Future Reform of PEPFAR: Exploring the Use of a Graduation Policy

Jennifer Kates
Published: Apr 23, 2025

Overview

As the Trump administration and Congress look to reform PEPFAR, and other U.S. global health programs, in part to ensure that aid does not continue forever, one potential approach is the use of a graduation policy and criteria – that is, metrics for determining when a country is ready to transition away from U.S. support. To inform such efforts, this policy brief reviews the graduation policies of five institutions and programs. Overall, the review identifies the following graduation approaches and components:

The use of country-income to target graduation process and threshold
The use of other (non-income based) criteria to target graduation process and threshold
Timeframes that allow for scale-down and predictability
Allowing for re-eligibility for assistance
Accommodating exceptions and emergencies
Continue to monitor countries after graduation

Introduction

Starting on day one of his second term, President Trump began instituting several executive orders and other actions that have fundamentally altered the U.S. global health response. These included an executive order calling for a 90-day foreign aid review (which has been extended for 30 days) and the freezing of almost all program operations; steps to dissolve USAID, the government’s main global health implementing agency; and the cancellation of most global health projects. Thus far, these steps have been blunt, causing significant service disruption in health services and loss of health capacity globally. Now, with the foreign aid review period drawing to a close, the administration has notified Congress of its intent to restructure remaining global health programs and institute reforms, including seeking to establish a more transactional model of aid with time-bound arrangements to ensure that aid does not continue forever, a position of the first Trump administration. Indeed, as part of its foreign aid review, a survey sent to all U.S. foreign aid recipients included a question about whether they had a plan for transitioning projects from U.S. support.

Should the administration and Congress seek to move in this direction for PEPFAR, as well as other U.S. global health programs, one potential approach for putting time limits on aid is the use of a “graduation” policy and criteria – that is, metrics for determining when a country is ready to transition from U.S. support, as well as a process and timeline for scaling down that support (another such reform is progressive co-financing, which we discuss here). Some have recommended such an approach for PEPFAR, including at a recent Congressional hearing. With limited exception, however, the U.S. government has not used formal graduation criteria or eligibility cut-offs for its bilateral global health programs, including for PEPFAR.

To help inform such efforts, this policy brief reviews the graduation policies of five institutions and programs, including three international institutions – Gavi, the Vaccine Alliance (Gavi), The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), and the World Bank’s International Development Association (IDA) – and two U.S. programs – the Millennium Challenge Corporation (MCC) and USAID’s family planning program (due to the administration’s foreign aid review, the family program is currently not operating). Specifically, it looks at the measures used to initiate and conclude graduation processes, the timeframe for graduation, whether exceptions are made, and whether re-eligibility is allowed. Where data are available, it also identifies the number of countries that have graduated from assistance. Summary measures are provided in Table 1. Detailed information for each institution or program examined is provided in an Appendix.

Findings

Each of the five models examined uses varying criteria, timeframes, and processes for determining when a country is ready to transition from donor assistance. There are also some commonalities.

Table 1
Summary of Graduation Criteria and Process
Institution/Program	Income Criteria	Other Criteria	Scale-down w/ economic growth	Timeframe to Graduation After threshold	Re-Eligibility Allowed	Exceptions Allowed	Number Graduated
Gavi	Yes	No	Yes	8 yrs	Yes	Yes	19
Global Fund	Yes	Yes	Yes	At least 3 yrs	No	Yes	11
IDA	Yes	No	Yes	Average of 6 yrs	Yes	Yes	46
MCC	Yes	No	Yes	At least 5 yrs	Yes	Yes	Unknown
USAID FP	No	Yes	Unknown	2-6 yrs	Unknown	Unknown	25
See Appendix for detailed information and sources.

