America First Global Health Is a Slogan in Search of a Strategy
On February 7, 2026, the U.S. Department of State announced a five-year health agreement with Burundi under what it calls the “America First Global Health Strategy.” The press release promised more than $129 million in U.S. funding, alongside a $26 million domestic spending commitment from Burundi, framed as an investment that would “protect Americans from infectious disease threats” by strengthening surveillance and outbreak response abroad (U.S. Department of State 2026a).
Burundi, however, is not the story. It is merely the latest example in a rapidly expanding network of bilateral global health agreements being signed under the same banner. According to the State Department itself, as of early February 2026 the United States had signed 16 such memoranda of understanding (MOUs), representing more than $18.3 billion in combined health spending, including over $11.18 billion in U.S. assistance and more than $7.12 billion in pledged co-investment from partner governments (U.S. Department of State 2026a).
That scale alone should force a basic question: what, exactly, is the “America First Global Health Strategy”?
This is not a semantic objection. Strategy implies prioritization, tradeoffs, metrics, and exit conditions. Yet despite repeated invocation of the phrase, the U.S. government has never clearly defined what makes these agreements “America First,” how they differ strategically from previous global health programs, or how success will be judged in terms of concrete benefits to U.S. citizens. What exists instead is a slogan attached to a large and growing set of bilateral spending commitments, defended largely through assertion.
The absence of clarity matters because U.S. global health policy has genuinely entered a new phase. But that shift has occurred by default rather than design, and officials appear reluctant to acknowledge the deeper logic driving it.
The post-WHO context everyone avoids naming
The real backdrop to the America First Global Health Strategy is not Burundi or malaria. It is the United States’ withdrawal from the World Health Organization (WHO).
In After Withdrawal: How the United States Can Shape Global Health from Outside the WHO, a 2026 working paper I co-authored with Brett Schaefer for the American Enterprise Institute, we argued that U.S. global health interests do not disappear when institutional membership ends. The United States still benefits from outbreak intelligence, technical standards, pathogen surveillance, and early warning systems. Withdrawal, therefore, should not create a strategic vacuum; it should force clarity about which functions matter to U.S. interests, which do not, and under what conditions re-engagement might ever be warranted (Bate and Schaefer 2026).
The America First Global Health Strategy is best understood as the operational response to that post-WHO reality. It is an attempt to preserve U.S. influence and disease-control capacity without WHO governance, relying instead on bilateral agreements, direct government-to-government funding, and selective information-sharing arrangements.
Framed this way, the strategy is coherent.
What is not coherent is pretending that this shift represents a fundamentally new philosophy of global health spending, rather than a structural workaround driven by institutional rupture.
What has actually been signed
State Department communications often present these agreements as discrete, country-specific initiatives. In reality, they form a rapidly assembled and internally consistent network, concentrated overwhelmingly in sub-Saharan Africa and built around similar design features: five-year terms, large U.S. commitments, explicit co-investment pledges, and integration of long-running disease programs.
Table 1 summarizes the MOUs that can be identified from State Department releases, embassy statements, Reuters and Associated Press reporting, and secondary policy analysis as of February 2026.
Notes: n/r = not reliably reported in public sources. Variations across figures reflect limited transparency rather than analytical disagreement.
The table makes one thing unmistakable. “America First Global Health” is not a pilot project. It is now the dominant operating model for U.S. global health engagement.
Security framing without strategic discipline
Official messaging increasingly frames these agreements as national self-protection: stopping outbreaks abroad before they reach the United States (U.S. Department of State 2026a). That logic is plausible, but it remains almost entirely unexamined.
Which pathogens pose the greatest risk to Americans? Influenza? Drug-resistant tuberculosis? Novel respiratory viruses? Vector-borne diseases expanding through trade and climate change? The strategy offers no ranking. Which countries matter most based on travel links, migration patterns, or laboratory capacity? Again, no answer.
Without prioritization, the claim that a $129 million investment in Burundi materially reduces risk to Americans is an assertion, not an analysis. No cost-benefit comparison is offered. No explanation is given for why this investment is superior to alternatives such as strengthening influenza genomic surveillance hubs, improving ports-of-entry health screening, or expanding domestic wastewater monitoring.
If these MOUs are national security expenditures, they should be defended as such. Instead, security language functions as a rhetorical shield, discouraging scrutiny rather than inviting it.
Self-reliance as narrative rather than enforcement
A second pillar of the strategy is self-reliance. Nearly all MOUs require partner governments to increase domestic health spending. In Nigeria, the reported deal totals roughly $5.1 billion, with $2.1 billion from the United States and $3.0 billion pledged by the Nigerian government (U.S. Embassy Nigeria 2025). Kenya’s agreement pairs $1.6 billion in U.S. funding with an $850 million domestic commitment (CGD 2025). Uganda’s agreement reportedly involves up to $1.7 billion in U.S. assistance and over $500 million in local spending (Reuters 2025d).
