Trump's global health strategy takes shape with a $1.5 billion Zambia deal, as questions grow over transparency and Congress

The U.S. approach to global health aid is changing fundamentally. On October 8 in Lusaka, Zambia, U.S. and Zambian officials signed a global health agreement, called a Memorandum of Understanding or MOU. At the ceremony were U.S. Embassy Charge d'Affaires Mich Coker, Zambia's Minister of Finance and National Planning Situmbeko Musokotwane and Health Minister Roma Chilengi.

Coker said at the signing, 'This MOU represents a fundamental shift.' 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.'

Janeen Madan Keller, acting co-director of the Global Health Program at the Center for Global Development, said, 'The shift that's currently unfolding is very large and it's very rapid.' Experts say that after months of turmoil at the start of President Trump's second term, a clearer strategy has emerged, one with big goals, a short timeline and a lot less transparency than what came before.

Trump's second term started dramatically. When he dismantled USAID, citing alleged 'fraud, waste and abuse,' everything changed overnight. Madan Keller described the period as 'chaos.' Clinics shut down suddenly, patients ran out of HIV medications, and in Zambia and a number of other countries many patients who relied on U.S.-supported clinics and programs faced uncertainty and, often, dire health consequences.

Jennifer Kates, senior vice president and director of global and public health policy at KFF, said, 'For the first half of 2025, there was a complete upheaval.' Starting over the summer of 2025 and going into September, she said, there was a step back to develop an actual strategy and a plan.

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 the 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. In Zambia, Asia Russell, executive director of the HIV/AIDS advocacy organization Health GAP, said 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. Her organization helped expose the situation. While the part about minerals was separated from the health agreement after the public outcry in Zambia, many agreements do require the recipient country to share data such as pathogen information.

Speaking at the Lusaka ceremony, Coker said the U.S. would pay $1.5 billion over five years under the Zambian MOU, '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.' Zambian Health Minister Roma Chilengi said at the same ceremony, 'We are looking to have up to about 40,000 healthcare workers recruited through this support.' Another priority has been building up a country's own health infrastructure, not a parallel system run by nonprofits and NGOs.

The priorities in the MOUs, such as recipient countries contributing more and being weaned off aid money, are not new ideas and have long received bipartisan support, but up until now they have been hard to implement. 'This approach really does kickstart them in a new way that had not occurred before,' Kates said. In her view, however, the chaos before the kickstart makes implementing the goals more challenging, as does operating within a greatly diminished U.S. global health system.

The speed of the transition also troubles some. Madan Keller said 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 said. Russell worried that the main goal has been hammering out MOUs rather than setting ambitious health goals such as reducing HIV transmission, and that the administration is focused on process indicators, not impact indicators, as its first measure of success.

The State Department declined an interview request but said in a statement that most African countries with MOUs now have drawn up implementation plans, that U.S. embassies globally are focused on operationalizing those plans, and that recipient governments are also executing on the commitments they made in the MOUs.

Another major challenge, experts said, has been a lack of information provided to the public, a big break from past U.S. global health initiatives. The flagship HIV/AIDS program PEPFAR was a gold standard for collecting data regularly and sharing it transparently, said Ramona Godbole, former deputy director of policy, planning and programs at the now-defunct USAID. '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 said, although the text of some agreements became available through litigation or Freedom of Information Act requests. There is even less information on the implementation plans, which are supposed to contain detailed goals and metrics.

Kates said U.S. taxpayers are underwriting the aid, which totals $16 billion committed across the 36 agreements that have been signed, from money Congress allocated to foreign aid. KFF calculated that this represents a 34% drop in U.S. global health aid, and it has left some countries without an agreement. Zimbabwe, for instance, 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.'

In the wake of this week's midterms, new questions have arisen about how the shift will play out, with the Democratic Party returning to the majority in Congress. Many expect 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 said. She said there are still many 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.