Use of country-income to target graduation process and threshold. Four of the five models examined (Gavi, the Global Fund, IDA, and MCC) explicitly use country-income to determine in full or in part the threshold for ending assistance, and in most cases, to trigger a process for doing so. In addition, they each adjust their support downward as a country’s income rises but before it officially graduates (Gavi, the Global Fund, and MCC require increased co-financing and IDA tightens its financing terms). The Global Fund also uses an allocation formula that channels most funding to the lowest income countries. In PEPFAR’s case, while funding is provided to low and middle-income countries, there has been no policy to adjust or scale down financing as a country’s income increases. A graduation policy, using income as a criteria and scaling down support as income increases, would allow for a more defined and explicit way to move countries toward a graduation threshold and channel most support to countries with lower incomes.
Use of other (non–income based) criteria to target graduation process and threshold. Three of the five models examined (the Global Fund, IDA, and USAID’s family planning program) also use other, non-income-based criteria to assess graduation readiness (Gavi and MCC are the exceptions and only use income). The use of non-income-based measures, particularly in a health context, may be helpful for providing a fuller assessment of a country’s readiness for graduation and mitigating against negative health outcomes. The Global Fund, for example, also uses epidemiological criteria specific to each of the three diseases it targets (HIV, TB, and malaria). Thus, countries that reach upper middle-income status will only remain eligible if they also meet eligibility criteria for one of the disease components. IDA, in addition to income, also looks at “credit worthiness” (e.g., a country’s ability to service new external debt at market interest rates over the longer term) to help determine graduation readiness. The USAID family planning program only uses non-income-based criteria to trigger a graduation process, focused on two main measures: total fertility rate and modern contraceptive prevalence rate (other factors considered include access and quality measures and the extent which family planning products, services, and programs are financed domestically). PEPFAR has already been grouping countries into categories based on the status of their HIV epidemics, measures which could be incorporated into a graduation policy, in addition to income.
Timeframes that allow for scale-down and predictability. Each of the models examined allows for a multi-year period from the time a country reaches the eligibility threshold until full graduation from assistance, rather than an abrupt eligibility cliff, an approach designed to support planning and predictability. For Gavi, once a country reaches the last of three phases of eligibility (after exceeding the World Bank’s low-income threshold, based on a 3-year average), it has eight years before assistance actually ends. For the Global Fund, once a country is no longer eligible for assistance (after exceeding the World Bank’s upper-middle income threshold and no longer meeting any disease component criteria), it may receive “transition funding” for one additional allocation period of three years. If a country’s disease component becomes ineligible during an allocation period, the country remains eligible for Global Fund support for the duration of that period. The Global Fund also publishes projected graduation dates for countries, allowing for longer term planning, and conducts graduation readiness assessments. For IDA, while there is no set timeframe for graduation, there is an expectation that once a country reaches the graduation eligibility threshold, it will transition “within a reasonable timeframe” (which has typically been two IDA replenishment cycles or six years). For the MCC, the income eligibility threshold applies only to initial selection for a five-year compact but once selected, the MCC can continue to develop and implement the program even if the country no longer meets income eligibility during this time or during the compact itself. This means that the period between when a country first surpasses the income eligibility threshold and when it graduates from MCC assistance is at least five years but may be longer. USAID’s family planning program did not specify a graduation timeframe but most countries that graduated did so between two and six years after they met the threshold for starting the graduation process.
Allowing for re-eligibility for assistance. Three of the five models examined (Gavi, IDA, and MCC) explicitly allow for a country to become re-eligible for support should it meet eligibility criteria in the future. Gavi also allows some formerly eligible countries to receive support to prevent back-sliding in vaccine coverage and support the introduction of key missing vaccines, in certain cases, even if they do not meet eligibility criteria. On the other hand, the Global Fund does not allow for re-eligibility and USAID’s family planning policy does not specify whether a country could again qualify for support if it were to meet eligibility criteria. Permitting re-eligibility would allow PEPFAR to account for changing country circumstances that could affect service delivery and health outcomes, though it could also create unpredictability about the availability of U.S. resources in the future.
Accommodating exceptions and emergencies. Three of the five models examined allow for exceptions to graduation policies and criteria. Exceptions generally allow for longer graduation periods and/or less stringent criteria. Gavi, the Global Fund and IDA, for example, all make such exceptions for Small Island Developing States, a group of states that face unique social, economic, and environmental vulnerabilities, which are provided longer graduation periods (and in some cases, higher income thresholds). Gavi also has a “Middle-Income Country (MIC) Approach”, a policy that enables former and never eligible countries, as well as certain others, to receive funding to prevent back-sliding in vaccine coverage and to support introduction of key missing vaccines, and to help those facing emergencies access support to maintain routine immunization. The Global Fund has several exceptions. First, it allows non-eligible countries facing emergencies that adversely impact progress against the three diseases to be granted exceptional funding, subject to Board approval and availability of funds. It also allows UMICs that no longer meet HIV eligibility to be eligible for support to directly finance NGOs and civil society organizations where there are barriers to reaching key populations in a country. Finally, the Global Fund allows countries that no longer meet eligibility criteria but are part of a multi-country application to be eligible if the majority of countries included are eligible for funding in their own right. IDA allows, on a case-by-case basis, for “exceptional temporary access” to assistance for countries facing emergencies, conflicts, or other challenging conditions. While the MCC does not have exceptions to its graduation threshold, it does allow for exceptions to its country contribution requirement, made on a case-by-case basis, to account for emergencies and conflict.
Continuing to monitor countries after graduation. To varying extents, the institutions and programs examined continue to monitor countries after graduation, to assess whether they have been able to sustain program outcomes and identify potential backsliding due either to the loss of assistance or other factors. Gavi and the Global Fund, for example, have conducted evaluations of their sustainability policies and subsequently adjusted their graduation criteria and approach over time. IDA has also conducted such reviews to assess graduation policies, and there have been multiple analyses of USAID’s family planning graduation process, which also adjusted over time.

