There is an island in the Philippines situated in the Panay Gulf, home to some of the world’s sweetest mangoes and bursting with beauty, from its turquoise blue water to its renowned religious shrines and monasteries.  

It’s called Guimaras.

Soon, we hope it will be known worldwide for another accomplishment: tuberculosis (TB) elimination.

The Philippines faces one of the highest burdens of TB in the world, ranking third in TB cases. But that is not a reality Partners In Health (PIH) and our partners are willing to accept.

Despite being viewed as a romantic illness of artists and poets in the 1800s, TB is anything but beautiful. The disease, caused by Mycobacterium tuberculosis, is an airborne infection that most often attacks the lungs, but can also attack the spine, brain, and kidneys.

TB is the world’s deadliest infectious disease, killing more than 1.23 million people a year—about as many deaths as HIV and malaria combined.

For some patients, the disease causes symptoms ranging from coughing up blood to fevers to unexplained weight loss. Others may appear outwardly healthy, even as X-rays reveal severe damage to their lungs.

It’s been preventable and treatable for decades.

As PIH co-founder Dr. Paul Farmer liked to say, these are “stupid deaths.” There is no reason someone with TB should die. Yet, an estimated 150 million people have died from TB since a cure was discovered—nearly all of them in low- and middle-income countries—and an estimated 43 million people will develop TB between 2023 and 2030, resulting in 6.6 million preventable deaths.

Still, there is reason for optimism. Advances in diagnostics, shorter and more effective treatments, and preventive therapies make elimination possible. We can choose a TB-free future.

The TB-Free Guimaras Island Initiative is just one way we are acting now—together—to make TB a disease of the past. 

Falling in Hate with TB

When bestselling author John Green set out on a trip with PIH to Sierra Leone in 2019, a doctor took him to Lakka Government Hospital located just outside Freetown. There, he met a young man named Henry who had multidrug-resistant TB (MDR-TB).

Green was already a dedicated partner to PIH, having pledged to donate millions of dollars to support the creation of the Maternal Center of Excellence in Sierra Leone alongside his brother, Hank Green, and their spouses, Sarah Urist Green and Katherine Green. He is a staunch advocate for global health, participating in numerous congressional meetings with United States politicians, attending United Nations conferences, and becoming a PIH Board of Trustees member.

And as Green learned about TB and the inequities surrounding it, he began talking about TB publicly: to friends, family, online followers, and eventually in the form of a book titled Everything Is Tuberculosis: The History and Persistence of Our Deadliest Infection.

Green began to “fall in hate” with TB, as he termed it in that book.  

Like Paul Farmer, Green understands these deaths are not inevitable. The tools needed to prevent and treat TB already exist, but structural violence and poverty stand in the way.

Then, in 2023, the U.S. Agency for International Development (USAID), decided to fund a TB-elimination project in the Philippines—where a whopping 7% of all new global TB cases originate.

While the majority of the funding for the project came from USAID and the Government of the Philippines, Green also joined as a private philanthropist. His donation enabled PIH to serve as a technical accompaniment partner to the Guimaras Provincial Government.

Over the past 40 years, PIH has set a higher standard of care for TB and become a trusted advisor to governments and global health agencies, driving bold action to end the disease. PIH has shaped global treatment protocols and has been a leader in research to create shorter and more effective treatments for patients with MDR-TB.

Initially, the idea was to do comprehensive TB elimination across five provinces in the Philippines using the Search, Treat, Prevent approach. PIH is using this methodology in other countries, including Lesotho, where PIH is leading TB research while equipping frontline clinics with innovative case detection tools like AI-assisted portable x-rays, and medications allowing clinicians to search out, treat, and prevent TB more effectively than ever before, even in remote communities without access to a health facility.

PIH knows the Search, Treat, Prevent approach works, and implementing it at full force in partnership with the Government of the Philippines across the country was an exciting and promising idea.

But in January 2025, the Trump administration began dismantling USAID, dealing a devastating blow to global TB programs around the world.

Recommitment Amid Government Turmoil

The Trump administration’s decision to shutter USAID is a heartbreaking setback in the global fight against TB.

It is estimated that this decision could directly result in another 10.7 million people developing TB by 2030, leading to some 2.2 million additional deaths.

Without the massive chunk of funding from USAID, the project could have collapsed.

Instead, the Government of the Philippines, Green, and PIH regrouped around a new plan: the TB-Free Guimaras Island Initiative, focused on proving what TB elimination could look like on a single island.

“We didn't just want to leave our partners in a lurch because USAID left, especially when we had independent funding,” said Dr. Salmaan Keshavjee, the program technical director for the TB-Free Guimaras Island Initiative.

The strategy remained largely the same—just concentrated in one province instead of five.

From there, PIH began designing a program alongside our local health department counterparts centering on PIH’s ambitious Search, Treat, Prevent method. While many governments use the “search, treat, prevent” approach, patients are often missed under each pillar without universal access. PIH’s tenacious take on the historic standard means reaching virtually everyone in a community, no matter how hard they are to reach.

Only about 50% of TB cases show symptoms. That means people may never go to a clinic showing symptoms, unknowingly transmitting TB in their community.  

The first prong, “search,” aims to find these hidden cases—an essential piece of turning off the spigot of transmission.

In Guimaras, mobile chest x-rays will be used in all 98 of Guimaras’s barangays, meaning care will reach across the entire island. In just the last quarter of 2025, over 12,000 Guimaras residents underwent chest x-rays—that’s 6.2% of the population in just three months.

Paired with rapid diagnostic testing, these methods allow for swift diagnoses of TB.

Within seven days of a TB diagnosis, patients in Guimaras are connected to treatment, bringing in the next prong of this method: “treat.”  TB patients in Guimaras are already achieving a 90% treatment success rate.

Finally, the last prong, “prevent” can be the most challenging. This involves finding all contacts of an infected person and evaluating them for TB—whether active or inactive. It also means enrolling direct contacts into TB Preventative Therapy to break transmission chains.

“It’s something that we've been doing and that we know is effective in wealthier countries, but that (people) often don't implement in poorer places, especially rural areas, because it's really, really hard to do,” said Keshavjee. “You're getting to very, very remote communities. You're asking people to take a preventive medication for something they don't necessarily believe in because they don't even know they have it.”

While the Search, Treat, Prevent method may sound straightforward, implementing it at scale requires significant coordination and infrastructure.

For example, effective screening and treatment require an electronic medical record system.

“If you're thinking you're going to screen lots of people, you’ve got to know whether they were screened last week somewhere else, were they not,” said Keshavjee.” Do they have comorbidities? Do they not? You've got to have real-time data.”

That means not only having an electronic medical record system, but reliable internet connectivity to support it.  

“We've been thinking about the details,” Keshavjee said. “There's the Starlinks. The Starlinks have to talk to something—we're trying to figure that out—then you need tablets or some instrument to use in the field. And you need to have X-rays that can then transfer data to that instrument. There's lots of pieces to this puzzle that you have to put into place.”

This technical accompaniment is where PIH comes in. Unlike in some countries where PIH works, accompaniment in the Philippines has not meant rebuilding an entire health system. Instead, PIH has focused on supporting TB elimination strategies and strengthening the infrastructure needed to make them successful.

The end goal, however, remains the same: TB elimination. With this project, we hope to show what is possible when groups come together in the fight against TB—each bringing their own skills, resources, and passion to make TB a disease of the past.

"Despite significant progress over the last twenty years, the Philippines continues to experience a very high burden of tuberculosis,” Green said. “We hope that this project can provide a blueprint for how to eliminate tuberculosis from a community, and that other regions in the Philippines will get the support and funding they need to implement similar projects. We know that through partnership and shared commitment a world without tuberculosis is possible."

As we continue to treat TB around the world, from Lesotho to Peru to Guimaras, we hope to show that a world without TB is possible—not just in wealthy countries, but globally.

“Part of PIH's advocacy has always been that we do these at our own sites and then we show people what's possible,” Keshavjee said.

For weeks, drivers at Abwenzi Pa Za Umoyo (APZU), as Partners In Health (PIH) is known in Malawi, have been desperate.

They have been scouring the country for fuel: the precious resource responsible for making ambulances roar to life, for powering backup generators that keep hospital lights on during outages, and for enabling vehicles to get doctors, nurses and health service providers to the hardest-to-reach patients.

Some drivers have been spending the night at gas stations, hoping they will be there when the rare shipment of petroleum and diesel arrives. They know it could mean the difference between life and death for some patients.

The impact of the United States and Israel’s war with Iran has been felt worldwide since the end of February, with fuel prices soaring globally.

For Malawi, this is an acute-on-chronic crisis. The landlocked country has experienced fuel access issues for years.

Even before the war, fuel prices had already increased by over 40% in an effort to prevent shortages and preserve a limited amount of foreign exchange currency. This was, in part, due to economic reforms tied to international financing agreements, including currency devaluation and the removal of fuel subsidies.  

Malawi, whose economy relies heavily on agriculture, has had a chronic foreign exchange shortage problem, especially following structural adjustment programs. Foreign exchange currency is used to purchase oil and other essential goods—including medications and fertilizers—on the international market. This issue has been exacerbated as the value of tobacco, Malawi’s main export, has dropped.  

Combined with the war, which has spurred “the largest supply disruption in the history of the global oil market,” Malawi is facing an ongoing crisis that is rippling across the health care system.

“It's having a real impact on patients, not just in Neno—across the country,” said APZU Executive Director Basimenye Nhlema.

A Health System Under Strain

Just before the most recent shortage hit, days of electricity blackouts depleted APZU’s fuel reserves at Neno District Hospital.

Still, APZU has continued to keep operations running, even supporting the Ministry of Health in transporting patients 160 kilometers from Neno District Hospital to Queen Elizabeth Central Hospital in Blantyre.

Over the weeks, supplies have continued to fluctuate, and despite drivers working day and night to locate fuel across the country, difficult decisions have had to be made by APZU’s leadership as the crisis persists.  

Youth membership sessions and nursing education sessions scheduled for the month of May were among the first to be canceled in order to preserve fuel for APZU’s emergency clinical services.

But as the shortage has dragged on, the effects have spread far beyond postponed trainings and community programs. Essential health services have increasingly been disrupted, particularly in rural areas where fuel is already harder to access.

At Lisungwi Community Hospital, some surgeries have had to be delayed because there is no fuel to transport specialist doctors between facilities—or to bring patients to the care they need.

Elsewhere, outreach services have also been affected. During the most recent shortage, an outreach clinic in Kambale specializing in maternal and child health had to be canceled entirely, leaving residents without access to antenatal care, childhood immunizations, HIV testing, family planning services, and general clinical care.

Palliative care home visits for noncommunicable diseases were also impacted.  

“Usually it's pain management,” APZU obstetrician and gynecologist Dr. Thokozani Kaliati said of the regular services provided to palliative patients. “For example, if they're bleeding, you help them with medication to stop the bleeding. Also, since palliative care is about mental and psychological support, you would offer that.”

For many patients, these visits are not only routine check-ins; they are a lifeline. Beyond pain management and emotional support, fuel shortages have also disrupted the delivery of medications for patients living with chronic illnesses such as hypertension and diabetes.

When Ambulances Cannot Reach Patients

The situation has grown more dire as the shortage has dragged on, with even essential ambulance services compromised.  

In the recent fuel shortage crisis, there were challenges to transport a baby approximately 70 kilometers from the Lisungwi Community Hospital to the Neno District Hospital, which has the only NICU in the district.  

“The baby had to wait for about 6 hours and 30 minutes for an ambulance, but it didn't come soon enough,” said Kaliati.

For health workers, stories like this have become devastating reminders of how quickly a fuel shortage can turn into a medical emergency.

Despite the country's recent hardship, there are glimmers of hope. The Malawian government sold $30 million worth of gold reserves in April in an attempt to increase fuel access in the country.

At the moment, gas filling stations are sporadically receiving petroleum and diesel, but will often not have both at the same time, which makes planning for health service delivery still problematic, said Nhlema.

Despite all these uncertainties, people have held on to hope that things will get better.

“We don't know how long it will take for this situation to stabilize fully, but we remain resolute in our mission of accompanying patients and the Ministry of Health,” Nhlema said.

Preparing for a More Uncertain Future

Fuel shortages in Malawi are not uncommon, but with a more turbulent global oil market and shortage of foreign exchange currency, they could become more frequent or prolonged.

As health care workers, it is essential to develop systems to prepare for this reality. APZU has spent years building infrastructure to reduce the impact of crises like this, including installing automatic transfer switches to maintain electricity during outages and establishing backup fuel storage.

Still, every shortage carries consequences felt most sharply by patients waiting for care. With your support, we can continue working to find solutions and create backstops to ensure patients can get the high-quality care they deserve. 

Editor's Note: This article was originally published in June 2021 and has been updated to include the most recent data and information.

When we think of health system strengthening at Partners In Health (PIH), we always refer to five key elements: staff, stuff, space, systems, and social support. We call them the “five S’s” and use them to guide our work every day. Each element is equally important in providing high-quality care to our patients across the four continents where we work, responding to emergencies and building and reinforcing strong, long-term health systems, in collaboration with government partners. Each "S” is essential; eliminating just one of them results in a weaker health system.

The following is a definition of each of the 5 S’s, with concrete examples of our work:

1. Staff

With more than 17,200 PIH-supported global staff, we make it a priority to have well-trained, qualified teams in sufficient quantity to respond to needs around the globe. The roles of our staff are diverse and fall into nearly two dozen categories, such as community health, mental health, operations, nursing, program management, development, and communications.

We prioritize hiring staff from the country where they work and are proud to note this is true for 99% of PIH’s clinical staff, programmatic staff, and community health workers.

Meet some of our staff, including a nurse who manages primary care services in Malawi, midwives who deliver community-based care in Peru, and a surgeon who oversees PIH's care delivery around the world.

2. Stuff

The list of “stuff” we need is vast and includes everything from proper and ample vaccinations and medications, such as antibiotics to treat tuberculosis, to IV fluid and oxygen supplies. PIH’s global supply chain team has a list of 6,525 different items staff select to streamline procurement orders, standardize requests from health facilities to warehouses, and align with the different protocols in countries where we work. Because of their efforts, our colleagues have the tools and resources they need for care delivery and administration.

Read more about how PIH tracks resources and shipments.

3. Space

Founded in a single clinic in Haiti, PIH has since expanded to more than 300 facilities globally. In order to treat patients, we need safe, appropriate spaces equipped with electricity and clean water. Sometimes these spaces already exist, but in most cases, facilities need to be renovated or built from the ground up. In collaboration with our partners, PIH creates, expands, and equips spaces so that they meet clinicians’ needs and provide a healing environment for patients.

Some examples of our work include:

• Opening the Maternal Center of Excellence, a state-of-the-art facility in Sierra Leone
• Expanding oxygen production and supported isolation for tuberculosis patients in Lesotho
• Improving water, sanitation, and hygiene facilities in Haiti

• Creating youth-friendly reproductive health centers in Liberia

   

4. Systems

This area of the 5 S’s seems invisible, but is no less important. Many systems must work in harmony to ensure consistent, quality care for patients around the world, including: a leadership and governance structure for solid decision-making, financial and accounting systems to track income and expenses, supply chain management to ensure well-stocked health facilities, medical informatics expertise for nimble record-keeping, and more.   

Here are some examples of essential systems used across PIH-supported countries:

•  An electronic medical record system in Sierra Leone
• A distribution center and software for medical storage in Haiti
• Strong management that uplifts and upholds PIH’s global mission

5. Social Support

To ensure effective care, we provide basic necessities and resources including food, housing, transportation, and financial support for patients and their families. PIH’s social support programming across all sites focuses on treating the whole patient, not just their condition.

Social support has proven an essential part of patient care and made the difference between a patient’s ability to recover from sickness and maintain good health over the long term. This support comes in many forms: healthy food grown in community gardens on the Navajo Nation, travel vouchers for patients on taxing tuberculosis regimens, or safe housing for women living with schizophrenia.

When the Trump administration began dismantling the U.S Agency for International Development (USAID) in January 2025, it set off a chain of reactions globally, including the termination of numerous global health programs tackling malaria, HIV, tuberculosis, and polio. Organizations like PIH rushed to fill in the gaps while global health advocates and experts appealed to members of Congress to restore foreign aid funding.

When these systems of aid that had been developed over decades were destroyed, global health experts around the world knew there would be ripple effects for years to come—from individual patients not receiving lifesaving care to entire supply chains breaking down.

Now, a new Ebola Disease (EBOD) outbreak in central Africa has, as of Wednesday, resulted in more than 600 suspected cases and 139 deaths. It comes from the Bundiugyo strain, one of the least common variants of the disease that has no vaccine.

Dr. Alain Casséus, infectious diseases division chief and principal investigator for the PEPFAR Project for Zanmi Lasante, PIH's sister organization in Haiti, knows this outbreak is uncharted territory. To explain how USAID’s destruction could impact Ebola response in Africa, Dr. Casséus shared his expertise on infectious disease control and supply chain impact in the following piece, originally published on Substack.

⎯ 

The First Outbreak of the Post-USAID Era

On Friday, Africa CDC confirmed what health officials in eastern Congo had been quietly tracking for several weeks: a new Ebola outbreak in Ituri Province. By Saturday morning the count was 336 suspected cases and 87 deaths (Note: at the time of publication on Wednesday, suspected cases have risen to 600 with 139 deaths), with a confirmed cross-border export to Kampala. It is the seventeenth time the Democratic Republic of Congo (DRC) has faced Ebola since the virus was first identified there in 1976. In most respects, the country and the region know this script.

In one critical respect, they don’t.

This is the first major filovirus outbreak since the United States dismantled the foreign assistance architecture that scaffolded every DRC Ebola response since 2014. USAID was officially closed on July 1, 2025. Roughly 80% of its global health awards were terminated, $12.7 billion in committed funding pulled. U.S. assistance to Africa fell to its lowest level in a decade. The Disaster Assistance Response Team model — the operational fulcrum of the 2018-2020 response — no longer exists in the form it did even eighteen months ago. And the cuts did not happen in isolation: the UK, Germany, France, and Canada cut their aid budgets in the same year, the first time in nearly three decades the major donors moved together in that direction.

The outbreak unfolding in Ituri is, in epidemiological terms, already among the most difficult of the past decade: a strain with no licensed vaccine, an urban index case, a mining-town geography, an active conflict overlay, and a late detection window measured in weeks rather than days. Even with a fully functioning international response, this would be a hard outbreak.

It is not getting a fully functioning international response. What it gets instead is the question this piece is built around: what does global health response actually look like when the architecture that carried it for a decade is no longer there?

What’s Happening

The outbreak is centered in Mongwalu and Rwampara, two health zones in Ituri Province, with suspected cases now reported in Bunia, the provincial capital of roughly 800,000 people. The Africa CDC confirmation on May 15 reported 246 suspected cases and 65 deaths; by Saturday morning, those figures had moved to 336 and 87. Of the first twenty samples tested by DRC’s Institut National de Recherche Biomédicale, thirteen returned positive for Ebola... and the strain has been confirmed as Bundibugyo, not Zaire. That single laboratory finding reshapes the entire response.

The suspected index case was a nurse who died at the Evangelical Medical Centre in Bunia after presenting with fever, bleeding, vomiting, and severe weakness. A healthcare worker as the first identified case almost always signals two things: significant prior community transmission that went unrecognized, and nosocomial amplification among other clinical staff and their contacts. Both have likely been running for several weeks. Africa CDC and DRC’s health ministry believe the outbreak began in late April, which means the case count at announcement reflects transmission chains that had been propagating unobserved in two mining towns and the provincial capital.

On May 14, a 59-year-old Congolese man died of the virus in Kampala after travelling from DRC. He had been admitted to Kibuli Muslim Hospital on May 11. Uganda’s Ministry of Health has classified the case as imported and has not yet confirmed local transmission. His body was returned across the border to DRC for burial. This is itself a SIGNIFICANT exposure event, given how Ebola transmits through funeral practices.

The geography compounds the epidemiology. Mongwalu is a mining town with high seasonal and inter-provincial labor mobility, the kind of population that turned earlier outbreaks regional. Rwampara and Bunia are urban centers with dense daily contact patterns. Ituri borders both Uganda and South Sudan, and the affected areas sit close enough to the frontier that cross-border movement is routine rather than exceptional. The Kampala case, the first known export, will not be the last.

Why This One is Different 

Bundibugyo is the youngest of the four ebolaviruses known to infect humans, and one of the least understood. It was first identified in 2007 in the Bundibugyo District of western Uganda, with around 130 cases and 42 deaths. It surfaced once more in 2012, in DRC’s Province Orientale, with under 60 cases and around 30 deaths. Then it disappeared from human populations for fourteen years. This Ituri outbreak is only the third time the strain has been identified in history, and the current case count has already exceeded the two previous outbreaks combined.

The fourteen-year absence matters. Research, vaccine development, and therapeutic platforms have concentrated almost entirely on the Zaire strain, which is the cause of every major Ebola outbreak of the past decade and the strain for which licensed vaccines and monoclonal antibody treatments now exist. There is no licensed vaccine for Bundibugyo. There is no licensed monoclonal antibody. The experimental platforms that had been developed against the strain — including some trivalent constructs that progressed through Phase I trials — were never pushed toward licensure, because there was no market and no recent outbreak to justify the investment. Africa CDC’s principal advisor for program management put it plainly: the long absence of Bundibugyo outbreaks has left the research less advanced than it should be.

This is the operational consequence of that scientific gap: ring vaccination, the strategy that became central to ending the 2018-2020 outbreak in North Kivu and Ituri, is not available here. The entire protective effect of the response now rests on what epidemiologists call non-pharmaceutical interventions: case identification, contact tracing, isolation, infection prevention and control in health facilities, safe burials, and community engagement. These are the same tools that contained Ebola in the 1970s and 1980s, before any vaccine existed. They work. They are also, in a conflict zone, the hardest work in global health.

Ituri is a conflict zone. More than 920,000 people are currently displaced across the province. Fighting between the CRP militia and the Congolese armed forces resumed in late 2025, with the town of Bule, east of Fataki, at the center of repeated clashes. In the first quarter of 2026 alone, more than 100,000 people were newly displaced. The pre-existing health infrastructure that any response would have to lean on has been actively degraded for years: Fataki General Hospital suspended services in March 2025 after threats from armed groups; nearly half the health centers in Drodro health zone have been partially or fully destroyed; a patient was killed in her bed during an armed attack on Drodro’s general hospital in 2024; an MSF convoy was attacked in Bambou in 2024, with activities suspended in two health zones. This is the baseline before adding Ebola.

The late detection compounds everything else. The outbreak began in late April. It was announced on May 15. That is three weeks of uncounted transmission chains in mining towns and a provincial capital, during which contacts moved, returned to villages, attended funerals, and crossed borders. Contact tracing in such a context does not start at zero; it starts in a hole that may be impossible to climb out of. 

What the Response Used to Look Like 

Every major DRC Ebola response of the past decade (from the 2018-2020 Kivu/Ituri outbreak that killed over 2,300 people to the 16th outbreak in Kasai that was contained quickly in September 2025) rested on the same operational architecture. It is worth describing what that architecture actually did, because the public conversation about foreign aid tends to talk about money rather than function.

At the coordination level, USAID ran a Disaster Assistance Response Team. The DART was not a single agency operation as some would think. DART was a standing mechanism that integrated USAID, CDC, the State Department, the Department of Defense, and HHS into a unified response, deployed in-country, working alongside the DRC Ministry of Health and WHO. During the 2018-2020 outbreak, the DART was operational from September 2018 onward. The United States invested over $516 million in that single response, the largest single-country donor. The money mattered. The integration of the agencies behind it mattered more.

At the supply chain level, USAID’s logistics network moved PPE, lab consumables, IPC supplies, ETC construction materials, and pharmaceuticals into hot zones through a system that had been built over decades. Some of it ran through prime contractors like Chemonics, DAI Global, RTI, and Abt Global, several of which derived the majority of their revenue from USAID work. Some of it ran through pre-positioned humanitarian stockpiles. The unglamorous reality of outbreak response is that an ETC needs gloves, gowns, body bags, chlorine, fuel for generators, and reliable transport... every single day and in volumes that can only be sustained by an industrial supply chain. USAID was that supply chain.

At the workforce level, CDC’s DRC country office, established in 2002, had spent two decades building Congolese field epidemiology capacity. The Field Epidemiology Training Program graduated hundreds of Congolese epidemiologists who deployed to outbreaks across the country. INRB, under Jean-Jacques Muyembe, became one of the most capable filovirus diagnostic laboratories in Africa. During the 2025 Kasai outbreak, CDC deployed staff and lab equipment within 24 hours of the announcement, and the outbreak was contained in weeks. That speed was not improvised. It was the product of twenty years of investment in human and laboratory infrastructure.

At the partner level, USAID funded an ecosystem of implementing organizations (International Medical Corps, RTI, Catholic Relief Services, IRC, and dozens of smaller actors) who did the actual work in the actual places: community engagement in displacement camps, IPC training in rural health centers, contact tracing at the household level, safe burial teams in villages. This is the labor-intensive, slow, trust-dependent work that vaccines and monoclonal antibodies do not replace. It was almost entirely subsidized by US funding, even when implemented by international or local NGOs.

This is the system that responded to every prior DRC Ebola outbreak of the modern era. It was not perfect; the 2018-2020 response in particular had serious community trust failures, and the militarization of some response activities in Beni and Butembo produced backlash that cost lives. But it was an architecture. It existed. It could be activated. 

What it Looks Like Now

The Africa CDC Director General, Jean Kaseya, said on Saturday that PPE supply is already a problem. “We don’t have manufacturing for PPE,” he told reporters, adding that his team had flagged the need for funding and was working on the issue. It was the second day of the outbreak being public. In every prior DRC Ebola response of the past decade, PPE for the first responders was not a question someone asked at a press conference on day two. It was already in country.

At the coordination level, there is no DART. As of this writing, no Disaster Assistance Response Team has been deployed, and the operational mechanism that ran the 2018-2020 response no longer exists in the form it did even eighteen months ago. The Office of Foreign Disaster Assistance was absorbed into a smaller State Department humanitarian bureau, with most of its personnel removed. The CDC Acting Director, Jay Bhattacharya, said this week that the CDC country offices in DRC and Uganda were “well-staffed and equipped” and that the agency would “absolutely mobilize there as needed.” That language carries weight. It is also, notably, the language of contingent mobilization rather than active response. In previous outbreaks, the mobilization had already happened by the time the case count was at this level.

Former federal pandemic preparedness officials have been saying for months that what they’re observing is not the playbook. Paul Friedrichs, the former director of the White House Office of Pandemic Preparedness and Response Policy, has listed what the federal government would normally have done by this point in an outbreak of this scale. Namely: a CDC team deployed to put eyes on the ground; State Department patient movement capability readied for transport of an infected American (especially relevant given the presence of American mining companies in eastern Congo); HHS reaching out to the pharmaceutical manufacturers of Ebola countermeasures to confirm supply. None of this appears to have happened. John Lowe, who co-leads the US system of medical facilities equipped to respond to dangerous pathogens, put it plainly: “The conversations are happening. It’s just the level of structure and organization to them don’t appear to be there.”

At the supply chain level, the prime contractor base has collapsed. By January 2026, an estimated 258,000 jobs had been lost across the global development sector. Chemonics disclosed $103 million in outstanding invoices from terminated USAID contracts; DAI Global reported $120 million. Several of the largest contractors derived the majority of their revenue from USAID work, and many have either laid off most of their staff or exited the sector entirely. The logistics infrastructure that moved PPE and ETC supplies into Ituri during the 2018-2020 outbreak does not exist in the same form now, and there is no functional replacement for it.

