When the United States quietly rolled out its new “America First Global Health Strategy,” it marked more than a policy update. It signaled a fundamental reimagining of how the world’s largest historical health donor intends to support countries managing epidemics, chronic conditions, and fragile health systems. But the path to this new strategic direction has been anything but smooth. A year marked by abrupt foreign aid cuts and the dismantling of USAID, the decades-old agency that coordinated much of America’s global health footprint, forms the backdrop to a shift that health experts say carries real risks. Is this a new global health gamble?

Let’s piece together what this pivot means, by unpacking what seems to be shaping it: disruption, opportunity, skepticism, and a rapidly closing window for negotiations.

Officials vs. Practitioners

While U.S. officials insist the change will drive efficiency and empower national governments, global health practitioners warn that the strategy introduces new uncertainties, a narrower set of priorities, and a timeline that threatens to rush countries into agreements they may not fully understand.

The world after the cuts

Before the new strategy even enters the conversation, many health systems are still dealing with the fallout of unexpected U.S. foreign assistance cuts earlier this year. Organizations in multiple countries were forced to scale down or close programs overnight. Workers who had been providing testing, community outreach, maternal health services, and disease surveillance suddenly found themselves without funding. Only months later, the U.S. introduced a policy that now asks countries to rapidly commit to a new funding model.

Rachel Bonnifield of the Center for Global Development captured the contradiction when she noted that the approach could make sense for more stable, wealthier countries, but not for the poorest ones struggling to recover. She added that the rushed cut-offs earlier in the year made the transition far harder than necessary, saying they “just cut off tremendous numbers of awards and foreign assistance programs without warning.” The logic is simple: a disrupted system is not a ready system. Yet these are the same systems now being asked to sign onto five-year bilateral compacts.

The Strategy: built on direct deals, not global partnerships

At the heart of the new approach is a departure from multilateralism. Instead of routing funding through global health organizations or large implementing partners, the U.S. intends to negotiate one-on-one compacts with individual countries.

Officials argue this will streamline operations and eliminate unnecessary administrative layers. They describe a world where funding flows with fewer intermediaries, countries negotiate directly with Washington, and overhead is reduced. According to one senior State Department official, countries are eager to be “brought to the table,” and see this as an opportunity to take greater control of their systems. But others doubt whether the picture is so simple.

A senior aid worker explained that the so-called overhead often pays for what keeps systems functional: training, sanitation, medical education, and organizational management. As they put it, “A hospital is more than just a doctor and the medications.” Without these invisible systems, the visible ones collapse.

The shift also sidelines NGOs, private health groups, and community organizations that often reach populations national ministries struggle to serve. Vulnerable groups, those in remote communities, informal settlements, or areas where government services don’t reach, may find themselves cut out.

Deadlines: compressed timeline and high stakes negotiations

The strategy sets an end-of-year deadline for completing agreements with the countries that receive the bulk of U.S. health funding. Negotiation teams have already visited 20 nations, and diplomats are speaking with dozens more.

But speed is becoming a central concern. One experienced aid worker said many lower-income countries simply lack the capacity to negotiate under such pressure. If they need U.S. support to keep their programs running, and most do, they may feel compelled to sign whatever is put before them. As one put it, “They will agree to what they have to agree to, to keep going.”

This sense of being cornered contrasts sharply with the U.S. narrative of collaborative partnership. Meanwhile, the U.S. government claims that early pilot programs in Kenya, Zambia, and Nigeria demonstrate the model’s success. But details on what success means, coverage expansion, cost reduction, improved outcomes, remain unclear.

A narrower focus: what’s missing

One of the most striking facts about the new strategy is what it leaves out.

