Rumor has it that the State Department will soon release (some) implementation plans for its global health agreements. The plans should add much-needed detail to one of the most consequential shifts in US global health policy. That is big news for anyone following the Trump administration’s new approach.
For those who haven't been waiting with bated breath: a year ago, the State Department released its America First Global Health Strategy, laying out a reconfigured model of assistance anchored by bilateral Memoranda of Understanding (MOUs) with partner countries. The agreements, spanning either three or five years, set out broad commitments to transition countries and their health systems beyond aid, with partner governments increasing domestic health spending as US assistance declines. That goal is not new. But the administration’s proposed timelines are ambitious and unprecedented. The State Department aimed to have implementation underway in all countries by April 2026. Needless to say, they’re running behind schedule.
The stakes are substantial: these plans will shape how billions of dollars in US global health funding are spent, with people’s health, well-being, and lives on the line. Yet transparency remains a problem. Little is publicly known about how the administration is designing these agreements—and even Congress, which plays a crucial oversight role, hasn’t been fully looped in. Documents and agreements obtained through FOIA requests fill in some details but still leave a yawning gap between text and execution. The hope is that these implementation plans bring us closer to how the agreements might be operationalized for people living in these countries—assuming we’ll actually get to see them. Here are six things we’ll be looking for:
1. How much money will flow through country systems, and how?
As we’ve pointed out, in recent memory the US has provided very little government-to-government (G2G) assistance for development purposes. Despite the headline transition goal, we expect few countries to receive direct assistance in year one, but how many, which ones, and at what scale remain key questions. Past direct assistance programs offer a template, with several mechanisms and structures the administration could deploy.
In addition, we’ll be eager to see how funding flows through country systems—whether it flows through the Treasury, directly to a Ministry of Health, or sits in a pooled donor fund—which has important implications for speed of service delivery, financial risk to the countries themselves, oversight, accountability, sustainability, and ownership.
At present, not enough is in the public domain about what factors have shaped dimensions of the negotiated partnerships. We hope to see greater transparency about what data and evidence (for example, fiduciary and public financial management assessments, audit findings, health financing data, or disease burden estimates) the State Department used to determine how much each country receives and through which channels and mechanisms. We’d also hope to see plans to scale up G2G that are calibrated to each country’s health system capacity, fiscal space, and political stability.
2. What is the spending breakdown by disease and health area, and how does it align with congressional directives?
There appears to be some tension between the administration’s approach, which, at least on paper, favors more systems integration and flexibility, and Congress’s, which continues to appropriate funding for specific disease programs. There’s some support on the Hill for the general tack of the America First Global Health Strategy, but Congress is hoping to preserve its oversight role, and there’s no sign that appropriators will abandon traditional spending directives.
If a disease-specific approach still guides these agreements, that cuts against the administration’s stated goals and could create challenges for partner governments, which don’t budget and plan in ways that necessarily align with US funding streams. The MOUs themselves contain some disease-focused spending and performance targets, but they also have distinct spending categories (such as data systems, disease surveillance and outbreak response, and health workers and and laboratory systems) that reflect neither country budgets nor traditional US appropriations. We’re curious to see how the implementation plans manage the tension between desired systems integration and lawmaker directives.
3. What happens when countries fail to comply with the MOUs’ terms or fall behind on milestones? And what’s the State Department’s backup plan?
The State Department is focused on using performance-based financing mechanisms. These arrangements are promising in some contexts, but the targets set in the agreements are numerous, ambitious, and often outside governments’ control. Yet the available MOU texts are explicit: falling behind on co-financing and performance targets could trigger a decline in US support. The agreements are vague on how and by whom these targets will be assessed, and on what timeline US commitments would be reduced—but with real money and lives on the line, that process is critical.
