Health experts are flagging concerns that the Trump administration’s novel “America First Global Health Strategy” may further strain public health infrastructures already diminished by billions in foreign aid cuts following the dismantlement of the U.S. Agency for International Development (USAID), and while some see potential merit in the new framework, there is consensus it signifies a sharp departure from decades of U.S. policy.
Under the refreshed strategy, framed as an ambitious overhaul of how the U.S. delivers medical aid globally, American assistance will be channeled via a new structure of one-on-one pacts with individual nations, bypassing international bodies and partners.
The stated objective is twofold: encouraging recipient nations to build up their own health systems while the U.S. reduces its aid expenditure.
The strategy mandates the conclusion of bilateral agreements by December 31st for nations receiving the bulk of American global health funding. A senior State Department official indicated preparations are underway to finalize some of these pacts as early as the beginning of December, adding that countries are “very excited about what this opportunity opens up.”
On Tuesday, as part of this strategy, the State Department announced an agreement to provide “up to $150 million” to an American drone manufacturer “to expand access to vital medical supplies, including blood and medicines,” across five African nations.
The core rationale behind the strategy is the assertion that U.S. global health aid has often been redundant and inefficient, burdened by considerable overhead costs, including funds allocated for technical assistance and program management. High administrative costs, such as generous CEO salaries, for certain contracting firms dubbed “implementing partners” tasked with executing U.S. foreign aid projects, have also drawn criticism.
However, some experts point out that numerous activities categorized as overhead are crucial for global health operations.
“While we all want as much money as possible going to direct services for people, a hospital isn’t just doctors and medicine. A doctor has to be trained. There’s medical school. There are people who have to keep the hospital clean,” one senior humanitarian official explained. “All those costs, while they can spiral, are justifiable.”
The senior humanitarian staff member further suggested that there is a risk that health ministries alone “won’t reach the last mile” or “get to the poorest and most vulnerable people”—a role frequently filled by private or autonomous charitable organizations.
Jeremy Konyndyk, President of Refugees International, told CNN, “A lot of the things they’re deriding as non-essential are essential because they are what make the basic functions work.”
Questions are also arising about how rapidly these agreements can become effective amidst the fallout from sudden, significant cuts to U.S. foreign aid earlier in the year, which resulted in service reductions or eliminations across numerous public health organizations and NGOs.
Rachel Boninefeld, Global Health Policy Director at the Center for Global Development think tank, stated that “what they are designing is truly a good transition and sustainability plan for countries with a relatively higher level of maturity and wealth, but it’s probably not going to be viable in the short term for the poorest and most vulnerable countries.”
“Part of what’s frustrating about this strategy is that while I believe the intent is correct, they’re making their job dramatically harder… by simply terminating vast amounts of foreign assistance grants and programs with no notice,” Boninefeld told CNN shortly after the policy’s release in September.
Konyndyk, who worked at USAID under both the Biden and Obama administrations, noted, “It would be one thing if they said, we want the U.S. out of the business of X, Y, and Z, and we’re going to do that collaboratively and phasing it in over an administration’s four years. I wouldn’t agree with it if they did it that way, but it would at least be a semi-responsible way of doing what they ostensibly want to achieve.”
“This is just pushing Humpty Dumpty off the wall and leaving the country to sweep up the pieces,” he concluded.
Critics warn of narrow focus
Boninefeld expressed sympathy for the arguments regarding the importance of working through countries’ health ministries and addressing duplication and lack of country ownership—points experts have previously noted—but stressed this is a “high-risk strategy.”
“There’s a risk that the money gets into the country and it gets stolen, or they do their best but don’t deliver health services, and people die,” she said. “It’s not very clear yet what, if anything, they plan to do to mitigate that risk.”
A senior State Department official countered that national governments “are not telling us they cannot make this work.”
The official argued that if they didn’t “aggressively” move NGOs “out of the process, we would never be able to build another health system.” They also shared that safeguards have been included to prevent misuse or theft of funds.
Another senior humanitarian official, working with an implementing partner, expressed concern that the tight timelines for negotiating bilateral agreements are cornering many nations.
“I suspect most countries that cannot fund their own response are going to agree to whatever they have to agree to in order to keep moving forward,” they stated.
Health experts have also criticized the new policy for its narrow scope, focusing predominantly on HIV/AIDS, malaria, tuberculosis, and infectious disease outbreaks.
The new strategy has “some crucial omissions,” noted Boninefeld of the Center for Global Development. “Minimal discussion around immunization or reproductive health… These are conspicuously absent.”
A statement from the Modernizing Foreign Assistance Network (MFAN), a bipartisan advocacy group, cautions that “the strategy endorses an extremely selective definition of ‘global health’ and neglects other global priorities such as maternal and child health, nutrition, and neglected tropical diseases.”
MFAN recently published a report warning that the State Department, which assumed control of U.S. foreign aid following the shuttering of USAID, “currently lacks the personnel and systems to effectively manage its global health and international development portfolio.”
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