For decades, the United States has been the world's largest funder of global health programs, from the President's Emergency Plan for AIDS Relief (PEPFAR) to malaria and tuberculosis control. In 2026, the way that money flows is being fundamentally redesigned. Under the Trump administration's America First Global Health Strategy, the United States is replacing much of its previous approach with time-limited, bilateral agreements signed directly with partner governments.
What the strategy does
The State Department released the America First Global Health Strategy in September
2025. It focuses on major infectious diseases and on protecting Americans from health
threats abroad, and it sets a goal of reducing U.S. funding over time while moving countries toward paying for their own health programs [1][2]. The main tool is a memorandum of understanding (MOU), a five-year bilateral agreement covering 2026 through 2030. Each MOU sets out how much the United States intends to provide and how much the partner country commits to spend, with targets, deadlines and consequences if commitments are not met [2][3]. Kenya was the first African country to sign [4].
The deals so far
As of April 22, 2026, the State Department had signed 32 bilateral global health MOUs with countries including Angola, Kenya, Nigeria, the Philippines and Uganda [5]. According to the department, the agreements represent more than $20.6 billion in health funding: more than $12.8 billion in U.S. assistance and about $7.8 billion in co-investment from partner countries [5]. A French research institute, IRIS, calculated that the United States is funding about 63% of the total and partner countries about 37% [3]. The agreements vary widely in size. Malawi's five-year agreement, signed January 14, 2026, is worth about $936 million [6]. Papua New Guinea's, signed April 22, totals $18 million, with up to $5 million for health security in the Pacific region [5]. KFF maintains a public tracker of the agreements, which has expanded beyond Africa into Latin America and the Indo-Pacific [7][8].
A smaller U.S. role over time
A defining feature of the deals is that U.S. funding is designed to decline. An analysis by the Center for Global Development (CGD), a Washington think tank, found that countries signing MOUs will see an average 58% cut compared with their 2024 U.S. global health funding [8]. Partner governments are expected to increase their own health budgets to make up the difference. The administration says this approach ends open-ended dependency and gives taxpayers more accountability for results. Supporters note that countries are being asked to take ownership of programs that, in some cases, have relied on foreign donors for two decades, and that the agreements build on long-running progress against HIV/AIDS, malaria and tuberculosis [5].
Different deals for different countries
The agreements are not identical. According to CGD, Uganda's and Nigeria's agreements prioritize faith-based health providers and include more detailed plans to expand health insurance [8]. The earliest deals were signed with African countries that had been among the largest recipients of U.S. global health aid, while later agreements extended the strategy to countries in the Western Hemisphere and the Indo-Pacific, where U.S. officials have emphasized regional health security [5][8]. In the case of Papua New Guinea, for example, the agreement focuses on infectious disease prevention, surge-response capacity and health system self-sufficiency rather than on large treatment programs [5]. Malawi's agreement is an example of the larger deals in countries with heavy disease burdens: worth nearly $1 billion over five years, it covers programs that have long depended on outside support, and Malawi is expected to take on a growing share of the cost as U.S. contributions decline [6]. The variety reflects the strategy's premise that each country should negotiate a plan tailored to its own disease burden, budget and capacity.
Rollout delays and open questions
The strategy aimed to have most agreements signed by the end of 2025 and implementation underway by April 2026. CGD reported in mid-2026 that it was unclear how many countries were ready for that next phase, noting that no MOUs were yet operational at the time and that implementation mechanisms for the earliest agreements were only expected to come online in the following months [8]. That gap matters because U.S. programs were already disrupted in 2025, when the administration paused foreign aid and dismantled the U.S. Agency for International Development (USAID), which had run many global health programs. Some of the terms have also drawn scrutiny. A policy analysis published by the Carnegie Endowment for International Peace examined provisions in Kenya's agreement related to health data sharing and how they interact with African countries' data protection laws [4]. The Center for Reproductive Rights has filed a public records request seeking the agreements' text, including any conditions related to reproductive health services [2]. Reporting has also described pushback from some African governments during negotiations [5].
The debate over bilateral aid
Critics argue that the strategy is transactional and serves a narrow definition of U.S. strategic and economic interests. A commentary from India's Takshashila Institution warned that shifting from multilateral cooperation to one-on-one deals could weaken coordinated responses to cross-border threats such as pandemics [6]. That concern has grown alongside the U.S. withdrawal from the World Health Organization in January 2026. Supporters counter that bilateral agreements let the United States set clear expectations, measure results and focus resources on the countries and diseases most relevant to American security. They also argue that many recipient countries have grown economically and can reasonably shoulder more of the cost. The CGD analysis noted that the model depends on "a relatively effective state committed to health outcomes," which some partner countries have and others lack [8].
Why it matters
The America First Global Health Strategy is the largest restructuring of U.S. global health assistance since PEPFAR was created in 2003. Its success will be measured not in signed agreements but in whether HIV treatment, malaria prevention and disease surveillance continue without interruption as U.S. funding declines. With implementation only beginning, the first evidence will come over the next one to two years, in clinics in countries such as Kenya, Nigeria and Malawi.
Sources
- 1. U.S. Department of State, "America First Global Health Strategy," September 2025. https://www.state.gov/america-first-global-health-strategy
- 2. Center for Reproductive Rights, "State Department FOIA: Global Health Memorandums of Understanding," April 14, 2026. https://reproductiverights.org/wp-content/uploads/2026/05/State-Department-FOIA-Global- Health-Memorandums-of-Understanding.pdf
- 3. IRIS (Institut de relations internationales et stratégiques), "America First Global Health Strategy: Is Global Health Dependent on U.S. Funding?" May 11, 2026. https://www.iris-france.org/en/america-first-global-he alth-strategy-is-global-health-dependent-on-us-funding/
- 4. Munga and Rosero, analysis of Kenya's health agreement under the America First Global Health Strategy, Carnegie Endowment for International Peace, March 2026. https://assets.carnegieendowment.org/files/Munga_Rosero-Kenya%20Health.pdf
- 5. "US and Papua New Guinea sign $18 million health MOU under America First Global Health Strategy," DevelopmentAid, April 2026. https://www.developmentaid.org/news-stream/post/206439/united-states-forg ing-a-healthier-oceania-through-trump-administrations-america-first-global-health-strategy-through-bilater al-health-memorandum-of-understanding-with-papua-new-guinea
- 6. "America First Global Health Strategy: The Risks of Transactional Health Diplomacy," Takshashila Institution, February 16, 2026. https://takshashila.org.in/content/blogs/2026-02-16-America-First-Global-Health.html
- 7. "KFF Tracker: America First MOU Bilateral Global Health Agreements," KFF, updated July 1, 2026. https://www.kff.org/global-health-policy/kff-tracker-america-first-mou-bilateral-global-health-agreements/
- 8. "Where the Trump Administration's Global Health Agreements Stand," Center for Global Development,
- 2026. https://www.cgdev.org/node/3136257 Information in this article is current as of October 9, 2026. Bracketed numbers refer to the sources listed above.