A Critical juncture in global health: Leveraging historical institutionalism to examine PEPFAR dependency and inform the development of self-reliant public health systems

The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has played an important role in expanding access to antiretroviral therapy (ART) and significantly reducing HIV/AIDS mortality globally. However, policy shifts in the United States(US) aimed at realigning foreign aid with US national interests have introduced significant uncertainty regarding PEPFAR funding in 2025, threatening to undermine decades of progress in the global HIV/AIDS response. Many countries that have long relied on PEPFAR funding are trapped in a cycle where sustained donor aid has limited their transition to self-reliant, country-led HIV programs. We leverage historical institutionalism to examine how past structures, especially colonial-era institutions, have constrained African nations and limited their capacity for self-determination through the phenomenon of path dependency. Foreign aid, often aligned with the geopolitical and economic interests of donor nations, has further undermined institutional resilience in aid-recipient countries. The recent halt in PEPFAR funding, marks a critical juncture in global health, with the potential to catalyze long-overdue systemic reforms in African health systems. As uncertainty around U.S. foreign aid grows, we anticipate an increase in engagement from private and philanthropic funders. Without corrective action, the persistence of inefficient institutional pathways will continue to undermine the impact of financial investments in many African institutions, jeopardizing the effectiveness and sustainability of initiatives aimed at improving national health outcomes. For sustainable reforms in former colonies, countries must first acknowledge the constraints of colonial legacies, decolonize mindsets and institutions, define their own development priorities, and establish transparent, accountable governance, alongside political stability as fundamental pillars for progress. PEPFAR is the first major global health program to be affected, and it is unlikely to be the last. How much longer will recipient countries remain dependent on donor funding to safeguard the health and lives of their populations?