Potential Lessons for PEPFAR

These examples, including some from the U.S., may help point the way to the type of indicators and processes that could be used for PEPFAR, as well as other U.S. global health programs, should the administration and Congress seek to institute a graduation policy. Collectively, they suggest that income is a common criteria for determining a graduation threshold, as well as for scaling down resources with economic growth. They also suggest that combining income with disease or other health criteria may be a way to mitigate against negative health outcomes. Other policy components identified include relaxing graduation criteria and timeframes in exceptional or emergency situations and allowing for re-eligibility should a country once again meet eligibility criteria. Additionally, a common finding identified across all institutions examined is that graduation from assistance is not a short process and typically takes several years to plan for and complete.

Appendix

Graduation Criteria for Select Global Health and Development Organizations and Programs
Gavi, the Vaccine Alliance (Gavi)	Country eligibility based on income criteria, as calculated by the World Bank Atlas Method for determining gross national income per capita (GNI p.c.). Eligibility is divided into three phases, which determine the amount of co-financing required and the path toward graduation: Initial self-financing (GNI p.c. less than or equal to the World Bank low-income threshold; co-finance of flat amount per vaccine) Preparatory transition (GNI p.c. greater than the World Bank low-income threshold but less than accelerated transition phase, although in certain cases, this phase may be extended by two years; co-finance % of each vaccine, with 15% increase per year) Accelerated transition (3-year average GNI p.c. and most recent GNI p.c. great than low-income threshold; co-financing at least 35% of vaccine costs).	After a country has been in the accelerated transition phase (in 2025, the income threshold was <= to $1,820) for 8 years, it is no longer eligible for Gavi support. Gavi support is scaled down as a country’s income increases (co-financing requirements increase).	Accelerated transition (the final phase of eligibility) lasts for eight years (Small Island Developing States have twelve years). After eight years, a country becomes fully self-financing and can no longer access new financial support. 19 countries have graduated from Gavi support since the graduation policy was first adopted in 2009.	Any formerly eligible country whose GNI p.c. drops below the low-income or Gavi-eligibility threshold, based on its most recent GNI p.c. in any given year, will be reclassified into the appropriate eligibility transition phase. Exceptions are made (via the Middle Income Approach) for former eligible, never eligible, and some IDA eligible countries to receive support to prevent back-sliding, support introduction of missing vaccines, and, for those with emergencies, help maintain routine vaccination.
Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund)	Country eligibility based on both income criteria, as calculated by the World Bank Atlas Method for determining GNI p.c. (using the latest three-year average), and disease burden criteria: All low and lower-middle income countries, as defined by GNI p.c., are eligible to receive support for HIV/AIDS, tuberculosis (TB) and malaria, regardless of disease burden. Upper-middle income countries (UMICs) are eligible to receive support if they meet additional requirements by disease component and, for HIV, are on OECD DAC List of ODA recipients. If not, a country may be eligible for HIV support to directly finance NGOs and civil society organizations if there are demonstrated barriers to providing funding for interventions for key populations. UMICs classified as IDA-eligible Small States, including Small Island Economies, are eligible regardless of national disease burden. Countries with existing grants otherwise ineligible due to disease burden or income level that are experiencing conflict/challenges may continue to be eligible. Multi-country applications are eligible if the majority (i.e., at least 51 percent) of countries included are eligible for funding in their own right.	Once a country reaches UMIC status, it is no longer eligible for funding if it does not meet any disease component requirements. Country disease components that become ineligible during an allocation period will remain eligible for the duration of that period. The Global Fund works with countries to plan for transition by conducting transition readiness assessments. Global Fund support is scaled down as a country’s income increases (co-financing requirements increase).	When a country disease component becomes ineligible for Global Fund support, it may receive one additional allocation period (three years) of transition funding. 11 country disease components have graduated from Global Fund support since the graduation policy came into effect in 2017 (additional country components transitioned from support before the policy was implemented).	Once a country disease component receives transition funding or voluntarily transitions from Global Fund support, it is no longer eligible but will continue to be considered eligible for multi-country approaches provided it is not a high-income country. Exceptions are made for non-eligible countries facing emergencies that adversely impact progress against HIV, TB and malaria may be granted exceptional funding, subject to Board approval and availability of funds. There may also be an exception made for countries with an unusual increase in malaria cases.
