Updated September 22, 2025 at 2:40 PM EDT
Since inauguration night, President Trump has cut billions of dollars in global health aid, upending everything from HIV clinics to Ebola containment efforts. Throughout this time, one question has loomed over the Trump administration's abrupt actions: What will be the future of U.S. foreign aid?
On Thursday, the State Department sought to answer that question, releasing a 35-page document that outlines how the Trump administration plans to proceed with global health work.
"We must keep what is good about our health foreign assistance programs while rapidly fixing what is broken – and this strategy lays out a plan to do just that," said Secretary of State Marco Rubio in a letter accompanying the document.
In a call with reporters on Thursday, a senior administration official who spoke on the condition of anonymity called it a "landmark" strategy.
"This is a roadmap. This is a strategy document that allows us to go and negotiate with countries," the official said.
What's in the roadmap?
The document spells out what the U.S. plans to do more of — and less of — in the global health arena.
"Change number one," the senior administration official said, "[is] it's the first time that we're really bringing the recipient countries of health foreign assistance to the table, giving them skin in the game and ownership."
The U.S. plans to work directly with the governments of lower income countries to build up their national health systems. The goal for this year is to reach individual agreements with the countries that receive the majority of U.S. global health assistance, with implementation starting by April 2026.
According to the document, the ultimate goal is to wean countries off foreign aid and reduce "the culture of dependency."
This vision largely severs the U.S.' [CHECK] longstanding work with international aid groups and multilateral organizations, like the World Health Organization. The strategy document
says global health programs "have become inefficient and wasteful" and points the finger at the nongovernmental organizations (NGOs) that have received the bulk of funding from Congress over the years.
The document suggests that NGOs rely on "perverse incentives" that encourage them "to self-perpetuate rather than work towards turning functions over to local governments." However, it does suggest the U.S. could work closely with faith-based organizations to roll out global health programs, emphasizing their broad reach. The document singles them out because of their trust within the community and their ability to continue operating independently since they can rely on tithing and private donations.
The second change, the official at the press conference highlighted, is: Integration.
The strategy aims to stop the traditional approach of creating disease specific programs — such as PEPFAR, the President's Emergency Plan for AIDS Relief, or the President's Malaria Initiative. Rather, the new U.S. plan is to merge different global health programs and data systems and analytics into one unified system. On the Thursday press call, the official who spoke on the condition of anonymity said this would be both cost-effective and delivers better results. The official also said there would be an integrated financial incentive and data incentive system for "positively measuring self-reliance." Specific details on an incentive system were not shared.
Finally, the document lays out two areas where the U.S. will concentrate its global health spending: frontline health care workers and procuring commodities, such as medications and diagnostic test kits. At the same time, the plan says, the U.S will "rapidly decrease" all other types of funding, such as technical assistance. In the past, technical assistance has been a significant part of U.S. foreign aid work in which specialists provide guidance and support as a way to build up local know-how.
Throughout the document, U.S. engagement in global health is presented as a way to counter China's influence abroad and boost U.S. health care and pharmaceutical companies by increasing their access to emerging markets.
What's the reaction?
Max Primorac, a senior researcher at the Heritage Foundation and author of the section on foreign aid in its Project 2025 report, calls the administration's strategy "a breath of fresh air."
"I think the American taxpayer is going to be happy. I think the HIV/AIDS health community should be happy. And I think the Africans will be happy, because it really is focused on success as an outcome," he says, adding that success in foreign aid can only be achieved by empowering recipient countries.
"[This strategy is] one that empowers people on the ground. It's one that is highly sensitive to taxpayer equities in an era of constrained budgets, but it's also one that recognizes that you don't alleviate poverty and you don't stabilize regions through financial transfers. We tried that. It does not work," Primorac says, referring to the grant-based program structure of foreign aid that the administration has moved away from.
Instead of financial transfers, which typically take the form of aid to a non-profit group, Primorac says the administration is pivoting to a more business-like model of investments in countries with the expectation that it will produce returns.
While some in the world of global health also welcomed the document, others have expressed confusion and frustration.
"This seems to be the first kind of logical strategy we've seen from [the administration]. That's great. And this is a huge change, I think, from what we've seen the past few months," says Elisha Dunn-Georgiou, the CEO of the Global Health Council, a nonprofit group that advocates for global health priorities and has sued the Trump administration for the release of funds appropriated by Congress.
Dunn-Georgiou says many elements of the vision presented by the State Department have long been part of the U.S. approach to foreign aid, such as working closely with recipient governments and moving toward a more integrated approach.
But the lack of specifics in the document itself raised concerns. "There's very little detail. It's big, broad picture strokes," says Nina Schwalbe, a senior scholar at Georgetown's Center for Global Health Policy & Politics. "Normally, a document like this would have gone through some sort of public comment before [its launch]."
Sources interviewed by NPR also raised one looming question: How do you square this strategy with nearly nine months of cutting billions of dollars from global health programs and destroying many of the global health systems the U.S. had built up over the years?
