Rebalancing Risk and Responsibility Under the America First Global Health Strategy
Nelson Aghogho Evaborhene examines the redistribution of responsibility, risk, and sovereignty in African health systems under U.S. bilateral health strategies.
As Washington recasts its global health agenda, the America First Global Health Strategy (AFGHS) positions itself as a corrective to decades of aid dependence. Open-ended, multilateral assistance is replaced with time-bound bilateral health compacts promising national ownership, domestic financing, and self-reliance—outcomes long advocated by global health practitioners. Africa has become the primary testing ground for this model at precisely the moment when continental institutions are attempting to consolidate collective health governance, coordinate surveillance, and assert claims to health sovereignty.
At first glance, the logic is appealing. Proponents argue it streamlines administration, reduces leakage through intermediaries, and strengthens accountability by embedding assistance within national systems. Its “promises and gaps” have generated mixed reactions among global health experts, raising questions about whether it “will prove as influential and consequential as its predecessor.” For African stakeholders, however, the problems invoked to justify the shift—fragmentation, parallel programs, and weak domestic oversight—are largely legacies of earlier donor architectures rather than endogenous failures. As Okereke observes, “To now criticize African countries for not owning what they were systematically excluded from creating is unfair and a distortion of history.”
The core question is therefore not whether the AFGHS is inherently good or bad, but whether African governments can leverage the transition to reclaim agency, improve coordination, and strengthen governance—or whether the strategy simply repackages dependency as ownership. Early bilateral agreements suggest the latter. Health assistance is no longer insulated from geopolitics. Rather than merely transferring responsibility, the AFGHS redistributes financial, political, legal, and epidemiological risk onto national health systems while upstream control over priorities, standards, and exit conditions remains largely external.
Countries with strong legal institutions and active civic space have contested, delayed, or partially renegotiated aspects of the compacts. Others absorb obligations with minimal scrutiny. Crucially, even high-capacity and high-investment states are not insulated. The outcome is a fragmented landscape in which risks once pooled through multilateral arrangements are internalized by individual states, while continental coordination mechanisms remain marginalized.
From Aid Retrenchment to Risk Transfer
The shift from pooled, multilateral risk sharing toward time-bound bilateral compacts designed around accelerated donor exit did not originate in Africa, nor was it driven by African preferences. For more than two decades, U.S. global health leadership operated through a hybrid architecture combining large-scale bilateral funding with multilateral coordination and intermediary-based delivery. That system delivered measurable gains. Its limits were known but managed incrementally rather than treated as grounds for wholesale abandonment.
The transition to the AFGHS was therefore not a response to technical failure. It emerged after COVID-19, as global health moved from expansion to contraction. Vertical programs proved lifesaving but insufficient for managing systemic shocks, while multilateral coordination faltered amid vaccine nationalism and supply chain competition. These breakdowns did not uniquely indict multilateralism—they reflected political choices by donor states. The pandemic repoliticized existing weaknesses.
Simultaneously, donor governments confronted inflation, rising debt, polarized domestic politics, and electorates increasingly resistant to open-ended foreign commitments. Health, once framed as a global public good, was recast as a matter of national security, border control, and strategic competition, particularly with China. Washington’s recalibration, framed as “flexible realism,” seeks to retain influence while limiting long-term exposure.
The AFGHS does not abandon global health; it reorganizes it. What is presented as sustainability is, in practice, a reallocation of obligation from donor to recipient. This distinction is crucial. Sustainability is not simply about spending levels; it is about who bears uncertainty when conditions change. Under earlier multilateral arrangements, volatility and failure were partially cushioned through pooled institutions. When programs faltered, responsibility diffused. Donors pointed to institutional constraints, governments pointed to donor volatility, and multilateral bodies cited structural limits. Space existed for negotiation and adaptation; risk was shared, targets could be adjusted, timelines extended, mandates revised.
Empirical Exposure: Financial, Political, and Epidemiological Risk
Under the AFGHS, health cooperation is explicitly subordinated to geopolitical calculation. As the U.S. State Department notes, “the President and Secretary of State retain the right to pause or terminate any program that does not align with its national interest” (10). Political divergence or non-compliance occurs abruptly, unevenly, and often without institutional recourse. A precedent for this dynamic is the suspension of critical HIV funding to South Africa under the Trump administration. Diplomatic positions, land expropriation laws, and ties with Iran demonstrated that political alignment can override epidemiological logic. Disease burden, programmatic performance, and technical capacity offer no protection. Even high-capacity health systems can face abrupt withdrawal without buffers, timelines, or safeguards.