International Development Association (IDA)	Country eligibility based on income criteria, as calculated by the World Bank Atlas Method for determining GNI p.c. and set below an IDA operational cut-off level adjusted annually. IDA is prohibited from assisting countries if it determines financing is available from private sources on reasonable terms or could be provided by IBRD. These “creditworthiness” determinations” are based on a country’s ability to service new external debt at market interest rates over the longer term.	Once a country reaches the IDA operational cut-off level ($1,335 in 2025), there are three phases of graduation to IBRD-only financing: Gap phase: countries above the IDA operational cut-off for over two years but not yet creditworthy for IBRD financing. Blend phase: countries with a positive creditworthiness assessment by IBRD. IBRD-only phase: countries no longer eligible for IDA. For small island economies above the operational cutoff, an exception may be made to allow them to remain classified as IDA-only countries due to characteristics that affect their creditworthiness and access to finance. IDA support is scaled down as a country’s income increases (financing terms are tightened).	No specific timeframe set and instead is dependent on several factors including individual country circumstances and access to financing from other bilateral and multilateral sources. Expectation is that countries will transition from blend to IBRD-only status “within a reasonable timeframe” (typically has been two IDA replenishment cycles or six years). 46 countries have graduated from IDA support since its founding in 1960.	If a formal determination is made that an IBRD borrower previously assessed as creditworthy and graduated from IDA is subsequently confronted with adverse circumstances rendering it non-creditworthy for IBRD financing, it is once again eligible for IDA. Exceptional temporary access to IDA has been provided on a case-by-case basis in the face of emergencies, conflicts, or other challenging conditions.
Millennium Challenge Corporation (MCC)	Country eligibility based on income criteria, as calculated by the World Bank Atlas Method for determining GNI p.c., and set =< the World Bank threshold for initiating the IBRD graduation process for the fiscal year ($7,895 in 2025). In addition, countries must meet several, measurable good governance criteria to be eligible. Selection is competitive. If successful, country enters into five-year compact (the MCC also has a “threshold program” which assists promising candidate countries to become compact eligible). After five years, if a country remains eligible, there is a possibility to be considered for another compact (subject to more rigorous standards).	Once country income surpasses the threshold, it is no longer eligible for MCC support. However, the income threshold for countries applies to initial selection for eligibility for an MCC compact program; once selected for a compact, the MCC can continue to develop and implement the program even if the country surpasses the income threshold during the development or implementation phase of the program. MCC support is scaled down as a country’s income increases (co-financing requirements increase).	For a country that no longer meets the income criteria, graduation would occur only after the compact ends. This means that the period from initial eligibility for selection to compact completion and graduation would be at least five years (potentially including the time it took to be selected and prepare the compact). Unknown how many have graduated after receiving support.	Any country that is below MCC’s income threshold in a given fiscal year can be considered for an MCC program, including countries that have previously graduated out of income pool. Exceptions to country contributions may be made on a case-by-case basis and can take into account emergencies and conflict.
USAID Family Planning (FP) Program	None specified. The Foreign Assistance Act of 1961 and official guidance do not specify any formal eligibility criteria for development assistance, although most support has been provided to low- and middle-income countries. This has been the case for USAID’s family planning (FP) program, which began in the 1960s. The FP program further concentrated its efforts in countries that had high rates of unmet need for FP, prevalence of high-risk births, and low contraceptive use.	A country is eligible for graduation once the following indicators have been reached: Modern contraceptive prevalence rate of at least 51% Total fertility rate at or below 3.1 children per woman Other factors considered are: At least 80% of the population can access at least three family planning methods No more than 20% of family planning products, services and programs offered in the public and private sectors are subsidized by USAID Major service providers in all sectors (public, non-governmental, commercial) can meet and maintain standards of informed choice and quality of care.	No specific timeframe set. Process could take 2-10 years, with most countries graduating in 2-6 years. 25 countries had graduated from USAID family planning support since 1976 (as of 2020).	No country that has graduated from family planning assistance had backslid to a point where they might have been re-eligible.

