By Ambassador Mark Green (ret) Former USAID Administrator,  and Chris Stewart, former Member of Congress | January 2026

For more than two decades, U.S. leadership in global health has been a pillar of international stability and American influence. Initiatives such as the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI) did more than save lives: they strengthened institutions, reinforced partnerships, and demonstrated that the United States could pair moral purpose with strategic discipline. Today, that legacy is being reshaped and moved forward in the Trump administration’s America First Global Health Strategy (AFGHS).

The strategy represents a deliberate effort to align global health assistance more closely with U.S. national interests, while addressing long-standing weaknesses in how foreign aid is structured. Its core premise—that global health programs should be accountable, results-oriented, and designed to end dependency rather than perpetuate it—reflects lessons learned across administrations and party lines. America’s global health programs have saved tens of millions of lives, but success should not exempt them from modernization and, yes, reform. In fact, the scale of U.S. investments in global health makes reform and optimization even more urgent.

The AFGHS bilateral agreements or MOUs establish clear priorities, timelines, and performance metrics, as they accelerate the transition of responsibility to partner countries. That is not abandonment, it is partnership with sustainability and capacity building in mind. It is very much in line with what we referred to during the first Trump Administration as the “Journey to Self-Reliance.”  No partner nation wants to be endlessly dependent upon foreign aid, so our global health and development programs should be centered on helping partners effectively take over program responsibility.  

At the same time, successful reforms to our global health assistance require careful execution. Negotiating and implementing more than 50 bilateral health agreements is an incredibly ambitious undertaking. To succeed, these agreements must be sufficiently funded and thoughtfully phased so that lifesaving services are not disrupted as partner countries assume greater responsibility. Negotiating and overseeing dozens of bilateral agreements will place unprecedented demands on U.S. diplomatic and technical capacity.  Maintaining the required numbers of skilled USG personnel, and the development of strong oversight mechanisms will be essential to ensuring that the AFGHS bilateral agreements succeed and do not erode hard-won global health gains.

Similarly, while the strategy appropriately focuses on major killers such as HIV, malaria, and tuberculosis, its success will depend on how well related investments—such as maternal and child health, nutrition, and immunization—are integrated into these new frameworks. These programs are not distractions from disease control, they are often the platforms that make disease-specific interventions effective and sustainable.

Nutrition interventions, such as American-made ready-to-use therapeutic foods (RUTF,) have saved millions of children from severe acute malnutrition and dramatically reduced child mortality in crisis and high-burden settings. Nutrition is not a competing priority to infectious disease control, but instead a force multiplier. Undernourished children are far more likely to die from malaria, tuberculosis, and other infections, and weak nutrition systems undermine the effectiveness of virtually every disease-specific intervention. Ensuring that the most proven and cost-effective nutrition tools are embedded within new country agreements will be essential to sustaining health gains.

The Trump Administration also is right to elevate global health security as a core pillar of U.S. policy. Pandemics by definition do not stay overseas. Early detection, disease surveillance, and rapid outbreak response abroad protect American families, American jobs, and American supply chains. Investing upstream to detect and prevent disease outbreaks is far cheaper—and far safer—than scrambling after a crisis reaches our borders.  Likewise, the U.S. must continue to partner with other donors to make critical investments in the development of rapid response countermeasures for high-threat pathogens that pose pandemic threats.

The new innovation fund proposed by AFGHS presents a tremendous opportunity to direct more USG global health dollars towards the development and delivery of private sector health solutions, where the State Department and DFC can combine grant and investment tools to advance new health technologies.  

America’s global health leadership also will continue to depend on smart partnerships. Bilateral agreements should work in concert with proven multilateral institutions such as the Global Fund, World Bank, Gavi, UNICEF, and CEPI, which provide increased reach and scale, critical burden-sharing, and coordination with partners that bilateral efforts alone cannot replicate. AFGHS appropriately recognizes that America should leverage, not surrender, its leadership role at multilateral organizations. 

AFGHS also should apply lessons learned from past reforms to U.S. global health assistance.  When President Bush established PMI in 2005, it was in response to congressional oversight identifying a fragmented and poor-performing bilateral malaria program.  Over nearly two decades, PMI has helped cut malaria mortality roughly in half in a focused set of priority countries with the highest malaria burdens, combining targeted disease control with investments in surveillance, commodity supply chains, and community health delivery. These gains were not accidental; they rested on predictable funding, clear metrics, and sustained engagement with national health systems. Efforts to integrate malaria into AFGHS bilateral agreements must preserve PMI’s technical rigor and focus on outcomes.

Congress has a vital role to play as well. Clear and bipartisan statutory authorities, appropriations directives, and oversight frameworks have been central to the credibility and success of U.S. global health efforts. Maintaining transparency and full reporting on performance outcomes will be critical as funding models evolve and more responsibility shifts to partner governments.  AFGHS can only succeed and be sustained over time if it is a joint venture between the executive and legislative branches. 

Global health has long been one of Washington’s most durable bipartisan achievements. By building on what works and executing reforms carefully, the United States can put America first—and the world on a safer, healthier path.