Overview
In 2025 the United States began dismantling its post‑Cold War global health architecture: withdrawing from the World Health Organization, freezing most foreign aid, and abolishing USAID’s development role. On this foundation, the Trump administration unveiled an 'America First Global Health Strategy' that replaces large multilateral and NGO‑run programs with tightly negotiated bilateral health compacts requiring partner governments to co‑finance HIV, TB, malaria and outbreak response programs and gradually assume full responsibility. Kenya signed the first such deal on December 4, followed on December 5–6 by a $228 million U.S.–Rwanda compact that will channel up to $158 million in U.S. funds and roughly $70 million in new Rwandan spending into disease programs and health‑system upgrades, including drone delivery and bio‑surveillance technology.
These compacts are intended as models for dozens of similar agreements by March 31, 2026, but they are rolling out amid severe disruption from USAID’s shutdown and U.S. withdrawal from WHO, which together have already triggered major cuts to HIV, malaria, maternal and child health, and immunization programs worldwide. Health experts warn this shift could reverse two decades of gains, with projections of millions of preventable deaths if no alternative funding emerges, even as Washington seeks to leverage health aid for geopolitical goals such as the Rwanda–DRC 'Washington Accord' on peace and mineral access in Congo’s east.
Key Indicators
People Involved
Organizations Involved
The State Department now houses the Bureau of Global Health Security and Diplomacy and has taken over most U.S. global health programming formerly run by USAID.
USAID was the primary U.S. development and global health agency until its effective abolition in mid‑2025.
Rwanda is positioning itself as a model of self‑reliant, tech‑enabled health systems under the new U.S. aid framework.
Kenya is the pilot case for the America First health compact model, with a large multi‑billion‑dollar agreement.
DRC is at the center of overlapping U.S. peace, mineral and health‑security initiatives in Central Africa.
Zipline operates medical drone delivery networks and is a flagship example of U.S. commercial technology folded into health compacts.
Ginkgo Bioworks provides genomic and surveillance tools and is funded under the Rwanda compact to build a regional 'biothreat radar.'
Timeline
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U.S. and Rwanda sign $228M bilateral health cooperation MoU
AgreementIn Washington, Rwanda’s foreign minister Olivier Nduhungirehe and U.S. officials sign a five‑year $228M health compact committing up to $158M in U.S. funding and about $70M in increased Rwandan health spending. The deal strengthens HIV, malaria and outbreak programs, embeds U.S. tech firms like Zipline and Ginkgo Bioworks, and is framed as a model America First Global Health compact.
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Fighting resumes in eastern Congo hours after peace ceremony
SecurityWithin a day of the Washington Accord ceremony, heavy fighting between Congo’s army and Rwanda‑backed M23 rebels flares in eastern DRC, highlighting the fragility of the agreement even as U.S. economic and health partnerships move forward.
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Washington Accords for Peace and Prosperity formally ratified
DiplomacyPresidents Trump, Kagame and Tshisekedi preside over the ceremonial signing of the Washington Accords in Washington, deepening U.S. involvement in Great Lakes security and granting U.S. companies preferential access to DRC’s critical minerals.
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Kenya and U.S. sign first America First health compact
AgreementSecretary of State Marco Rubio and President William Ruto sign a five‑year health agreement worth at least $1.6–$2.5B, depending on source, marking the first implementation of the America First Global Health Strategy. The deal shifts funding from NGOs to Kenya’s government health system and requires major domestic co‑financing.
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Health experts warn America First strategy is too narrow and risky
ReactionPolicy analysts and advocacy networks argue the strategy defines global health too narrowly, largely omitting immunization, maternal and child health, nutrition and reproductive health, and warn that bilateral compacts cannot substitute for multilateral cooperation in pandemics.
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America First Global Health Strategy published; NGOs sidelined
PolicyThe administration formally releases its America First Global Health Strategy, which will bypass most NGOs in favor of government‑to‑government compacts, narrow U.S. funding to a few diseases and security functions, and require co‑financing and transition plans to self‑reliance.
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House Foreign Affairs advances bill requiring global health compacts
CongressHouse Foreign Affairs Committee Chairman Brian Mast announces committee passage of H.R. 5300, mandating that all U.S. global health assistance be delivered through bilateral 'global health compact' agreements under the America First Global Health Strategy.
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Senate Foreign Relations Chair backs America First Global Health Strategy
CongressSenator Jim Risch praises the administration’s new global health strategy for emphasizing outbreak surveillance, 72‑hour response capacity, and co‑investment by partner countries, framing it as a more efficient use of U.S. resources.