Graduation Criteria for Select Global Health and Development Organizations and Programs

Institution/ Program

Eligibility Criteria

Graduation Threshold Criteria

Graduation Timeframe & Number Graduated

Re-Eligibility & Exceptions

Gavi, the Vaccine Alliance (Gavi)

Country eligibility based on income criteria, as calculated by the World Bank Atlas Method for determining gross national income per capita (GNI p.c.). Eligibility is divided into three phases, which determine the amount of co-financing required and the path toward graduation:

Initial self-financing (GNI p.c. less than or equal to the World Bank low-income threshold; co-finance of flat amount per vaccine)
Preparatory transition (GNI p.c. greater than the World Bank low-income threshold but less than accelerated transition phase, although in certain cases, this phase may be extended by two years; co-finance % of each vaccine, with 15% increase per year)
Accelerated transition (3-year average GNI p.c. and most recent GNI p.c. great than low-income threshold; co-financing at least 35% of vaccine costs).

After a country has been in the accelerated transition phase (in 2025, the income threshold was <= to $1,820) for 8 years, it is no longer eligible for Gavi support.

Gavi support is scaled down as a country’s income increases (co-financing requirements increase).

Accelerated transition (the final phase of eligibility) lasts for eight years (Small Island Developing States have twelve years).

After eight years, a country becomes fully self-financing and can no longer access new financial support.

19 countries have graduated from Gavi support since the graduation policy was first adopted in 2009.

Any formerly eligible country whose GNI p.c. drops below the low-income or Gavi-eligibility threshold, based on its most recent GNI p.c. in any given year, will be reclassified into the appropriate eligibility transition phase.

Exceptions are made (via the Middle Income Approach) for former eligible, never eligible, and some IDA eligible countries to receive support to prevent back-sliding, support introduction of missing vaccines, and, for those with emergencies, help maintain routine vaccination.

Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund)

Country eligibility based on both income criteria, as calculated by the World Bank Atlas Method for determining GNI p.c. (using the latest three-year average), and disease burden criteria:

All low and lower-middle income countries, as defined by GNI p.c., are eligible to receive support for HIV/AIDS, tuberculosis (TB) and malaria, regardless of disease burden.
Upper-middle income countries (UMICs) are eligible to receive support if they meet additional requirements by disease component and, for HIV, are on OECD DAC List of ODA recipients. If not, a country may be eligible for HIV support to directly finance NGOs and civil society organizations if there are demonstrated barriers to providing funding for interventions for key populations.
UMICs classified as IDA-eligible Small States, including Small Island Economies, are eligible regardless of national disease burden.
Countries with existing grants otherwise ineligible due to disease burden or income level that are experiencing conflict/challenges may continue to be eligible.
Multi-country applications are eligible if the majority (i.e., at least 51 percent) of countries included are eligible for funding in their own right.

Once a country reaches UMIC status, it is no longer eligible for funding if it does not meet any disease component requirements. Country disease components that become ineligible during an allocation period will remain eligible for the duration of that period. The Global Fund works with countries to plan for transition by conducting transition readiness assessments.

