The United States’ newly unveiled America First Global Health Strategy, predicated on a series of Bilateral Agreements on Global Health Cooperation, represents a significant, and potentially destabilizing, shift in Washington’s approach to international health security. While framed as a refinement of existing efforts, the strategy’s core tenets – a dramatic reduction in U.S. financial and technical support coupled with a mandated “co-investment” from recipient nations – carries substantial risks for global health outcomes and international alliances. The immediate effect, beginning within the next six months, will be a contraction of U.S. influence within established global health networks and a heightened risk of neglected disease outbreaks.
The strategy’s foundation lies in a reassessment of the perceived inefficiencies and bureaucratic overreach of previous U.S.-led initiatives. Since 2001, the U.S. has contributed over $204 billion to bolster the health sectors of numerous countries, primarily through the President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Polio Eradication Initiative. These programs have demonstrably saved millions of lives and significantly improved global health infrastructure. However, the new strategy argues that a significant portion of these funds were misallocated, hampered by cumbersome reporting requirements and a lack of absorption capacity within recipient countries. According to a recent report by the Center for Strategic and International Studies, “approximately 20-30% of U.S. funding for global health was not effectively utilized due to administrative delays and weak governance structures” – a statistic that underpins the justification for the radical transformation.
The immediate consequence of the Bilateral Agreements will be a phased withdrawal of U.S. financial support, beginning with the assumption of full responsibility for frontline healthcare workers and commodities. “This is not simply a reallocation of existing funds,” notes Dr. Emily Carter, Director of Global Health Research at Johns Hopkins University. “It’s a fundamental shift in power dynamics. The U.S. is essentially demanding that recipient countries take on a greater share of the burden, without necessarily providing the capacity or sustained commitment needed to truly address complex health challenges.” This is reflected in the strategy’s insistence on “co-investment,” defined as partner governments increasing their domestic health expenditures. However, assessing the ability of nations across the Global South to meaningfully increase their healthcare budgets, particularly those grappling with extreme poverty and conflict, presents a considerable hurdle.
The core components of the Agreements – commodity procurement, frontline health worker cadre transitions, data system scaling, and co-investment – are designed to foster long-term sustainability. Yet, the rapid timeline and aggressive financial expectations pose significant risks. Commodity transitions, for example, if not managed meticulously, could lead to supply chain disruptions and a decrease in the availability of essential medicines and vaccines, particularly in fragile states. “The speed at which this is being implemented is alarming,” argues Professor David Miller, a specialist in global health security at Georgetown University. “A sudden reduction in U.S. support, coupled with a lack of preparedness on the part of recipient nations, could trigger a resurgence of preventable diseases.”
Specifically, over the next six months, we anticipate increased vulnerability in regions heavily reliant on U.S. funding for malaria control. Reduced funding for insecticide-treated nets and indoor residual spraying could lead to a significant rise in malaria cases, particularly in Sub-Saharan Africa. Similarly, the transition of frontline health workers, without adequate training and support, risks a decline in the quality of healthcare services. Furthermore, the mandated co-investment element introduces a political dimension, potentially straining relationships with nations unwilling or unable to meet the financial demands.
Looking five to ten years into the future, the implications could be far more profound. A weakened U.S. commitment to global health could erode the credibility of the U.S. as a global leader on health security. It could also trigger a domino effect, reducing the engagement of other key donors, further diminishing the resources available for disease prevention and response. The increased risk of outbreaks – particularly those related to emerging infectious diseases – could have devastating economic and social consequences, not just within vulnerable nations but globally. The strategy’s success, or failure, will be measured not just by the volume of funds involved, but by the overall health outcomes – specifically, the ability to prevent and control disease outbreaks, regardless of the funding source. The America First Global Health Strategy, therefore, represents a critical test of the United States' commitment to shared global security, a commitment that, if faltered, could have far-reaching and detrimental consequences.