At the workforce level, the picture is more nuanced. The CDC DRC country office is still operational. INRB is still operational. The Congolese FETP-trained workforce is still in place. This is the inertia of twenty years of investment, and it is real. However, the upstream supports are eroding fast. PEPFAR cuts have shrunk the HIV/TB workforce that historically doubles as the surge labor pool for outbreak response... the same nurse doing HIV testing one week is doing contact tracing the next. The Field Epidemiology Training Program continues, but the partner contractors who supported deployments have collapsed. The capacity that responded to the Kasai outbreak in September 2025 was the product of an architecture that was already being dismantled around it. The Kasai response succeeded on inertia. Unfortunately, Ituri does not have that inertia to draw on.

At the partner level, the ecosystem of implementing organizations has been hollowed out. KFF documented that 80% of 770 USAID global health awards were terminated, with $12.7 billion in funding pulled. Physicians for Human Rights reported that the cuts in DRC specifically left “no time to develop alternative plans to ensure continuity of services.” International Medical Corps withdrew from Nundu Health Zone in South Kivu. Oxfam warned that the health of up to one million people in DRC was at risk from the funding cuts alone. The organizations that would normally surge into Ituri to support a response are, in many cases, no longer in the country, or are operating at a fraction of their prior capacity.

The simultaneous European withdrawal compounds the gap. The UK, Germany, France, and Canada all cut aid budgets in 2025; the first time in nearly three decades the major donors moved together in that direction. The obvious counter-argument to the US cuts has been that other donors would step in. They have not. They could not, even if they wanted to. The math does not work without the US share, which historically accounted for roughly 40% of UN-tracked humanitarian aid globally.

Direct Relief has offered $40 million in medical aid and is monitoring the situation. Africa CDC has activated a 72-hour Incident Action Plan and deployed surge teams to DRC and Uganda. INRB has the strain identified. The Congolese MOH has activated its public health emergency operations center. The response is not nothing. It is, however, structurally different from every response that came before it, and not in a way that helps the patients in Bunia.

What Carries Weight Now

The architecture that the United States built and led for two decades is not the only architecture in the field. A second one has been growing alongside it, and it is the one carrying most of the operational weight on this outbreak.

Africa CDC, established in 2017, is substantially more capable than it was during the 2014-2016 West African Ebola response — when, it is worth remembering, it did not yet exist as a continental coordinating body. Its activation of the regional Incident Management Support Team within 72 hours of the May 15 announcement, the deployment of surge teams to DRC and Uganda, and the convening of a tri-country response across DRC, Uganda, and South Sudan reflect institutional maturity that did not exist a decade ago. Jean Kaseya’s public-facing role this week, including the press conference flagging the PPE shortfall on day two, is itself a sign of a continental health agency willing to speak operationally and publicly about what it needs. It is also, frankly, one major outbreak away from being overwhelmed.

INRB, the DRC’s National Institute of Biomedical Research, is one of the most capable filovirus diagnostic laboratories in Africa. Jean-Jacques Muyembe, who co-discovered Ebola in 1976, runs it. The fact that the Bundibugyo strain was identified within days of the first suspected cases reaching the lab is a function of two decades of accumulated capacity that did not evaporate when its funding sources did. The same is true of the Congolese FETP graduates, the provincial laboratory network, and the MOH’s public health emergency operations infrastructure. This is institutional weight that belongs to DRC, not to any donor.

The MOH itself has now coordinated seventeen Ebola responses. The muscle memory matters. Health Minister Roger Kamba’s response architecture activated within hours of laboratory confirmation. That is what twenty years of repeated outbreaks builds, and it is not something a funding cut can immediately take away.

What this implies for the decade ahead is worth naming plainly. The model that responded to every prior DRC outbreak (Western donor architecture providing the financial, logistical, and coordination layer, while Congolese institutions provided the clinical and epidemiological labor) is gone. What replaces it is a leaner, more Africa-led model, with significantly less margin for error, fewer surge resources, and a greater dependence on private and philanthropic donors who cannot match the scale of what was lost. Primarily African institutions, with constrained support from Western governments and patchwork support from private actors, will manage the outbreaks of the next decade.

Whether that is sufficient is what the Ituri outbreak will tell us.

⎯

Dr. Alain Casséus currently serves as Infectious Diseases Division Chief and Principal Investigator for the PEPFAR Project at Zanmi Lasante, PIH’s sister organization in Haiti. Dr. Casséus has worked with ZL since 2007, with a primary focus on HIV/TB and improving care through research. In his nearly two decades working in Haiti, he has led massive vaccination campaigns, conducted cross-organizational research, and ensured thousands of HIV patients have received care - by his hand and others.

On February 14, 2026, the Paul E. Farmer Maternal Center of Excellence (MCOE) opened its doors to patients in Kono District, Sierra Leone. By the end of that first day, 27 women had been seen and 13 babies had been born. By the end of April, the facility had supported nearly 3,000 women with care and helped deliver more than 900 babies.

None of that happened by accident. It happened because of decades of deliberate work, and because every single one of what Partners In Health calls the "five S's" was in place.

When PIH thinks about building a strong health system, we return again and again to five essential elements: staff, stuff, space, systems, and social support. Each one is necessary. Remove any single element, and the whole structure weakens. Together, they don't just create a hospital—they create the conditions for people to get better.

The MCOE is, in many ways, the fullest expression of the five S's we have ever built. This series tells that story, one S at a time.

Staff: The People Who Make It All Possible

A building is only as strong as the people inside it. That's a lesson Francess Kamara, a senior midwife mentor at PIH-supported Koidu Government Hospital (KGH), knows well. When she started working in Kono, there were fewer than ten midwives to serve a district of hundreds of thousands. As PIH's reputation grew and more women came seeking care, the pressure on that small team became enormous. Something had to change.

Building the MCOE meant building the workforce to match it. In the months before opening, training intensified—staff ran simulations, practiced on new equipment, and worked through scenario-based exercises. On opening day, the MCOE welcomed approximately 200 clinical staff. That number will keep growing as the facility expands its phased opening.

"The building is beautiful, the systems and equipment are first class," Kamara says, "but none of that matters without the medical professionals to run it."
A dedicated training center and dormitory, a short drive from the MCOE, is now under construction. Lecture halls and simulation labs will ensure the next generation of Sierra Leonean clinicians is ready.

Read the full article on Staff

Stuff: The Tools That Make Treatment Possible

When 17-year-old Fanta Jimmy arrived at the MCOE on opening day with pre-eclampsia and a baby in distress, what saved her life wasn't just the skill of the clinical team. It was the ultrasound machine that confirmed the diagnosis. It was the IV fluids and the vital monitors. It was the neonatal transport incubator that carried her premature daughter to the NICU.

For years, clinicians in Kono had the training but not the tools. Midwife Boyama Gladys Katingor remembers the helplessness of knowing what a patient needed but not having access to the right equipment to provide it. During the 2014 Ebola epidemic, the gap became lethal—clinicians worked without adequate protective equipment while pregnant women labored with minimal clinical support.

The MCOE changed that equation. Today, it is the first facility outside Freetown to deliver piped oxygen and medical gas directly to patient beds. It houses Sierra Leone's first neonatal intensive care unit, with 39 NICU beds equipped with incubators and specialized monitoring systems. The "stuff" present at the MCOE isn't unusual in high-income countries—but in Sierra Leone, it is unprecedented.

The stuff article closes with a critical reminder: equipment alone isn't enough. The monitors, scanners, and oxygen systems matter because they are placed in the hands of people trained to use them well.

Read the full article on Stuff

Space: Where Healing Happens

Dr. Paul Farmer used to say you can deliver bad care in good facilities, but you cannot deliver good care in bad ones. The old maternity ward at KGH proved his point. It had 48 beds. Women in labor shared rooms with mothers recovering with newborns and patients arriving with unrelated emergencies. There was no dedicated triage area. The structure was, in Lascher's words, "designed for scarcity."

The MCOE replaced that with something radically different. Four buildings. 120 inpatient beds. Three operating theaters. A dedicated triage area. An isolation room on every ward—a lesson learned from Ebola. A dormitory for mothers with babies in the NICU so women don't have to choose between their infant's bedside and a place to sleep.

What's more, the MCOE was built in large part by women from Kono District itself, most of whom had never worked in construction before. At the peak of construction, women made up 65% of the workforce. Construction worker Diana "Success" Komba put it simply: "I see beauty. I see care in every detail. And I know that when a mother walks in, she will feel that too. She will know that she matters."

Natural light, ventilation, green courtyards planted with trees donated by community members—all of it was intentional. Farmer believed beautiful spaces help people heal. The MCOE was built on that belief.

Read the full article on Space

Systems: The Invisible Infrastructure That Saves Lives

Of the five S's, systems are the hardest to photograph and the easiest to underestimate. But when systems fail, people lose their lives.

The MCOE was designed around this truth. When a woman develops complications at a rural clinic in Kono District, a clinic staff member calls the National Emergency Medical Services (NEMS) toll-free number. An ambulance is dispatched—carrying oxygen, a paramedic, and pre-hospital care capacity. The patient arrives at the MCOE, is registered, and her record is entered into the electronic medical record system. She moves through triage, is assessed, and the clinical team determines the next step. Every link in that chain has to hold.

Former PIH Sierra Leone executive director Jonathan Lascher remembers what it looked like when the links broke. In 2014, one ambulance served 500,000 people. Rapid test results took days. Women arrived too late. "Reducing maternal mortality requires long-term commitment across multiple systems," Lascher says. "I knew PIH could not do everything, nor could we do anything alone."

Today, the MCOE has dedicated triage, electronic records, reliable backup power, and a functioning referral network across all 14 chiefdoms of Kono District. Biomedical engineer Henry Amoakwa sums up the stakes plainly: "Hospitals run all day, every day. There cannot be a gap or a breakdown otherwise lives are at risk."

Read the full article on Systems

Social Support: Closing the Distance Between Home and Hospital

Even the best hospital in the world can't save a woman who can't reach it. In Kono District, many women live hours from KGH over difficult roads. Getting there requires money for transportation, often accommodation, and someone to accompany them. For women with high-risk pregnancies, the distance isn't just inconvenient—it can be fatal.

PIH's answer is social support: the practical assistance that helps patients reach care and recover once they leave. At the MCOE, that starts before delivery. Women assessed as high-risk can stay at the birth waiting home at PIH-supported Wellbody Clinic, where they receive housing, meals, and around-the-clock monitoring until they're ready to give birth. Finda Lahai, a 23-year-old referred from five hours away, was hesitant at first. After delivering a healthy baby by C-section at the MCOE, she described the experience: "I feel like I am being checked up 24 hours a day. I feel really cared for."

After delivery, vulnerable women may receive discharge packages with food staples. Across the district, hundreds of community health workers and traditional birth attendants accompany patients to facilities, answer questions, and reduce stigma. All admitted patients now receive three free meals a day through an inpatient feeding program. 

The result is measurable. Deliveries at KGH increased by 69% from 2020 to 2025. More women are reaching facilities earlier. Trust in the health system is growing. "All of our community team members are our trusted messengers," says Kumba Tekuyama, PIH Sierra Leone's community-based programs manager in Kono. "The hope here has spread by word of mouth."

Read the full article on Social Support

What it Takes to Reduce Maternal Mortality

Sierra Leone has reduced its maternal mortality rate by 78% since 2000. The MCOE represents the next chapter of that effort, and a proof of concept for what's possible when no element of care is left behind.

No single S is enough on its own. Skilled staff without equipment cannot act. Equipment without trained people to use it sits idle. A world-class facility with no referral system leaves women stranded at home. The best systems in the world mean nothing if a woman can't afford the bus fare to the hospital.

What the MCOE represents is the belief that everyone deserves all five—and that when communities, governments, and global health partners build together, it is possible.

"What we have done here can be replicated," Tekuyama says.

That is the promise of the five S's.

The opening of the Paul E. Farmer Maternal Center of Excellence (MCOE) marks a major step forward for maternal and neonatal care in Sierra Leone, a country long challenged by high maternal mortality rates. Built through years of partnership, the MCOE aims to ensure every mother and baby receives safe, high-quality, dignified care.

In this webinar, advocates John and Hank Green joined Director of Nursing and Midwifery Isata Dumbuya and nurse-midwife Patricia Efe Azikiwe to share insights on compassionate, patient-centered care, highlighting progress made and the ongoing effort needed to reduce maternal mortality in Sierra Leone.

As the weather warms up in the Northern Hemisphere, school breaks begin, and vacations are on the horizon, there usually come more opportunities for reading by the water, listening to podcasts on a walk, and cozying up with a show after a long day. To help build your To Be Read list, Partners In Health (PIH) staff members share books, a TV series, a podcast, and a documentary they are loving right now. 

Editor's Note: The Paul E. Farmer Maternal Center of Excellence (MCOE), a Partners In Health (PIH)-supported facility, opened to patients in February 2026 on the campus of Koidu Government Hospital (KGH) in Kono District, Sierra Leone.

Built in partnership with Build Health International and the Sierra Leone Ministry of Health, the state-of-the-art facility was designed to confront one of the most urgent challenges in Sierra Leone: preventable maternal death. It represents years of deliberate work to strengthen care where it has long been weakest, part of a two-decade effort across Sierra Leone that has reduced the country’s maternal mortality rate by 78% since 2000.

This series explores the MCOE through what PIH calls the "five S's": staff, stuff, space, systems, and social support, the essential elements of a strong health care system. In this article, we focus on social support: the basic necessities and resources, such as food and transportation, needed to ensure effective care. 

Long before the MCOE opened, many women in Kono District faced pregnancy and childbirth with limited support and major barriers between home and the hospital, explains Kumba Tekuyama, PIH Sierra Leone’s community-based programs manager in Kono.

But access to quality care is only useful if it can be reached in time.

A woman in a remote community may spend hours traveling over poor roads before arriving at a facility equipped to manage complications safely. Some walk part of the journey before climbing onto motorbikes or crowded public transportation. Seeking medical care can also require money for transportation, accommodation, or food—resources many families do not readily have.

Addressing these barriers is what PIH calls social support, the practical assistance beyond medical care that helps patients reach treatment and recover with greater stability afterward.

At the MCOE, that support often begins before delivery and continues long after discharge.

Birth Waiting Homes

Finda Lahai, a 23-year-old pregnant mother of two, attended prenatal appointments at her local clinic in Kenema—a five-hour drive, at minimum, from KGH. Staff there referred her to KGH due to complications during her prior pregnancy.  

At KGH, staff advised Lahai to stay in the birth waiting home, which opened in 2017 at nearby PIH-supported Wellbody Clinic. This 12-bed facility provides housing, meals, and around-the clock care for women with high-risk pregnancies. Some women stay for weeks before delivery; others remain for months.

Lahai was initially hesitant about going to the birth waiting home. Leaving home and her family for an unfamiliar facility was daunting. But as she reflected on the complications during her previous delivery, she decided it was the safest option for both her and her baby.

“I feel like I am being checked up 24 hours a day. We are being monitored constantly,” Lahai said during her time at the birthing waiting home. “The nurses sometimes come up to just chat and talk. I feel really cared for.”  

For women living far from advanced maternal care or facing high-risk pregnancies, like Lahai, that proximity and daily monitoring can be lifesaving.

On Feb. 22, Lahai delivered a healthy baby via C-section at the MCOE.

Community Support Networks

Through a wide network of hundreds of community health workers (CHWs) and traditional birth attendants (TBAs), even more women and families have access to care and social support.  

CHWs and TBAs often accompany patients from their homes directly to health facilities, navigating the health system and reducing stigma for those seeking care.  

This is all in service of PIH’s community-based model, which recognizes a simple reality: transportation, food, shelter, and other forms of material assistance often determine whether a vulnerable pregnant woman seeks care at all.

“TBAs, CHWs, chiefdom representatives, and local stakeholders meet every month,” says Tekuyama. “People know we are doing the work, that we keep our promises, and that we care about their voices.”

These trusted relationships and networks existed before the MCOE was built. Tekuyama has supported communities in Kono for more than a decade, including through the Ebola epidemic and COVID-19 pandemic. During both crises, the social realities affecting patients remained impossible to ignore.  

“If you are asking people to quarantine, you must be able to provide their basic needs. We experienced this during Ebola; people were not staying in quarantine because they needed to go out for food,” Tekuyama said in 2020. “So, we developed a strategy for supporting affected patients and families; clinicians would refer quarantining families to us, and we would make sure there was food at home.”

Meeting Needs Beyond Direct Medical Care

Food support remains a key aspect of social support. At the MCOE, admitted patients now receive three free meals a day through a recently launched inpatient feeding program across KGH’s entire campus. Before the initiative, many patients relied on relatives to bring food from home. Others went without meals entirely while receiving treatment. This new program helps patients stay nourished during recovery while easing financial pressure on families already navigating a medical crisis.

Pregnant women assessed as vulnerable may also receive food assistance and a discharge package after delivery. These packages often include staples such as rice, palm oil, benny (sesame seeds), and kenda (fermented locust bean).

These forms of support can make the difference between someone seeking care early and arriving too late. They also shape how people understand and trust the health system.

“All of our community team members are our trusted messengers, and the hope here has spread by word of mouth,” Tekuyama says.

Through repeated engagement, communities begin to see that care is both available and accessible.  

PIH has trained TBAs and CHWs on MCOE services so they can answer frequently asked questions accurately: what services are available, what remains free, and where women should go for care.  

The message is reinforced through household visits, community meetings, and refresher trainings with local leaders. The goal, Tekuyama says, is to ensure trusted people in the community are sharing accurate information before fear or rumor fills the gap.    

Building Trust in Care

“You cannot achieve anything without inclusiveness,” Tekuyama says. “Engaging with communities to communicate your mission and then [working] together to achieve it.”

Still, trust is not built only through messaging. It grows through consistency and follow-through. As these networks strengthen, changes are becoming visible across Kono District. More women are choosing to deliver at health facilities. The number of women delivering at KGH increased by 69% from 2020 to 2025, while sharp increases were also observed in facility-based deliveries, C-sections, and antenatal care visits across PIH-supported sites as maternal access efforts expanded.

The shifts may be gradual, but they are significant. More women are reaching facilities earlier instead of delivering at home or arriving too late for treatment. Trust in the health system is growing alongside access to care.

“There are communities all over that are struggling with tuberculosis, HIV, and even malaria, in addition to maternal health,” Tekuyama says. “What we have done here can be replicated.”

For PIH and its partners, the goal extends far beyond providing care within the hospital walls.  

The MCOE may provide advanced maternal care, but social support is what helps women reach its doors in time. It closes the dangerous distance between home and the hospital. And most importantly, it ensures women are never left to navigate high-risk pregnancy, childbirth, or recovery alone. 

Editor's Note: The Paul E. Farmer Maternal Center of Excellence (MCOE), a Partners In Health (PIH)-supported facility, opened to patients in February 2026 on the campus of Koidu Government Hospital (KGH) in Kono District, Sierra Leone.

Built in partnership with Build Health International and the Sierra Leone Ministry of Health, the state-of-the-art facility was designed to confront one of the most urgent challenges in Sierra Leone: preventable maternal death. It represents years of deliberate work to strengthen care where it has long been weakest, part of a two-decade effort across Sierra Leone that has reduced the country’s maternal mortality rate by 78% since 2000.

This series explores the MCOE through what PIH calls the "five S's": staff, stuff, space, systems, and social support, the essential elements of a strong health care system. In this article, we focus on systems: the processes and leadership structures that link facilities, teams, and resources so that care can be delivered without delay.

Since opening its doors to patients on Feb. 14, 2026, the MCOE has supported over 2,900 women with care. They came from every district in Sierra Leone and from neighboring Guinea through multiple pathways: referrals from rural clinics, ambulance transfers, and antenatal appointments.  

What connects those experiences is not any single action. It is the system that allows care to move across distance and through critical moments where every minute matters.  

When referrals fail, transport is delayed, or triage systems break down, maternal deaths become more likely. The MCOE in Kono District was designed to strengthen these connected systems, so that health complications can be identified earlier and treatment delivered in time.

Why Maternal Mortality is a Systems Problem

The importance of these systems became starkly visible in 2014, when PIH began working in West Africa.

“It was the height of the 2014 Ebola outbreak,” recalls Jonathan Lascher, former executive director of PIH Sierra Leone from 2017 to 2021. “The obstetric complications routinely managed in well-resourced hospitals were the very ones killing women in Sierra Leone.

“Rapid Ebola tests would have allowed us to triage pregnant women,” Lascher says, referring to the easy-to-use tests to diagnose various diseases within minutes. “But in the fall of 2014, test results took days. Electricity was unreliable, water scarce, and pharmacy shelves sat empty.”

The problems extended beyond testing. “One ambulance served 500,000 people,” Lascher recalls. Transport delays often meant women arrived too late for clinicians to intervene.

“Women were dying because the district’s health infrastructure, even after years of improvements, was still insufficient,” Lascher explains. “Too few ambulances meant women in remote villages who made it to rural clinics were unable to reach emergency care in time. High-risk pregnancies arrived too late to be saved. Reducing maternal mortality requires long-term commitment across multiple systems. I knew PIH could not do everything, nor could we do anything alone.”

Triage and Patient Flow

Systems are not abstract; they determine whether a mother’s condition is recognized and referred in time or whether she can reach care at all.  

In Kono, that process often begins at a smaller local clinic, where pregnant women are expected to attend prenatal appointments and be assessed over time. But if warning signs or complications emerge beyond what the local facility can safely manage, staff call the National Emergency Medical Services (NEMS) toll-free number to request an ambulance to the MCOE.

When the MCOE opened in February to patients, the first ambulance soon arrived carrying Sia Jimissa, a 33-year-old pregnant mother of three. Throughout her pregnancy, Jimissa had attended prenatal appointments at her local clinic. But after several hours of labor throughout the morning, staff at her clinic identified complications beyond what they could safely manage.  

They decided to escalate Jimissa’s care, setting multiple parts of the maternal referral network in motion. The clinic contacted NEMS to transfer Jimissa by ambulance approximately two hours to the MCOE.  

“When a complication is identified, they call our numbers,” says Joyce Senesie, regional operations coordinator for NEMS.  

NEMS operates in every district in Sierra Leone. In Kono alone, NEMS supports 111 facilities across all 14 chiefdoms. Ambulances are strategically positioned to cover the widespread district as efficiently as possible.  

Once the call is received, the nearest ambulance is dispatched.  

“An ambulance is not just an ambulance,” says Senesie. “We have medical equipment, including oxygen. We have the driver and the paramedic, and while the patient is in the ambulance, we provide pre-hospital care to sustain her life before she reaches the MCOE.”

By the time Jimissa arrived at the MCOE later that afternoon, she had already moved through multiple layers of care: from community-based prenatal services to emergency referral, ambulance transport, and pre-hospital stabilization along the way.

Inside the MCOE

When a patient ultimately reaches the MCOE, the process begins with registration and an initial clinical assessment. If it is her first visit, she is registered, given an ID, and entered into the electronic medical record system. From there, staff begin evaluating the case based on why a patient has come and how she presents.  

At the MCOE, the triage area has become the point where those uncertainties are resolved. Some women require outpatient review. Others need admission to the antenatal or labor ward. Women in critical condition, or whose babies show signs of distress, are moved quickly toward surgery or other urgent care.  

For patients like Jimissa, that sorting process is critical. The sooner clinicians understand what kind of care is needed, the sooner treatment can begin.  

Before the MCOE, in the prior maternity ward at KGH, that distinction was often impossible. There was no dedicated outpatient triage space to assess women before sending them onward; patients who appeared distressed were often moved directly into labor and delivery, even when they were not yet at that birthing stage.  

The previous labor ward had four beds, while three additional observation beds also served as a post-delivery space. Women in labor often shared that setting with mothers recovering alongside newborns, as well as patients arriving with unrelated emergencies.

Now, with the introduction of a dedicated triage system at the MCOE, that flow has changed. Patients are assessed and stabilized before even entering the ward. Once registration staff have entered a patient into the system, clinicians can immediately see who is waiting and review cases sooner.  

And when multiple emergencies arrive at once, clinical teams must prioritize rapidly. Decisions are made based first on the mother’s condition and then on the level of risk to the baby—cases such as severe preeclampsia, postpartum hemorrhage, fetal distress, or near-immediate delivery demand fast coordination.  

After completing a thorough assessment, the triage team determined that Jimissa had prolonged labor and her baby was in distress. She was moved swiftly to an operating theater—one of three at the MCOE—where she underwent an emergency C-section with no complications and delivered a healthy baby boy.

Keeping the System Running

For clinicians to respond quickly when medical complications occur, such as those faced by Jimissa, the MCOE’s electricity, laboratory services, oxygen supply, and the communication infrastructure supporting the entire system must function continuously.  

“Hospitals run all day, every day,” says Henry Amoakwa, a biomedical engineer supporting the MCOE. “There cannot be a gap or a breakdown otherwise lives are at risk.”

When one systematic link fails, the consequences travel quickly. When those links function together, patients reach care sooner, and clinicians gain time to respond.  

For women like Jimissa, those connections can mean the difference between arriving too late and arriving on time; it can mean survival.

Editor's Note: The Paul E. Farmer Maternal Center of Excellence (MCOE), a Partners In Health (PIH)-supported facility, opened to patients in February 2026 on the campus of Koidu Government Hospital (KGH) in Kono District, Sierra Leone.

Built in partnership with Build Health International and the Sierra Leone Ministry of Health, the state-of-the-art facility was designed to confront one of the most urgent challenges in Sierra Leone: preventable maternal death. It represents years of deliberate work to strengthen care where it has long been weakest, part of a two-decade effort across Sierra Leone that has reduced the country’s maternal mortality rate by 78% since 2000.

This series explores the MCOE through what PIH calls the "five S's": staff, stuff, space, systems, and social support, the essential elements of a strong health care system. In this article, we focus on space: the physical environment where care takes place, and how it shapes what providers can do and what patients experience.

More than 30 years ago, Dr. Paul Farmer and co-founders started PIH in a single clinic in rural Haiti.

From there, PIH expanded across Haiti, then to Peru, across Africa, and to the Navajo Nation—supporting more than 270 facilities globally. Throughout, patients have remained at the center of PIH’s work.

In some communities, spaces for patients already existed, but in most cases, facilities needed to be renovated or built from the ground up, like the MCOE in Sierra Leone.

“Paul used to say you can deliver bad care in good facilities, but you cannot deliver good care in bad ones,” says Jonathan Lascher, former executive director of PIH Sierra Leone from 2017 to 2021. “Zanmi Lasante’s [PIH’s sister organization in Haiti] strategy lifted care for everyone. Our Haitian colleagues called this approach their chwal batay or their ‘battle horse.’ The MCOE is PIH Sierra Leone’s chwal batay.”

The MCOE was built because the former maternity ward at PIH-supported KGH had, for years, proven Farmer’s point and limited the care that clinicians were trained to give.

“The maternity ward, which was built with donor funds that had long since dried up, had never been equipped to serve Kono District,” says Lascher. “The structure was crumbling. It was a ward designed for scarcity.”

The inadequate space shaped the care clinicians could provide. Overcrowded rooms and aging infrastructure made it difficult to manage the growing number of patients arriving at the hospital. KGH’s maternity ward and special care baby unit had just 48 beds.

