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, 2025, followed by Rwanda on December 5–6 with a $228 million compact; by early 2026, 15 nations had signed agreements committing over $16 billion, with the U.S. covering 100% of commodity costs in FY2026 before tapering support.
These compacts aim for agreements with all 87 prior recipient countries, but rollout continues amid USAID shutdown disruptions and WHO withdrawal, triggering cuts to immunization and other programs. FY2026 global health funding totals $9.42 billion within a $51.4 billion foreign aid package. Critics warn of implementation gaps, potential reversals in health gains, and over 14 million preventable deaths by 2030 if transitions falter, even as the strategy leverages aid for geopolitical aims like countering Chinese influence.
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People Involved
Donald Trump
President of the United States (Architect of America First Global Health Strategy and foreign aid overhaul)
Marco Rubio
U.S. Secretary of State (Lead negotiator of new bilateral health compacts)
Brian Mast
Chairman, U.S. House Foreign Affairs Committee (Congressional architect of the compact requirement)
Jim Risch
Chairman, U.S. Senate Foreign Relations Committee (Key Senate backer of America First Global Health Strategy)
Paul Kagame
President of Rwanda (Signatory of Washington Accord and beneficiary of U.S. health compact)
Olivier Nduhungirehe
Minister of Foreign Affairs and International Cooperation, Rwanda (Co‑signatory of the Rwanda health compact and spokesperson on Washington Accord)
William Samoei Ruto
President of Kenya (First head of state to sign an America First health compact)
Félix Tshisekedi
President of the Democratic Republic of Congo (Partner in Washington Accord linking peace to investment and health cooperation)
Bill Gates
Co‑chair, Bill & Melinda Gates Foundation (Prominent critic warning of mortality surge from aid cuts)
Organizations Involved
U.
U.S. Department of State
Federal Agency
Status: Lead implementer of America First Global Health Strategy
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.
UN
United States Agency for International Development (USAID)
Former U.S. Federal Agency
Status: Development agency dissolved; programs absorbed or terminated
USAID was the primary U.S. development and global health agency until its effective abolition in mid‑2025.
GO
Government of Rwanda
National Government
Status: Early adopter of America First health compact; party to Washington Accord
Rwanda is positioning itself as a model of self‑reliant, tech‑enabled health systems under the new U.S. aid framework.
GO
Government of Kenya
National Government
Status: First signatory of America First health compact
Kenya is the pilot case for the America First health compact model, with a large multi‑billion‑dollar agreement.
GO
Government of the Democratic Republic of Congo
National Government
Status: Peace accord partner; linked to U.S. mineral and development deals
DRC is at the center of overlapping U.S. peace, mineral and health‑security initiatives in Central Africa.
ZI
Zipline International
Drone Delivery Operator
Status: U.S. drone company embedded in Rwandan health compact
Zipline operates medical drone delivery networks and is a flagship example of U.S. commercial technology folded into health compacts.
GI
Ginkgo Bioworks
Corporation
Status: Bio‑surveillance contractor in Rwanda compact
Ginkgo Bioworks provides genomic and surveillance tools and is funded under the Rwanda compact to build a regional 'biothreat radar.'
Timeline
FY2026 global health funding passes at $9.42B with PEPFAR preservation
Funding
U.S. foreign aid bill allocates $9.42 billion for global health, including $4.5B for PEPFAR and full FY2026 commodity cost coverage under compacts, as partner countries ramp up co-investments.
15 nations sign America First health compacts totaling $16B+
Agreement
Fifteen countries have executed bilateral Memorandums of Understanding, with implementation planning underway despite concerns over transparency and service delivery details.
Fighting resumes in eastern Congo hours after peace ceremony
Security
Within 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.
U.S. and Rwanda sign $228M bilateral health cooperation MoU
Agreement
In 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.
Kenya and U.S. sign first America First health compact
Agreement
Secretary 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.
Washington Accords for Peace and Prosperity formally ratified
Diplomacy
Presidents 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.
Health experts warn America First strategy is too narrow and risky
Reaction
Policy 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.
America First Global Health Strategy published; NGOs sidelined
Policy
The 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.
House Foreign Affairs advances bill requiring global health compacts
Congress
House 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.
Senate Foreign Relations Chair backs America First Global Health Strategy
Congress
Senator 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.
USAID’s global health supply chain shifts to State; mass cancellations follow
Implementation
Oversight 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.
DRC and Rwanda sign initial U.S.-brokered Washington peace agreement
Diplomacy
Rwandan 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.
Administration moves to dissolve USAID and fold health into State
Policy
The 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.
Aid freeze strands mpox and other outbreak responses
Investigation
Reporting 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.
Trump orders WHO withdrawal and 90‑day pause on foreign aid
Executive Action
On 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
1
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.
2
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.
3
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.
4
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.
5
Implementation stumbles: Compacts signed but service gaps emerge
Discussed by: AVAC, KFF trackers, global health advocates
While 15+ compacts are signed with $16B+ committed, lack of detailed operational plans leads to clinic closures, HIV treatment interruptions, and outbreak response delays during NGO-to-government transitions. Critics highlight insufficient multilateral coordination for pandemics, prompting congressional scrutiny or donor interventions.
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 Today
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–present
What 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 Today
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 2021
What 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 Today
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.
