World-class programs that once safeguarded vulnerable children have been dismantled, and future support is alarmingly limited and uncertain
The State Department’s America First Global Health Strategy and the consolidation of foreign assistance under the State Department fundamentally change the structure and goals of U.S. foreign aid in a way that marginalizes children. The shift moves the foreign assistance system away from a model that balanced U.S. strategic interests with humanitarian and development needs toward one focused primarily on serving national security interests. The Administration has justified this shift by claiming that U.S. foreign assistance was rife with “duplication, waste and alarming inefficiencies.”
On the positive side of the ledger: the strategy does say outright that the Administration’s goal is to end maternal-to-child transmission of HIV in several countries, eliminate malaria in 35 countries by 2030, and to eradicate all forms of polio by 2029. The 40-page document also commits to covering “100%” of “frontline costs” for these efforts in FY 2026.
The Strategy’s Drawbacks are Many
Unfortunately, the strategy’s drawbacks are many. While it makes the positive commitment to pay for frontline costs for one year, it seemingly fails to understand the complicated costs of supporting the frontline work to succeed because it simultaneously states that the U.S. will “significantly reduce all other non-frontline investments.” It harshly criticizes “overhead” costs, apparently without realizing that these expenditures are the very thing that supports the complex web of procuring, purchasing, and delivering medications and treatments to frontline workers, maintaining cold chain that preserves medications, training staff, and nurturing community-level buy in and contributions that allow for commodities, such as treatment for TB or bed nets to prevent malaria, to be taken up by their intended recipients. Frontline health workers and the commodities they distribute and administer cannot operate in a vacuum despite what the report maintains. Likewise, although the report begins by celebrating the “tremendous improvements in health outcomes over the past 25 years” and the vast and “amazing” accomplishments of the previous version of U.S. foreign assistance, it disparages the “overhead cost”, missing the connection between the aforementioned successes and the strong technical, logistical and monitoring and reporting that USAID provided.
It is important to acknowledge here the context in which this report arrives. The Administration is laying out this grand strategy after deliberately dismantling the leading technical agency in the world producing gold-standard development and humanitarian results and dismissing and disparaging its thousands of world-class experts. The Administration also slashed and clawed back billions in foreign assistance funding in 2025 and proposed a budget to Congress which included a record low foreign aid levels for 2026. The obliteration of USAID and the integration of its few remaining vestiges into the State Department eliminated the dedicated expertise and specialized offices once housed in the agency, including those that served children, such as the Office of Children in Adversity and PEPFAR’s Orphans and Vulnerable Children programs. The loss of these two streams of support for the world’s most vulnerable children, one for their healthy early development and one for the holistic support of HIV affected children, cannot be overstated.
U.S. Foreign Assistance will become Transactional
Going forward the Administration’s global health report lays out a transactional rather than a development-led approach to foreign aid. U.S. foreign aid will be directly tied to advancing American interests, such as countering adversaries like China and supporting American businesses abroad, rather than to traditional goals of regional stabilization, peace, poverty-reduction, and economic development. This model shifts U.S. support toward countries deemed strategically important but not necessarily low-income while reducing support for those with high humanitarian needs but less tactical value.
The Administration’s new global health strategy also spells out its plan to replace the traditional foreign assistance grant structure implemented by non-governmental organizations, with multi-year bilateral compacts with recipient country governments that mandate increasing country investment. These bilateral compacts are scheduled to be finalized by the end of this calendar year and implemented in 2026. Needless to say, this is an alarmingly short timeline and the off-ramp for countries for U.S. assistance is similarly short, with the Administration expecting countries to take over the entire aid budget by FY 2027. Those who will be hurt the most by this new transactional policy are the poorest and most marginalized people and the most vulnerable children. Most if not all low-income countries will be unable to continue supporting the health of their populations at the same rate as had been achieved with U.S. support.
While the report argues that channeling funds through recipient governments will strengthen their governance structures and institutions, the Administration’s planned investment in and technical support for achieving this worthwhile goal are lacking. An outcome as meaningful as that requires financial investment and accompaniment over many years, not a small handful of months.
New Approach will Endanger Taxpayer Funds
This new State Department plan also subjects American tax-payer money to reduced transparency and oversight. Channeling aid directly through foreign governments, without the proper supports and the oversight formerly provided by NGOs and demanded by Congress, can increase opportunities for misuse of funds. Most NGOs are trusted stewards of resources because they are mission-driven and not-for-profit, embedded in communities, and staffed by locals. They have direct lines of oversight at the project level and prioritize the needs of vulnerable people first and foremost.
This new policy subjects foreign assistance to political influence because aid channeled through bilateral deals can be used by donor and recipient governments to promote political agendas rather than to meet humanitarian needs. This situation can lead to aid allocation decisions that are less efficient and less targeted toward the most vulnerable. Unless it is done right, history tells us this strategy’s plan to move to bilateral compacts will not work on behalf of the poor or on behalf of children. And based on this report, the plans and guardrails are not being stood up to prevent U.S. foreign aid from being turned into a tool of favoritism or worse, into a method of promoting the personal wealth of those in power.
NGOs Must Remain a Lifeline
The report also maligns the work of NGOs and incorrectly lumps them together with contractors, and it is important to push back on this narrative. NGOs are nonprofits and contractors are for-profit companies. The costs of working with an NGO versus working with a contractor are vastly different. Further, pursuing bilateral, government-to-government operations as the global health strategy proposes assumes every nation has a functioning government. But in many countries that is not the case. In places where war and chaos rage and in regions facing insecurity and fragility, NGOs are often the only lifeline for the suffering. When funding is channeled exclusively through the central government, services for people in crisis-affected countries or hard-to-reach areas are likely to be neglected.
One more point about why most NGOs make better implementers than most governments: nonprofit NGOs prioritize the neediest and most vulnerable people and therefore have a greater impact on reducing poverty and suffering. For example, research suggests that aid delivered through NGOs is more effective at reducing infant mortality than bilateral aid. Many NGOs are deeply embedded in the communities they serve, and possess an understanding of local contexts, culture, and needs, allowing them to deliver services and help more efficiently than government-led programs. Sadly, the Administration’s strategy report dismisses this community-based expertise and is an example of the very “local leadership” that it accuses the previous foreign assistance model of undermining.
The Trump Administration has delivered a strategy that is concerning. The prioritization of U.S. national interests over humanitarian goals threatens to reverse decades of progress in global disease eradication and control, as well as the end of preventable suffering and death and the promotion of security and development. And for children the picture is even more troubling, potentially undermining decades of global achievements in child health and well-being.