This meant that women in labor, women recovering with their babies, and patients arriving with other emergencies were often managed within the same rooms. And for many families traveling long distances, there was little room not only for care, but for staying close by during it.

Designing the MCOE for Women, by Women

In a setting affected by resource constraints and histories of exploitation, a patient’s experience of care within a hospital impacts not only health outcomes, but trust.

PIH and the Sierra Leone Ministry of Health broke ground on the MCOE in April 2021. From a floor plan mapped around a patient’s journey to landscaped outdoor spaces that foster comfort and safety for patients and their families, it sets a new bar for maternal and neonatal care in Sierra Leone.

What’s more, before it could become a place for women to receive care, it was a place built by them. Diana “Success” Komba, a construction worker who helped build the MCOE, says the project carried enormous significance for the women involved.

“When we first heard about the Maternal Center of Excellence, many of us wondered: would this really be for us? Would it reflect our hopes, our needs, our pride?” says Komba. “Today, I can say with full heart: yes, it does.”

At the peak of construction, women made up 65% of the workforce and were trained on-site as laborers, quality assurance managers, and construction supervisors. Most had never worked in construction before, and as the building took form, so did a sense of ownership and pride.

“Many of us want to come and have our babies here in the future,” Komba says. “Every wall, every corridor, every detail in the MCOE carries that legacy. To give birth in a place we built with our bodies and our hearts is incredible to think about.”

Inside the MCOE: Design as Dignity

Composed of four buildings, the MCOE has three operating theaters and the first and only neonatal intensive care unit (NICU) in Sierra Leone. It is also the first facility outside Freetown to deliver piped oxygen and medical gas directly to patient beds. Outpatient services are located near the entrance, while the birthing center sits within its own cluster, all with heating, ventilation, and air conditioning systems for infection control and comfort.

The facility expands KGH’s 48 beds to 120 beds, including 39 in the NICU. From the triage area to the birthing center and in-patient wards, it replaces the constraints of KGH’s ward with a radically larger and more sophisticated physical environment capable of supporting modern maternal and newborn care.

The layout is organized around medical urgency—including the severity and complexity of a case—and  “clarity of circulation,” meaning a seamless and efficient flow of people through the facility.

A dedicated triage area gives clinicians space to assess women before directing them onward; the old maternity ward had no such separation.

Every design choice prioritizes privacy. In the birthing center, half-height walls and closable curtains offer separation, while each ward includes an isolation room with its own toilet and dual access—a lesson shaped in part by Sierra Leone’s Ebola epidemic in 2014.

Large, open-air covered waiting areas allow families to gather comfortably while maintaining a clear view of check-in stations. And critical infrastructure—including clean water systems, upgraded laundry and waste management, backup generators, and voltage regulators—support safe and uninterrupted care.

The Mother’s Dormitory and NICU Proximity

For families of critically ill newborns, the design goes further.

Because many women travel long distances to reach KGH, and babies may remain in intensive care for weeks or sometimes months, the MCOE includes a dormitory for mothers with babies in the NICU.

For patients like 19-year-old Phebian Baningo, that distance couldn't be closer. After a complicated and unplanned at-home birth in Feb. 2026, Baningo arrived at the MCOE, where she stayed in the mother’s dormitory while her baby Grace was admitted to the NICU.

The dormitory has 17 beds and a communal kitchen, allowing women like Baningo to stay close to their infants without daily travel or sleeping in public areas. When she first saw the space, she thought, “It looked like America.”

Every day while her baby received care, Baningo walked between the dormitory and the NICU, spending time at her daughter’s bedside. That proximity allowed her to remain present during a critical period in her baby’s life.

Anyone entering the NICU passes staff who enforce strict hygiene measures. The unit has two neighboring rooms—one for babies born at the MCOE and another for babies born at another facility or at home. This was a deliberate design choice to reduce infection risk.

Light, Air, Beauty

Just as the buildings were organized to support clinical care, nature was intentionally integrated throughout the facility as well.

Natural ventilation, daylight, and views of greenery were prioritized. In the in-patient wards, the design team oriented buildings around a central courtyard, with views directed toward green space. Many of the foliage and trees planted in the outdoor spaces were donated by community members.

Farmer always believed that beautiful spaces should exist alongside medical excellence. An avid gardener, he felt that such spaces could provide solace and help people heal, which is why he often incorporated gardens into PIH clinics around the world—and the MCOE was no exception. Farmer was deeply involved in planning the facility before his unexpected passing in February 2022.

Walking through the finished facility today, Komba observes so much more than a hospital.

“I see beauty. I see care in every detail,” she says. “And I know that when a mother walks in, she will feel that too. She will know that she matters.”

Editor's Note: The Paul E. Farmer Maternal Center of Excellence (MCOE), a Partners In Health (PIH)-supported facility, opened to patients in February 2026 on the campus of Koidu Government Hospital (KGH) in Kono District, Sierra Leone.  

Built in partnership with Build Health International and the Sierra Leone Ministry of Health, the state-of-the-art facility was designed to confront one of the most urgent challenges in Sierra Leone: preventable maternal death. It represents years of deliberate work to strengthen care where it has long been weakest, part of a two-decade effort across Sierra Leone that has reduced the country’s maternal mortality rate by 78% since 2000.  
 
This series explores the MCOE through what PIH calls the "five S's": staff, stuff, space, systems, and social support, the essential elements of a strong health care system. In this article, we focus on stuff: the critical tools and resources that staff rely on to deliver safe and effective care.

On Feb. 14, 2026, shortly after the MCOE opened its doors to patients, 17-year-old Fanta Jimmy arrived at the facility’s triage area.

She was quickly shown to one of the curtained beds, and a team of nurses, midwives, and doctors carried out an in-depth clinical assessment. They quickly found that Jimmy was suffering from pre-eclampsia with severe features and that her baby was in distress. An emergency C-section was needed.

For Jimmy, the situation was urgent, and every decision made by the clinical team depended on what they could see and measure.

Once she was moved through to the operating theater soon after, Jimmy gave birth to the first-ever baby born at the MCOE. Her newborn was then immediately placed in an incubator to maintain her body temperature and transported to the facility’s neonatal intensive care unit (NICU)—the first NICU in Sierra Leone.

Over the following week, staff closely monitored the baby’s progress.

Each step of Jimmy’s care, from diagnosis using an ultrasound machine to administering support through IV fluids to the use of vital monitors and incubators, depended on access to the right equipment at the right time. All of this is what PIH considers “stuff.”

Individually, none of these clinical items are unusual in a modern maternal health care facility in the United States and other high-income countries. But in Sierra Leone, they are unprecedented.

What Was Missing

For clinicians in Kono District, having access to the correct medical equipment and knowing the lifesaving impact is deeply personal.

Boyama Gladys Katingor began working as a midwife at Wellbody Clinic in early 2014, before PIH arrived in Sierra Leone. She remembers what it was like having limited tools to care for mothers.

“I felt that I was letting them down, that we were not providing the necessities,” she says. “We lacked so many instruments and things that we needed to do our best work.”

For years, many health workers faced this reality: knowing how to respond to clinical complications during pregnancy and childbirth, but not having access to the required equipment to diagnose or treat them.

In pre-eclampsia cases like Jimmy’s, where complications escalate rapidly, that gap between instinct and certainty can be the difference between life and death.

This cost of operating without the right equipment became starkly visible during the Ebola epidemic—the reason PIH was invited to West Africa just over a decade ago and has remained ever since.

“Contact with blood and amniotic fluid is expected while accompanying a woman’s labor,” says Jonathan Lascher, former executive director of PIH Sierra Leone from 2017 to 2021. “In 2014, without proper protective equipment and treatment, it was life-threatening.”

During that time, many health centers lacked basic supplies. In some cases, thermometers used to screen patients were unreliable, and protective equipment was scarce. Pregnant women often labored with minimal clinical support as health workers struggled to protect themselves from infection.

The consequences were severe. In settings where childbirth already carried enormous risk, the absence of proper equipment made routine care dangerous. It exposed mothers and newborns to delays, uncertainty, and preventable harm, while also forcing health workers to operate under fear.

A Turning Point

However, the situation began to change in late 2014, when PIH began supporting Wellbody Clinic, a primary health facility based in Kono District.

“Suddenly, we had what we needed,” Gladys recalls. “So many things arrived. From delivery beds and postnatal beds to linens and pillows. More than this, though, was the arrival of the things we needed to do our best observations for the women.”

Among the most transformative additions was ultrasound technology.

“This became a way to bring women to us,” she says. “Not only to have midwives here, not only to offer our support as women, but [to have] the right equipment. Mothers could ask to see the scan of [their] babies.”

For many mothers, seeing their baby on a screen for the first time became a powerful reassurance during pregnancy. It made care feel more tangible, more immediate, and perhaps more trustworthy.

Ultrasounds strengthened clinicians’ ability to understand what was happening inside a woman’s body, make earlier decisions, and recognize when a pregnancy might require closer monitoring or urgent referral.

What “Stuff” Makes Possible

Over the next decade, the supply of “stuff” expanded from fetal heart rate monitoring devices and protective equipment to vaccinations and medications—at Wellbody Clinic, KGH, and other PIH-supported facilities.

And with the opening of the MCOE in 2026, KGH’s previous maternity and special care baby unit (SCBU) has enhanced capacity from 48 beds to 120 inpatient beds, including 39 beds in the NICU.
 
Princess Sia Fatorma, a neonatal nurse who moved from KGH’s SCBU into the NICU at the MCOE has witnessed the change in daily patient care directly.

“Before, we would just carry a baby in a blanket from the theater to the SCBU,” Fatorma said, recalling how newborns were moved before incubators became available.
Now, in the NICU, babies like Jimmy’s daughter have their own incubator, also termed an infant warmer, which provides a sterile, temperature-controlled environment. Clinicians use specialized monitoring equipment to carefully observe each baby, alerting them to changes and emergencies faster than ever before.

There are also things that aren’t as readily visible. The MCOE introduced a piped medical gas system, allowing oxygen and other gases to be delivered directly to patient beds, making it the first facility outside the capital, Freetown, to do so.

In emergency situations, when minutes can determine survival, reliable oxygen access can make a critical difference for both mothers and newborns, including women in respiratory distress and babies who need immediate breathing support after birth.

Technology—and the People Who Use It 

Still, access to equipment alone is not enough.

As Isata Dumbuya, director of nursing and midwifery at the MCOE, has emphasized, training triumphs technology.

The MCOE is equipped with nearly every piece of advanced technology needed to treat pregnant women and newborns, but the presence of that equipment does not guarantee good care on its own. Staff must know how to use the tools, interpret what they show, and respond accordingly.

That is why the story of “stuff” inevitably points back to “staff.” The monitors, scanners, oxygen systems, and theater equipment inside the MCOE matter not simply because they are present, but because they are placed in the hands of clinicians, technicians, and support teams who were trained to use them well.

The impact is obvious in the kind of care clinicians are now able to provide. Where once clinicians worked with too few tools and too much uncertainty, readily available equipment now enables them to respond to complications sooner.

For Jimmy and her daughter, that difference was immediate and lifesaving.

Editor's Note: The Paul E. Farmer Maternal Center of Excellence (MCOE), a Partners In Health (PIH)-supported facility, opened to patients in February 2026 on the campus of Koidu Government Hospital (KGH) in Kono District, Sierra Leone.  

Built in partnership with Build Health International and the Sierra Leone Ministry of Health, the state-of-the-art facility was designed to confront one of the most urgent challenges in Sierra Leone: preventable maternal death. It represents years of deliberate work to strengthen care where it has long been weakest, part of a two-decade effort across Sierra Leone that has reduced the country’s maternal mortality rate by 78% since 2000.  
 
This series explores the MCOE through what PIH calls the "five S's": staff, stuff, space, systems, and social support, the essential elements of a strong health care system. In this article, we focus on staff: the full range of people who keep the facility running safely and effectively—from nurses and midwives to technicians, cleaners, and support teams— and the skills, training, and support they need. 

For Francess Kamara, a senior midwife mentor at the PIH-supported KGH, her work is deeply personal.

“My motivation in life and as a midwife has always been to help the most vulnerable people,” Kamara says. “That is why I applied to work at Wellbody, before it became part of PIH. I knew the problems in maternal care were very serious in Kono.”

Kamara began her career at Wellbody Clinic, a PIH-supported primary care facility in Kono District, where women often receive prenatal services before being transferred to the district’s only referral hospital, KGH, for complicated pregnancies and obstetric emergencies.

Over time, the number of patients at Wellbody Clinic and KGH has grown rapidly, placing strain on an already stretched team of midwives.

“Because of the reputation of PIH, many more people were coming in for care,” Kamara recalls. “Yet we were not even up to ten midwives initially.”

When Staff are Stretched

As more patients arrived, more space and better-supported staff were needed to address the demand.

In 2017, this need culminated in early planning beginning for the MCOE—a state-of-the-art facility designed to dramatically expand services at KGH and set a new standard of maternal care for women in Sierra Leone.

“It had to be a center capable of providing the best care possible in [what used to be] one of the most dangerous places on earth to be a woman,” says Jonathan Lascher, former executive director of PIH Sierra Leone from 2017 to 2021. “In a country [initially] with only 150 doctors, it also had to be a training center for Sierra Leonean clinicians.”

When PIH first began working in West Africa, during the Ebola epidemic in 2014, finding staff was one of the immediate priorities. During that time, PIH trained and deployed 200 volunteer clinicians from the United States and hired 2,000 community health workers and support staff across Liberia and Sierra Leone.

Building Toward Bigger  

Across PIH sites and clinics worldwide, hiring local staff is essential to what we do and the care we deliver. This is true across roles and departments, including the workforce hired to build the MCOE.

PIH and the Sierra Leone Ministry of Health broke ground on the MCOE in April 2021, and at the peak of construction, local women made up 65% of the MCOE construction workforce and were trained on-site as laborers, quality assurance managers, and construction supervisors.

Most women had never worked on a construction site or had a formal, steady job before.

“For many of us, this was the first time we saw a project like this led with respect. We are not just laborers; we are partners,” says Diana “Success” Komba, a member of the MCOE construction team.

This investment not only created economic opportunities for families while the MCOE was being built but, critically, strengthened the pool of skilled workers across the district for years to come.

Training Staff to Lead Care  

In the months leading up to the MCOE’s opening, staff training ramped up, ensuring teams were fully prepared to deliver care at the new facility.

“The building is beautiful, the systems and equipment are first class, but none of that matters without the medical professionals to run it, just like when I began at Wellbody,” says Kamara.

As one of the MCOE training facilitators, Kamara ensured staff trainings ran smoothly, topics were adequately covered, and most importantly, that staff felt confident and prepared ahead of welcoming patients.

That training was both formal and practical: before the move into the MCOE, staff were given time to practice operating equipment and become comfortable using it.

They were also supported through simulations, theoretical teaching with the use of written protocols, checklists, and visual aids, and scenario-based exercises, while senior midwife mentors helped train colleagues on the job.

Preparation Meets Reality

When the MCOE opened its doors to the first patients on Feb. 14, 2026, the facility welcomed 27 patients, with a total of 13 babies born in the first 24 hours. As of April 30, the MCOE has supported  2,957 women with care and helped deliver 901 babies.

Kamara is one of approximately 200 clinical staff working at the MCOE today—a steep increase since Kamara’s early days at the facility, and a number that will grow as the facility continues its phased opening to ensure quality and efficiency.

Patients have come from every district in Sierra Leone to seek care at the new facility, as well as from neighboring countries.

When 35-year-old Fatmata Jalloh, a Kono District resident, arrived at the MCOE, she was 42 weeks pregnant and past her due date.  The clinical team assessed her at triage and found that the protective fluid around the baby had become dangerously low, and an emergency C-section was needed. Jalloh was worried; she had hoped and planned to deliver her baby vaginally.

During this tense time, Kamara was on hand in the triage room to reassure Jalloh, standing by her bedside to carefully explain the care that the team would provide and the risks of inducing labor past her due date.

Later that day, Jalloh underwent a C-section in the operating theater, and she delivered a healthy baby boy.

Training the Next Generation  

To ensure the MCOE workforce continues to grow in the years to come, both in size and skillset, the creation of a dedicated training site and dormitory, a 10-minute drive from the MCOE, is underway. Equipped with lecture halls and simulation labs, it will provide a dynamic environment where clinicians can learn, grow, and thrive for decades to come.
 
For Kamara, this will be invaluable. To her, the most important legacy of the MCOE will be the people it helps train.

“The future of the MCOE looks bright to me,” she says. “I already do a lot of mentoring, and I will continue to do that. Those mentees will then do their own mentoring. Each person passes their experience along to the next, and that builds a great future for everyone.”

Before ambulances became widely available in Sierra Leone, pregnant women experiencing emergencies often faced impossible choices about how to reach care.  

In remote places, some women traveled for hours over rugged dirt roads by taxi or motorbike while in labor, others walked. For women experiencing complications during childbirth, those delays could be deadly.

By the time an expectant mother reached a clinical facility, her condition would likely have deteriorated. And, worse still, the challenges to receive care often continued: facilities outside of Partners In Health’s (PIH) network sometimes charge a fee for basic lifesaving services, such as blood transfusions.

At PIH-supported clinics, free health care services have been provided since 2014, when PIH began working in the country. Still, accessing care during emergencies remained challenging for those living in hard-to-reach areas for several more years.

Ambulances begin a new era of care

Twenty years ago, Sierra Leone was the deadliest place in the world to give birth. Women died from hemorrhage, preeclampsia, and obstructed labor. While the country’s maternal mortality rate has fallen dramatically in recent years, lifesaving maternal care depends not only on skilled clinicians and operating rooms, but on whether patients can safely reach them in time.  

In October 2018, a national network of ambulances began operations.

The initiative, led by the National Emergency Medical Services (NEMS), operates in every district in the country. PIH Sierra Leone directly supports the work in Kono District.  

“There’s a huge difference between 2018 and now,” says Joyce Senesie, regional operations coordinator for NEMS. “Since the intervention of the ambulance, we've reduced maternal death.”

The number of emergency referrals to PIH-supported Koidu Government Hospital (KGH) quickly increased after the ambulance service launched. Renowned for its quality of care, KGH, located in rural Kono District, provides free health services for patients that come from around the country as well as neighboring countries, Liberia and Guinea.  

Ambulances meant faster and safer emergency transportation. In 2025 alone, ambulances brought 562 pregnant women to KGH. Today, these ambulances are still pulling through the same gates they always have at KGH, only now, they turn toward the newly opened Paul E. Farmer Maternal Center of Excellence (MCOE), a cutting-edge maternal and neonatal referral facility built on the hospital’s campus.  

On Feb. 14, 2026, the MCOE opened its doors to its first patients—and that afternoon, the first ambulance arrived at the facility carrying Sia Jimissa, a 33-year-old pregnant mother of three. 

Referrals save lives

Throughout her pregnancy, Jimissa attended prenatal appointments for routine care at her local clinic—approximately a two-hour drive away from KGH. On the morning of Feb. 14, she began experiencing contractions and went to her clinic to give birth as planned. However, after three hours of labor there, the clinical staff identified complications and called an ambulance to refer Jimissa to the MCOE.  

Like many women across the world, Jimissa had expected to deliver close to home, surrounded by familiar staff and loved ones. But when complications arose, she needed access to surgical care that her local clinic could not provide. Staff at her clinic were well-trained in how to refer her case.  

They called a central ambulance dispatch center. And as they waited for the ambulance to arrive, called the maternity team at the MCOE to share the reason for Jimissa’s referral; important medical details that would enable the team to dive directly into administering appropriate care once she arrived.  

“From the caller to the dispatching of the ambulances to the maternity team, they are always ready to receive emergency services,” says Senesie. “They know how to identify dangers, and they know where to stop and [refer].”

For Jimissa, the referral was unexpected.  She later described feeling frightened that her labor was no longer progressing normally, and anxious about being transferred to a hospital she had never visited before. Jimissa boarded the ambulance alongside her elder sister.

It was one of five stationed across Kono District, which serve the entire district and are linked to PIH-supported health centers, such as KGH and the MCOE.

Upon arrival at the MCOE, all patients go through a triage process, whereby clinical staff quickly assess a patient’s needs to identify the next steps and prioritize emergencies.  

“These sometimes can be really hard decisions. Because you can have a baby that is in real fetus distress, but another one that is actually the mother [in distress], so you're having to constantly decide,” explains Isata Dumbuya, director of nursing and midwifery for the reproductive, maternal, neonatal, child and adolescent health program at the MCOE.  

The triage team determined that Jimissa had prolonged labor and that her baby was in distress. She was moved swiftly to an operating theater.

Ending preventable maternal deaths

The MCOE has three operating theaters built for advanced surgical care. There, Jimissa underwent an emergency C-section with no complications, and she delivered a healthy baby boy.  

For years, the delay between a clinician identifying the need for an emergency C-section and actually performing one could stretch dangerously long. But today, ambulance referrals, improved coordination, and immediate access to operating theaters at the MCOE are helping reduce those delays dramatically.

Ambulances play a key role in getting women like Jimissa from distant communities to care quickly. Equipped with four-wheel drive, the vehicles are designed to navigate uneven terrain. To ensure 24/7 availability, each ambulance has a rotating staff of three drivers and three paramedics—all of whom are trained to handle a delivery that happens en route to the hospital.

Jimissa’s son was among the first babies born at the facility. As of April 30, there have been 901 babies delivered and 2,957 women have received care at the MCOE.

“We should have zero preventable maternal death, zero preventable newborn death,” emphasizes Senesie. “And with NEMS and the MCOE, I believe we can achieve it.”

In 2025, improved ambulance availability resulted in a 5% increase in referrals through NEMS, and will likely increase this year because of the MCOE.  

While Senesie’s primary job responsibility is to provide timely coordination and support for health care staff, it also involves collaborating with expectant mothers in remote communities.

“Our role is not only to dispatch an ambulance, but to make sure that the people know about the ambulance service,” says Senesie.

Despite challenges such as vehicle maintenance and fuel availability, the team’s dedication ensures that women and their families know services are free and accessible.

‘Every one minute is very important’

KGH has long been a vital referral center for high-risk pregnancies and obstetric emergencies. Now, the MCOE is raising the standard of maternal heath in Sierra Leone even higher.

The MCOE radically increased the size and sophistication of KGH’s maternity ward and special care baby unit, expanding it from 48 beds to 120 beds, including a cutting-edge neonatal intensive care unit, the first in Sierra Leone.

Within the first two weeks of opening, all the hospital beds were full.

“No matter what you do, you can never plan enough for these sorts of things,” reflects Dumbuya. “We continue to adjust and change things to ensure that every woman that comes in, every parent, every father that comes in, and every baby that is born here gets the quality and standard of care that they deserve.”

As the team refines protocols, they’re actively improving the referral process in collaboration with NEMS—specifically sorting out roundtrip transportation for women after they’re discharged.

A facility like the MCOE can only function effectively when strong referral networks are in place—and when timely emergency resources, like ambulances with well-trained staff, are available.

Across Kono District, women like Jimissa—who once may not have survived obstetric emergencies—are now reaching advanced maternal care in time. The ambulances represent a rapidly strengthening system of care designed to ensure that childbirth is dignified and no longer a life-threatening gamble.

“For pregnant women, every one minute is very important,” says Senesie.

Editor’s note: This article was originally published in Spanish on Socios En Salud’s website.

Each year, more than one million adolescents worldwide contract tuberculosis (TB)—the world’s deadliest infectious disease.  

Fortunately, TB is fully treatable and preventable, and most adolescents do receive and complete treatment. But unfortunately, that doesn't always mean they make a full recovery.  

Between 57% and 67% of TB survivors experience some degree of chronic lung damage, according to various studies. These are young people with decades of life ahead of them who could be living with reduced lung function without knowing it, simply because it wasn't assessed in time.  

Until now, the main problem has been that no validated tools to measure this harm in adolescents have existed. The available tools were all designed for adults with chronic illnesses.  

To address this massive gap in care, Socios En Salud (SES), as Partners In Health is known in Peru, participated in a study that would create tools specifically for younger patients.  

TB Doesn't End When Treatment Does  

When a teenager is discharged from the hospital after treatment for TB, they are considered cured of the disease by clinical staff. However, this does not always mean their lungs have fully recovered. Post-tuberculosis lung disease encompasses respiratory complications that can persist long after successful treatment.  

"Pulmonary tuberculosis, even when successfully treated, is associated with worse lung health in adolescence," said Dr. Silvia Chang, a pediatric infectious disease specialist at Hasbro Children's Hospital and Brown University.

The adolescent population is particularly vulnerable because during this stage of life, the lungs are still developing. TB can disrupt this process, leaving permanent scarring and altering how air enters and exits the lungs.  

In SES's study, evaluating 101 adolescents who had overcome pulmonary TB in Lima between March 2022 and September 2023, chest CT scans widely showed damage and complications such as structural distortion and bronchiectasis—irreversible expansion of the airways.  

Unlike adults, adolescents typically have fewer comorbidities and less exposure to lung irritants, making the damage caused by TB particularly obvious and less attributable to other causes. Even so, they are one of the least studied groups in this field.  

The result is worrying: every year, thousands of young people treated for TB are discharged without any follow-up on their lung function. Hospital discharge should not mark the end of care, but rather the beginning of a new phase of attention.  

A Global Reach

To begin to give this patient population the attention they deserved, an international team, led by Dr. Chang, developed a research study, with SES leading the field activities, including recruitment, coordination with the Peruvian Ministry of Health (MINSA) facilities, and application of assessments.  

Each of the 101 study participants was compared to a healthy adolescent of the same sex, age, and environment. Both groups had similar characteristics in height, weight, respiratory history, and exposure to irritants, which allowed the observed differences to be attributed to a participant's experience with TB.  

Three types of assessment were used. First, researchers utilized an adapted version of the St. George's Respiratory Questionnaire (SGRQ), which measures symptoms, physical limitations, and impact on daily life. Second, the team considered spirometry, which assesses the amount of air a person can exhale with effort. Third, lung function was tested through oscillometry, a technique that analyzes respiratory function using sound waves while a person breathes normally.  

“Assessing lung function and symptoms after treatment is just as important in adolescents as it is in adults,” Dr. Chang said.  

Without the on-the-ground work of SES, this type of research—connecting scientific evidence to communities that need it most—would not be possible.  

Results and Next Steps  

The results were clear in several aspects. The oscillometry assessment proved easier to perform, with all participants able to complete the function test. For the spirometry assessment, only 91.1% of participants were able to perform the test, which requires several strong exhales and can be difficult for adolescents with lung impairment.  

Furthermore, the oscillometry test also showed greater consistency in its measurements. This does not replace spirometry but rather reinforces the idea that both techniques complement each other and can allow for a more comprehensive evaluation.  

The questionnaire was also adjusted. The original version of the SGRQ, designed for adults, included questions that were not very relevant for adolescents. The team reduced it to 18 items and demonstrated that it maintains its validity, while also being easier to administer in the field.

The conclusion is straightforward: combining the abbreviated SGRQ, spirometry, and oscillometry allows for a comprehensive assessment of lung health in adolescents who have had TB.  

Each tool contributes a different piece of the picture.  

This study not only confirms the need for closer attention on this particular group but also identifies appropriate tools for contexts like Peru, where the TB burden is high and resources are limited.

However, the completion of this assessment doesn’t conclude the effort to support these adolescents. As Dr. Chang explains, “More research is needed to understand how TB leads to long-term lung damage and to identify potential interventions.”

