The United States is dramatically reshaping its approach to global health aid, shifting away from traditional grants and instead tying billions of dollars in funding to commitments from recipient governments. This move, spearheaded by the State Department, aims to replace the long-standing system previously managed by the U.S. Agency for International Development (USAID).
New Agreements, Reduced Funding
Over the past month, the US has secured deals with 16 African nations, pledging over $11 billion in health assistance for the next five years. Negotiations are ongoing with dozens more countries across Asia and Latin America. However, these commitments represent a significant reduction in overall funding compared to pre-Trump administration levels.
An analysis by Partners in Health reveals steep cuts:
– Rwanda faces a 69% reduction
– Madagascar: 61% decrease
– Liberia: 42% less aid
– Eswatini (where 25% of adults live with HIV): 34% funding drop
A Shift in Power Dynamics?
While the cuts are substantial, some African governments and analysts view this as a positive development. The new framework could increase country ownership over health programs, reducing reliance on external aid. Others criticize the deals as exploitative, arguing they were negotiated from a position of power imbalance and impose unrealistic conditions.
The US strategy explicitly prioritizes spending that benefits American interests—making the US “safer and more prosperous.” This is exemplified in stalled negotiations with Zambia, where Washington seeks access to the country’s mineral wealth in exchange for continued funding for its critical HIV treatment program. This deal would slash Zambian health funding by over 50%.
A “Reimagining” of Foreign Aid
According to Jeremy Lewin, acting under secretary of state, these agreements mark the first phase of a complete overhaul of the existing foreign aid system, which he describes as “failing and dysfunctional.”
This approach raises questions about the long-term impact on public health, especially in countries heavily dependent on U.S. aid. The restructuring prioritizes strategic leverage over humanitarian needs, potentially undermining decades of progress in disease control and healthcare access. The new system will likely force recipient nations to balance health priorities against political and economic concessions to the United States.
