October 2, 2026 2:16 PM ET Fatma Tanis In December, State Department senior official Jeremy Lewin welcomed Rwanda Foreign Minister Olivier J.P. Nduhungirehe for theg of a multi-year Memorandum of Understanding on global health cooperation.

U.S. Office of Foreign Assistance The Trump administration says that October 1 marks the dawn of a new era in global healthcare. It's the age of the " America First Global Health Strategy " And that means rewriting the rules for funding healthcare in low- and middle-income countries.

A key part of the "America First" strategy is the idea that the U.S. should not hand out billions of dollars for health and development programs without reaping concrete benefits — access to local minerals, for example — and without a commitment from governments to spend their own money.

To be eligible for U.S. funds, each country is asked to sign a Memorandum of Understanding detailing the amount of money the U.S. will invest as well as the country's financial pledge.

The administration says the requirement that countries chip in will make them more self-reliant and eventually less dependent on U.S. assistance.

It's an idea that has merit, according to Jocilyn Estes a policy analyst at the Center for Global Development, a think tank in Washington, D.C. But she wonders if the plan is being rolled out too rapidly. As for the nations involved, reaction has been mixed. Here's a look at how this new arrangement is supposed to work — and what potential obstacles lie ahead.

The U.S. rationale for the new strategy The U.S. has been — and still is — the largest donor for global health programs, despite the Trump administration's drastic cuts to funding in 2025 and its dismantling of America's premier aid agency USAID.

Previous administrations viewed global health spending as an important way to build strong relationships and influence with recipient countries and as a key element of U.S. soft power — using donations to incur good will.

"Historically, the focus has been primarily that everybody benefits. That better health and better development in low and middle-income country regions lifts all boats, and the U.S. benefits from that," says Tom Bollyky director of the global health program at the Council on Foreign Relations. Here's how the State Department describes the new strategy on its website: "It will protect the homeland by preventing infectious disease outbreaks from reaching U.S. shores; strengthen our bilateral relationships by entering into multi-year, bilateral agreements that require co-investment from recipient governments, saving millions of lives and moving countries along the path to decreased dependency on foreign assistance; and promote American health innovation around the world." What's new is what Bollyky calls a more transactional view of health aid.

"The U.S. wants to be more clear about what U.S. taxpayers receive in return, beyond just countries doing well on their health and development objectives," he says.

That could mean "preferential access to critical minerals," he says — or direct access to patient data from other countries. That request for confidential records is perhaps the most controversial part of the administration's approach, he says. According to the Trump administration, the payoff for the U.S. is an enhanced ability to identify outbreaks and protect itself. Who is participating? And who is not?

The U.S. has signed MOUs with 35 countries committing around $14 billion in health investments over five years.

They span the globe and include Nigeria, Rwanda, the Philippines, Tajikistan, Bolivia and El Salvador.

In the case of Rwanda the U.S. will provide $157 million and Rwanda will pitch in $70 million. In return, Rwanda will share patient data with the United States — and will accept the U.S. Food and Drug Administration's approval of medicines for use during outbreaks without requiring further approval from Rwandan regulators.

So far three countries have refused to sign MOUs with the U.S., citing sovereignty issues: Ghana, Namibia and Zimbabwe. Negotiations between the U.S. and Zambia stalled for months over provisions for the U.S. to access critical minerals.

On September 25, during an event at the U.N. General Assembly, Ghana's president John Dramani Mahama said the country rejected the American proposal after seeing the stipulations requiring Ghana to hand over medical records of patients and pathogen data, and accept the FDA as the ultimate drug authority. "It was humiliating," Mahama said.

"Ghana is a sovereign nation and we have our processes. We're a democratic country." He referred to the funding proposition from the U.S. as "a pittance, 100 and something million." The consequences for notg can be quite serious. Also on September 25, U.S. Ambassador to Zimbabwe Pamela Tremont said the U.S. was stopping all global health funding to the country because it declined the agreement for the same reasons as Ghana. Instead, she said the U.S. would shift the focus of its relations with Zimbabwe from health to economic investments and trade.

Bollyky says the question is whether other countries who refuse will also be totally cut off.

With the rollout expected this fall, Bollyky says it's only a matter of time before "we see whether the administration is really willing to follow through with that." What the experts are saying Global health specialists interviewed for this story say that American First represents a pragmatic approach to healthcare aid.

"When it comes to public health, it does make sense to actually coordinate closely with governments, and countries should eventually run and pay for their own health systems," says Jocilyn Estes of the Center for Global Development.

Yet, she says, "the scope and scale of this pivot is really unprecedented, and the pace that the administration wants to move seems pretty incompatible with the kind of careful planning required when the stakes are this high." On the ground implementation of the agreements was originally supposed to have begun in April 2026. When the administration couldn't meet that goal, it extended the start by six months to October 1. But it's not clear yet if the money from the State Department will flow on time.

Estes says this rapid-fire rollout is a high-risk moment for the future of U.S. global health assistance.

"They're sort of building the plane while flying it, and so if this administration's bet on this new approach doesn't work, there are real patients and real people who will suffer the consequences." And there's another concern: The amount of U.S. aid will be far less than in past years, says Stephen Morrison who oversees global health policy at the Center for Strategic and International Studies.

"At the end of the day, the baseline funding that the United States has brought to the table has been significantly reduced. So if you're a country with a large at-risk population for HIV, you're going to be upset with what has happened with the United States," he says.

Yet many countries may feel they have no choice but to sign on: "You're still going to be engaging with them because it's still the biggest game in town," Morrison says.

One of the biggest questions is whether countries will be able to meet the goals they agree to for their own contributions and also up their spending on healthcare to compensate for the drop in U.S. funds.

Take Rwanda, for example. It's set to receive $157 million from the U.S. over the next five years. In 2024 alone, Rwanda received over $200 million from the U.S. for health programs. But Rwanda, like many countries, is facing economic strains from high inflation and ripple effects from the Iran war.

"We've looked at the domestic budgets announced by those countries and whether or not we see a sign that they are picking up the slack that's expected to come from the shortfall in U.S. development assistance," says Bollyky. "And it seems that [they are] not."

The speed with which the administration rolled this out didn't give countries much time to adjust, he says — and that makes it more difficult to create "a more stable environment for countries to assume the burden of addressing their health needs, which everybody wants, including those governments themselves." NPR reached out to the State Department for comment on criticisms of its America First strategy and did not receive a response in time for publication.

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