Further research hopes to address new questions that emerged during this initial study: Why do some adolescents develop more long-term effects than others? Is there a key moment to intervene? What kind of follow-up should be routinely integrated after discharge?  

These questions will shape the study’s next stage. And, as before, SES will continue working on the ground, bringing research and innovation to those who need it most. 

Thirteen minutes after the doors of Sierra Leone’s first-ever neonatal intensive care unit (NICU) opened in Kono District, 19-year-old Phebian Baningo arrived carrying her newborn daughter, Grace, who was struggling to breathe.

In February 2026, the NICU within the Paul E. Farmer Maternal Center of Excellence (MCOE), began treating patients.

Several years ago, babies needing specialized care, like Grace, had slim chances of survival at Koidu Government Hospital (KGH). Although staff were well-trained and qualified, they simply did not have the resources needed to save babies facing complications.

This drastically changed with the establishment of the Partners In Health (PIH)-supported special care baby unit (SCBU) in 2020, which was equipped with modern technology and resources, at KGH.  

But challenges remained: there was no space for mothers to stay overnight, limited medications for discharge, and a growing influx of patients referred from other facilities.  

Now the MCOE’s NICU offers a level of care that has never existed in the country before.

Cutting-Edge, Modern NICU

After discovering her pregnancy, Baningo moved closer to Koidu, Kono District, with her mother, Marta Lebbie, and her 4-year-old brother, Abdulloh, in search of better maternal care.  

Last year, Abdulloh spent five days at KGH receiving treatment for malaria. Remembering the comprehensive care her son received, Lebbie suggested the family relocate.  

Throughout her pregnancy, Baningo attended prenatal appointments at KGH and hoped to deliver at the MCOE.  

“I heard the good news and was hoping one day I would see it for myself,” she says.

However, when her grandfather died, Baningo needed to travel to a village several hours away for the funeral. While there, she unexpectedly went into labor and was too far away from any health facility to reach care in time. With the help of a traditional birth attendant, she gave birth at the home of a family member.

When Grace was born, she did not cry—a silence that immediately signaled something was wrong. Baningo and Lebbie rushed to the MCOE.

At the NICU, Grace was swiftly placed on oxygen support and laid in an infant warmer to regulate her temperature, interventions that had not been possible in the same way just a few years earlier.

Incubators, or infant warmers, are one of the requirements to qualify as a NICU. These portable beds allow clinical staff to bring babies directly from the operating theater to the NICU in a temperature-controlled environment.

“Before, we would just carry a baby in a blanket from the theater to the SCBU,” says Princess Sia Fatorma, a PIH Sierra Leone nurse who began volunteering at KGH in 2015 before later becoming a registered nurse.

The space itself has also vastly improved. Capacity has expanded from 48 beds at KGH’s previous maternity ward to 120 beds at the MCOE, with 39 in the NICU. Like the SCBU, the NICU is divided into separate rooms for babies born at KGH and those referred from elsewhere—a key measure to strengthen infection prevention and control.  

“It was such a squeeze before,” recalls Fatorma. In the former SCBU, multiple babies would sometimes share a single bed.

Safe Housing for NICU Mothers  

There is also now a dedicated dormitory for mothers.  

Baningo stayed in these sleeping quarters, located in the same building as the NICU, while Grace received care. When she first saw the 17-bed dormitory, complete with a communal kitchen, she thought, "It looked like America."  

The MCOE, a cutting-edge 25-million-dollar facility, was designed in collaboration with  Sierra Leone’s Ministry of Health and Build Health International.  

Since opening, many patients have expressed the same reaction, says Isata Dumbuya, director of nursing and midwifery for the reproductive, maternal, neonatal, child and adolescent health program.  

“That is the difference that even the space itself says,” says Dumbuya. “For people who use the space to know that you’re valued, you’re treasured, and you mean something ... that’s why we we’ve created this space.”

Every day, Baningo walked between the dormitory and the NICU, returning again and again to her daughter’s bedside, watching for even the smallest signs of progress as nurses monitored Grace’s breathing, temperature, and nutrition closely.

In the SCBU, staff often needed to remain beside each patient after administering medication, monitoring for signs of distress. But in the NICU, modern equipment tracks patients continuously and alerts staff to any changes, allowing them to safely care for more newborns at once.  

There were 922 newborns treated in the SCBU between July 2024 and June 2025. With the new NICU, that number is expected to increase significantly. Already, 228 babies were admitted to the NICU between Feb. 14 and May 1, 2026.

Healthy Food for Mothers and Babies

Grace’s condition steadily improved, and by the fourth day, she was taken off all support equipment.  

That same day, Baningo breastfed her for the first time.

“It was discouraging because she was not breastfeeding,” says Baningo. “But I'm happy now. That’s the only food she needs, the breast milk.”

Parents learn from NICU staff about the importance of breastfeeding and kangaroo care—skin-to-skin contact that supports a baby’s growth and development.  

What was once known as kangaroo mother care at the SCBU has expanded in the NICU to include fathers as well, signifying a more inclusive approach to newborn care.  

Though single, Baningo had staff by her side supporting her every need. They advised her to continue breastfeeding and practicing kangaroo care regularly, explaining that once discharged, she would need to continue for two to three hours each day to regulate Grace’s temperature.

As she recovered from childbirth, Baningo received nutritious meals three times a day, part of a newly introduced feeding program at KGH.  

Previously, families crowded the wards at KGH to deliver food to loved ones who were receiving care, making hygiene difficult to maintain across the hospital. Now, meals are prepared centrally, with nutritionists ensuring they meet hospital standards. Clean water dispensers have also been installed throughout the wards to support hydration.

“The cooks are very good,” says Baningo. “It was a surprise to me. It’s good for mothers because the food has enough protein. The cooks will put it on a tray and come and distribute it.”

‘Going home happy and smiling’

On February 22, Baningo and Grace were discharged. After days of uncertainty, they left the NICU healthy, together.  

Baningo decided to remain living near Koidu, as she had grown to feel at home there. Her younger brother enrolled at a local school, and her mother began settling into life in the town.

For Dumbuya, seeing mothers’ “sense of relief and joy” as they leave the NICU has been a highlight of the past few months since the MCOE opened.  

“They’re going home happy and smiling,” Dumbuya says.

Editor's Note: This piece is part of a series highlighting the vital role nurses play in health care systems around the world. Look out for more stories on nurses from Partners In Health (PIH) sites leading up to International Nurses Day on Tuesday, May 12.

When Daniela Puma Abarca, head of the program management directorate for Socios En Salud (SES), as PIH is known in Peru, was still a student, she met a patient who would ultimately have a significant effect on how she approached her role as a nurse.  

Puma Abarca was doing her clinical rotations at the national Children’s Hospital, which receives patients from all over Peru. One of her patients was a young boy who had been brought to the hospital from a region in Peru that lacked access to specialized pediatric care. His family lacked resources for the trip, but they wanted answers for their son, who had dreamed of becoming an athlete, but due to an accident, wasn’t even certain he would ever walk again.

During his hospital stay, the young boy seemed unable to gain any weight, which Puma Abarca found unusual.  

“After investigating further, I discovered that he was saving portions of his food to give to his father, who had neither the resources nor a place to get a meal,” she recalled. “The boy would pretend to eat just to ensure that his father could.”

Puma Abarca brought this to the hospital’s attention. Thanks to a collaborative effort with the hospital’s volunteer staff, they were able to provide support to the father, supplying him with daily meals and a place to spend the night. This holistic approach to patient care has been paramount in Puma Abarca’s career since then.  

“This experience allowed me to grasp the profound social disparities that exist in our country,” she said. “As well as the importance of building trust with patients, looking beyond the obvious, and never hesitating to act when we have the power to do something more.”  

A Path Beyond the Beside

Since childhood, Puma Abarca had always known she wanted to work in health care. But it wasn’t until her experience in nursing school that she discovered the impact she could have, even beyond the bedside.  

“Since childhood, I have considered myself a curious person, driven by a desire to seek out new experiences and face new challenges,” Puma Abarca shared. “I studied nursing in Peru at the Universidad Peruana Cayetano Heredia. Initially, I intended to specialize in emergency nursing or pursue a path in oncology; however, during my studies, I discovered that my greatest interests lay in epidemiology, research, and community health. “

Her first job out of nursing school was with SES as a field nurse for Proyecto “Epidemiología de la Tuberculosis Multi Drogo Resistente,” or Proyecto EPI—one of the largest studies on tuberculosis (TB) epidemiology in Peru.  

In this role, Puma Abarca found deep fulfillment in her experience, learning both from patients and the health professionals around her. She dedicated her days—often from 5 a.m. until at least 9 p.m.—conducting home visits, collecting samples, administering diagnostic tests, assessing patient signs and symptoms, and completing follow-up care in line with research protocols.

“Although I would return home quite late—typically around 9 or 10 p.m.—I felt a deep sense of fulfillment from the work I had accomplished and from the gratitude expressed by the people I served,” she said. “A simple smile or a 'thank you' was enough to give meaning to every single day.”

A Desire to Understand

Over time, Puma Abarca fell in love with the research side of her work, which led her to pursue a master's degree in clinical research with a scholarship from the Peruvian government. Several years later, she returned to SES as a project coordinator to implement a pilot project for active TB case finding—which she notes was one of the greatest challenges of her career.  

“At first, it was a challenge to convince my family that a nurse could work outside of a hospital or clinic, engaging in community health and research,” Puma Abarca said. “Now, my professional life revolves around management, project implementation, and research—a combination I consider essential for continued growth.”

Puma Abarca now serves as SES’s head of the program management directorate, providing support to over 20 projects—including several TB initiatives expanding care through access and prevention through active case finding—from their initial formulation through to their completion. She credits her experience as a nurse for her success as a leader.

To support her professional development in this role, Puma Abarca participated in PIH’s fourth cohort of the Global Nurse Executive Fellowship (GNEF), a 12-month fellowship that aims to invest in the leadership of nurses and midwives. This experience provided her with tools that not only helped her own personal and professional growth but also taught her how to best support the growth of others.  

“It marked the first time I experienced mentorship firsthand,” she shared. “It’s a practice I now strive to replicate in my own team, with the aim of ensuring that we all grow in alignment with our goals.”

A Voice That Demands to Be Heard

Nurses and midwives, including Puma Abarca, are an important part of SES. Within the organization, many leadership positions are held by these professionals. Throughout SES’s 30-year history, the organization has championed key public health strategies—many of which have been led by nurses, an anomaly in health care settings in Peru.  

“The nursing and midwifery group constitutes one of the largest and most organized cohorts within the health care system,” Puma Abarca said. “Nevertheless, resistance persists regarding the notion that non-medical personnel can take the lead in health management... Ours is a voice that demands to be heard.”

What makes Puma Abarca most proud in her current role is seeing her team step into new roles and lead projects. The foundations of her leadership are the same qualities that she utilized in nursing school to dig deeper with her patients—active listening, empathy, proactivity, and a holistic perspective on people.  

She hopes to see the number of nurses in leadership positions continue to grow, as she credits her experience as a nurse for her success as a leader.

“Nursing has been pivotal in my professional development,” Puma Abarca said. “While academic training is important, the experience gained through working with patients, internships, and various job roles has been fundamental in enabling me to face and overcome diverse challenges.” 

Editor's Note: This piece is part of a series highlighting the vital role nurses play in health care systems around the world. Look out for more stories on nurses from Partners In Health (PIH) sites in the weeks leading up to International Nurses Day on Tuesday, May 12. 

For years, a young woman worked to keep Hôpital Saint-Nicholas in Haiti safe and sanitized.

She cleaned patient rooms, common areas, and operating rooms to maintain a sterile environment and stop the spread of disease—an essential but often overlooked part of patient care.

Phalone Louis was just glad to be a vital part of hospital operations, even though her family looked down on her decision to become a cleaner.

As a young girl, Louis dreamed of becoming a doctor—to be the one leaping into action when a person arrived at the hospital sick, injured, or in critical condition. But her family was too poor to afford to send her to medical school, an opportunity only a miniscule amount of the population in Haiti are afforded.

Louis grew up. She became a mother. And in her early 30s, she was drawn to Hôpital Saint-Nicholas, which is supported by Zanmi Lasante (ZL), a sister organization to Partners In Health (PIH) in Haiti, when she needed a job to support her son.

Day after day, she worked as a cleaner, feeling her old childhood dream beginning to reignite and kindle in her mind.

Hope Flickers to Life

Her dream of treating patients seemed impossible—at least at first.

Louis was a single mother and needed to keep her job to support both her and her 13-year-old child.

Still, she couldn’t get the image of her wearing a nurse’s uniform out of her mind. While her aspiration had shifted and evolved from when she was a child, it was still alive.

Louis wanted to go to nursing school.

She confided in her supervisors about her dream. They offered to switch her schedule to the emergency room night shift so she could attend classes during the day, but still be able to work at night to support her family.

Louis accepted.

For years, she would work all night, sleep a few hours, and go to class the next day, all while taking care of her son. Money was still tight, and on the days Louis couldn’t afford her son’s school lessons, she brought him with her to the hospital.

After finishing her cleaning duties, Louis would sit beside him, open his notebooks, and help him review his lessons as he completed his homework, a mirror of her own studies.

Nurse by Day, Housekeeper by Night

As Louis progressed through her degree, she started clinical rotations.

She chose to work at Hôpital Saint-Nicholas—the same clinic she was keeping clean.

At that time, she filled two roles at once: nursing intern by day, and housekeeper at night.  

It was a physically and mentally exhausting time. At one point during her clinical rotations, she witnessed her peers disregard support staff, including the hospital’s cleaners.  

She and other members of ZL defended the essential role cleaners play in daily hospital operations. Doctors, nurses, and other colleagues consistently supported Louis and encouraged her to keep going, especially in difficult moments.

She did. After more than four years of intense sacrifice and exhaustion, Louis earned her degree in nursing science in 2025.

Now a licensed nurse, Louis is already looking ahead. She plans to pursue a specialization, either as a clinical nurse or in community health, with the ambition of strengthening the quality of care offered to the most vulnerable populations. Louis joins ZL's physicians, nurses, and community health workers who continue to show up for patients, even against a worsening backdrop of political, economic, and social crisis in Haiti.

ZL continues to provide programs across the Central Plateau and Artibonite regions. In 2025, ZL delivered over 16,000 babies in-facility and provided more than 630,000 outpatient visits.

“No matter the sacrifices, never give up on your dreams,” Louis said.

Just seconds after birth, a newborn began going into distress and not breathing. Without hesitation, Midwife Malerotholi Rakhooanyana checked the baby’s airway in an attempt to resuscitate them at Partners In Health (PIH)-supported Lebakeng Health Center in Lesotho.

There was no time to panic or nearby hospital to rely on. The closest referral facility is four to five hours away by road, across Lesotho’s mountainous terrain.

But Rakhooanyana felt prepared and confident, even in the face of a crisis.

Using resuscitation skills she had recently refreshed through the Global Action in Nursing (GAIN) training, she worked quickly and carefully at the bedside. First, she kept the baby’s skin dry and warm to prevent hypothermia. Next, she repositioned the baby to properly check its airway. She noticed fluids, so she began removing them with a suction bulb designed for infants. Then, she gently rubbed the baby’s back to stimulate breathing.  

Finally, the baby began to breathe and the mother was stable.  

"I wasn’t panicking because I knew what to do,” says Rakhooanyana. “The training improved my confidence, preparedness, and ability to provide timely and lifesaving care.”

Days later, the newborn returned for its seven-day postnatal visit—healthy and thriving. Before the GAIN training, the last time Rakhooanyana reviewed her resuscitation skills was 16 years ago during nursing school—and was admittedly long overdue for a refresher.

Building lifesaving skills for rural midwives

Through the GAIN program, Rakhooanyana and her colleagues receive advanced clinical and leadership training and hands-on mentorship to prevent unnecessary complications during childbirth. Founded in 2017, GAIN—a women- and nurse-led organization of global health experts—has trained 677 nurse-midwives across Liberia, Malawi, Sierra Leone, and the United States (Memphis, Tennessee).

In February 2026, GAIN expanded to Lesotho and trained 29 midwives and nurses from three rural PIH-supported sites—Bobete, Nohana, and Lebakeng Health Centers—and Paray Mission Hospital, the referral facility for those clinics.  

GAIN is led by the University of California, San Francisco, and works in collaboration with PIH Lesotho and Lesotho’s Ministry of Health. Together, all ensure that nurses and midwives have the skills to provide high-quality care during routine visits and emergencies alike.

“Our mentors work side by side with facility staff at the bedside. This is not just about theory, it’s about transferring practical skills that save lives in the moment,” says Joalane ‘Mabathoana, PIH Lesotho’s nursing director.

Reignited passion for nursing

During a five-day training, participants attended presentations, engaged in hands-on demonstrations, had lively discussions, and more. The curriculum included leadership topics, such as how to give feedback and effective presentations; and clinical topics, including how to manage pre-eclampsia and postpartum hemorrhage.  

“It has reignited our passion,” says Khomonngoe Moea, Bobete Health Center's nurse-in-charge and clinical site director. “It has opened our eyes to things we are not even aware of."

For example, Moea and colleagues learned how to more accurately manage labor using a partograph—a graphical, monitoring tool. It’s used to detect risk early before life-threatening complications arise for a mother and her baby. Previously, the midwives used the tool to monitor the active, intense phase of labor. During the GAIN training, they learned how to monitor the latent, or early, phase of labor to detect complications sooner.

“There are so many new things that we learned that we never knew we needed. Now, we are able to prepare for emergencies,” says Moea. “It’s going to improve patient outcomes.”

Providing consistent support and care

Expectant mothers in rural Lesotho often live hours away from the nearest health facility. They take long treks, often traveling over steep slopes across rough terrain, and through harsh weather, in the only country in the world with an elevation entirely above 1,000 meters. The geographical obstacles and long distances to care are among many factors contributing to the country’s high maternal mortality rate—approximately 478 deaths per 100,000 live births.  To promote safe deliveries and regular care, PIH Lesotho established maternal waiting homes, where expectant mothers live as they await delivery.  

While this addresses patient housing, staff housing wasn’t available—until recently.  

Recognizing that rural Lesotho presents unique challenges for long-term mentorship, PIH Lesotho and GAIN have prioritized infrastructure, with guest houses being constructed at Lebakeng, Bobete, and Nohana Health Centers to provide reliable accommodation for nurse mentors and visiting clinical staff. This will ensure consistent support, instead of irregular visits. Construction materials were difficult to transport by road and required transportation via helicopter, ensuring timely progress of the building projects.

Once complete, GAIN mentors will move into the guest houses and provide ongoing training for at least one year. Prior to the establishment of the guest houses, visiting staff would stay off site, sometimes hours away.

“This project is not just about training or buildings,” says ‘Mabathoana. “It is about building a stronger, more resilient health system that meets women and newborns with the dignity, safety, and care they deserve.”

In rural clinics like Lebakeng Health Center, where help can be hours away, the skills Rakhooanyana used that day meant the difference between life and death for the newborn. With GAIN, now more staff have the skills to provide safe, emergency care for mothers and babies—no matter where they live.

Editor's Note: This piece is part of a series highlighting the vital role nurses play in health care systems around the world. Look out for more stories on nurses from Partners In Health (PIH) sites in the weeks leading up to International Nurses Day on Tuesday, May 12.

Growing up as the youngest of six siblings in Liberia, Veronica Nimene was surrounded by family who cared for her every need.  

“I had people doing everything for me,” recalls Nimene, PIH Liberia’s director of nursing. “My only focus was go to school, come home from school, and read my books.”

As she grew older, she began realizing the importance of reciprocating care and love. Her upbringing, along with her first profession, led her to nursing. But first, she was an English and Literature teacher at elementary and high schools in Sierra Leone and Liberia.

Her experience teaching and caring for students, particularly one girl struggling in her class, reinforced her desire to help others beyond the classroom. Nimene noticed the student frequently arrived late with messy hair, torn clothes, and no lunch. Eager to help and understand the situation, Nimene spoke with the child’s mother and learned she was a single parent of four working as a street vendor. With permission, Nimene stepped in to help the girl.

“It became a routine every weekend,” reflects Nimene. The child would go to Nimene’s house, do school lessons, get her hair done, and go to church. She soon started to do well in school and made friends. Seeing the positive change, Nimene knew, “I needed to do something more. I wanted to take care of the individual holistically.”

She pursued a career change, feeling that the nursing profession would give her the chance to provide the type of care she longed to give. Upon starting nursing school, she immediately felt a sense of belonging.

“This is the right place,” says Nimene. “I found my comfort zone.” 

A Liberian national: ‘I need to also pay my dues’ 

After graduating with an associate degree in nursing in 2003, she worked at a nonprofit mission hospital in Monrovia, the country’s capital, and her home city. In 2005, she moved to rural Maryland County—where her husband lived—and spent a year working at J.J. Dossen Memorial Hospital. At the time, PIH hadn’t started working in Liberia.  

The hospital had “dilapidated structures, bush all around, and few staff,” reflects Nimene. “The condition was terrible. You couldn't find many Liberians willing to come to this end [of the country]. Even finding food here was a challenge.”

A year later, she went back to school to earn a bachelor’s degree in nursing, before going on to climb the career ladder working in health facilities across many countries, including Niger, Nigeria, Kenya, and South Sudan.

In February 2026, Nimene was hired by PIH Liberia and returned to J.J. Dossen Memorial Hospital for the first time in two decades.  

“I couldn’t recognize the hospital. It’s a different J.J. Dossen, a brand new J.J. Dossen,” she says. “The entire city has changed. Now it’s populated. There are shops. The roads [improved]. Tubman University is now operational. Back then, it was closed from the effect of the war.”  

Many other organizations fled the country because of the civil war and Ebola epidemic, among other reasons. In 2014, PIH began working in Liberia and has remained ever since—recently celebrating a decade of impact and accompaniment. Nimene admires that PIH decided to stay.

“It wasn’t only just to stay, but to strengthen the health system for a country, not just an institution,” she says. “Being a Liberian, I told myself if others are coming in to support to take care of my country, I think I need to also pay my dues.”

Patients remain top priority

An experienced nurse, Nimene is excited to be a PIHer. Despite being in a leadership role, she plans to continue providing hands on patient care, noting she’s not an “office person.”

“I always like to be with the patients to understand their needs and how best, from the leadership level, that we can support the nurses and midwives to provide quality and dignified care for our patients,” she says.

Decades into her career, her ongoing motivation to do this work comes from the patients themselves.  

As she looks ahead to the future of the nurse workforce in Liberia, she sees ample opportunities to improve nursing and midwifery education. In particular, she’s excited to closely collaborate with the Liberian Board for Nursing and Midwifery and Tubman University—including a partnership with University of Global Health Equity, which PIH operates in Rwanda.

“I’m really excited and privileged to be part of PIH,” she says.

The United States President’s Emergency Plan for AIDS Relief, or PEPFAR, was launched in 2003 by the Bush administration to support the global effort to reduce suffering from HIV/AIDS. Since then, the program has saved 26 million lives and prevented millions of HIV infections.

However, deeply intertwined in this lifesaving legacy is behind-the-scenes advocacy that has helped shape and sustain the program. For decades, leaders from Partners In Health (PIH) have been heavily involved in PEPFAR’s policy and programming. Unfortunately, PEPFAR is under threat from the current administration.

Help us save PEPFAR for people around the world >

Read on for a few key dates highlighting PIH’s history with PEPFAR and see how we’re uniquely positioned to protect its lifesaving legacy together.

1998 – The HIV Equity Initiative

PIH began the HIV Equity Initiative in 1998 in Cange, Haiti, when AIDS was the leading cause of death among young adults, and an estimated 6% of adults in the country were infected. The project provided lifesaving antiretroviral therapy to patients dying of AIDS at no cost to them—just two years after it was available to treat patients in the United States and Europe. 

At the time, this initiative was considered radical at best, and at worst, a waste of resources, impossible to sustain in impoverished communities. PIH set out to prove the opposite. As one of the first projects in the world to effectively deliver antiretroviral therapy in a poor, rural setting, the initiative—and its patients demanding and knowing that they needed more—would eventually provide the evidence for PEPFAR's massive scale-up of access to treatment for millions of HIV patients around the world.

2002 – Dr. Paul Farmer visits the White House to advocate for PEPFAR

In 2002, the late PIH Co-founder Dr. Paul Farmer was invited to the White House by Dr. Anthony Fauci to present his findings from the HIV Equity Initiative. The program’s success demonstrated the possibility of HIV care being delivered in resource-poor settings and was ultimately a key part of the evidence that convinced President George W. Bush to announce PEPFAR. His announcement began with a sentiment that remains true today: “Ladies and gentlemen, seldom has history offered a greater opportunity to do so much for so many….” Since its establishment in 2003, PEPFAR has uniquely had consistent bipartisan support.

2007 – Dr. Joia Mukherjee testifies before the Committee on Foreign Affairs

In 2007, PEPFAR was facing reauthorization, a process it goes through—like other legislation—every 5 years to allow lawmakers and advocates to set new priorities. This reauthorization was pivotal in moving away from addressing a crisis to expanding support for strengthening entire health systems, including training local health workers. On September 25, Dr. Joia Mukherjee, who was PIH’s medical director at the time, joined several global health advocates to provide testimony in front of the Committee on Foreign Affairs in favor of reauthorizing PEPFAR.

In addition to highlighting the work PIH was doing with PEPFAR’s support, in her statement, Mukherjee said, “I urge you to build on the successes of PEPFAR, and to use the AIDS crisis to examine and address the illness and suffering throughout the world; not to preserve the first five years of PEPFAR in the museum of unrealized possibilities, but rather as the beginning of a movement to strengthen health systems as a response to combat the worst epidemic in the history of mankind.”

2018 – PIH Engage begins annual advocacy to sustain PEPFAR's funding levels  

PIH Engage is a grassroots network of volunteer community organizers mobilizing local communities to build a global movement for the right to health. The Engage network spans the U.S. and utilizes advocacy to target political action towards congressional offices.

Public funding wouldn’t be able to survive without pressure from advocates. Since 2018, Engagers have been advocating annually for sustained funding for PEPFAR and its overwhelmingly positive track record, ensuring that voices from both patients and clinicians who rely on PEPFAR were represented in the decision-making processes. In all the years that they’ve been advocating, funding levels have either increased or remained steady—until the Trump administration took office in 2025.

2025 – PIH participates in a congressional briefing on PEPFAR

Over 20 years after PEPFAR was announced, Dr. Mukherjee and colleagues were back in front of Congress, defending PEPFAR. In January of 2025, funding for the program was frozen, and in February and March, 65 percent of USAID PEPFAR programs were terminated. In June, the Trump administration tried to cut significant funding to PEPFAR as part of a larger rescissions package that gutted foreign aid. In October, CDC PEPFAR programs were cut down 35 percent globally. In response, PIH used both constituent and expert power to inform Congress and help protect PEPFAR’s lifesaving legacy.  

Zanmi Lasante (ZL), PIH’s sister organization in Haiti, is one of the main implementers of PEPFAR funding in the country. In collaboration with congressional champions for PEPFAR, ZL leaders—including Executive Director Dr. Wesler Lambert, Director of Development Coralie Noisette, and Director of Infectious Diseases Dr. Alain Casseus—provided firsthand accounts of how U.S. government funding cuts were harming their patients in Haiti.  