The U.S. will concentrate its efforts on:

         •       HIV/AIDS

         •       Tuberculosis

         •       Malaria

         •       Outbreak response

Traditionally, U.S. global health engagements also supported:

         •       Immunization coverage

         •       Maternal and child health

         •       Nutrition

         •       Reproductive health

         •       Neglected tropical diseases

But these areas receive little to no attention under the new framework. Bonnifield described these absences plainly: “There is minimal discussion of immunization, for example, or reproductive health … those are loudly absent.” The Modernizing Foreign Assistance Network (MFAN), a bipartisan advocacy group, also warned that the policy reflects an unusually narrow definition of “global health.” This narrowness matters. Health sectors do not operate in silos. Weak maternal health affects neonatal outcomes. Poor nutrition affects TB resilience. Limited immunization coverage increases outbreak vulnerability. Cutting one part of the ecosystem destabilizes all of it.

Data: the most controversial piece

One aspect of the new strategy that is raising confidential but widespread concern is the long-term data requirement. According to aid officials, the standard compact requests that countries share their epidemiological data with the U.S. for 25 years. While some nations have negotiated shorter terms, fears remain about:

• how the data will be stored,
• who will control it,
• which private entities will access it, and
• whether countries providing data will directly benefit from future innovations.

A senior aid worker described it bluntly: “It’s not a data-sharing agreement. It’s a data-giving agreement.” This raises worry that pharmaceutical companies could use the data to advance research or commercial products without guaranteeing that newly developed treatments will be accessible or affordable to the countries that provided the raw information. The transactional framing marks a shift away from the Soft-Power-For-Good model that traditionally characterized U.S. global health leadership.

Priorities: ties to U.S. business interests

Perhaps the most symbolic indicator of the strategy’s new priorities is the announcement that the U.S. will provide “up to $150 million” to an American drone company to supply medical products in five African countries. While drones can indeed offer real logistical advantages in remote areas, the emphasis on a U.S. private firm underscores the strategy’s commercial dimension.

One senior official described the new compacts as being modeled after “modern private-sector contracts” that encourage countries not just to improve their systems, but also to “deepen connections to the United States” and create market opportunities for American industries. This approach is consistent with the administration’s broader economic agenda, but it also shifts the character of global health assistance toward a more transactional, business-oriented model. A senior global health official acknowledged this change, saying, “It’s a lot more transactional than we’ve been before.”

Concerns about capacity at home

The strategy transfers enormous responsibility for global health management to the State Department, an agency that, according to MFAN’s report, “currently lacks sufficient staffing and systems” to manage what USAID previously oversaw.

Managing complex bilateral health compacts, overseeing multi-country implementation, ensuring accountability, monitoring data agreements, and evaluating outcomes are tasks requiring specialized technical expertise, administrative architecture, and dedicated personnel. In short: it’s unclear whether the U.S. government is ready for the system it is attempting to build.

Vision: high-risk with unknown outcomes

It is possible that the new bilateral approach could push countries toward stronger ownership and greater long-term sustainability. Some officials genuinely believe this shift will be transformational. But health experts remain cautious, noting that the strategy asks fragile systems to take on more just months after losing steady U.S. support.

Jeremy Konyndyk, president of Refugees International and former senior USAID disaster-aid and global health official summarized the concern with a sharp metaphor, arguing that instead of a careful transition, the U.S. has “just pushed Humpty Dumpty off the wall and left the country to pick up the pieces.”

In conclusion…

Whether this new chapter strengthens global health or strains it further will depend not only on political intention but also on implementation, timing, and the real capacity of both sides to manage the risks.

For now, what the world is seeing is a major gamble: a compressed negotiation timeline, fewer intermediaries, narrower priorities, long-term data commitments, and a stronger commercial footprint. It is bold. It is disruptive. And, as many experts note, it is high-risk.

Source articles:

1. U.S. Department of State (2025). America First Global Health Strategy. Official policy document published on state.gov.

2. CNN – Kent, L. & Hansler, J. (2025). “The US has released an ‘America First Global Health Strategy.’ Health experts warn it is risky.” CNN Politics, 26 Nov 2025.

3. Center for Global Development – Bonnifield, R. (2025). “Unpacking the US’s New Global Health Strategy.” CGD Blog, Oct 2025.

4. Think Global Health (2025). “Questions for the America First Global Health Strategy.” Council on Foreign Relations, Nov 2025.