Analysis by the Kaiser Family Foundation (KFF), and the Institute for Health Metrics and Evaluation (IHME) suggest that the new approach to US bilateral health assistance maintains much of the vertical programming that the original strategy was designed to eliminate. The America First Global Health Strategy (AFGHS) published in September 2025 stated that vertical programs resulted in “lack of coordination…..duplication, and missed opportunities to maximize and
leverage investments across multiple diseases. This vertical disease-specific approach has also made integrating programs into countries’ existing health infrastructure more difficult as country health systems are almost always integrated across diseases.”
Nevertheless, the current allocation of AFGHS resources in many countries appears to remain largely oriented towards specific diseases, with well over 2/3 of funding dedicated to HIV in countries such as Kenya, Uganda, Mozambique. Moreover, while the original AFGHS criticized the U.S.-created structure of implementing partners (IPs) as “duplicative and highly inefficient” and “operating in silos” with “little connection or collaboration with one another,” it appears that many of the new G2G agreements maintain much of the IP structure – although most of the IPs will be locally based. The AFGHS stated that “for programs to be sustainable long-term, much of the training, quality, and program management work ultimately needs to be led by local ministries of health” “….data systems, need to be made in such a way as to integrate with the country’s own health data systems.” The strategy document cites an “analysis by the Kaiser Family Foundation and Boston University found that these technical assistance, program management, and overhead costs are negatively correlated with improvements in health outcomes.
For sure, the job loss among the many health workers in the IPs has been devastating. And many of the vulnerable populations served by the IPs are at tremendous risk of being further marginalized when IPs focused on their care and support close their doors. But many of these important community activities are better funded than government health systems, where MOH nurses, doctors/clinical providers, pharmacists, and others have worked for years with very low salaries, inadequate working conditions, and lack of essential medicines and supplies – or even electricity and water – usually due to government financial constraints. AFGHS calls for maintaining support for commodities and front line health workers. In order for this support to be effective, funds to support of the basic health infrastructure and health workers within that infrastructure could, and should be, the first priority.
The overall reduction in external aid has been estimated at 21%: however, since the funds will no longer go directly to the IPs, Ministries of Health have unprecedented opportunities to re-imagine – and re-allocate – how the extermal health assistance funds might be used. Let’s hope this is not an opportunity lost.
Check out these articles to delve deeper into these financing mechanisms.
Tracking the “America First” Bilateral Health Agreements | Think Global Health
KFF Tracker: America First MOU Bilateral Global Health Agreements | KFF