“Every line item in the budget, there is a person, a patient, a nurse, a family,” Dr. Casseus said during the briefing, “I’m asking you to remember the people behind these numbers.”

2026 – PIH provides transparency and forces accountability

After a year of funding cuts in 2025, PIH continued to monitor the State Department’s spending in 2026 and discussed concerns with policymakers. During this analysis, it was discovered that CDC funding was cut significantly for programs happening this year, which would impact 12 million people living with HIV across 51 countries and regions who receive support from PEPFAR. For PIH patients in Haiti, without PEPFAR funding, 18,000 people risk losing access to lifesaving treatment. 

After discovering this, PIH began sounding the alarms with local and national media, hoping to build constituent pressure against these cuts. PIH’s spending dashboard and analysis led to several news outlets—including the New York Times, Washington Post, NPR, Science, and Devex—covering the emerging impacts of these cuts on programs and patients. Since then, promising discussions have occurred behind the scenes to avoid such a dramatic cut in funding, allowing services to continue.

It would be reassuring to report that media pressure and congressional oversight have secured PEPFAR’s future, and that’s where the story ends. However, our fight to protect PEPFAR is far from over. The advocacy started in Cange by Zanmi Lasante and Dr. Farmer in 1998 must continue.

As the U.S. State Department looks to sunset PEPFAR funding over the next five years through its "America First Global Health Strategy,” PIH will keep advocating against an estimated $1 billion in cuts and the tying of aid to the extraction of minerals—an approach that is already leading to humanitarian funding shortfalls in Malawi, amid a severe food insecurity crisis.

If we’ve learned anything from PIH’s history with PEPFAR, it’s how important our voices, our experiences, and our expertise are in protecting its lifesaving programming. This is your chance to be a part of that legacy alongside us. 

Editor's Note: This piece is part of a series highlighting the vital role nurses play in health care systems around the world. Look out for more stories on nurses from Partners In Health (PIH) sites in the weeks leading up to International Nurses Day on Tuesday, May 12.

When Chisomo Kondowe arrived at the Mulanje Mission Hospital in Malawi to begin her nursing career, she thought she knew what to expect.

Kondowe had dreamed of becoming a nurse for years, undergoing skepticism from her family—who wanted her to pursue law—in addition to the intense coursework and preparation required to enter the field.

Soon after Kondowe started, the hospital matron, one of the senior leaders of the hospital, took notice of her. She saw Kondowe’s potential and quickly promoted her to nurse in charge, which meant Kondowe would be running the maternity ward almost immediately out of nursing school.

She was 22 years old.

Kondowe was thrilled and excitedly accepted.

“I think (the hospital matron) understood me well,” Kondowe said. “I was young and I was willing and I showed enthusiasm into taking up that role.”

But it soon became one of the “hardest and most challenging” experiences in her professional career.

Despite her initial eagerness about the role, Kondowe hadn’t had formal leadership training and was learning her new position while already working in it. She felt immense responsibility to care for the mothers and babies in her unit.  

To make matters worse, some of the older nurses talked poorly about her because of her age.

“I had nurses who were older than me who undermined my leadership, who would look down upon me,” Kondowe said. “Who even coaxed the mothers saying, ‘No, she's too young to take care of you.’”

But Kondowe refused to give up. She stayed and learned, growing into the leader the Hospital Matron always saw in her.

Now, decades later, Kondowe has brought her passion and experience of being a nurse leader to Abwenzi Pa Za Umoyo (APZU), as Partners In Health (PIH) is known as in Malawi, and has helped to transform care and passionately serve the country’s children.

Kondowe "Heard the Calling" of Nursing

Kondowe’s father did not want her to be a nurse.

“He kept on saying, ‘It's a low paying job. You will be forced to be taking care of all your relatives.'”

But when Kondowe’s grandmother got sick and she began caring for her, her passion for the profession only grew. Kondowe helped her with her medication, eating, walking, or even just sat by her bedside. Over time, Kondowe watched her grandmother grow healthier. She imagined being able to provide the same consideration and care for all patients, even ones who were not her relatives.

Rather than pursuing law, as Kondowe’s father hoped she would do, Kondowe applied to nursing school. She felt that being a nurse was “embedded” in her.

“We always said if you're becoming a nurse, you must have heard the calling of becoming a nurse,” she said. “You just didn't walk into nursing, but you actually had a call upon your life that you're going to be a nurse.”

It’s been decades since Kondowe was a nurse in charge at the hospital in Mulanje. Over the years, she was promoted to Antiretroviral Therapy (ART) Coordinator and eventually Hospital Matron—taking over the role of the person who once saw potential in the 22-year-old Kondowe.

Her work in nursing has taken her to different countries, including South Sudan, where she was an international registered midwife for a project aimed at reducing maternal and neonatal mortality in the country.

Then, in 2021, she joined APZU as a pediatrics nurse mentor in Neno District. Kondowe helped run APZU's newly established Pediatrics Development Clinic (PDC), a unit focused on providing comprehensive medical, developmental, and nutritional support to high-risk infants and children under 5 years old.

“One of the biggest changes that I really appreciate was removing the stigma,” Kondowe said. “There was a lot of stigma around women having children with disabilities, women having children with complications, and how much of the time they were discriminated in our community. But when PDC came, there was a lot of change: women would come out openly, women would invite other women to the program.”

The initial goal was to enroll 100 children in three years.

At the end of the first year, there were more than 300 children involved with PDC. Over time, with nutrition support, physiotherapy, and tailored treatment for the specific needs of the patient, children were able to be discharged back into the community.

To date, more than 950 children have enrolled.

“That's why I have so much attachment to the PDC,” Kondowe said. “Because it's something that we saw how it started, and the steps that were added to the program, and how it grew to become what it is today.”

"Why Am I Jumping?"

Throughout Kondowe’s career, her leadership has sometimes brought challenges—but always with the best interests of her patients in mind.

Early in her career, before Kondowe joined APZU, she was a nurse in the maternal ward of a different hospital. There was a patient who had been in labor for a long time, and Kondowe was growing concerned. When she told the doctor, he kept encouraging her to "wait one more hour," Kondowe recalled.

She pushed back, even though she worried the decision would be unpopular, because she knew the mother needed treatment immediately.

“At first I thought I would get in trouble for that,” she said. “But I said, ‘No, let's get in trouble for the safety of this mother and her baby.’”

They both lived.

Kondowe said the interaction—though tense at the time—set a precedent for the hospital. Higher standards were set to ensure doctors were capable and willing to do work the right way.

In the next year, the hospital reported zero maternal deaths—an incredible achievement, especially given that Malawi's maternal mortality rate is at about 225 deaths out of every 100,000 births. That's over 13 times the amount in the United States, which is at about 17 deaths per 100,000 births.

Kondowe learned to trust herself and push back for her patients, even if it was hard. She recalled a lesson a teacher gave on the first day of nursing school, which she has carried with her ever since.

“She came and then she asked us as a class, ‘If somebody came to you and said, “Jump,” what would you do?’ Most of us answered, ‘I would jump.’ And she says, ‘No, no, no. That's not how you bring about change in any place or in any profession, especially nursing. Because if somebody came to you and said, “Jump,” you should be able to ask them, “How many times am I supposed to jump? Why am I jumping? What is the outcome of the jumping?”’”

Kondowe hopes to see more nurses becoming empowered and innovative—which is one of the reasons she was drawn to join APZU later in her career. She took notice that the CEO of PIH, Sheila Davis, is a nurse, in addition to noticing the amount of grants and fellowship opportunities supported by PIH to expand nursing leadership training and growth.

Kondowe is passionate about connecting nurses to one another and creating spaces for them to support each other.

“Because of being mentored at a younger age, I was able to motivate others to say, ‘It's not about how old or how young or where you are coming from, but it's what you can bring out from what is being put before you.’”

Two years ago, she was promoted from pediatrics nurse mentor to primary health care manager at APZU. She spends her days in Neno, working to strengthen health systems with patients at the center of all decision making.

Now, every day, she lives her “calling.”

Since the Trump administration took office over a year ago, systems of aid that had been built over decades fell into disarray. Resources that had been a lifeline for millions of people around the world disappeared overnight. Organizations like Partners In Health (PIH) rushed to help fill the gaps while advocates and experts appealed to members of Congress to restore foreign aid funding.  

This month, a frightening reality emerged: updates from the United States Department of State revealed that national supply chains are in immediate danger. Dr. Alain Casséus, infectious diseases division chief and principal investigator for the PEPFAR Project for Zanmi Lasante, PIH's sister organization in Haiti, knows the country will feel the effects of a supply chain collapse immediately. To explain this rapidly approaching change, he shares his firsthand perspective on what would happen to the people of Haiti if these systems fail. Below is a piece Casséus originally published on Substack. 

⎯

When the Supply Chain Is the System

There is a warehouse in Port-au-Prince. It sits in the Fleuriot Industrial Park, sixty thousand square feet of pharmaceutical-grade storage, climate-controlled on one side, ambient on the other, with an 82-square-meter cold room holding reagents and biologicals at precisely 2-8°C. A backup Thermo King container stands ready for overflow. On any given day, eight to fifteen million dollars’ worth of antiretrovirals, viral load reagents, HIV test kits, pediatric drug suspensions, and laboratory supplies are stored there, sorted across roughly four hundred unique product lines. Every month, some six hundred dispatches leave this building bound for 272 health facilities scattered across Haiti’s ten departments—clinics in the Artibonite valley, hospitals in the Central Plateau, treatment centers in the southern peninsula, faith-based dispensaries in places most maps don’t bother naming.

Few people outside the global health supply chain world have heard of this warehouse. It has no public profile. It does not appear in foreign policy debates. It is not the kind of thing that trends.

And yet, for roughly 140,000 Haitians living with HIV, and for the thousands more diagnosed with tuberculosis each year, this warehouse—and the system that feeds and empties it—is the single most important piece of infrastructure in the country. More important than the shuttered parliament. More important than the airport, which hasn’t handled a commercial flight since November 2024. More importantly, in the most literal sense, than anything the Haitian state itself operates.

That system is called GHSC-PSM. It is run by Chemonics International under a USAID contract. And it is being shut down.

I. A System You Only Notice When It Disappears

The full name—Global Health Supply Chain Program, Procurement and Supply Management—is the kind of acronym-heavy bureaucratic title designed to convey seriousness while discouraging curiosity. It tells you nothing about what the program actually does, which is this: it buys the medicines that keep HIV-positive Haitians alive, stores them in controlled conditions, and delivers them to the clinics where patients show up each month hoping the drugs are there.

This sounds simple. It is not. In most PEPFAR countries, GHSC-PSM handles procurement and delivers to the national medical stores. The government takes it from there. Haiti does not have a national medical store system for HIV commodities. There is no “from there.” GHSC-PSM manages the entire chain: international procurement under negotiated global contracts, customs clearance at Port-au-Prince, warehousing at Fleuriot, and last-mile delivery via contracted local trucking companies to every single facility. It quantifies demand. It forecasts need. It manages the cold chain. It runs the electronic logistics management information system—SYGDOCC—that tells everyone what is where.

Among the 73 countries where GHSC-PSM operates, Haiti is one of roughly twenty where the program manages end-to-end distribution. Among those twenty, it is the one where the gap between what the program provides and what the country can provide on its own is widest. The Center for Global Development calculated that USAID supply chain funding to Haiti — $23.7 million per year — represents 37% of the country’s total domestic government health expenditure.

That is the highest ratio of any country in the world.

The government of Haiti, for its part, allocates roughly $250,000 per year to HIV, TB, and malaria combined. After the PEPFAR crisis began in January 2025, this was increased to a $900,000 national budget line for ARV procurement—a meaningful gesture, representing approximately 3.8% of the annual USAID contribution it would need to replace.

There is a temptation, when confronting numbers like these, to reach for the word “dependency”—as though the problem were one of weak national character or misplaced paternalism. But dependency implies a relationship that could be otherwise. What we are describing in Haiti is something closer to substitution. The supply chain was never Haitian. It was always American — designed, funded, operated, and managed by a Washington-based contractor under a USAID contract. The question was never when Haiti would take it over. The question was whether anyone would notice when it stopped.

II. Who Pays, Who Delivers, Who Disappears

To understand why the GHSC-PSM wind-down matters so much, you need to understand the architecture it sits inside: an architecture of almost total external dependence that has been decades in the making.

PEPFAR contributes approximately 79% of Haiti’s national HIV response. The Global Fund provides about 18%. The Government of Haiti covers roughly 2%. Under COP23, PEPFAR allocated approximately $112 million annually to Haiti, with $8.76 million earmarked for ARVs, $6.28 million for HIV laboratory services, including viral load and early infant diagnosis, and smaller amounts for supply chain management and lab systems strengthening.

The Global Fund’s current grant (Grant Cycle 7, 2024-2026) provides approximately $82 million for HIV and TB combined, with World Vision International as the principal recipient and GHESKIO, PIH/Zanmi Lasante, and the national programs as sub-recipients. A separate $7.9 million goes to health systems strengthening through MSPP’s project management unit.

The system operates on two parallel tracks that have never fully merged, despite years of aspiration to do so. Track one: HIV commodities flow through GHSC-PSM—international procurement, customs, Fleuriot Warehouse, 3PL delivery to facilities. This track bypasses PROMESS, Haiti’s national essential medicines program, entirely. Track two: TB and malaria commodities flow through the Global Fund to PROMESS, then through ten departmental depots to facilities. More than twenty distinct actors are involved across both tracks.

The implementing partners who depend on this machinery are organizations that have spent decades building Haiti’s HIV response from nothing. PIH, through its Haitian sister organization Zanmi Lasante, runs 13 hospitals and health centers in Plateau Central and Bas Artibonite, among the country’s most remote regions. PIH launched one of the world’s first ARV treatment programs in a resource-limited setting in 1998, before PEPFAR existed. They have achieved near-95-95-95 targets in their catchment areas, making Plateau Central one of the most successful HIV programs in the Caribbean. GHESKIO, the oldest AIDS research and treatment center in the developing world, serves metropolitan Port-au-Prince. Over half its staff have been displaced by gang violence in the past three years.

None of these organizations procure their own ARVs. None operate warehouses. They all receive their HIV commodities from the Fleuriot Warehouse, delivered by GHSC-PSM’s contracted truckers.

When those trucks stop coming—and they will—there is nothing behind them.

III. The Particular Genius of Last-Mile Delivery in a War Zone

Perhaps the most quietly remarkable thing GHSC-PSM has done in Haiti is something that, by its nature, resists celebration: it has kept delivering medicines in conditions that would have defeated most logistics operations on earth.

In early 2024, when the Viv Ansanm gang coalition launched coordinated assaults across Port-au-Prince, shutting down the port and the airport and seizing control of every major road artery, GHSC-PSM’s Haiti team arranged something unprecedented. They partnered with the World Food Programme to transport ARVs from Port-au-Prince by barge — sea transport around the coast to reach distribution points that could no longer be reached by road. By the end of the quarter, almost all 270 health centers had received vital supplies valued at $2.7 million.

This kind of adaptive logistics (improvising maritime routes under active armed conflict) is not a function you can write into a transition plan. It is the product of institutional knowledge accumulated over a decade: which roads are passable on which days, which local truckers have relationships with which armed groups, where the alternate routes are, when to use barges, when to wait. It is the kind of knowledge that lives in people, not systems, and that disappears when those people leave.

The Fleuriot Warehouse itself tells a similar story. Run by an all-female management team recognized for near-perfect stock accuracy — best-in-class globally within GHSC-PSM — the warehouse handles PEPFAR commodities as well as Global Fund HIV products and supplies for UN agencies. It is, in effect, the shared physical infrastructure on which the entire HIV response depends, regardless of which donor funded the pills inside.

For viral load and early infant diagnosis, GHSC-PSM’s 2019 global procurement awards to Abbott, Hologic, and Roche established all-inclusive contracts that brought Haiti’s per-test cost down from roughly $21 to $13.50, with service-level agreements covering instrument uptime, maintenance, and training. No other procurement mechanism on earth offers these terms. They are a function of PEPFAR’s aggregate global volume, over ten million tests per year, which gives Chemonics leverage that no individual country, and no alternative pooled procurement platform, can replicate.

When people talk about “replacing” GHSC-PSM, they are usually talking about procurement — can the Global Fund buy ARVs? Can PAHO purchase medicines? The answer to both is yes. But procurement is not the problem. The problem is everything that happens after the medicine arrives in-country. And in Haiti, “everything that happens after” is the entire supply chain.

As Emily Bass, the investigative journalist who has provided the most detailed real-time documentation of GHSC-PSM’s emergency closeout, put it: “None of the existing procurement mechanisms identified as eventual replacements for the US supply chain enterprise provide the range of services, including in-country delivery and logistics, for the commodities that GHSC-PSM supported."

IV. The Country Behind the Supply Chain

There is a reason Haiti is different from every other country in the GHSC-PSM portfolio, and it is not primarily about health systems. It is about the collapse of the conditions that make any system possible.

As of mid-2025, approximately 90% of Port-au-Prince is under the control of the Viv Ansanm coalition: an alliance of formerly rival gangs estimated at 12,000-20,000 members, roughly 3,000 of them heavily armed. Every national road artery passes through gang-controlled territory. Route Nationale 1 north to Cap-Haitien. Route Nationale 2 south to Les Cayes. Route Nationale 3 east to Hinche and the Central Plateau. Blockades, ambushes, and extortion tolls are routine.

The Varreux fuel terminal, where 70% of Haiti’s fuel is stored, has been blockaded by gangs before, for two months in 2022. This matters for cold chains. You cannot keep reagents at 2-8°C without power, and you cannot run generators without diesel, and you cannot get diesel when armed groups control the terminal.

The main port has been “inaccessible due to insecurity” and “unreliable for consistent cargo delivery” since late 2024. International commercial flights to Port-au-Prince have been suspended since November 2024. In a country where 70% of medications are imported, this is an existential threat.

As of February 2025, only 10% of health facilities nationwide were fully operational. In Port-au-Prince, over 60% were closed or non-functional. Nine of forty HIV/TB treatment sites in the capital had shut down. MSF, or Doctors Without Borders, an organization that operates in active war zones as a matter of institutional identity, permanently closed its main Port-au-Prince emergency centre in October 2025 and suspended its Bel-Air clinic in January 2026 after a former volunteer was killed at the entrance.

Forty percent of Haiti’s medical staff had left the country by the end of 2023. MSPP reported 39 kidnappings of doctors in the first half of 2023 alone. A survey found 44% of health workers reported a colleague had been kidnapped in the previous two years. The national ratio of health professionals stands at 6.4 per 10,000 population, against a target of 44.5.

There are 1.4 million internally displaced persons—a record, up 34% since December 2024. Each one a potential treatment interruption. Each one a person who was in care somewhere and is now somewhere else, without medicines, without a clinic, without a chart.

This is the environment in which someone, somewhere, is supposed to design a “transition.”

V. The Transition That Isn’t

Here is what we know about the plan to replace GHSC-PSM in Haiti: there isn’t one, for now.

The GHSC-PSM contract was extended through November 28, 2026, intended as a bridge to the NextGen successor program. Then the Trump administration froze all foreign aid on January 20, 2025. A stop-work order halted all operations on January 24. A limited waiver on February 1 allowed some HIV treatment to resume, but as of February 9, fewer than 10% of surveyed PEPFAR partners had restarted services. PEPFAR’s statutory authorization expired March 25, 2025, without reauthorization—the first time in its history. USAID was formally absorbed into the State Department. Eighty-six percent of USAID staff and contractors were terminated or departed. The FY2026 budget request cut PEPFAR by 40%.

The NextGen PSA HIV/AIDS contract (the roughly $5 billion successor to GHSC-PSM’s core procurement function) was cancelled in August 2025. USAID stated it “no longer has a requirement for the services described." The program being shut down has no designated successor mechanism.

By March 30, 2026, emergency closeout planning had formally begun. An internal Chemonics email documented by Emily Bass laid out the arithmetic of collapse: eight countries facing program halts by April 30, 2026, thirteen more in subsequent months. The State Department simultaneously denied that any direction to cease operations had been issued.

Under the America First Global Health Strategy, the U.S. has been negotiating bilateral MOUs with PEPFAR-recipient countries. By April 6, 2026, twenty-seven countries had signed, totaling at least $20.1 billion for 2026-2030 (Think Global Health, April 2026). All were African nations or a handful of Latin American countries. Haiti is not among them.

The Global Fund Advocates Network confirmed in November 2025 that “MOUs are being drafted by the US Embassy and the MOH in Haiti." But negotiating a bilateral agreement with a government that controls almost none of its national territory, has no fiscal capacity for cofinancing, and is engulfed in armed conflict is, to put it charitably, a hard case.

What about the Global Fund? Its $82 million Haiti grant is active. Its Pooled Procurement Mechanism already handles about 90% of procurement within the grant. But the PPM delivers to port or central stores. It does not manage in-country logistics, warehousing, customs, last-mile delivery, or LMIS—the functions GHSC-PSM performs and that keep the entire system from being just a pile of medicines in a building somewhere. The wambo.org procurement platform has been experiencing performance issues. The grant budget was assembled before USAID withdrew and doesn’t include resources to absorb USAID-funded functions.

PAHO’s Strategic Fund can purchase medicines. But Haiti cannot pre-finance orders. And PAHO does not deliver to facilities.

KFF reviewed eight global pooled procurement mechanisms and concluded that all have “key structural gaps relative to GHSC-PSM’s end-to-end model." The polite way of saying: everyone can buy the drugs, no one can deliver them.

VI. What Fails, and in What Order

Not everything breaks at once. But the sequence matters, because it determines where intervention is most urgent — and where the window is already closing.

The first thing that fails is distribution. The moment GHSC-PSM ceases operations, the monthly delivery cycle to 272 facilities stops. No other organization in Haiti has the 3PL contracts, the routing knowledge, the security protocols, or the warehouse operations to substitute. The Fleuriot Warehouse, containing millions of dollars in inventory, becomes an inaccessible asset if Chemonics staff depart and the lease lapses. Medicines exist. They simply cannot reach patients.

This is the distinction that gets lost in policy conversations about “procurement mechanisms.” National stock and point-of-care availability are different things. A warehouse full of ARVs in Port-au-Prince does nothing for a patient in Hinche if no truck is coming.

The second thing is viral load and early infant diagnosis testing. The global contracts with Abbott, Hologic, and Roche—which brought Haiti’s per-test cost to $13.50 and included maintenance SLAs—are tied to GHSC-PSM. Without contract management, equipment maintenance stops, reagent supply becomes irregular, and the negotiated pricing disappears. VL testing turnaround times, already described as “unacceptably high” in COP23, will deteriorate further. EID testing for HIV-exposed infants is among the most time-sensitive diagnostics in medicine: a delay of weeks can mean the difference between a treated child and a dead one.

Pediatric ARVs are already in crisis. As of May 2025, Haiti had fewer than six months of stock in two pediatric ARV lines, one of only four countries globally in that position. Pediatric formulations (DTG-10 dispersible tablets, nevirapine suspensions, raltegravir granules) have complex manufacturing, limited suppliers, and long lead times. They are the kind of products that simply do not appear through alternative channels on short notice.

Adult ARVs have a fragile buffer. The emergency flight in February 2025 delivered roughly six months of supply. Haiti’s high multi-month dispensing rate (72% of patients receive 6+ months at a time) provides some patient-level cushion. But this buffer is finite and was calibrated to pre-crisis volumes. It is being drawn down without systematic replenishment.

TB drugs are at lower immediate risk because they flow primarily through PROMESS and the Global Fund track rather than GHSC-PSM. But the “Common Basket” coordination mechanism — intended to unify quantification across both donors — loses its PEPFAR half. And site-level TB drug stockouts were already documented at two facilities in September 2024.

Over the medium term, six to eighteen months, everything compounds. The cold chain fails as maintenance lapses and fuel becomes unavailable. SYGDOCC, the eLMIS, loses technical support; without data, supply planners are blind. The GeneXpert network—already down to only two sites connected via VPN as of May 2024—goes fully offline. TB case detection, already at only 63% in a country with the highest TB incidence in the Western Hemisphere (149 per 100,000), collapses further.

And the cascade begins: patients miss refills, viral loads rebound, resistance emerges, onward transmission accelerates. The 50,000+ people on ART in the West Department alone, identified by UNAIDS as “at high risk of disruption” before the closeout even began, begin falling out of care.

The expected order of failure:

1. Last-mile distribution stops (immediate)  
2. VL/EID testing deteriorates (weeks)  
3. Pediatric ARV stockouts deepen (already occurring)
4. LMIS data goes dark (1-3 months)
5. Facility-level adult ARV stockouts begin (3-6 months)
6. National adult ARV stocks deplete (6-12 months)
7. GeneXpert network goes offline (3-6 months)
8. TB case detection collapses (6-12 months)

VII. The Comparative Cruelty of Context

It would be misleading to suggest that the GHSC-PSM transition is only dangerous in Haiti. It is dangerous everywhere. But the nature of the danger in Haiti is categorically different from what Uganda, Zambia, or Mozambique face — and understanding why illuminates something about the limits of the entire global health architecture.

Zambia (composite readiness score: 3.8 out of 5) is the benchmark. ZAMMSA—the national medicines agency—performs at 78-93% across central supply chain functions. Domestic procurement funding reached 52% in 2023. The eLMIS covers nearly every facility. A $362 million Global Fund grant explicitly targets supply chain strengthening. Zambia has problems. It does not have a crisis.

Uganda (3.2/5) occupies an aspirational middle. Its 10-Year Supply Chain Roadmap is the most sophisticated transition plan among comparators. The National Medical Stores has real warehouse capacity: 43,000 pallets. But 77% of ARV financing remains donor-funded, and PEPFAR covered 100% of last-mile transport. When the January 2025 freeze hit, ARV supplies dropped to seven-day rations at some facilities in midwestern Uganda. At one site, babies were born HIV-positive because the warehouse was locked and drugs went undelivered. Uganda has a plan. It is years from executing it.

Mozambique (2.3/5) is the cautionary tale. A 2013 strategic plan for pharmaceutical logistics was never implemented over eleven years. CMAM received legal supply chain authority only in March 2024. A 2025 audit found 87% of facilities with significant stockouts and $15.8 million in expired medicines at the central level. Mozambique has a framework. It has not built the house.

Haiti (1.1/5) is not on the same scale.

When PEPFAR froze, 128 of 181 PEPFAR-supported sites in Haiti halted completely, that’s a 71% collapse rate. In the African comparators, sites were disrupted but continued operating. The difference reveals something fundamental: in those countries, the government, however weakly, provides a floor. In Haiti, there is no floor. GHSC-PSM was not supporting a national system. It was performing the functions that a national system would perform if one existed.

The distinction matters because transition planning assumes something to transition to. In Zambia, you can design a phased handover to ZAMMSA. In Uganda, you can fund the Roadmap. In Haiti, there is no institution to hand over to, no budget to phase in, no secure corridor to transport through, and—increasingly—no facilities to deliver to.

VIII. The Signals Before the Silence

One of the cruelties of supply chain failure is that it is invisible until it is catastrophic. A patient who receives their last bottle of ARVs does not look different from a patient who receives their next-to-last bottle. The warehouse that dispatches its final shipment looks exactly like the warehouse that dispatched the one before. The system appears functional until, quite suddenly, it doesn’t.

This is why early warning indicators matter — not as an academic exercise, but as the only tool available to detect collapse before it becomes irreversible.