"It's a very perplexing document," says Jeremy Konyndyk, president of Refugees International and a USAID official during the Biden and Obama administrations. "Because it seems to be written in a world in which they have not just demolished U.S. global health assistance and fired all of the people who had managed it for years."
"If they're sincere about the vision that they lay out here, they're basically going to have to rebuild it from scratch, rather than adapting and reforming it from what was," he adds.
Jen Kates concurs. As senior vice president and director of Global Health & HIV Policy at KFF, she's been tracking the aid situation. "So much has been disrupted," she says, and "that is going to make the goals in here much more difficult [to achieve]."
What's missing?
As global health practitioners and scholars scour the document for clues about what's to come, many have been struck by what's not in the document as much as what is in it.
"There is an astounding lack of mention of our Centers for Disease Control, which has been at the forefront of our foreign technical assistance in the areas that they're discussing [like] infectious disease prevention," says Schwalbe, who is also the CEO of Spark Street Advisors, a group that supports organizations working in global health and development. "We cannot do this without a fully staffed, fully funded Centers for Disease Control."
Irene Koek — who has worked in global health for over 30 years and was the senior deputy assistant administrator for global health between 2016 and 2020 at the U.S. Agency for International Development — was struck by the absence of discussion of child and maternal health, which has been a core priority of the U.S. government for decades. She says that's a "major gap."
Dunn-Georgiou can also tick off a list of topics that would have been emphasized in past foreign aid documents but are missing here. Among the issues high on her list: water, sanitation and hygiene efforts. From a public health standpoint, she says, these issues "are the bedrocks of preventing the spread of disease. But they're not mentioned.
"Again, it's a question of: Are they just coming up with a very high level strategy, and we'll see follow-on implementation plans [later]. I don't know."
Dean Karlan, professor at Northwestern University and former chief economist at USAID, noticed another gaping hole in the newly unveiled strategy: There are no plans for development assistance, such as programs aimed at alleviating poverty or supporting education and critical infrastructure like roads and electricity or providing technical support.
Specialists interviewed by NPR say development assistance is key in order to help create self-reliance among recipient countries, and that health interventions alone — as the administration has planned — will not be enough.
"For a country to get out from aid dependency, the government must strengthen and the economy must grow. Both are absolutely essential," says Karlan.
He says while the administration's plan is "elegant in its simplicity" it is ultimately naive.
"What good is buying malaria drugs for parts of the countries with no roads to deliver them on and no supply chain management gurus to make sure clinics are stocked and medicine prescribed properly? And how can you shift a country and its people to buying health services if their income does not go up?" Karlan asked. "This plan is akin to baking chocolate chip cookies and thinking you only need one ingredient: chocolate chips. That's just not how cookies work. Nor the world."
Fred Muhumuza, the director of the economics forum at Makerere University in Kampala, Uganda, says the new U.S. plan to work directly with recipient governments is in fact not new. In the 1980s, he says, when the current existing non-profit sector was much smaller, many donor countries, including the U.S., were working with African governments directly, designing health programs together and requiring financial contributions from the recipient nation. But Muhumuza says it didn't go as planned.
"[Often] the government did not meet its part of the bargain," he says. "So it never put in money to the level that it had promised. And it never lived up to the accountabilities that were required, or even by the project implementation that was required."
Ultimately many donor countries, including the U.S., scaled back from that model.
"There is clear evidence that it has not worked in the past in most of the areas. It may have worked in a few areas, but not most of the areas," he says.
Max Primorac with the Heritage Foundation says one challenge the administration faces as it implements this plan is " holding the recipient governments accountable and holding their feet to the fire."
"But I think this administration has already shown that it is ready to look at the breadth of diplomatic tools that we have at our disposal, and be able to use them in order to encourage these governments to come through on their commitments [in their agreements with the U.S.]," Primorac says.
What about funding (and Congress)?
At the press briefing, officials said the new strategy would not be accompanied by a new budget. Instead, the senior administration official who spoke on the condition of anonymity explained: "There's not a change today in terms of how much we're spending. All of the amount, all of the money that we're going to spend on health is going to be programmed in this manner."
However, several of the experts interviewed by NPR noted one line in the strategy document that made them nervous about the financial approach put forth by the State Department. It reads: "To the extent appropriations from Congress exceed funds needed to support bilateral agreements, the United States will seek to invest some of these funds in innovative, breakthrough technologies from American companies that have the potential to change the course of epidemics globally."
In other words, if there's money left over after the U.S. creates bilateral agreements, the federal government will take that extra money and spend it on new technologies being developed by U.S. companies to help combat diseases.
This line stood out to Schwalbe as running counter to the Constitution, which gives Congress the power to decide how to allocate taxpayer money. "This document is a blatant middle finger to the Congress," she says.
Dunn-Georgiou noticed it too. "That's not how appropriations works. You cannot, as the executive, just take the money and do what you want with it," she says.
Constitutional debates aside, the public health experts interviewed by NPR say they hope many details will become clearer as government-to-government agreements are hammered out in the next few months. Administration officials say that discussions for those agreements will begin this week at the U.N. General Assembly in New York City.
NPR correspondent Jonathan Lambert contributed to this story.
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