By all appearances, it was a classic government ceremony. Officials in suits. Big black chairs around a wooden table. A cluster of microphones. It happened on October 8 in Lusaka, Zambia. Amid applause, U.S. and Zambian officials signed a global health agreement, called a Memorandum of Understanding or MOU.
But Mich Coker — the Chargé d'Affaires at the U.S. Embassy in Zambia — said this agreement was anything but classic.
"This MOU represents a fundamental shift," he said, speaking at the signing ceremony. He explained that the relationship between the two countries was moving "from a traditional donor-recipient model to a true partnership, one grounded in Zambian leadership, in Zambian ownership and in shared accountability."
Global health experts on all sides of the political spectrum and all over the world agree with Coker that there's been a fundamental shift in the U.S. approach to global health.
"The shift that's currently unfolding is very large and it's very rapid," says Janeen Madan Keller, acting co-director of the Global Health Program at the Center for Global Development.
The story of this fundamental shift starts at the beginning of the second Trump Administration with months of global health turmoil — Madan Keller and other experts say — but has given way to a clearer strategy. One with big goals, a short timeline and a lot less transparency than what came before.
Here is a look at where things stand now and how a Congress controlled by the Democratic Party might impact the new landscape.
First, the "chaos"
President Trump's second term started dramatically. When he dismantled USAID (the U.S. Agency for International Development), citing alleged "fraud, waste and abuse," everything changed overnight.
"It is a period that is best described as chaos," says Madan Keller. The repercussions were massive and immediate, she says, "for people and communities in some of the poorest countries of the world."
Clinics shut down suddenly. Patients ran out of HIV medications. In Zambia, as well as a number of other countries, many patients who relied on U.S.-supported clinics and programs faced tons of uncertainty and, often, dire health consequences.
"For the first half of 2025, there was a complete upheaval," says Jennifer Kates, senior vice president and director of global and public health policy at KFF.
A strategy emerged
Next came a new stage in the history of U.S. foreign aid. "Starting over the summer of 2025 and going into September, there actually was a sort of step back to develop an actual strategy and a plan," says Kates.
What emerged from the State Department was the America First Global Health Strategy with the stated goal of making "America safer, stronger, and more prosperous." The main way this strategy is being implemented is through agreements with individual countries. In the past, the U.S. had done more work through large international organizations or local non-governmental organizations.
Experts say one defining feature of these agreements is that they are transactional. For example, in Zambia "there was a massive scandal because activists were able to show that the agreement was planning to condition access to [U.S. global health] funding on access to [Zambia's] copper and rare earth minerals," says Asia Russell, executive director of the HIV/AIDS advocacy organization Health GAP. Her organization helped expose this situation.
While the part of the agreement about minerals was separated from the global health agreement after the public outcry in Zambia, many of the global health agreements do require the recipient country to share data such as pathogen information.
Big (but not new) goals
Speaking at the signing ceremony in Zambia, Coker ticked off some of the top priorities in the new strategy, including that recipient countries increase their financial contributions to health in the years ahead and that they are transitioned off aid in the near future.
He said in the Zambian MOU, the U.S. would pay $1.5 billion over five years "with Zambia simultaneously committing to increase its own domestic health expenditures by $975 million. We are charting a path toward a stronger, more self-reliant health system."
Another priority has been building up a country's own health infrastructure — and not a parallel system run by non-profits and NGOs.
"We are looking to have up to about 40,000 healthcare workers recruited through this support," said Zambian Health Minister Roma Chilengi at the same ceremony.
The priorities in the MOUs — such as recipient countries contributing more and being weaned off aid money — are not new ideas. In the world of global health they have long received bipartisan support. But, up until now, they've been hard to implement. "This approach really does kickstart them in a new way that had not occurred before," says Kates.
But in her view the chaos before this kickstart makes implementing these goals more challenging — as does the fact that everyone's now operating within a greatly diminished U.S. global health system.
The speed of the transition also troubles some. Madan Keller says that the strategy aims to achieve major changes in just a handful of years. "It's happening on a compressed timeline with arguably limited capacity to manage it, and that's where some of the risks and concerns are coming from," she says.
And Russell, for her part, is worried that the main goal of the Trump Administration has been hammering out MOUs rather than setting ambitious health-related goals, such as reducing HIV transmission. The Trump administration is focused on "process indicators — not impact indicators — as its first measure of success, which is basically a loser's gambit when it comes to pandemics," she says. "Rubio crowed about signing documents. That doesn't save lives."
The State Department declined an interview request but said in a statement that most African countries with MOUs now have drawn up implementation plans and "U.S. embassies globally are now focused on operationalizing these implementation plans [and] recipient country governments are also executing on the commitments they have made in the MOUs."
"Very hard to get the information"
Another major challenge in assessing the new strategy has been a lack of information provided to the public, says global health experts.
This represents a big break from past U.S. global health initiatives. For example, the U.S.'s flagship program for HIV/AIDS — called PEPFAR – "was a gold standard for collecting data on a regular basis and sharing it transparently — and then using that data to really inform decision making," Ramona Godbole, the former deputy director of policy, planning and programs at the now-defunct U.S. Agency for International Development, told NPR earlier this year.
"Now it's much more opaque and very hard to get the information. The agreements themselves have not been publicly released by the U.S. government," Kates says. Although, the text for some of the agreements have become available through litigation or Freedom of Information Act requests filed by advocacy groups.
There is even less information on the implementation plans, she says, which are supposed to contain detailed goals and metrics for how the money will be spent and what programs will be supported.
Kates says this is true despite the fact that U.S. taxpayers are underwriting the aid, which totals $16 billion committed across the 36 agreements that have been signed. That money comes from U.S. taxpayer dollars that Congress allocated to foreign aid. KFF has calculated that this represents a 34% drop in U.S. global health aid and it has left some countries without an agreement. For instance, Zimbabwe lost U.S. global health aid since the two governments were not able to agree to MOU terms.
In its statement, the State Department said: "Claims of a lack of accountability and transparency are unfounded….We have and will share every signed MOU with Congress."
A new blue Congress
In the wake of this week's midterms, there are new questions about how this fundamental shift in global health will play out. With the Democratic Party returning to the majority in Congress, many expect that lawmakers will demand more transparency.
"I think 100% they are going to demand: give us the MOUs, show us the implementation plans, come in and tell us more detail about what you're doing," Kates says.
Another question is whether the new Congress might try to resurrect what was dismantled. Kate says there are still a lot of unknowns about what the new Congress will do after it convenes on January 3 and how the Trump Administration will respond, but she expects lawmakers will first push for the public to get more information on what global health work the U.S. is and isn't currently supporting.
Russell says many global health activists are calling for more oversight — and she is one of them. "Congress needs to slam its feet, both feet, on the brakes unless and until it gets this information, gets this accountability," she says.
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