For many low- and middle-income countries, the central risk under the AFGHS is no longer inefficiency or reform failure—it is abandonment. This becomes salient in empirical cases. Nigeria’s compact, for example, pairs roughly $2.1 billion in U.S. funding with nearly $3 billion in domestic financing, the largest national contribution under the America First model. Obligations rise annually as donor funding tapers. Yet the agreement embeds explicit political conditionalities , including prioritization of Christian faith-based providers and continuation contingent on U.S. religious security assessments. Even when targets are met, funding stability remains subject to congressional and political calculations beyond Nigerian control.
These provisions reflect heightened U.S. scrutiny of religious violence in Nigeria and domestic political dynamics where religious freedom has become salient among segments of Republican leadership, congressional debate, and advisory bodies. Nigerian authorities emphasize that insecurity affects multiple faith communities and is driven by banditry, insurgency, and organized crime. Nevertheless, externally defined religious framings are embedded directly into health cooperation, narrowing Nigeria’s capacity to contest how insecurity is interpreted or operationalized. This dynamic was reinforced in December 2025 when U.S. airstrikes against Islamic State militants in northwest Nigeria were publicly framed as protecting persecuted Christian communities, aligning with domestic political narratives and the conditional language embedded in the compact.
Epidemiological and operational risk compounds fiscal and political exposure. Countries such as Rwanda, hosting advanced surveillance platforms and logistics infrastructure, assume frontline responsibility for outbreak detection and reporting. Failures, delays, or contested data carry domestic political consequences, yet influence over technology design, data governance, and downstream benefits remains limited. Surveillance obligations persist long after financing cycles end, converting short-term assistance into long-term exposure.
Political and legal risk further intensifies vulnerability. Executive health agreements increasingly collide with constitutional review, parliamentary oversight, and public contestation over data sovereignty and consent. Judicial and legislative interventions, as seen in Kenya and Liberia, impose accountability and transparency but do so through disruption, delaying service delivery while leaving underlying asymmetries intact.
Oversight, evaluation, and accountability themselves emerge as structural weaknesses. Unlike earlier U.S. health engagement models anchored in field-based USAID missions, the AFGHS operates through a lean institutional architecture. Only a fraction of USAID’s former Global Health Bureau capacity has been transferred to manage these compacts, leaving small in-house teams responsible for procurement, contracting, and program design. This raises unresolved questions about milestone enforcement, quality assurance, and service continuity if implementation falters. Previously embedded monitoring systems enabled adaptive learning and risk mitigation; under the current model, these functions are limited, fragmented, or still under development. In their absence, African governments absorb disproportionate operational, financial, and reputational exposure.
Aligning Risk, Responsibility, and Sovereignty
The central problem exposed by the AFGHS is not the expectation of greater domestic responsibility - it is both inevitable and overdue. The harder question is whether responsibility is being transferred faster than the governance capacity required to manage accompanying risks. Health systems do not operate in stable environments. Funding delays, procurement failures, epidemiological shocks, political transitions, and macroeconomic downturns are predictable features of public health governance. If domestic ownership is to be meaningful, risk must be explicit, negotiable, and governable.
Aligning responsibility with sovereignty requires three corrections. First, co-financing must be redefined as leverage rather than substitution. Every increase in domestic spending should be contractually linked to verifiable gains in control: technology transfer, regulatory authority, manufacturing readiness, or procurement autonomy. Without this, fiscal effort deepens dependency rather than reducing it.
Second, surveillance and data obligations must be reciprocally structured. Where African countries assume long-term responsibilities for outbreak detection, reporting, and pathogen sharing, they must secure enforceable rights over access to countermeasures, regional manufacturing capacity, and benefit sharing. Surveillance that extracts data without conferring downstream influence converts sovereignty into compliance.
Third, bilateral compacts must be disciplined by continental frameworks. Engagement through institutions such as Africa CDC and the African Medicines Agency does not undermine national ownership—it anchors it. Without regional buffering, bilateralism fragments leverage, accelerates exclusion, and localizes failure. With it, risk can be pooled, standards harmonized, and renegotiation made collective.
The evidence is clear. Under the AFGHS, African countries are increasingly responsible for outcomes they do not fully govern. Capacity mitigates exposure but does not eliminate it. Alignment insulates some, excludes others, and leaves most vulnerable to abrupt political recalibration. Until risk, authority, and responsibility are aligned within enforceable institutional arrangements, the strategy will continue to produce fiscal cliffs, political volatility, and epidemiological insecurity under the banner of ownership.
Nelson Aghogho Evaborhene is a PhD Fellow in Global Health Governance at the Centre for Interdisciplinary Study of Pandemic Signatures, Roskilde University.
Photo by Jonas Von Werne