Global Fund support is scaled down as a country’s income increases (co-financing requirements increase).

When a country disease component becomes ineligible for Global Fund support, it may receive one additional allocation period (three years) of transition funding.

11 country disease components have graduated from Global Fund support since the graduation policy came into effect in 2017 (additional country components transitioned from support before the policy was implemented).

Once a country disease component receives transition funding or voluntarily transitions from Global Fund support, it is no longer eligible but will continue to be considered eligible for multi-country approaches provided it is not a high-income country.

Exceptions are made for non-eligible countries facing emergencies that adversely impact progress against HIV, TB and malaria may be granted exceptional funding, subject to Board approval and availability of funds. There may also be an exception made for countries with an unusual increase in malaria cases.

International Development Association (IDA)

Country eligibility based on income criteria, as calculated by the World Bank Atlas Method for determining GNI p.c. and set below an IDA operational cut-off level adjusted annually. IDA is prohibited from assisting countries if it determines financing is available from private sources on reasonable terms or could be provided by IBRD. These “creditworthiness” determinations” are based on a country’s ability to service new external debt at market interest rates over the longer term.

Once a country reaches the IDA operational cut-off level ($1,335 in 2025), there are three phases of graduation to IBRD-only financing:

Gap phase: countries above the IDA operational cut-off for over two years but not yet creditworthy for IBRD financing.
Blend phase: countries with a positive creditworthiness assessment by IBRD.
IBRD-only phase: countries no longer eligible for IDA.

For small island economies above the operational cutoff, an exception may be made to allow them to remain classified as IDA-only countries due to characteristics that affect their creditworthiness and access to finance.

IDA support is scaled down as a country’s income increases (financing terms are tightened).

No specific timeframe set and instead is dependent on several factors including individual country circumstances and access to financing from other bilateral and multilateral sources.

Expectation is that countries will transition from blend to IBRD-only status “within a reasonable timeframe” (typically has been two IDA replenishment cycles or six years).

46 countries have graduated from IDA support since its founding in 1960.

If a formal determination is made that an IBRD borrower previously assessed as creditworthy and graduated from IDA is subsequently confronted with adverse circumstances rendering it non-creditworthy for IBRD financing, it is once again eligible for IDA.

Exceptional temporary access to IDA has been provided on a case-by-case basis in the face of emergencies, conflicts, or other challenging conditions.

Millennium Challenge Corporation (MCC)

Country eligibility based on income criteria, as calculated by the World Bank Atlas Method for determining GNI p.c., and set =< the World Bank threshold for initiating the IBRD graduation process for the fiscal year ($7,895 in 2025). In addition, countries must meet several, measurable good governance criteria to be eligible. Selection is competitive. If successful, country enters into five-year compact (the MCC also has a “threshold program” which assists promising candidate countries to become compact eligible). After five years, if a country remains eligible, there is a possibility to be considered for another compact (subject to more rigorous standards).

Once country income surpasses the threshold, it is no longer eligible for MCC support. However, the income threshold for countries applies to initial selection for eligibility for an MCC compact program; once selected for a compact, the MCC can continue to develop and implement the program even if the country surpasses the income threshold during the development or implementation phase of the program.

MCC support is scaled down as a country’s income increases (co-financing requirements increase).

For a country that no longer meets the income criteria, graduation would occur only after the compact ends. This means that the period from initial eligibility for selection to compact completion and graduation would be at least five years (potentially including the time it took to be selected and prepare the compact).

Unknown how many have graduated after receiving support.

Any country that is below MCC’s income threshold in a given fiscal year can be considered for an MCC program, including countries that have previously graduated out of income pool.

Exceptions to country contributions may be made on a case-by-case basis and can take into account emergencies and conflict.

USAID Family Planning (FP) Program

None specified. The Foreign Assistance Act of 1961 and official guidance do not specify any formal eligibility criteria for development assistance, although most support has been provided to low- and middle-income countries. This has been the case for USAID’s family planning (FP) program, which began in the 1960s. The FP program further concentrated its efforts in countries that had high rates of unmet need for FP, prevalence of high-risk births, and low contraceptive use.