What to Watch Weekly

What to Watch Monthly

What to Watch Quarterly

The most critical single indicator is whether the Fleuriot Warehouse is open and staffed. If it closes, everything downstream fails immediately. The second most important is viral load test turnaround time — a sensitive proxy for overall system health that deteriorates early and reflects supply chain problems before they show up in patient outcomes.

IX. Three Futures

Best Case: Coordinated Transition (Probability: ~10-15%)

A bilateral MOU is signed before GHSC-PSM closes. U.S. funds are channeled through the Global Fund or PAHO for procurement continuity. The Fleuriot Warehouse is transferred to a designated operator (perhaps World Vision, perhaps a local 3PL) with bridge funding. The Global Fund Emergency Fund is activated specifically for in-country logistics. WFP and PAHO provide distribution support. SYGDOCC deployment continues under the RSSH grant.

This scenario requires simultaneous coordinated action by the State Department, Global Fund Secretariat, PAHO, MSPP, and World Vision in a gang-controlled operating environment where basic meetings are difficult to schedule. No transition of this complexity has been executed under comparable conditions. As of April 2026, no evidence of this level of coordination has emerged.

Most Likely Case: Fragmented Patchwork (Probability: ~55-65%)

GHSC-PSM closes down over months in a managed but incomplete process. Some stocks are transferred to PROMESS or partners, but without integrated distribution management. The Global Fund expands procurement somewhat, but cannot fill the logistics void. Implementing partners—PIH/Zanmi Lasante, GHESKIO, World Vision—improvise local distribution using their own resources. PAHO provides episodic emergency shipments, as it did with 7.7 tons in February 2025. VL/EID testing degrades. Stockouts hit the most insecure and remote areas first, then spread. Data visibility deteriorates. The emergency ARV buffer is consumed without replenishment.

The outcome: twelve to twenty-four months of degraded but not entirely collapsed service delivery. ART coverage drops from 84% to an estimated 60-70%. VL testing coverage falls sharply. Pediatric programs suffer most. TB case detection dips below 50%. Twenty years of gains erode but are not entirely lost…provided partner organizations can sustain improvised operations long enough for a new arrangement to materialize.

Worst Case: Systemic Disruption (Probability: ~20-30%)

GHSC-PSM closes abruptly. The warehouse lease lapses or the facility is compromised by gang activity; millions in inventory are lost. No distribution mechanism is established before facility stocks run out. VL/EID testing ceases. The GeneXpert network goes offline. Multiple ARV formulations stockout nationally. Implementing partners lose operational funding. The security situation deteriorates further, closing more facilities. Treatment interruption cascades. Viral resistance emerges. Onward transmission accelerates. TB case detection effectively stops.

Haiti’s HIV prevalence—driven below 2% over two decades of sustained work, from over 6% at the epidemic’s peak—begins to reverse.

The worst case does not require a catastrophic event. It requires the absence of coordinated action in a context where coordination is already nearly impossible. Every individual failure (warehouse closure, 3PL contract lapse, cold chain breakdown, LMIS blackout) is independently probable. Their simultaneous occurrence creates a systemic failure that no single actor can reverse.

X. What Is to Be Done

For program managers

The immediate priority is contingency planning for distribution. Map which facilities are reachable by which routes under current security conditions. Identify local transport providers, however compromised their access may be. Pre-position maximum stocks at facility level while the warehouse still operates. Expand multi-month dispensing to twelve months where possible, not best practice, but a survival strategy. Explore direct maintenance and reagent agreements with Abbott, Hologic, and Roche, independent of GHSC-PSM. The per-test cost will be higher. The alternative is no testing at all.

For PEPFAR and the U.S. government

The highest-impact single action is keeping the Fleuriot Warehouse operational—through a new contract, a Global Fund transfer, or a bridge arrangement with Chemonics. Losing the warehouse means losing the physical infrastructure on which everything depends. Any bilateral MOU must include specific provisions for in-country logistics, not just commodity procurement. An agreement to buy ARVs through the Global Fund, but not to fund their delivery in Haiti’s security environment, is an agreement to procure medicines that will sit in a building.

For the Global Fund

The Emergency Fund should be activated proactively for in-country logistics—a function outside the Fund’s normal scope, but one the crisis demands. The GC8 allocation process should treat Haiti as a special case requiring logistics funding beyond normal parameters. The wambo.org platform issues need urgent resolution.

For implementing NGOs

PIH, GHESKIO, CMMB, and others need to prepare for a period where they function as de facto supply chain operators in their catchment areas, a role for which they were never designed or funded. Build emergency stockpiles. Coordinate with WFP and the Logistics Cluster on distribution alternatives. Prepare community-based dispensing protocols. And document everything! Because the amfAR finding that bilateral MOUs lack measurable metrics means that implementing partner data may be the only accountability mechanism available.

XI. Coda: The Architecture of a Preventable Catastrophe

There is something revealing about the phrase “supply chain transition.” It is the language of managed change — orderly, planned, sequential. It assumes a handover from one functioning system to another. It assumes institutional capacity to receive what is being handed over. It assumes, at a minimum, the existence of roads that trucks can drive on and warehouses that staff can enter.

None of these assumptions hold in Haiti.

What is occurring is not a transition. It is the withdrawal of a system with no successor in place, no institutional capacity to absorb its functions, and no operating environment in which conventional alternatives can function. The reference brief that grounds this analysis states it precisely: “The situation represents a supply chain continuity risk rather than a pure funding gap.”

Money can be redirected through the Global Fund, through PAHO, through bilateral channels. But money does not drive trucks through gang checkpoints. Money does not maintain cold rooms during power outages. Money does not negotiate passage through Viv Ansanm territory. Money does not deliver dolutegravir suspensions to a health center in Plateau Central accessible only on foot—which is what Zanmi Lasante staff have done, repeatedly, because the road was blocked and the patients were waiting.

Haiti is the most supply-chain-dependent country in the world by USAID funding share, with the lowest institutional capacity, the worst security environment, and no signed transition agreement. The expert consensus—from CGDev, from CSIS, from KFF, from UNAIDS, from Partners In Health, from the journalists tracking the closeout in real time—is unambiguous: without deliberate, coordinated, and rapid intervention, the second half of 2026 will see Haiti’s HIV and TB programs enter a period of systemic degradation from which recovery will take years and cost lives.

The early warning indicators are already flashing. Pediatric ARV stocks are in shortage. Viral load turnaround times are “unacceptably high.” Two TB treatment sites ran out of drugs in September 2024. LMIS reporting rates are below target. The GeneXpert network is functionally disconnected. And the institution that held all of this together, however imperfectly, however dependent on foreign money and foreign management, is being wound down.

There is a warehouse in Port-au-Prince. It is still open, as of this writing. The women who run it still show up. The trucks still leave when the roads allow it. The cold room still hums at 2-8°C.

The question is, for how long.  

⎯

Dr. Alain Casséus currently serves as Infectious Diseases Division Chief and Principal Investigator for the PEPFAR Project at Zanmi Lasante, PIH’s sister organization in Haiti. Dr. Casséus has worked with ZL since 2007, with a primary focus on HIV/TB and improving care through research. In his nearly two decades working in Haiti, he has led massive vaccination campaigns, conducted cross-organizational research, and ensured thousands of HIV patients have received care - by his hand and others. 

In the United States, there's an opioid crisis. In Sierra Leone, there’s a kush (a potent mixture of substances) crisis.

The drug crisis is global. And it’s a severe public health emergency—causing an estimated 600,000 deaths around the world every year.

Treating people with substance use disorders is complex, regardless of where they live or their income. But recovery is possible. In Sierra Leone, Partners In Health (PIH) is providing comprehensive care for people with substance use disorders—and seeing promising results among patients and their families.

Treating complex wounds

Last fall, a group of 50 patients—including 42 with significant wounds covering large areas of their feet and legs—were admitted to PIH-supported Sierra Leone Psychiatric Teaching Hospital (SLPTH). It's unclear exactly what causes such wounds, but they’re increasingly appearing on people who use kush, a highly addictive mixture of opioids, sedatives, stimulants, and more.

Some of the sores were so severe, infected with maggots, leaving patients unable to walk or stand. For some, the intense pain left them pleading for amputation.  

The situation required rapid intervention.  

“It was a learning curve. This is a psychiatric institution where people were not ready to be nursing wounds,” explains PIH Sierra Leone Mental Health Program Manager Chenjezo Gonani, noting the lack of supplies and knowledge gaps. Still, he thought: “How best can we support these people? How best can we manage to make their wounds better?”

In November, nurses at SLPTH’s drug treatment and rehabilitation center participated in a two-day training co-led by Sam Kelts, PIH’s manager of grassroots strategy. Outside of PIH, Kelts works part-time as a community health nurse in Boston, primarily caring for people with substance use disorders. Many of the wounds she treats in Boston are caused by contaminants in the drug supply that lead to rapid tissue damage once introduced into the bloodstream. She explained that in Sierra Leone, the wounds look very similar; however, the drug supply isn't tested in the country, so the exact cause is unknown.

Regardless, she knew treatment and recovery were possible.

A wound-certified nurse, Kelts led 10 nurses through a day of classroom learning around the science behind wound development, assessment, and proper cleaning and dressing techniques. On the second day, nurses put their learnings into practice with hands-on demonstrations and care best practices with patients in the facility.  

From November 2025 through January 2026, nurses provided around-the-clock care for patients at the SLPTH. Back in Boston, Kelts virtually provided ongoing accompaniment and support.

Upon returning to the SLPTH in January, Kelts witnessed extraordinary outcomes.

"Every patient I saw had either full or substantial healing with really healthy-looking wounds," says Kelts. "This is a direct result of the countless hours of detailed, careful wound care put in by the team of nurses. It's incredibly impressive to do wound care of that caliber with so few resources."

The wound outcomes at the SLPTH were better than she sees in Boston, explains Kelts.

“This demonstrates the power of high-quality training, clinical care, and accompaniment,” says Kelts. “It’s a huge area of work to continue to evolve.”

‘Are you sure this is my son?’

Alongside wound care, all patients received mental health care. At admission, social workers conduct a detailed psychosocial assessment to identify each patient’s needs. Based on the results, patients were connected to appropriate services, including psychotherapy, occupational therapy, and skills-building sessions.

From the beginning, the team focused on what would happen to patients after being discharged. Most patients were living in the streets and disconnected from their families and friends for years. Rebuilding those relationships required intentional, and often difficult, mediation.

The psychosocial team began by taking detailed social histories—identifying loved ones and locating them across the country. From there, they reached out directly, traveling into communities.

When families were shown photos, and told their relatives were receiving care and doing well, reactions varied. Some “believed that their loved ones died a long time ago,” says Gonani.

Others were in disbelief.

“Are you sure this is my son?” a relative asked, as the team showed them a current photo.

Each family was invited to a discharge ceremony to celebrate their loved one’s recovery. At first, not all families were immediately open to reunification. To address this, the psychosocial team facilitated conflict resolution meetings between patients and their families. They also involved community leaders, including chiefs, faith leaders, and other respected figures, to rebuild trust and encourage reunification.

These efforts successfully reunited 48 out of 50 patients with their families; and culminated in a celebratory discharge ceremony at the SLPTH.

“It was really beautiful to see families embrace their loved ones,” says Gonani.

Back home, patients continue to receive regular visits from community health workers who monitor medications and provide long-term support.

An evolving crisis

The kush crisis remains complex and evolving. But the work at the SLPTH is helping shape a model for care by integrating clinical treatment, mental health support, and community reintegration. SLPTH’s drug and rehabilitation center opened in June 2024, in response to the country’s national emergency on substance abuse. It’s staffed by a multidisciplinary team including a drug addiction specialist, one clinical psychologist, three psychiatrists, seven resident psychiatrists, and a cadre of nurses.

The team is also collaborating with PIH colleagues in Liberia, a neighboring country also facing a kush crisis, to expand and adapt approaches to substance use care across similar contexts. In rural Maryland County, Liberia, PIH provides outpatient community therapy for people with substance use disorders. In Kono District, Sierra Leone, a similar community-based approach is underway.  

“I’m so excited about what we have learned,” says Gonani. “We are ready for the next 50 patients.”

Partners In Health (PIH) utilizes hill days to bring constituent concerns directly to their members of Congress. A hill day is an issue-specific advocacy event where constituents travel to Washington, D.C., or their state capitol to meet with legislators or staff to influence legislation or funding for a particular cause. According to congressional staffers, in-person visits from constituents are the most influential way to communicate with a legislator who is undecided on an issue.

PIH has helped organize hill days to advocate for tribal health care funding, community health workers, and overall global health funding, among a number of other key issues related to health equity. Most recently, PIH joined hundreds of other advocates for our annual Tuberculosis (TB) Hill Day.  

We invite you to follow Hannah Kenny, a TBFighter and member of PIH Engage, through her 2-day experience as both an organizer and an advocate for this year’s TB Hill Day. Travel with us to Washington, D.C., on March 2 and 3 through the following images and reflections:  

Day 1: Training Day

This year, Georgetown University hosted PIH and TBfighters, alongside other TB advocates and experts, for the training day preceding a day full of congressional meetings at Capitol Hill. The training day is designed to give all Hill Day participants a chance to learn how to navigate their meetings with congressional offices and, importantly, gives folks a chance to connect with old and new friends in the fight against TB.  

“This was my second TB Hill Day, and it’s so fun to see so many familiar faces,” Kenny said. “The TB community doesn’t have a lot of opportunities like this, where experts, survivors, and grassroots advocates are all in the same room. It feels like a class reunion and the first day back at school at the same time.”

The day starts at noon, allowing for time to travel to D.C., and includes getting signed in, receiving informational folders, and being gifted with lots of merch. This year, there were friendship bracelets, pocket squares, pins, notebooks, bookmarks, and pens that were traded around between attendees.  

Kenny helped kick off the training day with fellow TBFighter, Tori Sandifer, by sharing some housekeeping reminders and thank-yous. Once the training officially started, there were presentations from TB survivors and advocates, sharing information that advocates can use in their meetings: stories of survival, information about government funding processes, tips for congressional meetings, and talking points.  

Training day also provides a chance for breakout sessions where people get to meet the other members with whom they’ll be advocating alongside, and gives them a chance to rehearse for their meetings.  

“During state breakout sessions, everything you learned during training comes together,” Kenny said. “Last year, I only went to meetings in my state of California, so my state breakout time was all with one group. This year, I accompanied meetings for six different states. It was really cool to check in with so many different groups and hear how they were coming up with unique strategies for each meeting.”

The training sessions concluded with a message from bestselling author and PIH Trustee, John Green, where he thanked everyone for being a part of the movement to end TB and emphasized the importance of the advocacy that happens both on the Hill and throughout the year. To wrap up the day, all the nearly 300 attendees gathered for a group photo. 

“We had so many people that it was hard to find a space where everyone would fit in a photo,” Kenny shared. “TB advocates have been persistently coming to the hill for over a decade, but this year, we focused on really strategic growth, trying (and succeeding!) to find participants from all 50 states.”

Day 2: Hill Day

At 8 a.m. on March 3, hundreds of folks donning “TB isn’t over” pins—that Kenny designed—gathered on the front steps of Capitol Hill. This time gives everyone a chance to connect once again before everyone splits into their meeting groups and heads out to offices for the day.  

For this year’s TB Hill Day, there were over 260 congressional meetings held—including meetings with every office in the Senate—to advocate for resources to help eliminate the world’s deadliest infectious disease. Many of the advocates in the group who have participated in other hill days have never seen one of this size.  

“One thing that makes this hill day really special is not only how many meetings we have for a group of our size, but also how these meetings were all scheduled and managed by our own advocates,” Kenny said. “Some people doggedly followed up with offices five, six, or seven times, to make sure a meeting happened. This scale is the result of a giant group effort.”

After another group photo on the steps of the Capitol, everyone dispersed to the building of their first meeting. The Congressional buildings can be a bit challenging to navigate, and include having to go through security, so it helps to have time—and accompaniment—to find the correct offices.  

Most attendees would be attending at least three meetings—which generally last around 30 minutes each—but some folks had up to twice that. Kenny, for example, attended six meetings.  

“Every meeting group is a little different,” Kenny explained. “All meetings will have at least one constituent, and some of them have many, like California or New York Senate meetings. Survivors and experts are also sent to keep meetings to share their stories or make a stronger argument.”  

Advocates generally arrive at their meeting office a bit early so they can huddle quickly before they enter. This gives them a chance to reestablish their roles, rehearse as needed, or discuss any ideas or suggestions that have come up in other meetings throughout the day.  

The vast majority of meetings are with the congressional member’s staff, as opposed to the members themselves. These staffers then take the concerns and requests of constituents to their boss, the member of Congress.  

“The most important part of these meetings is showing up,” Kenny said. “We know that our advocacy is going to take repeated efforts to achieve our goal of ending TB. I hope that by continuing to show up, we remind our representatives that we’re serious about this and that ending tuberculosis has a constituency behind it.”

With such a significant number of meetings, TB Hill Day was exhausting for many advocates, generally wrapping up around 5 p.m.  

“It was a long day, and came after a long period of hard work in preparation, but the tiredness at the end felt satisfying, like getting to the summit of a mountain after a hike,” Kenny shared.

Following their last meeting, attendees could choose how to spend the rest of their evening—some flew home, some chose to explore D.C., and some just couldn’t get enough of the infectious group energy and chose to continue spending time together.  

“This event, and this group of people, are truly something special," Kenny said. “It would be easy to become cynical about the task at hand. But cynicism was not on offer at TB Hill Day. I was surrounded by a group of people who truly believe (as do I) that we can end TB together. That faith and grit are things I value and carry with me in other parts of my life all year long.”

Once the day concluded, advocates began preparing their follow-up messages, completing next steps, and started dreaming and scheming for next year’s event, already getting excited for TB Hill Day 2027. 

Federal funding decisions can often feel incredibly challenging to follow, and the process isn’t always as linear as one might think. Tracking the flow of federal funds has become even more difficult during President Donald Trump’s second term in office, as funding cuts have affected numerous sectors.  

Vincent Lin, Partners In Health (PIH) Associate Director of Health Policy and Advocacy, joined forces with colleagues at the Health Security Policy Academy, a policy think-tank in the Division of Global Health Equity at Mass General Brigham, to create a new dashboard that provides a visual guide to public global health spending data.  

“After the hundreds of project terminations in global health across USAID back in early 2025, our goal was to figure out where funding stopped flowing and what new spending took place,” Lin said.

Congressional Appropriations  

Upholding what is written in Article I of the U.S. Constitution, Congress possesses the “power of the purse” and determines how discretionary federal funds are distributed to federal agencies. The current administration—in direct conflict with Congress’s power of the purse—has not consistently followed through with the timely disbursement of this critical funding.  

In July, the federal government cut foreign aid funding by over $8 billion through a large rescissions package. Shortly thereafter, in September, the administration withheld $4.9 billion in congressionally-approved foreign aid by using a tactic called “pocket rescissions.”  Subsequent investigations found that additional funding was being withheld by not being distributed to core lifesaving foreign aid programs such as the Global Fund and PEPFAR, the U.S. President's Emergency Plan for AIDS Relief.

Due to this volatile aid landscape, the need for more transparency in global health spending has become increasingly clear.

“Historically, there has been a lot of interest in the global health budget, which is set by Congress. But this admin is different from previous ones,” said Dr. KJ Seung, Associate Physician, Division of Global Health Equity, Brigham and Women's Hospital. “This admin might not spend what is budgeted, or spend it on something different, or spend it in a different way completely. The dashboard uses financial data to shed light on what's going on downstream. It's not the whole story, but an important part of it.”  

As of the writing of this article, the Global Fund is owed $3 billion by the U.S. State Department in already-approved funding from Congress. Based on analysis of public financial data, appropriated funds for PEPFAR are being significantly underspent. Additionally, PIH has stated our opposition to new massive funding cuts being written into global health-financing agreements by the United States State Department as part of the “America First Global Health Strategy.”

The U.S. Global Health Spending Watch Dashboard

It’s in this context that Lin, alongside partners including Seung and Leanne Friedrich, a TBFighter, helped develop the U.S. Global Health Spending Watch dashboard to track how much money the U.S. government commits to global health each year—and how that money is actually spent—to inform advocates and other global health organizations.

Friedrich helped develop the code after seeing how challenging it can be to parse data from existing public sources that report on federal spending. She hopes this new platform will be more user-friendly and easier to understand.  

“The USASpending [application programming interface] is fairly gnarly,” she said. “There are a lot of endpoints that are all slicing and grouping and summarizing data in different ways, and the input format for requests is pretty finicky.”

At present, no other organizations have translated award-level data, spending reports, and related resources into a single, accessible format for the public. This project aims to change that.

Following the Funds

By consolidating spending information into a clear, digestible dashboard, the team has created a new tool to provide greater transparency and inform future policy—particularly as decisionmakers channel funds through new mechanisms and to new priorities.

“The data available provides a picture of spending trends we haven't seen before, and where there is either more or less funding for different areas of global health spending,” Lin said.

At PIH, the terminations of programs have already undermined patient care, innovation, and health advancements for people around the world. In Lesotho, clinics were forced to close, leaving patients without access to necessary care or critical medication. In Peru, life-changing research screeched to a halt overnight, abandoning hundreds of adolescents going through treatment for HIV. In Sierra Leone, plans were being finalized for the opening of a new tuberculosis ward when funding was pulled, and Koidu Government Hospital lost a crucial resource.  

These impacts are not hypothetical. They involve real patients, communities, and health systems being harmed by cut and withheld funds. By making federal global health spending more visible—what is promised, delivered, and withheld—the U.S. Global Health Spending Watch dashboard gives advocates and the public a clearer view of how funding decisions translate into real-world consequences.

Editor's note: If you are a member of the press and eager to learn more, please see PIH's full statement here.

Editor’s note: This article was originally published in Spanish on Socios En Salud’s website.

“I wept with emotion... They told me that I had beaten it—that I was in remission...”  

María Soledad Romero repeats the phrase again carefully, as if she still doesn't fully believe she’s finally cancer-free.  

Romero is 53 years old and lives on Túpac Amaru Avenue in Comas—a district north of Lima—where she arrived when she was barely two months old. Since then, she hasn’t left the community.

In 2022, Socios En Salud (SES), as Partners In Health (PIH) is known in Peru, offered free breast cancer screenings through the ALMA project, part of their Noncommunicable Diseases (NCDs) and Cancer program. Through this effort, more than 1,800 women were screened for the first time. Romero was one of them.

Her results confirmed what would alter her life significantly: she had breast cancer.

“A million things went through my mind,” Romero said. “I have a son, three grandchildren. In that moment, I thought of them. More than myself, I thought of them.”

After receiving her diagnosis, Romero was swept up in appointments, paperwork, and impending  treatments she still hadn’t fully grasped. She was referred to the National Institute of Neoplastic Diseases (INEN) and tried to come to terms with her new normal.  

In those early days, Romero had no idea how significant her journey would be for other women and cancer patients in Peru.  

“María is the first person to achieve remission through this intervention,” said Santiago Palomino, head of the NCD and Cancer Program at SES. “At one point, the project had to shift direction—moving beyond just offering screenings—and today, it provides follow-up care to women who have already been diagnosed with breast cancer.”

For Romero, however, the process was just beginning. And though she didn't know it yet, from that point forward, she wouldn't be navigating this illness alone.  

The Power of Accompaniment

María Rosas, a community health worker (CHW) for SES’s NCD and Cancer Program, remembers traveling with Romero on her first trip to INEN to secure an appointment. At four in the morning, a vehicle from SES came to pick the women up in Comas.

“We had to be at INEN by six a.m. to secure a slot, so that (Romero) could get in and attend her clinic appointment,” Rosas said.

Rosas knows that this initial contact is often difficult. The women arrive bearing the fresh weight of a diagnosis. Sometimes, they are still speechless.  

“You don’t always know what to say,” she said. “They are despondent over the results.”  

In those moments, the work consists of simply being available: sharing a phone number, repeating instructions, and following up with calls.

This daily work—travel, phone calls, and education—is a core part of treatment for SES’s patients. In the past year alone, SES screened 496 women for breast cancer in North Lima. Of those, 372 received continuous care and support throughout their diagnostic and therapeutic journeys, including Romero.  

Early Detection, Better Support

In Peru, breast cancer is the most common cancer among women. Each year, more than 7,000 new cases are diagnosed, and around 2,000 women die from the disease. However, Peru’s Ministry of Health notes that when detected early, the likelihood of women being cured can reach 90%.

Romero has watched friends die from various types of cancer—almost always after receiving a late diagnosis. Upon receiving the news of her cancer, those images returned with overwhelming intensity: weakened bodies, hair loss, and pain that seemed to offer no respite. For several days, the future appeared to her as a succession of scenes in which she had no desire to play a part.

But after her initial shock, Romero began to rationalize her immediate situation. As she prepped herself for the journey ahead, she realized she wouldn't be able to navigate the process alone. Fortunately, she had her family and partner, as well as a support system through SES that extended beyond just medical treatment.  

“To date, we are providing clinical navigation support to 20 women with breast cancer,” said Diana Huamán, coordinator of the ALMA project. “This support consists of offering psychological counseling and social assistance to alleviate the immense burden involved in facing this disease.”

As Romero navigated chemotherapy, she was relieved—and surprised—that she could mostly stick to her normal routine. Aside from a trip to the emergency room due to joint pain after her final session of chemo, her work as a seamstress was uninterrupted.  

Although she still had a long road ahead, the journey was much less daunting.  

No One Fights Alone

Now in remission, it’s not medical procedures or specific appointments that stand out the most to Romero from her years of treatment, but rather SES’s presence: the phone calls, the messages, and the visits that required no explanation.  

“I felt that I wasn’t alone,” she said. “I felt that I had even more family than I already did. It felt so much easier.”

This feeling of presence—of navigating these scary moments surrounded by love and care, rather than loneliness and fear—echoes in the stories of other women who have received care from SES. In 2025, SES CHWs conducted 118 visits to women with breast cancer, with many of these visits ultimately preventing women from dropping out of care. That same year, 22 women who had been diagnosed completed their treatment—hopefully leading to even more women like Romero being declared cancer-free.

Over the years, Romero has borne witness to the profound significance of not having to navigate cancer treatment in isolation. When asked what was critical to her healing, alongside the chemotherapy and medical appointments, she speaks of support and the people who were there from the day of diagnosis in 2022 to now.  

For Romero, having companionship transformed her cancer journey. It didn't always make it easy, but it made it possible. 

In early March, Partners In Health (PIH), alongside the TBFighters, We Are TB, and the TB Roundtable, participated in one of the United States’ largest global health advocacy events aimed at eliminating tuberculosis (TB). This year’s TB Hill Day convened around 300 advocates, including volunteers, experts, and survivors—representing all 50 states—at the U.S. Capitol in Washington, D.C.  

This event has grown significantly in the last couple of years with the support and spotlight of bestselling author and PIH Trustee, John Green. In 2024, TB Hill Day consisted of 35 meetings with congressional offices. This year, advocates attended 265 meetings with Congress, including all 100 Senate offices.  

Green’s book, Everything Is Tuberculosis, and videos on his VlogBrothers YouTube channel have helped garner much-needed attention for TB, the world’s deadliest infectious disease. With his influence, a group of advocates called the TBFighters joined the movement to make care more accessible worldwide.

