Trump's 'America First' global health plan sidelines NGOs

The Trump administration’s State Department team brought its “America First” vision for the future of U.S. global health efforts to New York this week, and left little doubt as to who it wants — and doesn’t want — to have a seat at the table. In lieu of working with NGOs that have implemented U.S. government global health and development projects for decades, the Trump administration’s new strategy — released last week — calls for bilateral agreements with governments and partnerships with private sector companies. Jeremy Lewin, the State Department official in charge of foreign assistance, drove home the point in opening remarks — delivered without notes — at a United Nations General Assembly side event on the future of U.S. global health assistance on Monday. He said that U.S. global health efforts have been “tremendously successful in many respects.” But he added the Trump administration believes that “progress has stalled,” with “too much focus on creating parallel health care systems” and “promoting NGOs,” while “the countries and the private sector have been cut out.” “We want to help promote genuine self-reliance,” he said. The America First Global Health Strategy takes aim at NGOs, accusing them of following “perverse incentives to self-perpetuate,” rather than shifting program ownership to governments. In the minutes before Monday’s event, a clash over the guest list put a sharp edge on that message. Entering the room before most attendees had arrived, Lewin noticed that the Global Health Council — a U.S.-based global health member organization that is currently suing the Trump administration over its aid cuts — had a reserved seat at one of the main tables. Upon seeing this, Lewin objected to the organization’s inclusion — describing them to others in the room as “anti-American” — and the placard marking GHC’s seat was removed. A Devex reporter witnessed the incident. Multiple sources confirmed that GHC was denied entry to the event. GHC did not respond to an inquiry from Devex. Nor did the State Department, or the U.S. Chamber of Commerce, which hosted the event. In addition to suggesting that legal battles over foreign aid funding have spilled over into tensions outside the courtroom, Lewin’s ouster of a major U.S. global health organization from an important public discussion on global health highlighted the Trump administration’s split from mainstay civil society voices. It served as an eyebrow-raising preface to an otherwise measured, detailed discussion of the State Department’s new strategy — which has generated a mix of cautious optimism and alarm. Monday’s event offered a clear picture of who the Trump administration wants involved in that process — putting U.S. officials on stage with African health ministers and American tech and pharmaceutical companies — but not NGO leaders. “The message is: We want to put the countries in the driver's seat,” Lewin said. “We want to be a partner. We want to help deliver American commodities at scale, but we don't want to be sort of dictating how countries fund their own national health care systems. We want to be supporting them and supporting American businesses at the same time.” The ‘next phase’ Brad Smith, a State Department senior adviser and architect of the new strategy, outlined how the administration plans to rapidly shift responsibility for funding and delivering health programs to partner governments — a goal Trump’s team has portrayed as “sustainability,” but which some experts worry signals U.S. retreat. The U.S. global health budget for 2025 is $12.4 billion, which includes funding for both U.S. government programs and contributions to multilateral initiatives. The Trump administration has canceled billions of dollars in funding for foreign aid programs. Global health makes up nearly two-thirds of the programming that has survived the dismantling of the U.S. Agency for International Development. Smith said the “next phase of U.S. global health investments” will be structured around two- to five-year bilateral agreements — or compacts — that prioritize “performance benchmarks” and commitments from partner governments to provide co-financing that increases over time. Republicans in Congress have also thrown their support behind this new model, including it in a sweeping proposal to reform the State Department that mirrors Trump administration plans. Smith said the bilateral agreements will try to work backwards from what partner governments want their health systems to look like in 2028 or 2030. “If we can see that future together, how do we ensure that the U.S. investments over the next two to five years are helping lead to that future in a sustainable way?” That process will involve examining different health spending areas. Smith said the Trump administration is “committed” to ensuring that spending on frontline health supplies and health workers is sustained. “In the immediate future, the U.S. will provide 100% of that funding for fiscal year 2026 and then, depending on the country, and depending on the timeline, we'll think about co-investments from individual countries based on their capabilities over the next handful of years,” he said. The strategy does signal a significant reduction in funding for technical assistance, however, which the State Department hopes to achieve with cuts and efficiency gains. “While there was probably a phase in the epidemic where it made sense to have these parallel systems and this high level of technical assistance, the capability of many of these countries has really risen remarkably,” Smith said. The strategy also lists the salaries of CEOs from a sampling of nonprofit and for-profit NGOs, alleging that high compensation and overhead have contributed to high costs. After walking through the strategy, Smith turned to two African health ministers for their reaction. “When you hear us talking through these principles, what is your response?” Smith asked. Both invited ministers — from Nigeria and Rwanda — voiced support for the new strategy, while offering their own suggestions. “We welcome it,” said Nigerian health minister Mohammed Ali Pate. Pate urged U.S. officials to ensure their global health investments “get into the cycle” of governments’ public budget planning so they can “help improve the quality of the spend of domestic resources” and “lock in” governments to an appropriation. Sabin Nsanzimana, the health minister of Rwanda, offered his own critique of past U.S. government global health investments and the heavy planning burden they have placed on partner governments. “Sometimes the process of discussion was longer than the time of implementation,” Nsanzimana said. Unanswered questions While the tone inside the room — among those permitted to attend — was generally optimistic about the Trump administration’s global health plans, the new strategy has raised alarms for some — and a long list of unanswered questions for others. “A worry that a lot of people have is that they’re going to force these time frames that are just too concentrated,” a U.S. congressional aide told Devex. They noted that in discussions about the strategy, Smith — from the State Department — has stated that the Trump administration intends to begin its new bilateral agreement model in the dozen or so countries with the largest U.S. global health funding portfolios, rather than in countries that are particularly primed for transitioning away from aid. “You can’t help but look at that and say — your goal is simply to target these big ones because you want these budgets to go down, not because you’re serious about sustainable transition,” they said. The administration’s claim that technical assistance is outdated has also gotten pushback — particularly when the State Department intends to shift so much additional responsibility onto partner governments. While Trump officials project confidence that they can do more with less, some skeptics worry their true intention is to simply do less with less. “I don’t think they can say, 'We want to transition to governments but we don’t want to offer any [technical assistance] to make sure it’s being done in a correct and sustainable way,” the aide said. While many welcome a more concerted effort to attract private sector innovation and investment to global health, that does not absolve the administration of addressing the massive disruption caused by its rapid suspension and cancellation of a huge number of global health and development programs. “The private sector is not going to fill all these gaps that are now being left by the termination of contracts and awards to NGOs,” said the aide. “They’ve not articulated how they’re going to bridge that divide.” Some global health experts have rejected the Trump administration’s new strategy altogether. “The bottom line: this is not a global health strategy. It signals the end of America’s engagement in global health,” Nina Schwalbe, a global health expert and the CEO and founder at Spark Street Advisors, wrote on her Substack. “Going forward, the focus is on bilateral deal-making, outsourcing contracts to the private sector, and promoting American products.”