Four months after Kenya was the pioneering partner in the America First Global Health Strategy (AFGHS), the country faced severe flooding that increased the risk of cholera, malaria, and other endemic diseases. The bilateral agreement signed by President William Ruto in December has meant a reduction in U.S. support and aid compared to the U.S. Agency for International Development’s (USAID) previous model, hoping to develop a system of self-reliance in the country. AFGHS presents a clear departure from previous U.S. precedent, adopting an approach to policy that diverges from earlier strategies of cooperation and humanitarian priority. These deals do not simply restructure aid but transform global health into a transactional tool of U.S. strategic and economic leverage.
Since Kenya, 26 other countries have followed suit and signed their very own memorandums of understanding (MOUs). These MOUs are bilateral agreements that create a culture of co-investment, seeing the U.S. still providing substantial financial aid but also expecting host countries to advance their own programs with reciprocal funding. Under the co-investment model, Kenya must spend $850 million over five years, while the U.S. contributes $1.6 billion through 2030, a challenging demand for a country with some of the highest levels of debt to the International Monetary Fund among African nations. While the U.S. contribution is large, it is still less than the $2 billion USAID allocated for health-related services, and the structure of the agreement still highlights conditional aid practices, placing previously unseen pressure on recipient governments. By replacing the United States Agency for International Development (USAID)’s NGO-based model, AFGHS fundamentally alters how accountability is defined.
AFGHS has goals that could, in principle, benefit participating nations. The new system aims to streamline funding and reduce fragmentation, as previously, multiple sources provided funding without a focus on efficiency. It also desires a move towards country ownership, where countries build their own systems instead of NGO reliance, developing sustainable, self-sufficient infrastructure. While long-term, these ambitions could potentially be sustained, the funding cliff model creates a practical impossibility. The funding cliff specifically means shifting financial burden onto host countries in only five years, creating a sense of urgency for Western states, but a lack of stability, which prevents sustainable change for diseases that already ravage many sub-Saharan nations, such as HIV, tuberculosis, and malaria. AFGHS attempts to be pragmatic in theory, but in practice, its mechanisms contradict these stated promises.
USAID’s NGO-based model insulated aid from political pressure. AFGHS removes that buffer. USAID relied on NGO-based aid delivery to bypass local governments and send aid directly to vulnerable populations. Conversely, AFGHS is moving operations to the State Department, with Secretary of State Marco Rubio pioneering the program, and aid delivery shifting to direct government-to-government funding. By sending aid directly through state ministries, potential concern arises over corruption, proper implementation, and the lack of developed infrastructure. While USAID was meant to act as a safety net for when state systems failed, using third-party NGOs, the new system means accountability is no longer measured by humanitarian reach or with unbiased oversight, but by the relationship between certain countries and the U.S. government.
The changes in American global health policy challenge the future of aid efficacy, a concern resonating with Dr. Michael Buckley, who formerly served as a full-time volunteer at Reach Out Mbuya, the first clinic in Africa to distribute President’s Emergency Plan for AIDS Relief (PEPFAR)-funded antiretrovirals. Buckley notes that at the time he worked there, the main hospital in Kampala, Uganda, had limited services and variable quality, attributed to the corruption and mismanagement within the government. The Reach Out clinic, which primarily worked on HIV and TB, was “well-run [and] frugal with its resources.”
“It’s not an exaggeration to say that the money spent at Reach Out by PEPFAR, facilitated by USAID, saved the lives of thousands of people,” Buckley said. “I trust Reach Out to do that work, with those resources, more than I trust government-to-government grants to do it.”
The largest criticism of AFGHS is the exploitative approach that creates contingent deals. The transactional nature includes inserting the U.S. in lucrative mineral supply chains and spreading American foreign policy initiatives abroad. The Trump administration has kept the individual agreements largely secret, and the details are only known through leaks and an accidental upload that was quickly taken down.
Among the leaked documents was Kenya’s “Cooperation Framework.” The MOU subjects the Kenyan government to data auditing, which is explicitly described as a “national strategic asset.” This clause makes aid explicitly contingent, turning public health data into leverage over national policy, even as the country is expected to develop self-reliance. While it is currently unknown exactly how this health data will be used, speculations suggest it could be tied to the development of American pharmaceuticals and tracking, another requirement of the deal, FDA approval for medical supplies. Requiring approval from a domestic organization effectively removes agency from Kenyan organizations, contradicting the core goal of the program.
Rwanda’s MOU reflects a different American interest in the region, defining the country as a “proof-of-concept market,” where “U.S. investors and companies can introduce new solutions and scale innovations” before expanding them across the rest of the continent. The provision essentially positions Rwanda as a testing ground where U.S. companies can address shortcomings before rolling them out elsewhere. An example is that Rwanda will be an “early adopter” of new HIV technology such as lenacapavir. The specifics of these clauses position Rwanda as more than a recipient of aid but a commercial partner, and also risk focusing the benefits of putting America’s foot in the door of African health markets by promoting domestic technology and preventing the financial benefits of supporting infant pharmaceutical industries from going towards developing the continent.
Something universal among the leaked documents is the 7-1-7 biosurveillance metric that requires outbreaks to be reported seven days after emergence, reported to the U.S. government in one, and a response will be enacted seven days after. While framed as a cooperative effort, the 7-1-7 model shifts surveillance priorities towards containment rather than long-term disease reduction. Specifically, the phased withdrawal of U.S. funding for the salaries of frontline workers risks equitable support. For example, in Kenya’s MOU, the state is expected to transition from covering 0 to 13,293 salaries in a single year, posing a huge hurdle for an already struggling economy and an example of the funding cliff effect. The goal of this early warning shifts the focus from the humanitarian mission of ameliorating these diseases in the long term to containment within participating states and away from American shores, on a contractual level.
Journalist Emily Bass has connected the AFGHS MOUs to Project Vault, the new initiative promoted by the Trump administration to get a competitive edge against China in the minerals sector. Bass identifies Project Vault as the reason behind the transactional nature of the memorandums, and countries such as Rwanda are exchanging mineral supply chain access in exchange for their health aid. Additionally, these rare earths and minerals are necessary for the advanced technology of the modern age. This necessity frames the commercial engagement clauses with Rwanda as an alignment of their economies that will promote these Project Vault deals as lucrative for both countries. Despite this veil of equal benefit, the agreement develops a further contingent relationship that changes medical assistance into leverage in the resource war.
The current policy clearly prioritizes ‘America first,’ but regarding global health, it may lead to dangerous crises amidst the scramble for new funding sources by countries with already struggling economies. The new agreements replace humanitarian aid with transactional deals that force nations to trade their sovereignty for assistance that solicits regional instability. AFGHS is a mission to further isolate the developing world in poverty, while ensuring a “safer, stronger, and more prosperous” America, not attempting to conceal itself as anything different.
AFGHS tries to compartmentalize health crises onto coasts, but diseases do not respect borders, and the threats of these illnesses extend beyond the countries where they begin. By failing to support coordinated, global responses in the poorest nations, AFGHS will inevitably lead to worldwide emergencies, surrendering its own mission to protect international health security. By turning health assistance into a tool of leverage, AFGHS risks undermining the very “safety, strength, and prosperity” it claims to protect.
Featured Image Source: William Ruto on X