‘Risks and opportunities’ in US global health strategy

[KAMPALA, SciDev.Net] A new US global health strategy could undermine decades of progress in low- and middle-income countries (LMICs) unless national governments can commit to sustained investment in health, policy experts warn.

On 18 September, the US government unveiled its America First Global Health Strategy, which repositions global health as a mechanism to advance American safety, prosperity and influence.

According to the US State Department, global health programmes have become “inefficient and wasteful and created a culture of dependency among recipient countries”.

The new approach will focus on containing infectious disease outbreaks before they reach American soil, strengthening bilateral relationships, and promoting American health innovation worldwide.

“Self-reliance shouldn’t mean abandonment, it should mean genuine partnership where LMICs are setting priorities, not just hosting trials.”

Jirair Ratevosian, infectious disease fellow, Duke Global Health Institute

Health experts say this change puts LMICs in a delicate position.

“There’s an opportunity and a risk,” said Jirair Ratevosian, an infectious disease fellow at Duke Global Health Institute, in the US, and former advisor on health equity policy at the US Department of State.

“The strategy could turbocharge the areas where US science is strong, like long-acting prevention, cure research, and AI-driven surveillance. But if it becomes too America-centric, we risk sidelining LMIC researchers and missing the realities of their epidemics.”

HIV research

He pointed to HIV research as one of the clearest examples of what is at stake.

US funding through the President’s Emergency Plan for AIDS Relief (PEPFAR) has saved more than 26 million lives since 2003, largely through collaborations in LMICs, particularly in Sub-Saharan Africa.

“From a scientific standpoint, HIV research has always relied on aligning discovery with the epidemiology of the epidemic,” Ratevosian told SciDev.Net.

“It’s not sufficient to identify new molecules in US laboratories — we must evaluate them in populations where HIV incidence is high.”

He highlighted the case of lenacapavir, a long-acting injectable prevention drug, whose trials in Uganda and South Africa generated the evidence that underpinned global approval.

Such collaborations have not only delivered breakthroughs, but also strengthened local research capacity, laboratory systems, and pathogen surveillance — now central to pandemic preparedness.

If US funding tilts inward, it could mean slower product development and reduced readiness to detect and respond to future infectious threats, warns Ratevosian.

Beatriz Grinsztejn, president of the International Aids Society, says the strategy raises major questions around US funding contributions, the future of HIV prevention services, and whether donor countries can feasibly increase their health budgets enough to ensure continuity of care.

“At the same time, the proposed ‘sunset’ of UNAIDS by the end of 2026 underscores the need to safeguard HIV as a global priority,” she said, referring to plans to close the UN agency focused on HIV/AIDS as part of a restructuring.

“Without clarity on funding from PEPFAR, the Global Fund replenishment and beyond – millions of people living with and affected by HIV face uncertainty about their access to life-saving treatment and prevention,’’ she added.

‘Dependency culture’

The US strategy frames existing aid structures as having created a culture of dependency. It requires LMICs to co-invest and meet performance benchmarks before funds are released. This could encourage accountability and local ownership, but risks becoming punitive if countries are unable to increase spending.

“There’s a risk of weakening LMIC capacity if the US pulls back,” Ratevosian added. “But there’s also an opportunity for these institutions to step up, diversify funding, and take more ownership of research agendas.

“For me, self-reliance shouldn’t mean abandonment, it should mean genuine partnership where LMICs are setting priorities, not just hosting trials.”

According to Herbert Luswata, president of the Uganda Medical Association, the strategy could be positive if well implemented, especially on research and disease surveillance.

“For years, the US government has been supporting us financially but after the closure of USAID and 90-day funding freezes a lot of research was crippled,” he told SciDev.Net.

“We hope with this new strategy, disease surveillance and prevention will help poor countries.’’

We thank President @realDonaldTrump for continuing the legacy of America’s health foreign assistance. https://t.co/m45pec5oVv

— Dr. Jane Ruth Aceng Ocero (@JaneRuth_Aceng) September 19, 2025

However, Luswata cautioned that many lives and vital research is at stake if developing countries fail to sustain domestic health financing.

“We hope the new strategy will not delay all the progress we are making as developing countries but it takes us back to own our health systems, because we cannot keep riding on someone’s tunes,” he added.

He stressed that ending diseases and public health threats such as HIV requires doubling down on data, reaching the populations driving transmission, financing prevention at scale, and ensuring access to the most effective tools.

Project lifeline

The dismantling of USAID earlier this year left dozens of health programmes without funding.

In response, the Project Resource Optimization (PRO) Initiative hosted by the Center for Global Development mobilised US$110 million from private donors to keep more than 80 high-impact projects alive, ranging from malnutrition treatment to safe water access.

“The PRO Initiative shows what’s possible when donors move quickly and collaboratively,” said Grace Morgan of PRO.

“By channelling resources to proven programmes, we not only preserve progress already made but also save lives that might otherwise be lost.”

However, such stopgaps cannot replace the scale and stability of US assistance. The longer-term question is whether LMICs can build resilient systems that are less vulnerable to shifts in Washington’s politics, say policy specialists.

“PEPFAR has always been most effective when it has followed the science and the evidence,” added Ratevosian. “If the US shifts away from science-driven priorities toward purely domestic or ideological ones, we risk stalling progress and allowing new infections to rise.”

This piece was produced by SciDev.Net’s Global desk.