A country is eligible for graduation once the following indicators have been reached:

Modern contraceptive prevalence rate of at least 51%
Total fertility rate at or below 3.1 children per woman
Other factors considered are:
At least 80% of the population can access at least three family planning methods
No more than 20% of family planning products, services and programs offered in the public and private sectors are subsidized by USAID
Major service providers in all sectors (public, non-governmental, commercial) can meet and maintain standards of informed choice and quality of care.

No specific timeframe set. Process could take 2-10 years, with

most countries graduating in 2-6 years.

25 countries had graduated from USAID family planning support since 1976 (as of 2020).

No country that has graduated from family planning assistance had backslid to a point where they might have been re-eligible.

Sources

GAVI

Current Eligibility Policy, January 2023: https://www.gavi.org/sites/default/files/programmes-impact/gavi-eligibility-and-transition-policy.pdf
Middle Income Country Approach, December 2020: https://www.gavi.org/types-support/sustainability/gavi-mics-approach
Graduated Countries: https://www.gavi.org/types-support/sustainability/eligibility

Global Fund

Current Eligibility Policy, November 2024: https://resources.theglobalfund.org/media/7443/core_eligibility_policy_en.pdf
Current Sustainability, Transition and Co-financing Policy, 2016: https://archive.theglobalfund.org/media/4221/archive_bm35-04-sustainabilitytransitionandcofinancing_policy_en.pdf
Sustainability, Transition and Co-financing Guidance, December 2022: https://resources.theglobalfund.org/media/13890/cr_sustainability-transition_guidancenote_en.pdf
Graduated Country Components (p. 26): https://archive.theglobalfund.org/media/14276/archive_bm51-04a-sustainability-overview_report_en.pdf
Projected transitions from Global Fund country allocations by 2028, July 2024: https://resources.theglobalfund.org/media/13893/cr_projected-transitions-2028_list_en.pdf
Approach to Non-eligible countries in crisis, May 2018: https://archive.theglobalfund.org/media/7397/archive_bm39-03-approachtononeligiblecountriesincrisis_report_en.pdf

IDA

Borrowing Countries: https://ida.worldbank.org/en/about/borrowing-countries
Graduated Countries, https://ida.worldbank.org/en/about/borrowing-countries/ida-graduates
World Bank, IDA20 Mid-Term Review: IDA Access, Terms, and Graduation Prospects, November 2023:
https://documents.worldbank.org/en/publication/documents-reports/documentdetail/099012624123036908/bosib1cd951f870011b87d1243b7b5be036

MCC

Millennium Challenge Act of 2003: https://assets.mcc.gov/content/uploads/mca-legislation-2018-amendments.pdf
Millennium Challenge Corporation Candidate Country Reform Act, 2024: https://www.armed-services.senate.gov/download/hr-5009-fy25-ndaa?download=1
Additional Considerations for Countries with a High Probability of Transitioning Out of MCC’s Candidate Pool after Initial Selection: https://www.mcc.gov/resources/doc/guide-to-supplemental-information/#additional-considerations-for-countries-with-a-high-probability-of-transitioning-out-of-mcc-s-candidate-pool-after-initial-selection
Selection Criteria and Methodology Report for Fiscal Year 2025: https://assets.mcc.gov/content/uploads/20240013028-report-fy25-scmr.pdf
MCC, personal communication, April 2025.

USAID Family Planning Program

CRS, U.S. Bilateral International Family Planning and Reproductive Health Programs: Background and Selected Issues, 2020: https://www.congress.gov/crs-product/R46215
Angela K Shen AK, Farrell MM, Vandenbroucke MF, Fox E, Pablos-Mendez A, “Applying lessons learned from the USAID family planning graduation experience to the GAVI graduation process”, Health Policy and Planning, Volume 30, Issue 6, July 2015: https://doi.org/10.1093/heapol/czu045
USAID Graduation from Family Planning Assistance: Implications for Latin America, October 2011.

Future Reform of PEPFAR: Exploring the Use of a Graduation Policy

Overview

Introduction

Findings

Summary of Graduation Criteria and Process

Potential Lessons for PEPFAR

Appendix

Graduation Criteria for Select Global Health and Development Organizations and Programs

Sources

Topics

Tags

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