Country controversies, secret terms, opaque procurement, and massive unspent congressional funds have characterised the first year of the America First Global Health Strategy.

“Services are weaker than they were a year ago, HIV testing is down, treatment of children living with HIV is down, and community-based prevention is gutted,” said Emily Bass, expert consultant for Physicians for Human Rights (PHR), about the change in US policy.

Introducing the new strategy a year ago (18 September 2025), United States Secretary of State Marco Rubio pitched it as an antidote to “inefficient and wasteful” past global health programmes.

Since then, 35 countries have signed bilateral memorandums of understanding (MOUs) with the US in terms of this strategy. Two of these, Kenya and the Democratic Republic of Congo (DRC), face legal challenges from civil society groups over the terms.

Three – Ghana, Zimbabwe and Namibia – have refused the terms offered by the US, the main sticking point being US demands for sensitive health data. Zambia is struggling to find a way to secure US aid without having to sell the family silver. Several countries, including the DRC and Guinea, signed health MOUs alongside deals to sell minerals to the US.

The Trump administration has also refused any further aid to South Africa, the country with the largest HIV population in the world, primarily over its measures to address apartheid-era racial injustice and its case against Israel at the International Court of Justice.

‘Safer, stronger, more prosperous’?

The stated aim of the MOUs, which replace US Agency for International Development (USAID) and President’s Emergency Plan for AIDS Relief (PEPFAR) grants, is to “make America safer, stronger, and more prosperous”.

The five-year MOUs also aim to rapidly transfer responsibility for key health services to countries themselves, with domestic “co-financing” commitments progressively increasing every year.

The MOUs also demand that countries invest heavily in disease surveillance networks in order to supply the US with pathogen information within a week of any outbreak. 

The aim is not only to “keep America safe” but to give US firms exclusive access to pathogen information to enable them to make vaccines, medicines and diagnostics to combat these. This is a direct challenge to the pathogen access and benefit-sharing (PABS) system currently being negotiated at the World Health Organization (WHO), of which the US is no longer a member.

Onerous co-financing 

A recent analysis of 18 MOUs by Public Citizen and Partners In Health found US funding would be cut to the countries by over $2 billion by 2030, a 59% reduction in comparison to 2024 funding. 

The organisations had to resort to Freedom of Information Act (FOIA) requests and lawsuits against the Trump administration to extract some of the secretive MOUs.

Countries facing the steepest cuts are Rwanda (97% reduction), Liberia (84%), Burundi (78%), Madagascar (77%), and Sierra Leone (71%).

Five years will be insufficient for 11 of the countries to raise domestic funds to cover the gap left by the cuts, yet the US forbids countries from “including funding from other donors or multilateral organisations” to bolster their commitments, according to the analysis.

“Malawi would have to mobilise new funding equal to 56% of the country’s total health expenditure to meet its annualised co-financing commitment,” the analysis notes.

By 2030, seven of the poorest African countries will have fewer health workers, thanks to reduced US and partner government investment. These are Burundi, Cameroon, Eswatini, Kenya, Lesotho, Madagascar and Malawi.

Some of the 18 MOUs also stipulate financial punishment if countries fail to meet their co-financing commitments. Uganda and Côte d’Ivoire face a $2 reduction in US aid for every $1 they fail to pay. Ethiopia, Kenya, Mozambique, Cameroon, and Malawi will lose $1 for every $1 domestic shortfall.

Money in the House

Perversely, as the Trump administration slashes health aid packages for some of the world’s poorest countries, over $3.6 billion in funds allocated for this very purpose by the US Congress have not been disbursed.

“September 30 marks the expiration of $1.35 billion of appropriated funding for TB, malaria, HIV and maternal and child health. While this money has already been approved by Congress, it will not reach the patients it was meant for unless the State Department releases it in the next 12 days,” Sheila Davis, CEO of Partners in Health (PIH), told reporters on Thursday.

Her colleague, Dr Vincent Lin, described the date, the end of the US fiscal year, as a ”funding cliff”, noting that over 100 PEPFAR programmes under the Centers for Disease Control and Prevention (CDC) covering the HIV treatment of eight million people are also set to expire.

Meanwhile, PEPFAR is $2.3 billion underspent this year due to the US State Department delaying payments, jeopardising the HIV treatment of 20 million people.