The TBFighters have helped make TB Hill Day what it is today—an enormous event that brings folks from diverse backgrounds together to help move toward a world without TB. Following this year’s record-breaking day of meetings, we spoke with four TBFighters to learn about their experiences participating in D.C. Check out their responses, edited and condensed, below:

Celeste Moss, she/her, first TB Hill Day

A year ago, I didn’t know TB Hill Day even existed, let alone that my state wasn't represented at the last one. Being able to ensure Oklahoma had a voice this time meant so much to me. I felt really prepared, especially thanks to the PIH team, who helped me gain confidence through a variety of virtual advocacy opportunities over the past year. Arriving in DC having already established relationships with the offices of my members of Congress meant we were able to build on past conversations and make meaningful progress.

Being together with nearly 300 advocates who all share the same passion for ending tuberculosis filled me with more hope than I’ve felt in a long time. If I've learned anything from Hill Day, it's that we are so much stronger as a community than as individuals, and what a delight it has been to have found such a cool hive of bees to work with.

Advocacy is hard, but when you’re doing hard things with friends, it’s not so scary. We show up not because we expect to win every campaign, but because the other option is complacency, and we refuse to accept a world where over a million people are still dying each year from a disease we’ve known how to cure since the 1950s. I hope for a future where TB Hill Day is no longer necessary because tuberculosis is gone for good. Until then, we stand in solidarity.

Connor Hay, he/him, second TB Hill Day

With it being my second Hill Day, I had a lot more excitement than nerves. I was excited to see all the friends I had made at the previous Hill Day, and through the subsequent TBFighters advocacy sessions, livestreams, etc.  

There were some nerves still, however, since this year I was “state captain” for Massachusetts. This meant that, even though my meetings were all in the afternoon, I spent most of the day (and many hours leading up to Hill Day) making sure everyone in our Massachusetts delegation had what they needed to have successful meetings. And everything went well!

My favorite meeting had to be my House meeting, my last one of the day. This was my first time meeting the staffer in person, and she was extremely friendly and receptive to our asks. It was truly inspiring to witness the experts who accompanied me speak with such depth, passion, and compassion for those still suffering the injustice of TB today.

It was an incredibly fulfilling day, and just like last year, I walked away with my “hope battery” fully refreshed and ready for another year of fighting TB.

Nichole Ezell, she/her, first TB Hill Day

TB Hill Day was an incredibly eye-opening experience for me. I met so many passionate people who are focused on making the world—and millions of people's lives—better.

At Hill Day, we had the opportunity to participate in our democratic process in action. State team members and I met with staffers for congressmen and senators (and even met with a senator), which gave me an inside view of how constituents—common, everyday citizens—can impact and improve the policies that ultimately affect US support. It was truly an unforgettable and meaningful two days.  

In those two days, I made so many new friends and also met a ton of people that I had known for years while working together to raise awareness of tuberculosis and the TBFighters organization. We work as a group to change the world, gaining the notice of the people who we—the citizens—elected to represent us. I am so proud of the work the whole community did that day, and the work we continue to do every day.

Quinn Yates, he/him, second TB Hill Day

With over 300 advocates, survivors, and experts, Hill Day was marked by a strong sense of community. We exchanged anti-TB friendship bracelets (adding to my growing collection from last year) and cheered each other on as we entered the post-Hill Day after-party, along with much, much more.  

Starting with stories from TB survivors, the training went over everything from how the appropriations process is supposed to work (and how it really works) to how to actually conduct the meetings. By the end, I was armed with sheets of facts, statistics, and asks for my meetings. It is safe to say I could not have been more prepared.  

And I was right! My meetings went surprisingly well. And on the Hill, I was constantly reminded of our community. I frequently saw other advocates wearing our little "TB IS NOT OVER!" enameled pin as they made their way to their next meeting. It was hard to escape our community and the idea that we brought with us: that ending TB is a possibility. 

Partners In Health (PIH) mourns the passing of John Tracy Kidder, esteemed author and longtime friend. The Pulitzer Prize-winner died surrounded by loved ones on Tuesday, March 24, at the age of 80 in Boston, Massachusetts.  

In 2000, six years after meeting PIH Co-founder Dr. Paul Farmer, Kidder published “The Good Doctor,” in The New Yorker. The subtitle read, “Paul Farmer set out twenty years ago to heal the world. He still thinks he can.” The relentless persistence he saw in Farmer was something Kidder shared.  

A Vietnam War veteran with an MFA from the University of Iowa, Kidder set out to write fascinating features about people doing good. His work has inspired the curiosity of millions and shaped how the world talks about injustice and the experience of the world’s poorest.    

The Mountains Beyond Mountains Effect

Mountains Beyond Mountains, a book-length version of “The Good Doctor,” became a staple of high school and college curricula and book clubs across the United States over the next two decades. Today, it continues to bring folks of all ages to PIH, many citing Mountains Beyond Mountains as their first introduction to global health justice and PIH’s work. Many people who are a part of the PIH community today have Kidder to thank for bringing them into the movement.  

“I think it’s fair to say PIH wouldn’t be where we are today without Tracy Kidder,” PIH CEO Sheila Davis said. “His telling of PIH’s history and Paul’s teachings in Mountains Beyond Mountains ushered in a new era of awareness and growth for the organization.”  

A member of the PIH Board of Trustees since 2012, Kidder has accompanied the organization through extraordinary growth and hardship as a stalwart advocate for the rights of the poor. After the passing of Farmer in 2022, Kidder wrote an essay in The New York Times sharing parts of their friendship that started in Haiti in 1994.

“He wanted to make the whole world his patient,” he wrote. “And he made a good start on that.”

Kidder often spoke about how seeing Farmer and PIH in action made it impossible for him to remain on the sidelines. He felt a responsibility to stand up to injustice—demonstrating solidarity, rather than charity alone.

A Gift to the World

In 2013, Kidder wrote a reflection on what he believed was PIH’s “gift to the world.” Over a decade ago, his words still resonate deeply today: how to have hope in times of chaos. He points to PIH’s work as “vivid proofs of what can be accomplished in the face of poverty and disease” and notes this work is an example of “counterforces [that] will prevail” over the cruelty of the world. He described it as “one of PIH’s most important gifts to the world.”

The feeling was mutual.

To PIH, Kidder was a great gift. A steadfast supporter, board member, and true friend, he dedicated so much of his time and life to the movement for global health equity.  

“Tracy was that rarest of beings—an artist and a man charged up about injustice,” PIH Co-founder Ophelia Dahl said. “Throughout most of this century, he spoke out on behalf of Partners In Health’s patients, wrote book forewords and opinion pieces, submitted to interviews, served on PIH’s board, and encouraged young people with grit and curiosity and high ideals. I miss him so much already.”  

Kidder’s compassion left an indelible mark on PIH. We extend our deepest condolences to Kidder’s family, friends, and all who were moved by his extraordinary life and work.

For media inquiries, please see PIH's full statement.

At Partners In Health (PIH), we take a community-based approach to tuberculosis (TB) treatment. This means bringing care and resources directly to hard-to-reach areas, collaborating closely with local leaders and neighbors, and keeping patient concerns at the center of care.

In Lesotho, a recently launched initiative—called the TB Elimination Project—is deepening community outreach by bringing screening, diagnosis, and care directly to people most at risk of TB, the world’s deadliest infectious disease. The project is built around an innovative, multipronged approach known as the universal access search, treat, and prevent approach—learn more here.

Over five years, PIH Lesotho seeks to detect and treat an additional 5,151 people with TB, significantly reducing TB incidence in the country. Digital tools and diagnostic technologies play a key role in the project, drastically increasing TB detection. Below, learn about six tech innovations improving tuberculosis care in Lesotho.

1. Mobile X-ray Trucks

Box trucks were converted to mobile X-ray clinics, equipped with technology to provide screening, education, and follow-up care directly in communities. PIH Lesotho currently has three of these trucks in its fleet, which provide weekly outreach to Mohale’s Hoek District—a rural region with a population of approximately 153,000 people. Each outreach team includes a doctor, two nurses, a laboratory technician, and an X-ray assistant. From September 2025 through February 2026, the mobile trucks have screened 2,237 people for TB, tested 1,712 people for TB, and diagnosed 47 people with TB.

2. Digital X-ray Machines

TB diagnosis relies on chest X-rays, as the infectious disease usually attacks the lungs. The trucks are equipped with digital X-ray machines, which provide instant results on a mobile phone, enabling rapid review by a doctor, and timely next steps for patients. In addition to the truck-based machines, staff also use portable digital X-ray machines. The portable machines are compact enough to travel via horseback to reach patients living in communities without road access.

3. Portable Ultrasound Devices

PIH Lesotho uses portable ultrasound devices that connect to a tablet or smartphone. They’re designed for whole body imaging and allow clinicians to detect TB in other parts of the body, beyond the lungs. The ultrasound has artificial intelligence (AI)-supported features that help clinicians capture and interpret images. Two of the mobile trucks are equipped with portable ultrasound devices. The devices are also used across all PIH-supported rural health clinics and Botšabelo Hospital—where, in 2007, PIH and Lesotho’s Ministry of Health launched the country’s first treatment, care, and support program for people with multidrug-resistant TB.

4. TB Hunter

TB Hunter is a data system, designed by PIH Lesotho, that enables real-time management of cases, tracks linkages to care, and supports contact tracing efforts. The digital system incorporates teleradiology and geographic information systems (GIS) to monitor data across PIH Lesotho’s seven rural health facilities. Through teleradiology, medical images are shared remotely with a full-time radiologist—based in Maseru, the country’s capital—who provides expert interpretation and feedback to frontline clinicians at rural health clinics. GIS technology is used to identify and map TB hotspots, enabling targeted follow-up in areas with the highest TB burden. This strategic use of GIS ensures that resources are allocated efficiently, reaching the populations most in need and facilitating the swift containment of outbreaks.

5. Artificial Intelligence

AI software analyzes patients’ chest X-ray images and determines if the patient has been affected by TB in less than one minute. This computer-aided detection tool helps clinicians prioritize patients who need further testing. AI is also used with the portable ultrasound devices, allowing for faster diagnostics and care.

6. Smart Pill Boxes

Digital adherence technologies, such as smart pill boxes, help patients keep up with their TB treatment by sending medication reminders, logging doses in real-time, and allowing remote monitoring by health care staff. This approach has helped replace directly observed therapy, which involves watching people take their medications. In the coming months, the smart pill boxes will be used in Mohale’s Hoek District.

A Global Honor for Local Leadership

Partners In Health (PIH) Sierra Leone’s Isata Dumbuya has been named to TIME’s annual Women of the Year list, recognizing 16 women working toward a better, more equitable world.  

Dumbuya’s recognition highlights her pivotal work in Sierra Leone, where she joined PIH in 2018, and currently serves as the director of nursing and midwifery for the reproductive, maternal, neonatal, child and adolescent health program at the Maternal Center of Excellence (MCOE). The list spotlights exceptional women who are trailblazers in their fields. This year’s list will appear in the February 27 issue of TIME and today through its online edition.

“It is an honor to be recognized for work that is truly a collective effort at Partners In Health,” said Dumbuya. “I am so proud and grateful to share this spotlight with the thousands of colleagues, especially the heroic nurses, midwives, and doctors in Sierra Leone, whose unwavering commitment is the foundation of our work. Together, we are proving that health equity is not just a dream but can be a life-saving reality.”

Leading Maternal Health Transformation in Sierra Leone

A highly decorated public health expert, Dumbuya’s professional background includes 25 years of service with the National Health Service in the UK as a nurse, midwife, and public health specialist, before she pivoted her attention to maternal care in Sierra Leone. Her contributions to maternal and child health in Kono District, where she was born, are countless.  

Most recently, she played a key leadership role in the launch and development of the MCOE, which officially opened the doors to its first patients on February 14. The MCOE is a state-of-the-art facility providing women and newborns with the care they need and deserve in rural Sierra Leone.

Milestones in Dumbuya's Work with Partners In Health

Over the years, PIH has documented key milestones that reflect the breadth of Dumbuya’s leadership. Below, learn more about her work at PIH:

2019: On the Road in Sierra Leone, Spreading Health and Hope

Dumbuya formed a community outreach team of six clinicians from PIH-supported Koidu Government Hospital (KGH) and nearby Wellbody Clinic, who traveled to all 14 chiefdoms in Kono District to make known the critical care and services available and to empower community members. The profile follows Dumbuya and team on an outreach visit, as they work to strengthen rural health systems and expand access to maternal health care. 

2020: Q&A: Reimagining What’s Possible For Maternal Health Care in Sierra Leone

In this Q&A, Dumbuya discusses her experience moving from the U.K. to Sierra Leone, the ongoing improvements at KGH, and her vision for high-quality maternal health care for women and their babies.

2021: ‘Rooted in Elevating and Empowering Women:’ Women’s Health, Equity Central to PIH

Listen to Dumbuya read the International Women’s Day letter she wrote with PIH CEO Dr. Sheila Davis, which highlights PIH’s commitment to women’s health, rights, and equity.

2022: The Washington Post Highlights PIH’s Maternal Health Work in Sierra Leone

A feature in The Washington Post highlighted 17-year-old Susan Lebbie’s pregnancy journey at KGH, which led to the birth of a healthy baby boy. Dumbuya was featured in the story, as she was part of Lebbie’s comprehensive clinical care team who provided support throughout her entire pregnancy.

2023: In the News: Our Favorite Moments From 2023

One of PIH’s favorite media moments in 2023 was when Dumbuya, alongside Build Health International employees, spoke with the BBC about the significance of the MCOE.

2024: Maternal Center of Excellence: The Future of Dignified Care in Sierra Leone

The longtime vision of the MCOE was becoming closer to reality, as structures—built by a construction team of mostly women—began to take physical shape. “This is women building for women,” Dumbuya said in the article, and expressed excitement for the future.

2025: Video: A New Era for Women – The Maternal Center of Excellence

In this video, hear from Dumbuya and others, as they talk about the MCOE and its groundbreaking investment in mothers, families, and babies. “When you dream and when you believe, and when you have people that believe in you and in that dream, you can accomplish this,” said Dumbuya.

2026: How Staff Are Preparing for the Maternal Center of Excellence’s Opening Day

As the MCOE prepared to open its doors, Dumbuya led intensive staff training and orientation amid the new space and equipment. Alongside colleagues, she ensured training ran smoothly, topics were adequately covered, and staff were fully prepared to be able to deliver high-quality care. 

Looking Ahead

Dumbuya remains closely involved in the MCOE’s operations, which officially opened, and will serve as a crucial training center for Sierra Leonean health workers, including doctors, nurses, and midwives. Her recognition as a TIME Women of the Year highlights her pivotal work and ongoing dedication to mothers and babies.

When current events coverage and social media feeds feel like a barrage of bad news, it can feel exhausting to be informed. It can be easy to slip into despair after being exposed to widespread agony on a daily basis. When these catastrophes seem unstoppable, it’s difficult to know how we can each make a difference.  

At Partners In Health (PIH), we refuse to accept suffering as inevitable, particularly for communities that have been subject to past—and present—injustices. If you feel particularly bogged down by the weight of the world these days, several PIHers have tips for actionable items you can do right now:  

1. Educate yourself

Awareness can expand by going beyond the most recent headlines. Often, problems of today are the result of systematic inequities that have existed long before our time. Understanding these systems—and those who fought them before us—can help inform how we respond to the current moment.

“Health injustice is not an accident but a consequence of power,” said Joel Curtain, PIH senior director of advocacy. “Our work is informed by social movements that have challenged power to advance health rights, like the HIV activist movement, which itself was deeply informed by the anti-Apartheid struggle. We know the fight for health justice is a deeply intersectional one and is inseparable from climate justice, racial justice, gender justice, economic justice, labor justice, and so on.”

PIH Co-founder Dr. Paul Farmer wrote several books about poverty and disease, such as Pathologies of Power, which we would recommend as a starting point. To see other books that show the intersection of health and social justice, see a list of recommended reading from PIH staff.  

2. Get in touch with Congress

One assertive way to get involved is to contact your members of Congress. Senators and representatives are supposed to be a voice for their constituents, so sharing your thoughts and concerns with them helps inform how they respond to legislation—including government spending.  

This year, PIH has leveraged online tools to make calling and emailing members of Congress as straightforward as possible. In the last year, the PIH community reached out over 73,000 times to congressional offices using these tools alone. And it’s made a difference.

“Hundreds of PIH Engage volunteers and tens of thousands of PIH supporters have called Congress this past year about the importance of global health funding,” said Vincent Lin, PIH associate director of health policy and advocacy. “In the recently passed 2026 budget, global health funding is maintained and even restored from the rescissions.”

The power of constituent voices was evident in the amount of funding dedicated to global health in the 2026 budget. We encourage our supporters in the U.S. to reach out to their members of Congress to release critical global health funding for the Global Fund and PEPFAR. PIH supporters helped secure congressional support for this funding, and now you can help ensure it gets out the door.

3. Protect your personal health

Similarly to using an oxygen mask on an airplane, you can’t take care of others without taking care of yourself first. It’s important to recognize when you’re feeling overwhelmed or out of sorts so you can prioritize your wellness. Our minds were not meant to process this amount of stress regularly.  

“It’s essential to prioritize your mental well-being. You can’t fill from an empty cup, so try to be intentional about taking time to care for yourself in the midst of everything going on in the world,” said Rachel Isaacs, PIH cross-site mental health officer. “Slow down, take a break from the news cycle, and make sure you get outside every day. Spend time doing things you love with people who energize you, and remember to celebrate moments of joy, no matter how small.”

According to the National Alliance on Mental Illness, more than 1 in 5 U.S. adults experience mental illness each year. Today, as videos and stories of tragedies can be nearly impossible to avoid, it’s even more critical that we are aware of how our minds and bodies are handling it.

*Editor’s note: If you or someone you know is struggling with mental health issues, there are numerous national and local resources available for support. For anyone in emotional distress or crisis, call or text 988 to speak with a trained counselor from the Suicide & Crisis Lifeline.

4. Organize and build community

Organizing, in the simplest terms, means finding the people who care about the same issues as you and turning your individual outrage into collective action. Working together to arrange strikes, protests, talks, mutual aid, or other forms of community organizing can help make the work much more feasible and change much more possible.  

“When the world feels overwhelming, ‘doing hard things with friends’ is how change happens, as we can gain strength from others,” said Rosie Poling, PIH health policy officer. “I find hope in not only those who are doing good today, but also in the generations of advocates who faced horrible injustices before us and came together to work for a better future anyway. I'm especially inspired by those in the PIH community who imagined and worked towards a better world before PEPFAR even existed. Thank God they didn’t give up."

Community organizing can take many forms, and there are numerous movements to participate in. It could look like becoming an active member in your local tenants' rights organization, labor union, or anti-imperialist movement chapter, and organizing with people with shared values. Or, if you’re particularly passionate about global health, you can sign up for updates on our advocacy efforts and join our network of grassroots advocates.

5. Join PIH Engage

With 735 active team members across the country, PIH Engage is the largest grassroots network of global health advocates. Engage helps organize and equip teams of volunteer high schoolers, college students, and professionals toward building a global movement for the right to health.  

"Being a part of a community rooted in justice and action is a powerful antidote to despair. Many students and young professionals find solace in our PIH Engage community for this reason,” said Sam Kelts, PIH manager of grassroots strategy. “If you're looking to impact the U.S.'s role in the right to health globally, consider getting in touch with our PIH Engage team to learn more." 

On February 14, 2026, a warm breeze swept over Koidu Town in Kono District, Sierra Leone, as the sun rose over the Paul E. Farmer Maternal Center of Excellence (MCOE). At 7 a.m., the new facility on the Koidu Government Hospital (KGH) campus was bustling with activity, as staff prepared for the first patient to arrive, putting the final touches in place. Clinicians finished stocking the crash carts, the janitorial team completed final cleaning, and the biomedical team ensured all equipment was turned on and functioning.

These were the last moments the MCOE would ever be without patients.

At 10 a.m., the MCOE opened its doors to the very first patients for inpatient maternal and neonatal care. The day marked a profound transition from years of planning, collaboration, and construction to the delivery of lifesaving care for women and newborns. In the first 24 hours of opening, the MCOE welcomed 27 patients, with a total of 13 babies born. Seven babies were delivered via cesarean section (C-section) and six via vaginal delivery.

First Patients at Registration and Triage

At 10:03 a.m., the first woman arrived at the MCOE’s registration desk after being directed there from KGH’s main entrance and screening point. Twenty-five-year-old Wulimatu Koroma came all the way from Waterloo, a five-hour drive from Kono, after hearing about the high-quality care provided at KGH. She was 36 weeks pregnant and experiencing chest pain. After being assessed at triage, Wulimatu became the first patient admitted to the antenatal ward to receive continuous care until delivery.

Fatmata Jalloh from Kono District was registered at the MCOE as the second patient. At 42 weeks into her pregnancy, she was past her due date. After the team assessed her at triage, they found that the protective fluid around the baby had become dangerously low, and an emergency C-section was needed. She delivered a healthy baby boy later that day— the second C-section performed at the MCOE.

The First Outborn NICU and Mother’s Dormitory Admissions

At 10:13 a.m., the first neonate born outside the facility arrived at the MCOE and was admitted to the outborn section of the country’s first neonatal intensive care unit (NICU). The baby girl, Grace, was delivered 57 hours earlier at home. She did not receive enough oxygen at birth and, upon arriving at the NICU, immediately began receiving care, including being placed on oxygen support and laid in an incubator to regulate her temperature.

The baby’s mother, Phebian Baningo, was transferred to the postnatal ward for monitoring and later brought to the mother’s dormitory, a dedicated, dignified space where she could remain close to her baby in the same building.

Phebian had initially hoped to deliver her baby at the MCOE. “I heard the good news and was hoping one day I would see it for myself,” she said. But she traveled to a funeral toward the end of her pregnancy when she unexpectedly went into labor and was too far away from any clinical facility to make it to care in time. Phebian is now enjoying spending time with other mothers in the dormitory, and her baby girl is stable and getting stronger every day.

First C-Section and Inborn NICU Admission

At 10:34 a.m., 17-year-old Fanta Jimmy from Kono District arrived at the MCOE’s triage and was assessed. The skilled team of nurses, midwives, and doctors determined that she was suffering from pre-eclampsia with severe features, and that her baby was in distress. An emergency C-section was needed as soon as possible.  

Fanta was taken into the pre-anesthesia room to prepare for surgery. Due to the severity of her condition, her C-section was prioritized over other patients arriving at that time.

At 1:21 p.m., she gave birth to the first-ever baby born at the MCOE, a girl weighing 1.72 kilograms and measuring 41 centimeters in length. The premature newborn was immediately transferred to the inborn NICU in an incubator for specialized care.

The baby girl is now stable, doing well, and eating eagerly.

After recovering in the post-operative ward, Fanta moved to the mother’s dormitory, where she will stay until her daughter is ready to go home. Fanta’s mother, Yei, has been a devoted birth companion and is ready to support her granddaughter wherever needed. They enjoy spending time together in the MCOE courtyards.

First Referral via Ambulance

At 2:27 p.m., the first ambulance arrived at the MCOE carrying 33-year-old Sia Jimissa from Kono District. Throughout her pregnancy, Sia attended antenatal appointments at her local clinic.  

On the morning of February 14, she began experiencing contractions and went to the clinic to give birth. However, after three hours of labor, the clinical staff identified complications and called an ambulance to refer her to KGH.

Sia’s sister accompanied her in the ambulance for support. Upon arrival at the MCOE, the team determined that Sia had prolonged labor and that her baby was in distress, requiring an emergency C-section. She safely delivered a healthy baby boy not long after.

First Vaginal Delivery

At 8:17 p.m., Fatmata Sow arrived at the labor and delivery ward and became the first woman to give birth there, delivering her baby girl at 12:25 a.m. on February 15. It was a smooth delivery with no complications.

Fatmata had been attending antenatal appointments at KGH throughout her pregnancy, where she first learned about the MCOE. She was excited to welcome her fifth child at the new facility.  

Fatmata’s husband, Amadu, accompanied her to KGH and stayed by her side throughout the delivery as her birth companion. After delivery, both Fatmata and her baby recovered in the postnatal ward before returning home to their family.

The Start of a New Era

The first 24 hours at the MCOE were filled with moments of excitement, anticipation, and rapid decision-making by a team of outstanding clinicians. Years of planning, construction, and training finally came together to provide every woman and newborn who arrived at the MCOE with the highest standard of care, in a dignified, patient-centered, and beautiful environment.

We are deeply grateful to the Government of Sierra Leone through the Ministry of Health, especially Dr. Austin Demby, Minister of Health, for believing in the vision of the MCOE and walking alongside PIH-SL to make it a reality.  

We thank Build Health International, led by Co-Founder and Managing Director Jim Ansara, for transforming architectural sketches into healing spaces, one wall at a time.  

None of this would have been possible without the endless support of the district health management team, local chiefs, and community leaders and members standing as vital allies, advocating for improved maternal care.  

And we are profoundly thankful to John and Hank Green, and to every supporter who believed in this dream and donated, making it possible for mothers to leave the MCOE with healthy babies and smiles on their faces.

On January 25, Partners In Health (PIH) celebrated a momentous occasion when the first dual medical degree students and 10th cohort of master's degree students graduated from the University of Global Health Equity (UGHE) in Rwanda.

UGHE’s curriculum was born out of PIH’s decades of experience in community-based health treatments, and founded by PIH Co-founder Dr. Paul Farmer and then-Rwandan Minister of Health Agnes Binagwaho.

Each of these 78 graduates has learned the importance of building equitable health systems and treating patients holistically, with environmental factors like food access and poverty included at the forefront of care. Equity is a core thread through each semester’s course, rather than a unit in one class.

Here’s a peek into the graduation ceremony, with a few of our favorite photos.

On February 14, the longtime vision of the Paul E. Farmer Maternal Center of Excellence will become reality, as the doors open to its first patients. Formally named in honor of Partners In Health (PIH) late Co-founder Dr. Paul Farmer, the facility will dramatically expand services and set a new standard for care—two aspects that guided his life’s work and are part of his legacy.

Over more than three decades, Farmer dedicated his time and talent to furthering the field of global health and ensuring the right to health care for all. Through his words and actions, he left behind countless lessons that continue to guide us today. At PIH, we are deeply committed to carrying forward his legacy and vision.

Below, learn about a select handful of initiatives, awards, and other efforts—by PIH and partners—honoring Farmer:

1. Paul E. Farmer Maternal Center of Excellence

The Maternal Center of Excellence on PIH-supported Koidu Government Hospital’s campus is a state-of-the-art teaching and referral facility in Kono District, Sierra Leone. The facility reflects Farmer’s lifelong commitment to health care as a human right and belief that hospitals should be spaces of both health and beauty.

2. Paul Farmer Collaborative of the University of Global Health Equity and Harvard Medical School

This 10-year grant supports joint activities between the University of Global Health Equity (UGHE) and Harvard Medical School, including student and faculty exchange programs, support for research, and clinical training for medical students and residents.

3. Paul E. Farmer Scholarship Fund

The scholarship fund is dedicated entirely to students attending UGHE in Rwanda. It covers tuition, room, board, and expenses for 3,000 medical students and global health delivery master’s degree candidates over a 25-year period.

4. Paul Farmer Symposium on Global Health Equity

The annual event convenes experts, partners, and supporters to advance Farmer’s vision for health equity. Each year, the event is centered around a different theme, such as mental health—watch the 2025 recording.

5. Paul Farmer Mausoleum and Glade in Rwanda

The memorial site, which includes a nondenominational chapel and mausoleum, is Farmer’s final resting place in Butaro, Rwanda.

