Health experts are warning that the Trump administration’s new “America First Global Health Strategy” could further damage public health systems already reeling from billions of dollars in foreign aid cuts following the destruction of the US Agency for International Development (USAID), and while some say the new system could bring benefits, there is agreement it marks a radical change in approach from decades of US policy.

Under the new strategy, touted as an ambitious overhaul of the way the US provides health assistance throughout the world, American aid will be funneled through a new system of one-on-one agreements with individual countries, rather than distributed through international aid partners and organizations.

The stated goal is to have recipient countries further develop their own health systems – and the US decrease its assistance spending.

The strategy calls for bilateral agreements to be completed by December 31 for countries that receive the vast majority of US health foreign assistance. A senior State Department official said they are preparing to finalize some of those compacts by early December, and that countries are “really excited about what this opportunity presents.”

On Tuesday, as part of the strategy, the State Department announced an agreement to provide “up to $150 million” to an American drone company “to expand access to life-saving medical supplies, including blood and medicines,” in five African nations.

The strategy’s core argument is that US global health aid was often duplicative and inefficient, with significant overhead costs, including money spent on technical assistance and program management. It also criticizes high overhead costs, including high CEO pay, for some of the contracting companies called “implementing partners” that carry out US foreign aid projects.

However, some experts note that some of those activities are crucial to global health work.

“While we all want as much money as possible to be going to direct services for people, the truth is, a hospital is more than just a doctor and the medications. A doctor needs to be trained. There’s a medical school. There are people who have to keep the hospital clean,” one senior aid worker explained. “All those costs, while they can get out of control, are legitimate.”

The senior aid worker added that there is a risk that government health ministries alone “don’t get to the last mile” or “don’t get to the most poor and vulnerable people,” which are often taken care of by private sector providers or independent charity providers.

Jeremy Konyndyk, the president of Refugees International, told CNN: “A lot of the things that they deride as non-essential are essential, because they are the things that make the essential functions work.”

There are also questions of how quickly the agreements can be effective amid the fallout from the sudden, significant cuts to US foreign assistance earlier this year, which caused scores of public health organizations and nonprofits to decrease or eliminate services.

Rachel Bonnifield, the director of the global health policy program at the Center for Global Development think tank, said that “what they are outlining is a really good transition and sustainability plan for countries that are relatively higher levels of maturity and wealth, but probably will not be viable in the short term for the poorest countries and most fragile.”

“Part of what’s frustrating about this strategy is that, while I think it is the right thing to do, they have made it much harder for themselves … in just cutting off tremendous numbers of awards and foreign assistance programs without warning,” Bonnifield told CNN shortly after the policy was released in September.

Konyndyk, who worked for USAID under the Biden and Obama administrations, noted that “it would be one thing if they had said, we want to get the US out of the business of X, Y and Z, and we’re going to do this in a collaborative and phased way over the four years of the administration. I wouldn’t have agreed with that, with them doing that, but that would at least be a semi-responsible way to do the thing that they claim they want to do.”

“This is just pushing Humpty Dumpty off the wall and leaving the country to pick up the pieces,” he said.

Critics warn of narrow focus

Bonnifield said she is sympathetic to the arguments that it’s important to work via countries’ Ministries of Health and to tackle issues with duplication and lack of country ownership – all things that experts have previously noted – but it is “a high-risk strategy.”

“There is a risk that the money goes to a country, and the money is stolen, or they do their best, but they fail to deliver the health services and people die as a result,” she said. “It’s not quite clear what, if anything, they are currently planning to do to mitigate that risk.”

The senior State Department official said that national governments are “not telling us that they can’t make it work.”

The official argued if they hadn’t “aggressively” moved NGOs “out of the process, we never would have been able to build a different health care system.” They also said they’ve included safeguards to prevent misuse or theft of funds.

Another senior aid worker, who works at an implementing partner, expressed concerns that the tight timeline for negotiating bilateral agreements is backing many countries into a corner.

“I think that the majority of countries that don’t have the ability to fund their own response will agree to what they have to agree to, to keep going,” they said.

Health policy experts have also criticized the new policy for having a scope that is too narrow, as it focuses mainly on HIV / AIDS, malaria, tuberculosis and infectious disease outbreaks.

There are “several important omissions” in the new strategy, said Bonnifield, of the Center for Global Development. “There is minimal discussion of immunization, for example, or reproductive health … those are loudly absent.”

A statement from the Modernizing Foreign Assistance Network (MFAN), a bipartisan advocacy group, said: “We caution that the strategy endorses a highly selective definition of ‘global health’ and lacks a focus on other global health priorities, such as maternal and child health, nutrition, and neglected tropical diseases.”

MFAN recently released a report warning that the State Department, which took over US foreign assistance after USAID was shuttered, “currently lacks sufficient staffing and systems to effectively manage its global health and international development portfolio.”

Negotiation teams in 20 countries

The senior State Department official said they expected to sign some of the bilateral compacts in early December. They noted that negotiation teams had visited 20 countries in the preceding days. They also said diplomats had been engaging on the ground in another 50 countries.

In addition to the bilateral agreements, the official said the strategy also includes “globally managed programs, particularly in the global health security space, responding to epidemics” and partnerships with organizations like the Global Fund.

They did not say which countries were close to finalizing agreements but said they aimed “to reach nearly all of the traditional health recipient countries, absent ones like South Africa, where there’s obviously a unique political dynamic.” The Trump administration has an extremely tense relationship with South Africa and has made unfounded accusations about genocide being committed there against White Afrikaners.

“What we’ve heard in a lot of these negotiations, as we go out there, the countries are really excited to be brought to the table, and for them to be taking over private responsibility for their healthcare system,” they said.

The senior State Department official said they had run successful pilot programs in Kenya, Zambia, and Nigeria.

The bilateral agreements will last for five years, but the specifics of the deals would be different based on each country, the official said. Some elements, such as data sharing, might be longer.

“We’re going to structure it like a modern private-sector contract,” the senior State Department official told CNN in a recent interview.

They want to “help incentivize countries to move towards the type of healthcare system that will allow them to develop and also deepen connections to the United States and create opportunities for US businesses,” they said.

Tuesday’s announcement of the “up to $150 million” for the drone company underscored the emphasis on creating opportunities for American businesses.

The data sharing element has raised some concerns among aid officials. A source told CNN that the standard compact asks countries to share their epidemiological data for 25 years, but some countries have negotiated fewer years of data transmission.

“It’s not a data-sharing agreement. It’s a data-giving agreement,” one senior aid worker said, expressing concerns that the information could be used to give a non-competitive advantage to American pharmaceutical companies, with new drugs and vaccinations not guaranteed to benefit countries most in need.

“It’s a lot more transactional than we’ve been before,” a senior government official working in global health told CNN. “For many years, we’ve criticized China for giving foreign aid that’s very transactional, very self-serving, traps countries into agreements that go beyond the amount of support they get, and this feels like we’re leaning into that kind of a posture.” (CNN)

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