If the implementation plans add more metrics, the State Department risks asking countries to focus on too many things and thereby prioritize nothing. And if missing any one target could mean a reduction in assistance, more indicators mean more potential points of failure. The plans should clearly lay out the process for applying penalties under the performance-based system and explain how the US will manage underperformance and help fill any resulting gaps. They should also identify backstops the US can activate quickly to respond to crises, reach populations governments may underserve, and independently verify results.
4. Who will collect, verify, and publish data to inform performance-based payments?
Performance-based mechanisms are only as credible as the data they rely on. For each performance indicator, the plans should identify the data source, whether national household surveys, routine health information systems, facility or commodity records, or something else. They should also specify who collects and verifies the data: governments, national audit institutions, or independent third parties. We’ll also be looking at how often results are measured and whether that aligns with disbursement schedules.
As of now, it’s unclear how stakeholders will be able to keep tabs on progress. The State Department seems keen to pass the baton to partner governments, but the US has a vested interest in understanding how things are going. Lawmakers and others should be able to see if the transition is working as intended and if populations are being appropriately served. Beyond ensuring data quality, how will data be made accessible and publicly available?
5. Are the co-financing requirements and transition timelines realistic for each country and appropriately tailored for each context?
We’re curious whether, and how, the State Department will advance meaningful country ownership without creating a financing cliff. Co-financing requirements across the MOUs are sizeable, though they vary considerably. While some partner countries could increase domestic investments in health, the financing commitments and three- or five-year transition timelines remain unrealistic for many countries.
The pace of US drawdowns and required co-investment doesn’t always match a country’s actual and projected resources, and a handoff that isn’t carefully planned risks service interruptions for patients, stockouts of essential commodities, and other life-threatening disruptions.
We’re also interested to see whether there’s evidence that these co-financing requirements are truly additional and not resulting in countries reallocating resources away from other priorities to meet MOU obligations. Do the plans spell out an accounting process to transparently assess changes in domestic health spending? And does that process integrate with country systems, or does it add an onerous, off-cycle reporting burden?
6. How will other moving parts play into the rollout?
The implementation plans are moving forward amid significant shifts: major changes to legacy implementation arrangements and procurement contracts, as well as broader uncertainty about how the US will fit into the multilateral health system. And a year after the strategy’s release, only a small cohort of staff is designing and managing these new awards.
Procurement is one particular concern. The rapid transition from a Chemonics procurement contract to the Global Fund’s Wambo platform could carry high risks. When commodity procurement is handed off from a US-supported mechanism to a government, we'll be looking to ensure continuity in real-time visibility into stock levels, pipeline orders, and delivery schedules. Implementation timelines should reflect the risk involved with these shifts, even if that means moving more slowly.
We’ll also be looking for details on how the administration will continue to spend through nongovernmental channels under the MOUs while pursuing new partnerships. Several countries' plans include faith-based organizations or NGOs in service delivery or temporarily extend existing implementing partner contracts during the transition. The State Department has issued umbrella solicitations for private, academic, and faith-based organizations to complement the agreements. We hope the implementation plans will explain how these channels connect to the G2G agreements and when they will be used.
Transparency is a step toward accountability
Much of this will sound familiar—we've opined on these issues before, as have others. There’s still a long road ahead for the bilateral health agreements, but as the administration moves from a high-level commitment to “country ownership,” the operational choices outlined in these plans will determine how that vision becomes reality. Greater transparency is the first step. Whether lawmakers and other stakeholders get answers to key accountability questions, including those above, will be critical.
The State Department’s approach is bold—and we’ve said before that we largely agree with the broad direction of travel. But a massive and rapid reenvisioning of global health assistance means lives are on the line. Piloting new models before scaling, publishing results, and adjusting as country contexts evolve will be vital to safeguarding progress and ensuring vulnerable populations don’t lose access to life-saving treatment and services. Countries that perform well should move toward more direct funding, but populations shouldn’t be put at risk where arrangements aren't working. Assuming, as reported, the implementation plans are released this week, they’ll offer the next meaningful signal of how the State Department intends to manage that balance. Whether they answer the many remaining questions will be telling.