Co-investment is sensible in principle. The problem is credibility.
Public documentation does not specify how domestic commitments will be verified, what counts as new spending versus relabeled expenditure, or what consequences follow if targets are missed. Some reporting suggests that non-performance could trigger reductions in U.S. support (Reuters 2025b), but benchmarks and enforcement mechanisms remain opaque.
As Bate and Schaefer (2026) warned, transferring formal responsibility to governments with weak institutions risks producing paper compliance rather than genuine capacity. Without independent verification and credible sanctions, “self-reliance” becomes a narrative device rather than an accountability structure.
Recreating WHO functions without admitting it
The most revealing feature of the America First Global Health Strategy is what it attempts to replace.
Withdrawal from the WHO reduced U.S. access to global surveillance networks, informal verification channels, and technical coordination mechanisms. Rather than openly negotiating limited technical re-engagement, the United States is rebuilding fragments of that system bilaterally. MOUs increasingly reference surveillance capacity, outbreak response, and data-sharing; some reportedly include pathogen-sharing provisions analogous to those being negotiated multilaterally (Health Policy Watch 2025).
This approach is understandable. It is also inefficient.
WHO’s comparative advantage lay in information aggregation, standardization, and coordination. Recreating those functions country by country risks fragmentation, duplication, and gaps. It also undermines the claim that bilateralism is leaner or more disciplined than multilateral engagement.
More importantly, it exposes a core contradiction. The United States rejects WHO governance as politicized and unaccountable, yet recreates many of its functions without solving those same governance problems. Authority is decentralized, but accountability remains elusive.
The transparency deficit
A serious strategy would make three things straightforward for Congress and taxpayers to evaluate: what the United States is buying, how success is measured, and what happens if partners fail to deliver.
Instead, information about these MOUs must be pieced together from press releases, wire reports, embassy statements, and secondary policy analysis. Even basic figures often diverge across sources. Côte d’Ivoire’s agreement, for example, is described in State Department materials as a $937 million deal, while Associated Press reporting cites $480 million in U.S. funding and roughly $292 million in Ivorian co-investment, leaving substantial ambiguity about the remaining balance (U.S. Department of State 2025b; AP 2025).
If the administration wants these agreements to be seen as disciplined and performance-oriented, it cannot operate them as a black box.
Strategy requires saying no
A genuine America First global health strategy would be narrower, not broader. It would identify a limited set of threats with clear relevance to U.S. security and prosperity. It would rank countries by risk, not need. It would publish performance metrics tied to threat reduction rather than service counts. And it would include explicit termination clauses.
Most importantly, it would say no—to programs that feel virtuous but lack strategic justification.
Burundi’s MOU may well save lives. That is not the question. The question is whether it, and the dozens of similar agreements now being signed, meaningfully advance U.S. interests in a way that is transparent, prioritized, and accountable.
Until the government is willing to define the America First Global Health Strategy in those terms, taxpayers are not funding a strategy. They are funding a slogan.
References
Associated Press (2025) ‘U.S. signs major health agreement with Côte d’Ivoire’, Associated Press, December.
Bate, R. and Schaefer, B.D. (2026) After Withdrawal: How the United States Can Shape Global Health from Outside the WHO. Washington, DC: American Enterprise Institute.
Business Insider Africa (2026) ‘U.S. adds Malawi to its multi-million-dollar bilateral health deals’, January.
Center for Global Development (CGD) (2025) ‘What we know and don’t know about the Trump administration’s global health agreements’.
Health Policy Watch (2025) ‘U.S. signs bilateral health agreements with African countries under new global health strategy’.
Kaiser Family Foundation (KFF) (2025) ‘Tracker: Bilateral global health agreements under the America First strategy’.
Reuters (2025a) ‘U.S. signs health pact with Kenya under new aid model’, December.
Reuters (2025b) ‘U.S. signs health agreements with African nations, warns against non-performance’, December.
Reuters (2025c) ‘U.S. signs $228 million health deal with Rwanda’, December.
Reuters (2025d) ‘U.S. signs multibillion-dollar health deal with Uganda’, December.
Sierra Leone Ministry of Health (2025) ‘Sierra Leone and United States sign landmark health agreement’. Freetown.
U.S. Department of State (2025b) ‘Advancing the America First Global Health Strategy through a landmark bilateral global health MOU with Côte d’Ivoire’. Press release.
U.S. Department of State (2025c) ‘Advancing the America First Global Health Strategy through landmark bilateral global health MOUs’. Press release.
U.S. Department of State (2025d) ‘Strengthening health ties with Uganda and Lesotho under the America First Global Health Strategy’. Press release.
U.S. Department of State (2026a) ‘Building Health Resilience in Burundi Through the America First Global Health Strategy’. Press statement, February 7.
U.S. Embassy Nigeria (2025) ‘Strengthening U.S.–Nigerian health cooperation under the America First Global Health Strategy’. Abuja.