In September, the U.S. State Division issued the “America First International Well being Technique.” The doc denounces the long-established follow of utilizing international help to fund U.S.-based nongovernmental organizations (NGOs) to ship well being providers in low-income international locations, arguing that this follow is wasteful and promotes these international locations’ dependency on help. Surprisingly, the technique requires a pivot to straight funding poor international locations’ governments, a lot of which have lengthy been accused of corruption and ineffectiveness. In December, U.S. Secretary of State Marco Rubio signed the primary settlement beneath the brand new technique—a take care of Kenya to fight infectious ailments.
Many help consultants and international governments have advocated for some model of this shift. The outdated mannequin of funneling help via NGOs and personal contractors saved lots of of thousands and thousands of lives and helped untold others prosper, however by bypassing nationwide governments, it undermined their efforts to construct up their very own public well being methods and wean themselves off help. In 2024, solely of the U.S. Company for Worldwide Growth’s (USAID’s) multibillion-dollar funds went on to international governments, whereas practically 90 p.c went to giant U.S. and worldwide contractors and NGOs.
In September, the U.S. State Division issued the “America First International Well being Technique.” The doc denounces the long-established follow of utilizing international help to fund U.S.-based nongovernmental organizations (NGOs) to ship well being providers in low-income international locations, arguing that this follow is wasteful and promotes these international locations’ dependency on help. Surprisingly, the technique requires a pivot to straight funding poor international locations’ governments, a lot of which have lengthy been accused of corruption and ineffectiveness. In December, U.S. Secretary of State Marco Rubio signed the primary settlement beneath the brand new technique—a take care of Kenya to fight infectious ailments.
Many help consultants and international governments have advocated for some model of this shift. The outdated mannequin of funneling help via NGOs and personal contractors saved lots of of thousands and thousands of lives and helped untold others prosper, however by bypassing nationwide governments, it undermined their efforts to construct up their very own public well being methods and wean themselves off help. In 2024, solely of the U.S. Company for Worldwide Growth’s (USAID’s) multibillion-dollar funds went on to international governments, whereas practically 90 p.c went to giant U.S. and worldwide contractors and NGOs.
If the State Division had been to redirect only a portion of international help funding, it might characterize billions of {dollars} to assist these international locations strengthen their well being care methods themselves. The settlement with Kenya consists of an unprecedented $1.6 billion in direct U.S. help over 5 years. Support to international governments of this magnitude has not existed in latest a long time—besides to nationwide safety priorities reminiscent of Egypt, Israel, Jordan, and Ukraine.
The shift to direct help is in step with reforms that we pushed for as profession employees at USAID beneath each Democratic and Republican administrations for a few years, and such a transfer could be welcome in different sectors of international help past public well being. The brand new International Well being Technique represents a rare alternative to not solely fund lifesaving work but in addition construct up sustainable authorities capability that’s much less depending on exterior help.
Nevertheless, promising coverage doesn’t guarantee profitable implementation.
Within the months because the Trump administration shut down USAID and the State Division took over its features, there have been quite a few studies of well being methods breakdowns, lack of medical providers, and elevated morbidity and dying, together with projections of extra dire penalties if help applications should not restored or changed.
That is unsurprising: Even when the division desired to keep up lifesaving providers as USAID was shuttered, it lacked the methods to take action. USAID was basically a contracting and grant-making company, and the State Division doesn’t have the employees and required methods to spend and oversee billions in grant and contract funding all around the world annually. The division appears to have acknowledged this when it rapidly rehired 800 former USAID profession officers as non permanent employees to assist restart among the grants. This degree of staffing represents solely a fraction of USAID’s former employees of 14,000 folks.
That is all of the extra regarding as a result of the State Division goals to signal new agreements with the biggest recipient international locations by the top of this month and start implementation in April 2026.
Utterly reorienting the U.S. international help program—the largest on this planet—is a formidable enterprise, even beneath regular circumstances. Doing so instantly after gutting Washington’s international help experience and methods is all of the extra daunting.
Based mostly on our in depth expertise in government-to-government work at USAID’s International Well being Bureau and Africa Bureau, the place we supported quite a few international locations within the growth of bilateral agreements and applications, we see three main dangers for the brand new coverage, in addition to some potential fixes.
Refugee youngsters push a wheelbarrow of water containers previous a wall produced from used USAID tins in a camp in Kenya on July 20, 2011.Oli Scarff/Getty Photographs
The most alarming danger is backsliding in world well being progress—particularly in ending HIV—for which U.S. help was lengthy celebrated. Many recipient international locations already had fragile well being methods, and the in a single day elimination of help applications was a large blow (though some parts have not too long ago been restarted).
As breakdowns proceed and coverings are rationed, extra folks will get sick and die. There’s additionally a rising danger of recent, drug-resistant illness strains growing and making therapy tougher and costly, each overseas and in america. Much less monitoring of illness outbreaks might let Ebola, mpox, and different potential pandemics develop and unfold extra quickly, hitting america quicker and with out warning.
Restarting the movement of funds is essential, however shifting implementation from U.S.-based NGOs to international governments is much extra advanced than simply transferring cash. These investments should not simply absorbed. In Kenya, for instance, the five-year grant is greater than the federal government’s total annual well being funds of roughly $1 billion. Growing international locations can and will tackle the work previously executed by NGOs, however doing so requires hiring probably lots of of recent employees, increasing their methods, upgrading bodily infrastructure, and extra. Constructing these capacities takes planning and time. With out satisfactory assist via the transition, gaps in service supply will proceed at a second when there’s little room for error.