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USAID’s global health supply chain shifts to State; mass cancellations follow
ImplementationOversight of the Global Health Supply Chain Program and many other USAID initiatives transitions to State. Analyses show more than 80% of USAID global health awards have been terminated or left unobligated, totaling over $12.7B.
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DRC and Rwanda sign initial U.S.-brokered Washington peace agreement
DiplomacyRwandan and Congolese foreign ministers sign a U.S.‑mediated peace deal in Washington aimed at ending fighting in eastern Congo and laying foundations for joint security and economic frameworks, including provisions on public health cooperation.
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Administration moves to dissolve USAID and fold health into State
PolicyThe State Department notifies Congress of plans to permanently dissolve USAID as the main implementing agency for global health and development, transferring remaining programs into a reorganized Bureau of Global Health Security and Diplomacy.
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Aid freeze strands mpox and other outbreak responses
InvestigationReporting reveals that USAID’s frozen funds and evacuation of staff from the Democratic Republic of Congo have stalled mpox vaccination, testing and surveillance efforts, foreshadowing broader disruption to global outbreak control.
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Trump orders WHO withdrawal and 90‑day pause on foreign aid
Executive ActionOn his first day of his second term, President Trump signs Executive Order 14155 to withdraw from the World Health Organization and Executive Order 14169 to pause most foreign development assistance pending a review, signaling a fundamental reorientation of U.S. global health engagement.
Scenarios
Model takes off: Dozens of health compacts lock in a new bilateral order
Discussed by: U.S. officials (Rubio, Mast, Risch), DevelopmentAid and pro‑reform think tanks
In this scenario, the Kenya and Rwanda deals are only the beginning. By the March 2026 target, the State Department successfully negotiates multi‑year health compacts with most major U.S. aid recipients. Countries accept steep co‑financing requirements in exchange for continued commodity and frontline health‑worker support. Over time, NGOs play a reduced role as funding and staff transition into government systems. Advocates of the strategy highlight reduced transaction costs, stronger national ownership, and more explicit alignment of health aid with U.S. security priorities such as outbreak surveillance and border bio‑threat detection. The compact model begins to resemble a health‑sector version of the Millennium Challenge Corporation, and future administrations, even if less ideologically aligned, retain its structure because partner governments have re‑organized around it.
Patchwork coverage and deadly gaps as some countries refuse or fail to sign
Discussed by: Global health experts cited by KFF, Gates Foundation–backed IHME modeling, Modernizing Foreign Assistance Network, CNN/Global Health Now commentators
Here, only politically favored or relatively capable governments—such as Kenya and Rwanda—secure compacts, while others with high disease burdens and difficult relations with Washington (for example South Africa or Nigeria) are left with sharply reduced or no U.S. health funding. Legal constraints, weak public financial management, or domestic opposition to perceived U.S. conditions cause negotiations to stall in multiple countries. Meanwhile, USAID’s dismantling and WHO withdrawal have already disrupted service delivery; clinics close, HIV treatment is interrupted, and immunization campaigns stall. Independent projections of 14M preventable deaths by 2030 and rising child mortality begin to materialize, especially in fragile states. NGOs and other donors struggle to fill the gap but cannot fully replace U.S. scale. The America First compacts are then seen as having deepened inequities: strong states consolidate gains, while weaker ones face resurgent epidemics.
Domestic and international backlash force partial course‑correction
Discussed by: U.S. media investigations, legal analysts, congressional critics, multilateral advocates
Mounting reports of treatment interruptions, child deaths and uncontrolled outbreaks, combined with court challenges over executive overreach in dismantling USAID and cutting congressionally appropriated funds, spur a political backlash in Washington. Congressional oversight hearings and bipartisan concern about security gaps lead to legislation that preserves some bilateral compacts but restores a baseline of multilateral and NGO funding, potentially through a reconstituted development agency or expanded MCC‑style instruments. U.S. withdrawal from WHO, scheduled to take effect in January 2026, becomes a flashpoint: a future administration or a veto‑proof Congress could move to rejoin, as happened after the 2020 withdrawal attempt. The result is a messy hybrid system where America First compacts coexist with a partially rebuilt multilateral role, rather than wholly replacing it.
Health aid becomes an overt tool of resource and security politics in the Great Lakes
Discussed by: Reuters, Financial Times, International Crisis Group and regional analysts
In this scenario, the Rwanda compact is a prototype for tightly coupling health support to security alignments and resource access. U.S. investment in disease surveillance, drone logistics and health‑system strengthening in Rwanda and potentially DRC becomes part of a broader package aimed at securing supply chains for cobalt and other critical minerals under the Washington Accord. Health benchmarks are implicitly tied to security behavior—such as troop withdrawals, cooperation against rebel groups, and mineral export arrangements. If fighting in eastern Congo continues despite the accords, critics argue that health funding is effectively subsidizing militarized agendas, while supporters claim it stabilizes key partners. The risk is that health programs lose perceived neutrality, potentially making clinics and surveillance assets targets in conflict and complicating humanitarian access.
