A little over a year ago, on 18 September 2025, the United States published its America First Global Health Strategy. It arrived after months of cuts, the dismantling of USAID and the announcement that the United States would leave the World Health Organization. Much of the commentary since has focused on what was lost: programmes closed, health workers laid off, HIV services disrupted in countries that had relied on US support for two decades.
But the Strategy is also worth reading closely for what it proposes. It is the clearest statement we have of how the second Trump administration sees global health, and it describes US global health assistance as “not just aid” but “a strategic mechanism to further our bilateral interests around the world”. I presented research on this at the BISA Foreign Policy Working Group workshop Foreign Policy in the Age of Trump 2.0, at the University of Birmingham. For me, the most important thing about the Strategy is not any single programme decision. It is that it sets out a full model of global health built around one country’s national interest, and does so without once mentioning the institution that has been at the centre of global health governance since 1948.
Safer, stronger, more prosperous
The Strategy is built around three pillars, taken from its promise to make America “safer, stronger, and more prosperous”. Each one tells us something about how health is now being understood in Washington.
Safer means bilateral surveillance. The United States will assign staff with a health portfolio, drawn from the State Department, the Department of Health and Human Services and the Department of Defence, to every country with a US mission, with larger teams in countries with the highest infectious disease burden or the greatest risk of a future outbreak. The goal is early warning of threats that could reach the United States. Outbreak detection is a legitimate interest for any country. What is new is that it is organised through a US presence in each country, rather than through the shared reporting system that all states signed up to under the International Health Regulations.
Stronger means bilateral agreements with recipient governments. Instead of funding international NGOs and implementing partners, the United States will sign multi-year compacts directly with governments. These start by covering 100% of frontline commodities and frontline health worker salaries, then require rising co-investment from each country. They also come with long-term data-sharing commitments. This pillar is also where the Strategy names China, explicitly and at length. Under a heading on using US global health leadership to compete with China, it contrasts American grant-based assistance with the Belt and Road Initiative and presents health aid as a way to counterweight Chinese influence, especially in Africa. It is rare for a global health strategy to be this open about geopolitics.
Prosperous means using health aid to open markets for American firms. The Strategy talks about making American innovation “a cornerstone of health systems around the world” and describes this, in its own words, as “advancing commercial diplomacy”. Health assistance becomes a channel for US products, from medicines and diagnostics to regulatory approval pathways.
Taken together, the three pillars move global health assistance away from development cooperation and shared responsibility, and towards security, geopolitical competition and trade. Each of these motives has always been present in US global health policy; we cannot say that PEPFAR was purely humanitarian. But what has changed is that they are now the stated purpose, not the side benefit.
The diagnosis is not wholly wrong
It is important to say that the Strategy’s diagnosis is not wholly wrong. It criticises the old model for waste, high overheads and what it calls a “culture of dependency”, and argues that too much money went to intermediaries rather than to the frontline. Fragmentation and vertical programming are real problems and the global health literature has said so for years. And countries themselves have been asking for change. The Lusaka Agenda in 2023 called for exactly this kind of shift: fewer parallel programmes, more money through national systems, and a clear path towards country-led financing.
The problem is how the Strategy uses that critique. It is applied selectively, in service of a different agenda. The language of country ownership is used to justify a move away from multilateral channels. But the alternative it offers is not ownership in any deep sense. The terms of each compact are negotiated one country at a time, with the United States as the only party present at every table, and with the right to withhold funding if benchmarks are not met. The implementation plans due to start on 1 October have not been published, either to the US Congress or, in most cases, to parliaments and civil society in the countries signing them. A real answer to fragmentation would bring donors together around national priorities. This one replaces many voices with a single, more powerful one.
The early experience shows what that means in practice. Zimbabwe rejected a proposed US$367 million agreement in February 2026, describing its terms on sharing “biological resources and data” as “asymmetrical”. Ghana’s President John Mahama said his Cabinet turned down its compact over requirements to share the country’s pathogen profile and citizens’ medical records, and called the experience “humiliating”. Kenya’s High Court suspended the US–Kenya framework for five months on privacy grounds. Zambia, earlier this month, signed a plan that, as reported, no longer requires the sharing of patient data. Outcomes depended on what each country could bring to the table, not on what the Strategy says about partnership.
The silence about the WHO
There is one more point I think matters most, especially given my wider research on the future of multilateral governance and financing. The Strategy does not mention the WHO. Nor does it mention the International Health Regulations, the Pandemic Agreement, the Global Health Security Agenda, World Bank, UNAIDS or Gavi. For a document that sets out a country’s entire approach to global health, including surveillance, outbreak response and health systems, this is a striking absence.
It also tells us something about the kind of break this is. Previous US administrations have been critical of the WHO, sometimes harshly. In the 1980s the United States pushed for budget restraint, and in 2020 the first Trump administration announced a withdrawal that was reversed before it took effect. Those were arguments with the organisation, from within the system. The Strategy does something different. It does not propose to reform the WHO or the multilateral system. It describes the existing model as inefficient, dependency-generating and self-perpetuating, and then proceeds as if none of these institutions were relevant any more.
When the world’s largest historical funder of global health sets out its vision without any reference to the WHO or other key global health actors, it sends a message to every other government about how optional the multilateral system has become. In his video address to the World Health Assembly in May 2025, US Health Secretary Robert F. Kennedy Jr. made the message explicit, speaking of “a moribund WHO” and telling delegates “we encourage others to consider joining us”. Argentina did. Most countries did not: in May 2025 member states agreed to raise their assessed contributions by a further 20%, and China pledged US$500 million over five years. A year later, the World Health Assembly declined to treat the US exit as complete while its arrears remain unpaid.
I have been writing about the WHO’s dependence on donor money for years, so I know the question everyone is asking now: can the WHO survive without the United States? I think it can, in some form. But that will depend less on money than on whether the rest of the world is still willing to defend that the rules for outbreaks, data, samples and medicines should be written together, not country by country in agreements most people never see. For me, that is ultimately a question of power, and it will shape how ready we are for the next pandemic.