State Department outlines $16 billion global health shift
New bilateral agreements replace traditional aid models, prompting questions about transparency and oversight ahead of the January congressional session.
By Lily Carter ·
U.S. taxpayers committed $16 billion to foreign health programs under a series of bilateral agreements signed between 2025 and 2026. The administration has moved away from funding international organizations and non-governmental groups to negotiate directly with individual governments. This structural change requires recipient nations to match American funding with increased domestic spending and eventually phase out reliance on U.S. aid.
The pivot became visible on October 8 in Lusaka, Zambia, where U.S. and Zambian officials signed a Memorandum of Understanding. Mich Coker, the Chargé d'Affaires at the U.S. Embassy in Zambia, described the deal as a departure from the traditional donor-recipient relationship. He stated the new framework is grounded in Zambian leadership and shared accountability. The agreement specifies that the United States will provide $1.5 billion over five years while Zambia commits to raising its own health expenditures by $975 million.
Experts describe the early months of the second Trump administration as a period of disruption. The dismantling of the U.S. Agency for International Development caused sudden clinic closures and medication shortages in several countries. Jennifer Kates, a senior vice president at the Kaiser Family Foundation, characterized the first half of 2025 as a complete upheaval for communities in poor nations. By the summer of 2025, the State Department began developing a coherent strategy to replace the previous system.
The new strategy is defined by transactional terms. Asia Russell, executive director of Health GAP, noted that the initial Zambian draft linked health funding to access to copper and rare earth minerals. Activists exposed the link, leading the government to separate the mineral provisions from the health agreement. However, most signed documents still require recipient countries to share pathogen data and other information.
Transparency remains a point of contention. The State Department has not publicly released the full text of all agreements. Some documents have surfaced through litigation or Freedom of Information Act requests filed by advocacy groups. Ramona Godbole, a former official at the U.S. Agency for International Development, contrasted the current opacity with the PEPFAR program, which established standards for data collection and public reporting.
Jennifer Kates of the Kaiser Family Foundation said it is currently difficult to obtain information on the implementation plans that detail how funds will be spent. She noted that the new agreements represent a 34% drop in overall U.S. global health aid compared to previous levels. Zimbabwe, for example, lost its aid allocation because the two governments could not agree on the terms of a memorandum.
The State Department responded to these concerns in a written statement. It said most African countries with signed agreements have drawn up implementation plans and that embassies are focused on operationalizing those plans. The department stated that it will make a final determination on releasing full text once ongoing negotiations conclude. It also asserted that all signed memorandums will be shared with Congress.
The new Democratic majority in Congress is expected to demand more information after lawmakers convene in January. Kates predicted that legislators will request access to the memorandums and implementation plans. She said the administration's focus has been on process indicators, such as signing documents, rather than impact metrics like reducing disease transmission. Russell argued that Congress should pause spending until it receives detailed accountability reports.
Janeen Madan Keller, acting co-director of the Global Health Program at the Center for Global Development, warned that the compressed timeline poses risks. She said the strategy aims to achieve major changes in a short period with limited capacity to manage the transition. The administration’s approach relies on building local health infrastructure and recruiting workers, such as the 40,000 healthcare professionals planned for recruitment in Zambia.
