started, according to IMF estimates. These economies are resilient, but governments will have to contend with a pretty big expenditure shock.

 

What is the Health Aid Transition Fund, and why is now the right time for it? 

The Health Aid Transition Fund will provide technical assistance — cost analyses, finance strategies, support with moving allocated money out the door — to governments as they absorb steep cuts in aid funding. The idea is to provide support during a critical window (hence “transition”), by funding both practical help and high-level advice as countries transition to directly financing and often providing basic health services. 

 

What role does technical support play, and why is it so vital in an era of rapidly declining aid? 

Much of what the MOUs require is policy work, which technical assistance is well-suited to support. It can provide the people, resources, and research needed to implement reforms, as well as suggest areas for further changes. And many of these countries were already considering reforms before the aid cuts, meant to ensure that public funding for basic, cost-effective health services is spent as planned and reaches those most in need. 

We know that programs like PEPFAR and the President’s Malaria Initiative were effective at saving lives, and country governments might even do a better job at reaching those most in need. Now is a unique opportunity to support countries in building more resilient health systems. 

 

Given that most of these programs have historically run with no formal government cost-share at all, it’s a big leap from one budget year to the next.

Our Global Aid Policy Fund supports efforts to increase and improve international aid from wealthy to developing countries. How do you see the Health Aid Transition Fund fitting with that work?

The work is very complementary. The Global Aid Policy (GAP) team also supports efforts to meet the goals laid out in the MOUs, and broadly shares the goal of delivering on the State Department’s vision of co-funded programs. Both programs share the goal of ensuring that scarce resources help the most people in terms of health and wellbeing. 

GAP also focuses on influencing donors’ decisions, and operates across sectors, not just on health aid. The portfolio supports work to defend cost-effective aid programs funded by high-income countries, improve aid quality, and develop ideas and political consensus around the future of aid. None of these will be a central focus of the HAT Fund.    


The Fund may support some direct service delivery. Why not do more of that, and simply fund the most urgent gaps directly?

The narrow answer is that private philanthropy is not robust enough to fill the gaps left by global health cuts. But more broadly, basic, cost-effective health services belong on public budgets — people living in extreme poverty require public subsidy to access these services, and there are spillover benefits for the entire population when infectious diseases are effectively controlled. Most governments agree with this, but someone else was willing to finance the work. So now we have a new model, basically. Governments will handle this kind of thing themselves. 

It’s not easy to do, of course. There are serious tradeoffs. It takes a lot of effort to reallocate money and services to the highest-value services and the poorest, most in-need people and regions. That’s what the technical assistance would help with: managing trade-offs and helping governments navigate these transitions.

 

Most of this conversation has focused on government budgets, but many people seek care from private hospitals and pharmacies. Where does private care fit in? 

In both rich and poor countries, people with a fever or a cough will often go to a pharmacy before seeing a doctor because it’s faster (and sometimes cheaper). Basic cost-effective services should be publicly financed, especially for people who can’t afford them. But that doesn’t mean governments have to dispense the medicine. If an existing network of private clinics or pharmacies can deliver a malaria test and treatment more cheaply than a clinic formerly run by donors, then that’s a great outcome. 

We’re looking at grants along these lines — to support delivery through existing private and nonprofit networks. We’d be selective about it, but there could be additional savings in not having to build and staff parallel systems.

Aid is volatile. Public spending is much less subject to sudden shocks, because the job of a treasury or finance ministry is to protect that spending from year-to-year swings.

Some leaders, such as Ghana’s and Botswana’s presidents, have framed this as an opportunity. Curious whether you agree with this, or whether that framing feels too optimistic? 

The opportunity is to get these key services onto government budgets, which should have been the case anyway. As we’ve seen, aid is volatile. Public spending is much less subject to sudden shocks, because the job of a treasury or finance ministry is to protect that spending from year-to-year swings. If we can move these high-value services into their routine financing and (where relevant) provision while improving quality and targeting, then it would be a win. So in that sense, it’s an opportunity. 

When my colleagues and I at the Center for Global Development wrote about this potential transition, we were thinking a ten-year timeline might be reasonable. That didn’t happen, but the hope is that something good can come of this. 

 

What are some of your biggest uncertainties around the Fund? What do you think the biggest challenges will be?

Ensuring cross-governmental buy-in, for one. If a country’s ministry of health signs an MOU, it doesn’t necessarily mean that the ministry of finance shares the same goals. It’s important that these ministries work together to move the financing forward. 

The other piece is the efficiency of expenditure. A government doesn’t have to replace aid one-for-one, because there are overhead costs with traditional aid. So the actual cost of providing services is probably much lower for governments, but they’re also less efficient in other ways. Maybe they only spend 75% of what’s allocated, for example, because the treasury releases cash late or in smaller tranches than planned, or because payments to health providers or commodity suppliers are slow. We’ve seen countries take positive steps to make these flows more efficient, and we think those fixes can be replicated elsewhere. 

There are also politics involved. If you can’t increase the overall level of public health spending, you have to reallocate within the budget, which is much easier said than done. Take reallocating from a city hospital to a rural primary healthcare clinic, for example. Even if the rural clinic needs the money more, it still hurts the city hospital to lose that funding. 

And then lastly, it’s worth mentioning that technical assistance has a pretty mixed track record. But given the scale of the aid cuts, I think those earlier efforts can only give us so much signal. Wins from the $18 million in grants we’ve made so far have also been encouraging — they suggest that there’s more we can do here, and that governments are receptive to this kind of support.

What does success look like, both short-term and long-term?

The underlying question is whether there’s actually demand for this assistance, which seems to be the case so far. We’re in service to these governments — it’s their money, and it’s about supporting their agendas. 

The main short-term goal is for countries to successfully meet the MOU conditions: This unlocks the U.S. funds, and keeps alive the larger agreement. Long-term, the main goal is for important services (like malaria and tuberculosis, among others) to be delivered at a high standard and on-budget, and for lives to be saved. Saving lives is the bottom line.