America First Global Health Strategy
The Risks of Transactional Health Diplomacy
Authors
On January 14, 2026, the US and Malawi signed a five-year bilateral health cooperation Memorandum of Understanding (MOU), which was worth approximately $936 million. The agreement is a commitment by both countries to work together, strengthen disease surveillance, and support programs covering HIV/AIDS, malaria, and other infectious diseases. Malawi will increase its health budget by nearly $144 million over the five-year period, while the U.S. will contribute up to $792 million.
This deal is the kind of agreement that one can expect under the new America First Global Health Strategy. The U.S. has already signed more than a dozen similar MOUs with African governments, with Kenya being the first. But what might appear as a gesture of friendly cooperation is a part of a larger and more troubling shift in American foreign policy with significant implications for health governance in Africa and beyond.
The America First Global Health Strategy, published in September 2025, essentially represents a shift in US global health diplomacy. The new strategy abandons humanitarian or multilateral objectives and favours a more transactional and bilateral agreement that serves a narrower definition of US strategic and economic interests. This shift comes after several months of deliberate disruptions in U.S. foreign aid, including a foreign aid review and freeze in early 2025, along with the termination of important international commitments and the official dissolution of USAID, with global health programs transferred to the State Department.
The strategy emphasises co-investment and co-financing, which shifts more financial responsibility to partner countries, while U.S. support gradually declines. This marks the departure from the traditional approach to global health assistance, which was largely channelled through multilateral mechanisms such as the WHO, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), and the United States Agency for International Development (USAID). The new approach prioritises government-to-government contracts, co-investment agreements, data sharing, shared disease surveillance systems and notably uses these agreements to promote American medical innovation, creating pathways for a market presence of U.S. pharmaceuticals in the recipient countries.
The strategy prefers disease-specific programs with short-term and measurable outcomes rather than developing robust health systems. HIV/AIDS, tuberculosis, malaria, and polio are given priority because it is easy to measure the outcomes, which are also more visible from a geopolitical perspective. Health system strengthening and non-communicable diseases receive less focus. This, in turn, undermines the fundamentals that strengthen global health security.
As part of a broader strategic competition with China, the U.S. intends to leverage these agreements to serve as a tool to counter China’s increasing role in African health systems. However, unlike China’s infrastructure-heavy health engagement, the U.S. relies on disease programmes and data systems to exert influence without long term infrastructure commitments.
What is more concerning is that this bilateral approach undermines multilateral cooperation, which is the key backbone of global health preparedness. Institutions like the Africa Centres for Disease Control and Prevention (CDC), regional surveillance systems, and continental negotiations for the exchange of pathogen information will be undermined due to bilateral negotiations between the states. The termination of USAID in 2025, which had saved around 92 million lives over two decades, already illustrates this risk, with researchers estimating 600,000 deaths so far, two-thirds of them children, and projections suggesting up to 14 million more deaths by 2030. This comes at a time when collective responses to outbreaks are imperative.
For African nations, the implications are severe. On one hand, there is a possible weakening of cooperation on the continent. On the other hand, the transactional approach forces individual governments to live up to U.S. standards and reduces funds that could be spent on other health needs.
The MOU with Kenya, signed in December 2025, illustrates this tension. A High Court in the country suspended the implementation of the agreement, after civil society members raised concerns over patient data privacy and the bypassing of parliamentary approval. Critics warn that such agreements could lock African countries into digital and surveillance systems that primarily serve U.S. interests.
The implications are not limited to Africa. A U.S. model that promotes bilateral and interest-driven health diplomacy could shift the paradigm of global aid, while undermining multilateralism globally, along with undermining coordinated responses to cross-border health threats, like pandemics. This will have implications for countries like India, which have long supported multilateral health cooperation, making it harder to coordinate epidemic preparedness, equitable vaccine access, and shared health security.
In sum, while the America First Global Health Strategy could result in some gains for American companies in the health sector, it will likely hinder global health cooperation. This is because it fundamentally reframes global health as a negotiated deal that is driven by narrow interests, rather than a shared human responsibility rooted in collective action and equitable partnership.