Insight: One System, Not Four

Source note: this piece draws on and paraphrases the U.S. Department of State's “America First Global Health Strategy” (September 2025). Quotations are kept short and attributed; the strategy is a U.S. government publication.

For years, the argument for one integrated health system instead of four separate vertical ones — one for HIV, one for TB, one for malaria, one for polio, each with its own staff, its own supply chain, its own data system — has been a case we made to donors. It was, more often than not, a values argument: fragmentation wastes a nurse's time, confuses patients, and stops governments from seeing their own health system whole.

That argument no longer needs to be made from values alone. The U.S. Department of State's own 2025 global health strategy now states it as settled fact and stated policy.

The strategy is direct about what went wrong. It describes decades of U.S.-funded programs run “in silos, with HIV / AIDS, tuberculosis, malaria, and outbreak response all running as separate programs,” each with its own planning process and its own implementing partners, with little coordination between them. The consequence, in the strategy's own words, was duplication and missed opportunities — and a structure fundamentally mismatched to how health systems actually work, since “country health systems are almost always integrated across diseases.”

The fix the strategy proposes is the one this work has argued for all along: a single community health worker trained and equipped to test for HIV, distribute malaria testing, and refer suspected TB cases, rather than three separate workers funded by three separate budgets. One supply chain instead of four. One data system a ministry can actually see across, instead of four dashboards belonging to four different programs.

What changes because of this

Not the underlying logic — that was always sound. What changes is who else is now saying it, and how it changes the conversation with a donor.

A government or a partner making the case for an integrated health information system used to be asking a funder to accept a philosophy. Now it can point to the funder's own published strategy and ask a narrower, harder-to-refuse question: are we building toward the standard you have already written down, or against it?

That is a meaningfully different negotiation. It also raises the bar. A bilateral agreement, or a technical assistance proposal, that still proposes disease-specific systems running in parallel is no longer just old-fashioned. It is out of step with the funder's own stated position — a position now published, dated, and citable.

The strategy does not resolve every question about how integration should work in a specific country, with its specific disease burden and its specific existing infrastructure. That work is still local, still contextual, still something a government has to decide for itself. But the direction of travel is no longer contested. It is written down.

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