“The executive branch agencies, especially the Office of Management and Budget (OMB), USAID’s Legacy Unit, and the State Department, have been withholding and underspending global health funds at an unprecedented level,” said Lin.

“If that money is continuously withheld, that would cause tens of thousands of preventable deaths from infectious diseases, including TB, malaria, and HIV, and among moms and babies from illness in childbirth and delivery, further furthering this backsliding that we’ve already seen over the last two years,” he added.

In late August, 170 Members of Congress wrote to Rubio and OMB head Russell Vought demanding that they release the over $3 billion in “unobligated” global health funding, warning that their refusal to spend the funds as directed by Congress “defy the law and threaten lives”.

Opaque procurement

A year ago, Rubio described US foreign assistance programs as “deeply broken”, claiming that 60% of US health funding was “spent on technical assistance, program management, and other forms of overhead”.

This has been disputed by the Center for Global Development, which reviewed PEPFAR’s 2024 spending and found that 63% of funds “directly enables lifesaving treatment programs”. And what the US State Department characterised as “low-priority site-level technical assistance” – only 18% of funding – covered essential elements including data for tracking treatment adherence, health worker training, and community outreach.

However, procurement for the new MOUs is characterised by little transparency or official guidelines.

PIH monitoring of how the 35 MOUs are being implemented has uncovered “potentially $3- $5 billion” going out to implementers this month by “sole source or non-competitive mechanisms”, said Lin.

“We’re also tracing a new innovation fund for US companies that’s set to dole out $800 million this year to handpicked entities without a competitive process, and the [State Department’s] Annual Program Statement, a semi-competitive mechanism that will push out several billion dollars in funding without clear guidelines or alignment to federal procurement law,” he added. 

“It is shocking, to say the least, that federal procurement is not being utilised for huge volumes of US dollars,” Lin noted.

“We’ve heard through the grapevine a handful of junior staff are reviewing hundreds of submissions.”

Awards via the Innovation Fund include $150 million to US company Zipline, and undisclosed amounts to Gilead for HIV drug lenacapavir and SC Johnson for a mosquito repellent.

Congress has indicated that the Innovation Fund is set to scale up to at least $800 million, “which is a huge portion of overall global health spending, but there’s minimal information at all about what’s happening”, said Lin.

Distorting country priorities

Twenty-five years ago, African leaders committed to allocating at least 15% of their domestic budgets to health – but only four of the continent’s 55 nations have come close.

It is gratifying to imagine a dictator like Paul Biya, the draconian 94-year-old president of Cameroon who has ruled his country for 44 years, being forced to divert some of the money he spends on frequent Swiss shopping trips to his citizens’ health.

Under Cameroon’s MOU with the US, the Biya government has committed to increasing its health spending by $450 million over five years to unlock $400 million in US aid.

Shortly after signing the MOU, Cameroon proposed a health budget of over $684 million for 2026, an increase of around 30% on the previous year. 

But by July, it had only released 19% of its immunisation budget. MP Essomba Bengono told local media outlet SBBC that about 430,000 Cameroonian children had not received their vaccines because the country has been unable to meet its financial commitments.

While it is unclear why the immunisation budget has not been released, the danger with the new bilaterals is that rulers like Biya may make promises to the US, then shift money around to meet these terms with little regard for their countries’ health priorities.

Even more sensitive leaders may be forced to distort their budgets to meet the US needs rather than their own – for example, meeting the US demand for pathogen information requires an army of data capturers who will take funds away from health worker posts.

No provision for community-based care

Before Trump, PEPFAR grants were allocated via country operational plans developed by governments in partnership with civil society organisations. Even in countries where civil society organisations have little room, such as Uganda and Burundi, governments were forced to include them.

The current MOUs are purely government-to-government with no provision for civil society, and community-based services are all but abolished. This means that those who know best how to reach at-risk populations no longer have a seat at the table. 

It also almost certainly means service delivery will be weaker – particularly for “key populations” most at risk of HIV, such as sex workers and men who have sex with men.

Of course, the Trump aid shock provided the impetus for the “Accra Reset”, aimed at fostering African sovereignty and resilience. Achieving this is a long way off, but starting this journey has been long overdrew.

Finally, as the Ebola outbreak has shown, bilateral agreements are no match for outbreaks, epidemics and pandemics. Imagine trying to coordinate 35+ agreements in the face of a fast-spreading pathogen

Image Credits: Public Citizen/ Partners in Health, UNAIDS.