The United States has unveiled a new global health aid strategy that will bypass non-governmental organizations (NGOs) in favor of direct bilateral agreements with foreign governments. This marks the first clear direction of Washington’s health aid approach since the United States Agency for International Development (USAID) was dismantled in July.
Secretary of State Marco Rubio said the America First Global Health Strategy would “end the inefficiencies, waste, and dependency culture” while tying health aid to U.S. national interests.
“We will continue to be the world’s health leader and the most generous nation in the world,” he commented in the strategy’s foreword, “but we will do so in a way that directly benefits the American people and directly promotes our national interest”.
The plan reflects President Donald Trump’s transactional approach to foreign policy which is to treat health aid as a tool of bilateral diplomacy rather than a multilateral partnership.
The strategy document reveals the scale of American health-related investment so far, noting the U.S. “has provided more than US$204 billion in foreign health assistance since 2001, nearly one-third of the total global health aid delivered worldwide.”
What’s in the strategy?
The America First Global Health Strategy is built around three pillars: making America stronger, safer, and more prosperous. Within that framework, it sets out a series of shifts in how U.S. health aid will be deployed, who will receive it, and what outcomes are expected.
1️⃣ Bilateral agreements replace NGO model
The Trump administration will replace NGO-delivered aid with multi-year government-to-government agreements. The recipient nations will have to co-invest and meet performance benchmarks.
Under this model, technical assistance that once flowed to individual clinics will be redirected to ministries of health, with a focus on helping governments to take over vital functions. Private sector actors and faith-based organisations will be engaged to strengthen delivery.
To avoid disruption, Washington has created a six-month “bridge funding plan” starting in October to maintain services during the transition. Most deals are expected to be completed by December, with implementation beginning in April 2026.
Future aid will be conditional, with funding withheld if governments fail to meet financial contributions or benchmarks.
However, experts question this approach. Fred Muhumuza, an economist at Makerere University, noted that the direct government deals attempted in the 1980s often failed when the recipient governments failed to meet commitments.
2️⃣ Frontline services protected … for one year only
Despite this shift, the U.S. has committed to fully fund frontline health workers and the procurement of medical supplies through 2026, which will support over 270,000 doctors, nurses, and community health workers globally.
Subsequently, recipient governments will be required to gradually absorb these costs, with 71 countries expected to achieve full self-reliance.
The strategy argues this will reverse inefficiencies, noting that “less than 40% of health foreign assistance funding goes to frontline supplies and healthcare workers,” with 60% being absorbed by technical assistance and overheads.
3️⃣ Geographic refocus: Western Hemisphere and Asia-Pacific?
For two decades, U.S. health assistance has been heavily concentrated in sub-Saharan Africa, with approximately 85% of bilateral global health funding directed to the region in fiscal year 2023. While the new strategy pledges to maintain some support for HIV, tuberculosis, and malaria in Africa, anonymous U.S. government sources have indicated shift of attention toward the Western Hemisphere and the Asia-Pacific.
The document explains that “rapid urbanization, dense populations, and close human-animal interaction” in the Asia-Pacific region and Latin America can heighten the risk of disease outbreaks that threaten Americans.
4️⃣ Outbreak surveillance prioritized
The blueprint places heavy emphasis on the early detection and containment of epidemics, framing this to be vital to U.S. national security. It guarantees to “enable detection of an outbreak with epidemic potential within seven days of its emergence” and to contain it “within 72 hours of detection.”
To achieve this, the U.S. plans to assign health staff to every American embassy, creating what the document describes as an “early-warning presence” around the world.
5️⃣ Aid as a geopolitical tool
The strategy explicitly frames U.S health aid as a geopolitical influence. “Our global health foreign assistance program is not just aid; it is a strategic mechanism to further our bilateral interests,” it states.
The plan outlines health relief as “an important counterweight to China”, whose investments, it says, often lack transparency and involve debt sustainability risks, employment restrictions, political conditionality, and governance concerns.
The document contrasts U.S. grants with China’s “loan-based” deals that “raise concerns about debt sustainability.” Between 2002 and 2021, China invested US$339 billion in Africa, 85% in loans, compared to US$216 billion from the U.S. with 90% in grants and 60% going to health initiatives.
6️⃣ Aid as a commercial diplomacy tool
The strategy also links global health assistance to American economic interests, framing procurement as a form of “commercial diplomacy” by making “the purchase of innovative American products a key component of future U.S. health foreign assistance programs.”
It pledges to help American companies to break into emerging markets through health product procurement. Any extra congressional funding beyond country-level agreements could be used to invest in innovative technologies that are developed in the U.S, it stated.
7️⃣ PEPFAR and disease program integration
Regarding the President’s Emergency Plan for AIDS Relief (PEPFAR), the strategy emphasizes a shift from its traditional model, which relied on separate procurement systems, dedicated health workers, and program-specific data platforms. While these parallel structures helped to achieve rapid results, they are challenging for countries to sustain over time, the document noted.
Going forward, U.S. health assistance will merge with national health systems wherever practicable, providing polio, tuberculosis, HIV, and malaria services in a way that strengthens local capacity and long-term sustainability.
The strategy sets ambitious targets, aiming to cut new HIV infections and AIDS-related deaths by 90% by 2030, while also working to end mother-to-child transmission of HIV in those countries most affected.
Notable omissions
Despite its ambitious reforms, the strategy omits several core elements of U.S. global health aid. Family planning, maternal and child health, and water, sanitation, and hygiene programs, once central pillars, are absent.
It also overlooks the impact of climate change on health systems and the future role of the Disease Control and Prevention, historically a leader in epidemic response.
Experts warn these gaps could weaken U.S. efforts. Dean Karlan, former Chief Economist at USAID, called the plan “naive“, noting that strong health aid matters little if communities lack development assistance such as clean water, electricity, or roads.
The strategy’s timeline is also ambitious. It aims to finalize bilateral agreements with major aid recipients by December 2025 and begin implementation by April 2026 which represents a rapid overhaul of a system that has been built over decades with little room for delays in fragile political contexts.