6. Paul Farmer Memorial Resolution

PIH, alongside Congressional global health champions, developed a “north star” for global health politics: the Paul Farmer Memorial Resolution, which can guide policy and practice for decades to come.

7. The Paul Farmer Lectureship and Award for Global Health Equity

The award, presented by McGill University, recognizes an individual who models and demonstrates Farmer’s vision of a “preferential option for the poor” to achieve equity in health. Before his passing, Farmer received an honorary doctorate from McGill University.

8. The Paul Farmer Award

The award recognizes bold, transformative leadership in advancing justice, equity, and economic and social rights. It was developed by the activist organization Partners for Dignity & Rights, of which Farmer was a founding board member.

9. The Paul Farmer African Initiative for Research

The initiative, developed by the University of California San Francisco, supports African scientists through mentorship, sustainable research, and international exchange.

About a decade ago, a small group of determined, passionate leaders set out to create a new kind of health education.

They called it the University of Global Health Equity (UGHE)—an institute of higher education where equity was not just a unit during the semester, but a thread woven through every course taught and decision made.

It was built incorporating knowledge from Partner In Health’s (PIH) decades of success in community-based health treatment, and aims to increase health care education. Africa was a specific focus, as the continent’s health workers bear 24% of global health burdens but have just 3% of the world’s health workforce.

UGHE was established by PIH and co-founded by the late Dr. Paul Farmer and then-Rwandan Minister of Health Agnes Binagwaho. A band of Rwandan Ministry of Health members, Harvard University faculty, and PIH employees joined together to deliver the university’s first courses.

The university's creators wore many roles—with some of its first employees working to establish the university while simultaneously teaching within it.

UGHE’s leaders worked tirelessly and stretched into numerous roles to bring this pioneering school to life, with transformative support from the Government of Rwanda, Cummings Foundation, and Gates Foundation.

In the last decade, UGHE has rapidly grown from an ambitious startup to a robust, fully fledged university with a 5,200 square meter (or approximately 56,000 square foot) campus, numerous degree programs, impactful research, and international recognition as a model for the future of health education.

This is how we got here.

September 2015: Here Comes Cohort 1

After becoming accredited, UGHE’s founding faculty brought 27 students into UGHE’s flagship degree program, the Master of Science in Global Health Delivery (MGHD), which was modeled after a similar program at Harvard University’s Medical School.

The 18-month program focuses on systems, not symptoms. It includes a range of core topics, from epidemiology to finance to global health policy.

The inaugural class of MGHD students took a leap, joining UGHE before it even had a permanent campus.

Instead, students began their education both in Rwanda’s capital city, Kigali, and the rural Eastern Province, where PIH worked with the Rwandan Government to renovate the Rwinkwavu District Hospital.

Despite not yet having a permanent campus, UGHE leaders knew it was imperative to educate students in a resource-poor setting grounded in real health system experience, not academic hypotheticals—so this is where class began for these pioneering, passionate, and daring students.

July 2016: Construction Begins in Butaro

UGHE’s permanent campus was earmarked for a rural, hilly region in Rwanda’s northern Burera District.

Years before, Farmer had scoured those hills to find a place for one of the country’s last district hospitals. Weeks later, the Government of Rwanda generously approved for the Butaro District Hospital to be built, which began the process of reestablishing health care in the region.

When it came time to decide where UGHE would be located, Butaro seemed a natural fit. Students would get to witness—and even contribute—to growing the region’s health system. In addition, they would learn in a resource-poor setting, and understand the specific challenges it poses.

As future health leaders focused on equity and systems building, this was essential.

Campus construction began in July of 2016, with the official groundbreaking taking place a few months later.

May 2017: First UGHE Graduation

More than 20 students became the inaugural cohort to graduate with UGHE’s MGHD degree, going out into the world as the university’s first graduating class.

His Excellency Rwandan President Paul Kagame, the President of the Republic of Rwanda, attended the ceremony and spoke to the graduates directly.

“This initiative started a few short years ago, with the subversive idea that world-class health education could be delivered in Africa,” President Kagame said at the time. “Today, it is a reality. I wish to thank Partners in Health, and especially our old friend, Paul Farmer, for working together with the Rwandan team to see it through. You can be assured of our continued support as this institution grows, into a beacon of excellence, in our country and our region.”

Members of this class have gone on to achieve exceptional goals, from one graduate winning the Rising Star Award by the World Federation of Societies of Anaesthesiologists to another joining the United Nations Children’s Fund.

By 2018, more than 300 students applied for 24 spots in this degree program.

January 2019: Campus is Open!

After years of construction, UGHE’s permanent campus was completed.

Built on a hilltop in Butaro, the world-class campus has six academic buildings, dormitories and apartments for more than 200 students and staff members, athletic facilities, library access, and more.

Kagame officially inaugurated the campus with a ribbon cutting ceremony on Jan. 25, 2019.

July 2019: First Class of Medical Students

UGHE staff moved quickly to expand degree program options and began offering a 6.5-year dual medical degree program just a few years after opening.  

A cohort of 30 students joined the inaugural class, regardless of their income. Instead, their admission was based on academic excellence.

In return for their studies to be completely cost-free, the students agreed to work as doctors in resource-poor regions in Rwanda for five years after graduating.  

These first students were taught by Farmer, who was their professor, and joined them on clinical rotations. They have been dubbed “Paul’s Class” in the years since, and many members of this first cohort still keep the lessons Paul taught them in the forefront of their minds as health care workers.

February 2022: UGHE Honored by UNESCO

The United Nations Educational, Scientific and Cultural Organization (UNESCO), or the educational arm of the United Nations, recognized UGHE as a model for global health education in its 2022 rankings.

This acknowledgement marked a significant milestone for UGHE, and for the role the university has in furthering health equity.

November 2024: UGHE Ranked #4 University in Sub-Saharan Africa

In less than 10 years after opening, UGHE was ranked #4 in universities for sub-Saharan Africa, according to the 2024 Times Higher Education analysis.

Universities were scored on a variety of categories, from resources and finance, access and fairness, student engagement, ethical leadership, and impact on Africa. UGHE was the #1 scorer for the student engagement category, which includes the quality of teaching, critical thinking skills, experience, and practical courses.

It also scored #3 for impact on Africa, and #4 for ethical leadership out of 129 universities from 22 countries.

January 2026: First Dual-Degree Medical Students Graduate

For more than a decade, UGHE’s supporters and partners have been looking forward to the moment when medical students would graduate from the university.

In January of 2026, that vision became reality.

All 30 of the students who joined UGHE’s inaugural MBBS-MGHD dual medical degree program graduated.

During their time at UGHE, students explored long-held passions and discovered new ones—with interests spanning pediatrics, cardiothoracic surgery, obstetrics and gynecology, and more.

Each graduate has committed to working with underserved populations for five years as employees of Rwanda’s Ministry of Health, sharing their expertise to promote health equity and support their communities.

When President Donald Trump took office over a year ago, he almost immediately began destroying decades of bipartisan efforts and decimating foreign aid as we knew it. The administration started by issuing executive orders that halted critical work around the world, but that would just be the beginning.

Over the past year, billions of dollars for global health have been cut or unconstitutionally withheld.

As this was happening in the countries where Partners In Health (PIH) works and beyond, we were learning and adapting in time with the rest of the world. PIH shared resources with our communities as we watched these decisions unfold, harming projects and patients. Below, we’ve collected five of our top resources from the past year to help you understand some of the broad impacts of the foreign aid cuts:

It’s been about a year since alarm spread through the international development community as the Trump Administration took office and immediately set its sights on foreign aid. What initially began as a stop-work order for aid workers quickly escalated, turning into the dismantling of the United States Agency for International Development (USAID) and the cutting and withholding of billions of dollars in funding.

While generally pessimistic about the outcome of these cuts, many experts still couldn’t have predicted the scale of the destruction that has occurred over the last year—decades of work halted at the stroke of a pen, or the click of a mouse, without regard for the consequences. Consequences that have been far-reaching, spanning loss of progress, loss of long-term partnerships, loss of critical supply chains, and, most devastatingly, loss of life.

So, all of that considered, do you want the good news first?

The Good

Partners In Health (PIH) is still standing in solidarity with our staff and patients worldwide. Care continues in the communities that we serve, and, in some cases, PIH is helping to hold together entire health systems that would otherwise collapse without this support.

Additionally, Congress still supports funding critical global health programs like PEPFAR and the Global Fund. Just this month, the House reasserted its power of the purse—Congress's authority under Article I of the Constitution, which provides critical oversight to the executive branch—by passing a $50 billion foreign aid spending package for this fiscal year. With bipartisan support, this bill signifies Congress’s desire to continue providing significant funding to foreign aid, including global health. And while the spending amount in the bill is a decrease from previous years, it’s more than $5 billion higher than what was outlined in President Trump’s America First Global Health Strategy.

In reality, however, this is only good news if the money is actually spent as appropriated, which is constitutionally required. Currently, however, an expansive view of the power of the Presidency by the executive office has created a chasm between what Congress is asking for and what is actually being done with allocated funding, despite what the Constitution says. This implementation gap raises serious concerns about accountability, and about the future of U.S. foreign aid more broadly.

The Bad

The administration’s America First Global Health Strategy, as mentioned earlier, is already starting to reshape the U.S.’s approach to foreign aid. With a focus on government-to-government agreements and co-investment, the strategy aims to rely more heavily on bilateral agreements, "in a way that directly benefits the American people and directly promotes our national interest,” according to U.S. Secretary of State Marco Rubio. Outlined in the strategy is also the U.S.’s desire to leverage cheap access to “key minerals and rare earth elements needed as inputs into advanced technologies that fuel critical military and commercial applications.” This approach marks a clear departure from past administrations’ understanding of aid as a shared global responsibility.

As the current administration rolls out this strategy, negotiations between the U.S. and other countries on memorandums of understanding (MOUs) have already begun—largely behind the scenes and without crucial civil society involvement. And while all MOUs should be publicly accessible, in many instances they remain highly restricted, making it unclear how funding decisions are being made or how aid will ultimately be used. Organizations like PIH are left in the lurch, waiting for these monumental decisions to be made while unsure of which areas will receive funding and how to plan for the future.

Additionally, without meaningful transparency, local civil society groups have been unable to participate in the process, as seen in Malawi, and in some cases, even the country's Ministry of Health has been left out of negotiations. While the U.S. routing funds more through governments and requiring increasing co-investments could be good, many practical details have yet to be worked out.

The Ugly

This past year has been tumultuous, to say the least. The rapid and uncoordinated withdrawal of U.S. foreign aid roughly a year ago caused immense destabilization worldwide, revealing the unjust structures that have increased dependence on aid to begin with. But before those underlying structures can be transformed, we must first confront the immediate harm—the unnecessary suffering—caused by the reckless removal of lifesaving funding.

Over this past year, our teams around the world have documented examples of patients suffering and dying without access to medication or professional care as funding was pulled overnight. And we have to assume that for each story we hear, there are countless more that remain untold and unheard.

A patient in Lesotho traveled through challenging terrain to nine clinics searching for someone, anyone, to help him as he suffered from tuberculosis. Fortunately, he made it to a PIH-supported clinic where he was finally able to receive treatment and support. But we can’t ignore all the patients who couldn’t have made it to the ninth clinic, or even to a second one.

New data suggests that the U.S. federal government’s cuts to current spending have resulted in between 500,000 to 1,000,000 deaths, while the decrease in commitments to future foreign aid spending could lead to an additional 670,000 to 1,600,000 lives lost.

“Every line item in the budget, there is a person, a patient, a nurse, a family,” said Dr. Alain Casseus, director of infectious diseases for Zanmi Lasante, as PIH is known in Haiti, during a briefing call with Congress. “I’m asking you to remember the people behind these numbers.”

It’s for those people—their families, their communities—that we keep moving forward. Our work as clinicians, as global citizens, and as advocates remains essential to building a future where health is a human right, for everyone, everywhere.

Thirty health care leaders will graduate from the University of Global Health Equity (UGHE) in Rwanda with medical degrees on Jan. 25, 2026, marking a historic moment for the university and the future of global health education.

This exceptional achievement commemorates the first graduation of UGHE’s dual medical degree program, which combines the Bachelor of Medicine and Bachelor of Surgery (MBBS) with the Master of Science in Global Health Delivery (MGHD)—a rigorous curriculum designed to train clinicians to deliver high-quality care while strengthening health systems.

Note: For those who would like to experience the graduation celebration but are unable to attend in-person, the ceremony will be livestreamed on Jan. 25 at 11 a.m. CAT.

The graduation is a moment Partners In Health (PIH) and its worldwide partners, including the Government of Rwanda, Cummings Foundation, and the Bill & Melinda Gates Foundation, have been looking forward to for more than a decade.

The late Dr. Paul Farmer, PIH’s co-founder and former UGHE chancellor, had a bold vision of global health equity. He understood the sharp disparity in access to care across Africa, where the health workforce shoulders 24% of the global disease burden but represents only 3% of the world’s health workers.

Aiming to help bridge this gap, PIH partnered with the Government of Rwanda in 2015 to launch UGHE, a pioneering university campus in rural Rwanda located near the Butaro District hospital, allowing students to live and work in close proximity to the community they are serving and designed to rethink how health professionals are trained.

The university welcomed its first MGHD students in 2015 and, four years later, celebrated another milestone when its first class of dual-degree medical students arrived on campus.

The 6.5-year medical degree curriculum was shaped by experts in research and clinical care with equity at the forefront. Conversations about health disparities and social determinants of health are woven throughout the program, alongside rigorous research, community engagement, and clinical rotations.

“The University of Global Health Equity (UGHE) is the manifestation—in its students, faculty, and staff—of PIH’s mission and our conviction that care delivery must be linked to education, research, and replicable implementation models," said PIH CEO Sheila Davis. "Through the interdisciplinary academic programs at UGHE, we are shaping leaders who will provide high-quality care to patients; who will research and teach the science of global health delivery; who will steer ministries of health, nonprofits, and other influential institutions; and who will enable the replication of best practices around the world.

"This inaugural class of medical school graduates have been educated not only as clinicians with expert technical skills, but as scholars in human rights and social justice. Paul was thrilled to teach at UGHE—a university that, in his words, 'is built around the opportunity to serve'— and was in awe of every single student. I know this class—lovingly known by many of us as ‘Paul’s Class’—will make great strides in the pursuit if global health equity, delivering high quality health care starting with the communities that need it most. I can’t wait to see what the future holds and how this graduating class continues to bend the arc towards justice."

Paul taught the cohort of students graduating this year, joining them on their clinical rotations and working alongside them in hospitals and health centers, before he passed away on Feb. 21, 2022, in Butaro.

Paul’s deep commitment to treating patients with care, love, and dignity has been instilled in these students, many of whom continue to reflect on his teachings as foundational to their approach to medicine.

“I remember joining Dr. Paul Farmer on social ward rounds not to prescribe, but to listen and comfort patients. I grew to understand that medicine is more than a white coat; it requires being a diagnostician, leader, advocate, researcher, and social worker, depending on the situation,” wrote MBBS-MGHD graduate Alima Uwimana.

Another inaugural MBBS-MGHD graduate, Joselyne Nzisabira, said Paul taught them how to advocate for patients with love.

As this first cohort of clinicians prepares to embark on their professional lives, they will take with them the values of patient-centered care and a shared responsibility to strengthen health systems. Each graduate has committed to working with underserved populations for five years as employees of Rwanda’s Ministry of Health, a requirement of their education.

During their time at UGHE, students have explored long-held passions and discovered new ones—with interests spanning pediatrics, cardiothoracic surgery, obstetrics and gynecology, and more.

No matter which specialty each student pursues, they share a deep commitment to health equity and will carry forward the values of PIH and UGHE throughout their careers.

“(They) are pioneers, trailblazers who have set the foundation for future generations of medical professionals trained within UGHE,” wrote Dr. Shivon Byamukama, UGHE’s Deputy Vice Chancellor for Administrative and Financial Affairs. “(Their) commitment to excellence and service marks the beginning of a new chapter in the world’s healthcare sector. We believe in (their) potential to transform lives, strengthen health systems, and contribute meaningfully to the advancement of medicine in (their) respective countries and around the world.”

The ceremony will be available to watch live online on Jan. 25 at 11 a.m. CAT.

As the opening of the Paul E. Farmer Maternal Center of Excellence (MCOE) draws closer, staff are focused and eager.

“I'm so excited talking about it,” says Francess Kamara, senior midwife mentor for Partners In Health (PIH) Sierra Leone. “We have put a lot of energy and work to get [midwives] prepared. The whole team has done so much.”

On February 14, the longtime vision of the MCOE will become reality, as the doors open to its first patients. As training sessions continue, Kamara is eager for the midwives she’s mentored to apply what they’ve learned. Since the Oct. 25, 2025 ribbon-cutting and inauguration of the MCOE, staff have undergone intensive training and orientation amid the new space and equipment.

From electronic medical records to biomedical equipment, such as advanced vitals monitors and oxygen cylinders, staff are learning how to safely provide dignified, high-quality care in the 120-bed facility, which sits on the existing Koidu Government Hospital (KGH) campus.

Hands-On Training Builds Confidence

The MCOE, which will open in a phased approach to ensure quality and efficiency, will initially employ approximately 200 clinical staff. This includes 51 midwives, contracted by Sierra Leone’s Ministry of Health and trained by PIH Sierra Leone staff. As a facilitator, Kamara has supported new and existing employees, working alongside Isata Dumbuya, PIH Sierra Leone’s director of reproductive, maternal, and neonatal health. Together, they ensure training runs smoothly, topics are adequately covered, and most importantly, that staff understand the information and feel prepared to deliver care.

Dumbuya regularly reminds staff that training triumphs technology. The MCOE has nearly every piece of cutting-edge technology needed to skillfully treat pregnant women and babies. However, staff must know how to use the equipment as intended to effectively serve women. It's her priority to “ensure that every staff that works there, in whatever capacity, [are] motivated, equipped, and fully prepared to be able to deliver a high standard of care.”

Amid providing ongoing care at PIH-supported KGH, staff rotate through various training sessions. Through hands-on learning, they directly interact with equipment in the neonatal intensive care unit (NICU), the first in Sierra Leone. They learn the names and functions of every machine, practice how to operate and troubleshoot them, and review proper care and maintenance to ensure patient safety and longevity of the tools.

“Staff training is very, very important,” Kamara emphasizes. “It has given the midwives the confidence, the requisite skills, and knowledge that they may require to start operations at the MCOE.”

These lifesaving skills will directly impact mothers and babies. The MCOE has vital equipment, such as infusion pumps, to precisely monitor IV fluids and prevent serious complications, such as fluid overload—addressing an ongoing challenge at KGH.

Another component of the training focuses on the electronic medical record (EMR) system, ensuring staff understand how to accurately record patient information, including medical history, and use the proper filing codes.

Mariama Gifty Lahai, a critical care nurse for PIH Sierra Leone, completed the EMR training—among other courses—and is confident that this will allow clinicians to deliver better care. With the EMR system, staff can spend more time with patients and less time compiling handwritten paperwork and tracking down documents across units.

Lahai, one of only a handful of Sierra Leonean nurses with critical care nursing expertise, feels well prepared and is excited to begin work at the state-of-the-art facility. For her, the MCOE is deeply personal—especially after a recent pregnancy loss.

“I strongly believe my baby could have had a chance to live only if there was a facility like the MCOE, with a NICU, here in Kono,” says Lahai. “The presence of a place like this gives me hope.”

Training Rooted in PIH Values

Alongside technical training, sessions have emphasized PIH’s core beliefs and values. While the recently recruited midwives bring extensive experience in patient care, many are new to PIH’s unique approach to care.

During training workshops, Dumbuya teaches midwives about PIH’s mission to provide a “preferential option for the poor in health care,” including no-cost services. This is surprising to many trainees, as most come from clinics where patients pay for care.

“We really do mean that this is free,” Dumbuya emphasizes to trainees. “And this is how we go about ensuring that this can happen,” she says, before introducing the concept of social support. At PIH, health services extend beyond medication and include the essential resources, or social support, to ensure effective care: food, transportation, housing, education, and more. The training reinforces the importance of dignity, compassion, and teamwork as essential components of high-quality maternal health services.

When the MCOE opens its doors next month, most clinical staff—approximately 93%—will be Sierra Leonean nationals. Hiring locally is essential to PIH’s work and care delivery across every site around the globe. With a deep understanding of language, culture, and community, local staff can provide respectful and effective care.

A mother of two, Kamara went to KGH throughout her second pregnancy. She chose to seek care in Kono—rather than Freetown, where she delivered her first child—because of a deep trust in the staff and their expertise. Upon completing antenatal visits at KGH, Kamara underwent an emergency cesarean section there, delivering a healthy child, now 2 years old. The quality of care she received is the same as she sees her colleagues deliver every day to all patients, staff or not—and knows this will continue at the MCOE.

“As a mom, as a midwife, as a Salonean ... it's a dream come true for me,” says Kamara, as she eagerly awaits the opening of the MCOE.

Although a major milestone, the opening of the MCOE is just the beginning. Ensuring the facility can provide the highest quality care requires continued investment, including continuous training. Looking ahead, a dedicated training site and dormitory—a 10-minute drive from the MCOE—are underway and will provide a dynamic environment for ongoing learning.

Editor’s note: This article was originally published in Spanish on Socios En Salud’s website.

For decades, mental health has been a blind spot in public health systems. In low- and middle-income countries, such as Peru, only 3 out of every 100 people with depression receive treatment, largely because there are not enough specialized professionals, according to the World Health Organization (WHO).

To start to address this challenge, the WHO and UNICEF, in academic partnership with George Washington University, launched the Foundational Helping Skills Training Manual (FHS) in July 2025. The manual aims to equip doctors, nurses, social workers, and other community stakeholders with simple but essential tools to provide safe and effective support when interacting with adult patients.

FHS is part of an initiative from the same organizations called Ensuring Quality in Psychological Support, more commonly known as EQUIP. EQUIP proposes a new competency-based approach to mental health care: teaching specific skills—such as active listening, empathy, and conveying hope—and evaluating them in practice, not just through theoretical exams. It’s a flexible, widely applicable, and evidence-based method.

“EQUIP is many things, but above all, it's a response to the lack of standards that guarantee safe and high-quality mental health care. It's a paradigm shift,” said Dr. Gloria Pedersen, director of mental health and psychosocial support at Partners In Health (PIH), a researcher at Harvard Medical School, and one of the project leaders.

Socios En Salud (SES), as PIH is known in Peru, was a key part of this change in approach. SES’s work helped test EQUIP’s methodology before and during the pandemic, proving its effectiveness even during the most critical moments, with remarkable results. What began as a local initiative is now part of a global manual poised to transform the way the world approaches mental health.

What is EQUIP?

In the early 2000s, a simple yet powerful idea gained traction in mental health: sharing clinical tasks with non-specialized personnel, like community health workers. Promoted by the WHO and various universities, this approach spread to countries with fewer resources, bringing support to communities that often experience a shortage of trained professionals.

The challenge, however, was how to ensure that those providing psychosocial support—whether mental health specialists or not—offered safe and high-quality services. There was no clear way to assess this standard of care.

With this need in mind, EQUIP was born: a digital platform that seeks to improve mental health care and psychosocial support. Through simulations, direct observation, and feedback, EQUIP teaches and evaluates key skills, prioritizing how they are applied in practice, not just in theory. It's not simply a checklist, but a training philosophy.

"We designed a tool that allows us to measure skills, integrate them into training and supervision, and promote a competency-based approach that goes beyond simple knowledge tests," Pedersen said.

EQUIP fills a crucial gap by offering a standard valid for psychiatrists and psychologists, as well as community workers around the world.

“The main challenge, as is often the case, was funding, in which USAID initially played a key role,” says Dr. Pedersen. “Another challenge was adapting the tools to multiple cultural and linguistic contexts, as we worked with more than seven countries on rigorous research to ensure they were valid and useful in different settings.”

Fortunately, SES and PIH were able to use existing resources and decades of experience to support this part of the project.  

The Role of PIH in EQUIP’s Success

Before the pandemic, talking about mental health in Peru was difficult.

“There was a very strong stigma," said Carmen Contreras, head of the Mental Health Program at SES. In rural areas, almost half of women and more than a third of men feared being judged if they sought psychological help, which limited access to services.

With this context, it was surprising when Peru was chosen as one of the countries in South America to carry out EQUIP. The implementation was carried out through an existing project called Thinking Healthy (PENSA), led by SES's mental health program and aimed at women with perinatal depression in northern Lima. It was the first time that a global tool of this type had been tested in Peruvian communities.

“In addition to providing training, EQUIP allowed us to evaluate the entire intervention process, which was still under development,” Contreras said. “For me, it was an opportunity to position SES as a leader in the skills that every mental health professional should have, beyond traditional technical or academic training.”

From Dr. Pedersen's perspective, SES was crucial to EQUIP’s overall success.

“They adapted the tools to the Peruvian and Spanish-speaking contexts, and even co-developed specific instruments for the PENSA project,” she said. This flexibility allowed the practical integration of learning into community health services.

This effort became especially important with the arrival of the pandemic. Faced with restrictions and lockdowns, SES’s mental health program began utilizing innovations like chatbots and other remote tools to support the community through both specialized and non-specialized mental health professionals, including community health workers. These digital solutions ensured the continuity of psychosocial support at a time when the need was more urgent than ever.

The reach was remarkable. In addition to validating the methodology, SES contributed to the development of the FHS, an essential part of EQUIP's resources. With this collaboration, the training also reached professionals without prior training in mental health—nurses, midwives, and students—expanding the project's impact.  

"The impact was so significant that many professionals said it was the first time they had learned how to address suicide in a practical way," Pedersen said.

From Practice to Systemic Change

The FHS manual, which incorporates the EQUIP model, opened up an unprecedented opportunity for SES. After its initial success with PENSA, the team is now preparing to implement the tool in other local interventions.  

"As always, we want to start in Carabayllo [a district north of Lima]," Contreras said. "The idea is to demonstrate results and then present them to the Ministry of Health."  

This transition from the local to the national level is precisely what excites Dr. Pedersen. For her, EQUIP is changing the way mental health professionals are trained on the front lines.  

"The most impactful thing was seeing nurses and midwives applying what they had learned weeks later, especially during suicide risk screening, on their own initiative," she said.

EQUIP’s success lies in its approach. It's no longer about imparting theoretical knowledge that often remains purely academic but about developing observable and practical skills. Through simulations, feedback, and role-playing, professionals not only learn what to do, but also how it feels from the patient's perspective. This level of empathy changes the way care is provided.

The next challenge is to systematically demonstrate the impact of EQUIP—both locally and on a global scale.  

“There is already evidence that EQUIP’s approach reduces harmful behaviors and promotes helpful practices among providers,” Pedersen said. “What's missing is direct data on the patients themselves. We want to compare, for example, two groups of nurses, one trained with these competencies and the other using the traditional method, and analyze the clinical outcomes.”

Although the pandemic slowed down some of the studies, many of the results have been promising. In India, patients treated by professionals trained with simulations had better outcomes. In Nepal, a cost analysis showed that this approach is not only more effective but also does not increase training costs.  

"The evidence suggests that competency-based training is more useful and sustainable," Pedersen said. "Now, we are working to integrate these skills into undergraduate and graduate programs.”  

This is the type of systemic change that Partners In Health and Socios En Salud strive for: improving care at every level for people around the world, especially those most vulnerable.