Historical Context
PEPFAR: The 2003–2020s U.S. Global AIDS Initiative
2003–2023 (initial launch and expansion)What Happened
In 2003, President George W. Bush launched the President’s Emergency Plan for AIDS Relief (PEPFAR), a five‑year, $15B initiative targeting heavily affected countries in Africa and the Caribbean, including Kenya, Rwanda, Nigeria and South Africa. The program combined bilateral funding channeled through multiple U.S. agencies, extensive partnerships with NGOs and faith‑based organizations, and support for multilateral efforts like the Global Fund. PEPFAR was reauthorized several times, with cumulative commitments reaching around $120B by 2024 and an estimated 20–25M lives saved through expanded HIV treatment and prevention.
Outcome
Short term: Within its first decade, PEPFAR rapidly scaled access to antiretroviral therapy, reduced mother‑to‑child transmission, and strengthened laboratory and supply‑chain systems in partner countries, while also exporting U.S. influence and soft power.
Long term: By the early 2020s, PEPFAR became the flagship example of U.S. leadership in global health, though it also faced criticism and domestic political challenges. Analyses now warn that its abrupt contraction—linked to USAID’s demise and the America First shift—could trigger millions of additional HIV infections and deaths.
Why It's Relevant
PEPFAR demonstrates both the effectiveness and path dependency of large‑scale U.S. health investments built around NGOs, multilateral coordination and long‑term commitments. The America First Global Health compacts are, in many ways, a repudiation of that model—prioritizing country co‑financing, narrower disease scope, and transactional alignment with U.S. interests. The contrast helps explain why experts fear large reversals in HIV and broader health gains if PEPFAR’s infrastructure is not carefully transitioned rather than abruptly defunded.
Millennium Challenge Corporation (MCC) and the Compact Model
2004–presentWhat Happened
Created by Congress in 2004, the Millennium Challenge Corporation provides large, multi‑year 'compacts'—typically $100–700M—to countries that meet strict governance and policy criteria. Eligible countries design programs, often focused on infrastructure and economic reforms, co‑implemented with MCC oversight. The compact approach ties aid disbursement to performance indicators and can be suspended if governance deteriorates. By 2024, MCC had signed 45 compacts worth over $17B, largely in sub‑Saharan Africa, and was credited with helping lift hundreds of millions out of poverty, though some critics argue it can be politically selective and slow to implement.
Outcome
Short term: MCC’s early years showed that well‑designed, performance‑based compacts could attract bipartisan support, encourage policy reforms, and deliver large infrastructure projects in relatively well‑governed countries.
Long term: The compact model became a reference point for conditional, country‑ownership‑oriented aid, but its limited country coverage and focus on governance‑qualifying states also highlighted the risk that the poorest and most fragile countries might be left out.
Why It's Relevant
The America First Global Health Strategy borrows the language and mechanics of MCC‑style compacts—multi‑year agreements, co‑investment, strict metrics—but applies them to essential health services across a far broader and more fragile set of countries. MCC’s history suggests that such compacts can work where institutions are relatively strong, but also warns that tying core services to demanding performance conditions may exclude or destabilize the weakest states.
Trump’s 2020 Attempted Withdrawal from WHO
May 2020–January 2021What Happened
During the COVID‑19 pandemic, the Trump administration suspended funding to the World Health Organization, accused it of being 'China‑centric,' and in July 2020 formally notified the UN of U.S. withdrawal, set to take effect in July 2021. Health experts, allies and NGOs widely condemned the move as dangerous and counterproductive, arguing that WHO coordination and data were vital to pandemic response. President Joe Biden reversed the withdrawal on his first day in office in January 2021, keeping the U.S. inside WHO.
Outcome
Short term: The attempted withdrawal sowed uncertainty and temporarily disrupted U.S.–WHO collaboration, but did not fully materialize due to the 2020 election outcome. Critics saw it as a warning about how politicized global health could become.
Long term: The episode set a precedent for using WHO membership as a bargaining chip and previewed the 2025 withdrawal order, which now appears more likely to take effect given political alignment in Washington. WHO has since sought to diversify funding in anticipation of a lasting U.S. exit.
Why It's Relevant
The 2020 WHO withdrawal attempt illustrates both the immediate alarm such moves cause in the global health community and how quickly they can be reversed by political change. It is a key precedent for assessing whether the current combination of WHO exit and bilateral health compacts will be a durable realignment or a transient, contested phase in U.S. global health engagement.