To cut back these dangers, the State Division ought to guarantee satisfactory time and assets for this huge transition. Within the brief time period, this consists of continued service provision from NGOs to attenuate gaps. It could additionally imply delaying implementation to permit ample planning with associate governments, together with sturdy monitoring methods to make sure that the brand new applications ship lifesaving providers.
Native personal sector actors, in addition to faith-based and community-based organizations, also needs to be consulted. These organizations—which know native wants and constraints and may typically attain into communities and geographic areas that the general public sector can not—must be funded as key implementing companions by both their very own international locations or the U.S. authorities.
America also needs to enable associate governments and native stakeholders to form program elements. The brand new State Division technique focuses on infectious ailments whereas omitting areas reminiscent of household planning, vitamin, maternal care, and youngster well being. Public well being methods operate greatest with an built-in method, and international locations ought to be capable to embrace the weather that they decide to be important to reaching well being objectives.
A physician registers sufferers at a hospital’s maternity unit in Ghazni, Afghanistan, on Aug. 27.Elise Blanchard/Getty Photographs
The second main danger of the brand new world well being technique is elevated waste, fraud, and inefficiency. Shifting too rapidly and with out ample oversight will create alternatives for corruption, particularly the place U.S. and associate authorities methods should not but outfitted to safeguard help. In lots of recipient international locations, public monetary administration is weak, and corruption is frequent. We’ve got seen procurement kickbacks, ghost staff, and the theft of medication and different items.
To make sure that funds are used as meant, each the U.S. and recipient governments want satisfactory staffing and preparation for danger administration. No funds must be disbursed and no challenge ought to begin and not using a danger evaluation and danger administration plan. This not solely reduces corruption danger but in addition anticipates challenges—together with outdated staffing insurance policies or burdensome approval processes—thus serving to to keep away from expensive delays. It additionally helps compliance with U.S. danger administration coverage.
Equally, no funds must be launched with out sturdy oversight plans on each the U.S. and native authorities sides. Anybody who has labored on government-to-government applications will inform you that they’re extra staff-intensive than making a grant to an NGO. For main recipients of well being help, some former USAID nation workplaces had greater than 100 staffers, plus headquarters assist. These positions had been all eradicated this 12 months, with maybe one or two folks rehired by the native U.S. embassies on a short-term foundation—far too few for the work forward.
A terminated federal employee leaves the workplaces of the U.S. Company for Worldwide Growth in Washington on Feb. 28. Bryan Dozier/Center East Photographs/AFP by way of Getty Photographs
The State Division wants extra employees to make sure that U.S. funds are used successfully. U.S. embassies ought to rent full-time, in-country employees to barter and work intently with the native authorities, conduct web site visits, audit monetary transactions, and confirm well being outcomes. Extra Washington employees ought to develop customary steerage and supply assist to embassies. By lowering the danger of waste and fraud, these hires would pay for themselves in simpler applications. If staffing freezes make this initially unimaginable, then the division ought to briefly interact skilled organizations to help on this transition.
Lastly, the technique’s shift to direct authorities help dangers reinforcing the dependency that it goals to repair. USAID and the Facilities for Illness Management and Prevention—one other federal company that provides world well being help—have made this error earlier than by inserting funds in personal accounts relatively than recipient authorities methods, hiring staff exterior the civil service, and constructing U.S.-controlled knowledge methods relatively than native capability. These parallel buildings launch rapidly and supply extra management, however they make long-term possession by associate governments nearly unimaginable.
The brand new State Division technique commendably helps native knowledge monitoring and encourages the transition of U.S. funded healthcare staff to authoritiess. But it surely doesn’t point out the usage of official monetary channels and doesn’t elaborate on tips on how to combine employees into the native civil service. With out involving these international locations’ finance ministries, applications won’t ever enter routine funds planning or obtain home funding. And with out hiring via associate authorities methods, it is vitally unlikely that employees will probably be absorbed when help ends, even when the associate authorities initially agrees to do soagrees.
Utilizing a rustic’s personal system will not be at all times simple; it might probably require prolonged negotiations and lift delicate questions round budgets and civil service reform. But these discussions can drive wanted reforms, together with the modernization of budgeting, cost, and human useful resource methods, thereby bettering transparency and lowering corruption. Strengthening these methods is what helps low-income international locations turn out to be efficient companions to america in areas reminiscent of commerce and nationwide safety. It isn’t flashy or quick, however it’s growth diplomacy at its greatest.
All applications ought to use official authorities methods, together with authorities accounts and hiring processes. Negotiations ought to embrace finance ministries and plan for integrating aid-funded applications into nationwide funds and civil service planning, codified in written agreements. If the fast use of nationwide methods will not be doable, agreements ought to embrace particular timelines and plans for doing so. Information privateness issues, reminiscent of these raised in Kenya, also needs to be addressed up entrance.
The State Division can handle these dangers if it chooses to. However given present staffing ranges, bold timelines, and the abandonment of established help methods, that is tough to think about. Congress may add guardrails within the subsequent appropriations regulation, reminiscent of requiring danger assessments and administration plans, the usage of official financial institution accounts and civil service methods, and minimal staffing for planning and oversight. Present regulation consists of necessities for direct authorities help—reminiscent of primary capacities to struggle corruption and assist civil society—however these guidelines enable huge interpretation, and will probably be telling how the State Division chooses to fulfill and report on them.
The shuttering of USAID and contraction of international help funds resulted within the unnecessary deaths of lots of of hundreds of susceptible folks. Will the administration now add to that legacy by changing one flawed system with one other? Let’s hope that it takes the effort and time to construct the sturdy, sensible help system that this new technique makes doable—one which earns assist for years to come back. This chance could not come once more.
