US Puts Own Health Needs First Abroad
When President Donald Trump invoked the “America First” slogan at his second inauguration in January 2025, the United States rolled out a new approach to overseas health aid, branded the America First Global Health Strategy (AFGHS).
Agency shutdown and WHO exit reshape aid setting
Within weeks of the inauguration, the administration ordered the closure of the U.S. Agency for International Development, an organization that had overseen health projects across Africa and Asia. From 2001 to 2024, the agency allocated roughly $132 billion to health systems, economic development and humanitarian relief in Africa alone.
The shutdown left noticeable gaps. Nigeria now faces a $600 million shortfall, while Botswana lost a third of its funding for HIV programs. The agency had also been a primary implementer of the $110 billion President’s Emergency Plan for AIDS Relief (PEPFAR), which has saved over 26 million lives since 2003.
In parallel, the United States formally withdrew from the World Health Organization, a move that eliminated its contribution of about $1.2 billion for the 2022‑23 fiscal year. The WHO had relied on the United States for roughly 12‑15 percent of its budget, making the exit a major financial shock.
Bilateral agreements replace multilateral funding
Congress ultimately approved a $9.4 billion package for the current fiscal year, down from the $12.4 billion allocated for 2024‑25 but still $5.7 billion above the administration’s target. Lawmakers preserved funding for programs such as PEPFAR, the Global Fund to Fight TB, AIDS and Malaria, and other HIV/AIDS initiatives.
Under AFGHS, the United States is shifting from open‑ended aid to a series of multi‑year bilateral deals that require partner nations to co‑invest. As of September 2025, 28 countries—22 in Africa—have signed memoranda of understanding. The State Department reports that Washington has pledged $12.7 billion in assistance, with partner governments committing $7.8 billion in co‑financing.
For Nigeria, the United States will provide $2.1 billion, while the country must raise about $3 billion, roughly 40 percent of its 2025 health budget. Similar demands have sparked resistance; Zimbabwe turned down a $367 million offer after being asked to share sensitive pathogen data, and Kenya’s agreement was halted by a court over data‑protection concerns.
Michele Barry, director of the Centre for Innovation in Global Health at Stanford University, says the US must understand that a withdrawal from global health commitments makes the world – and therefore the US – less safe and less healthy.
These co‑investment clauses, while intended to curb dependency, may force governments to stretch already thin health budgets. In practice, the requirement could divert resources from primary care to meet financing thresholds, potentially slowing progress on disease control and maternal health.
Critics argue the strategy resembles “biomedical imperialism,” noting that the United States is tying aid to market access for its health products. Africa, which currently imports only about 4.4 percent of its pharmaceuticals from the United States, is a focal point for this commercial push, as the US seeks to expand its economic influence abroad.
AFGHS also seeks to reduce the role of non‑governmental organizations, which the administration claims have “perverse incentives” that encourage waste. According to the State Department, less than 40 percent of foreign health assistance funds go directly to supplies and health workers; the remaining 60 percent is spent on overhead and ambiguous costs.
PEPFAR’s budget illustrates this split. Of its allocation, $1 billion covers medical commodities and logistics, $600 million funds a 270,000‑strong frontline workforce, and the balance finances training, supervision and quality management.
The plan also proposes expanding U.S. staff in “high‑risk” regions to strengthen disease surveillance. While officials present this as a protective measure for America, some observers see it as an intrusion into national health sovereignty, similar to concerns raised by the modern mayoralty in London.
“Global health crises cannot be contained through a patchwork of bilateral agreements,” Barry adds. “Outbreaks demand cooperation, coordinated, multilateral responses rooted in trust and shared responsibility.”
Time‑bound agreements, averaging five years, include withdrawal clauses that allow either party to exit with 180 days’ notice, a feature that could lead to abrupt program disruptions. The combination of funding cuts, agency closures and new conditionalities marks a stark shift from the multilateral, long‑term aid model that has guided U.S. health assistance for decades, and is likely to impact the ability of organizations like the Interstellar Group to execute their plans quickly.
