The Trump administration has negotiated dozens of bilateral health deals with African governments, which will receive billions of dollars that they can spend as they see fit. | Allison Robbert/AFP via Getty ImagesA surprising quirk of the Trump administration is that every so often, it tries so hard to be anti-woke that it accidentally does something woke. See, for example, the efforts of Secretary of State Marco Rubio, who oversaw USAID’s demise — directives that have contributed to the deaths of hundreds of thousands of people — and who stood at the White House beside the president of Kenya a few months ago, railing against what he called the “NGO industrial complex.”Now, I don’t know who taught Rubio that progressive catchphrase, but I doubt that he got it from INCITE!, the radical feminist collective that popularized a variation of the term in an anthology that examined the role of nonprofits in undermining social progress. In the two decades that followed, the idea of a nonprofit or — as they’re often known in international contexts — NGO “industrial complex” grew into a snarky self-critique for much of that sector’s left-leaning young workforce. By the time Teen Vogue used the term in 2022, the phrase also hinted at an enduring related criticism of USAID’s tendency to primarily fund Western nonprofits rather than local governments and organizations in recipient countries. Key takeawaysUSAID’s critics have long called for the agency to fund more local governments and groups, instead of relying on the “NGO industrial complex” to do its bidding.The Trump administration has embraced this critique, negotiating dozens of global health deals that put aid in the hands of local governments, not foreign NGOs.Ideally, this means more funding for local health systems, and foreign aid that’s more cost-effective and better attuned to local needs.But this is global health MAGA-style after all, and skeptics fear the terms of the deals may be exploitative — and are already leading to deadly lapses in services.In an unexpected twist, this term has found its way into the vocabulary of a very Republican secretary of state, now reflecting a preference for funding foreign governments over non-governmental organizations (NGOs). “If we’re trying to help countries, help the country,” Rubio said in his remarks in December announcing a new $1.6 billion bilateral aid deal between the US State Department and Kenya. “Don’t help the NGO to go in and find a new line of business.”Whatever one thinks of Rubio, he has a point. As part of the “America First Global Health Strategy” announced last year, the Trump administration has embraced an approach to foreign aid that more left-leaning reformists have been talking about for years, a concept known as localization, or the idea that giving aid directly to local governments and organizations — not Western nonprofits — is the best and most cost-effective way to strengthen global aid overall and global health systems especially. In recent months, the US has negotiated dozens of deals between the State Department and African governments, which are set to collectively receive billions of dollars that they can spend as they see fit. The logic might seem sound. But it hasn’t happened sooner because it’s also risky. It’s harder to audit a foreign government than a well-established, well-connected NGO. And millions of lives are on the line. The transition from the one approach to the other is also fraught: Dismantling USAID has disrupted access to vital medications and health services around the world, leading to mass suffering and loss of life. It is unclear if this new strategy will be able to fill those lapses in care, especially for the women and children most vulnerable to aid cuts.But if there were ever a moment to blow up the entire old aid order, it’s arguably now, when there is very little left to lose. And it turns out some surprising figures in global health are cautiously optimistic about it. “They’re basically making a bet that they can do it and get away with it, and if things go wrong, they’ll get a bit of a pass,” Rachel Bonnifield, director of the global health policy program at the Center for Global Development, said of the administration. “And that’s probably true, and it very well might be a good thing” for global health in the long run.It comes at a critical juncture for global health and American foreign aid more broadly. “We all have to work hard to ensure that these disruptive moments are moments of real progress,” said Jirair Ratevosian, a senior adviser for health equity policy under the Biden administration and now a senior scholar at the Duke Global Health Institute. If all goes well, the strategy could “be a huge success for this administration,” he said, “something that I think, decades from now, public health will credit this administration for.” It’s worth noting, however, that this MAGA-fied global health strategy has also doubled as just another way for this administration to get other countries to do what they want. For example, watchdog groups have raised serious concerns about the terms of the new deals, which require African countries to share sensitive health data and even precious minerals with the United States just to keep their clinics open. Many people won’t get their HIV meds at all this year simply because Trump takes issue with the governments they live under. And the administration’s rushed timeline — which included shutting off existing aid flows overnight, instead of transitioning over time — has led to deadly lapses in services in the countries that can least afford it. What’s clear is that this administration has enacted the most sweeping reform to global health in a generation. But so far, they’ve opted to do so in the worst way possible. The question for those that inherit this new structure is whether something good can come from it: Will this change herald a new norm of more effective giving that advocates have dreamed about for decades — or will global aid fully transform into another cudgel that this White House and the next ones brandish to pressure poorer nations into doing their bidding? The USAID system was imperfect — even if its work was crucialMargaret Odera is a community health worker in Kenya. In 2006, she was diagnosed with HIV and nearly died of the virus before a local health worker, funded by USAID, convinced her to seek free anti-retroviral therapies through PEPFAR. “My life was saved through USAID,” Odera, who also credits the agency with helping her find her own calling as a health worker, told me. Despite that, she often felt that there was something amiss about how it distributed its resources.“Most of the money, maybe 70 percent of it, was going directly into people’s pockets,” she said with a sigh, instead of “coming to the ground for community members.” She’s referring here to the notion that foreign (often North American or European) nonprofits gobbled up most of USAID’s budget, while local health workers on the ground like herself received minimal support. It is true that almost all of the big USAID contracts went to a small group of large organizations, many of them American NGOs. As of 2024, just over 10 percent of USAID grants and contracts went to local groups in recipient countries, a statistic that Elon Musk later called out to smear the agency as fundamentally wasteful. Despite the Trump administration’s admonitions, there is no evidence of widespread waste, fraud, or abuse at organizations funded by USAID. In fact, their work saved millions of lives each year. Still, the US might have been able to save even more lives if local groups and governments played a more central role in distributing aid. The research group the Share Trust found that channeling funding through local groups is 32 percent more cost-effective than funding higher-salaried Western NGOs.“I don’t think it’s as inefficient as they say it is, but it’s undeniable that there is overhead incurred in the United States,” Bonnifield said. Between the higher prices of foreign salaries and the expense of transporting workers to and from the countries in which they’re working, the costs simply “add up and get expensive.” And that means less money for Odera and other local health workers, who in Kenya, are paid a meager government stipend worth about $35 per month — less than the country’s minimum wage. There are roughly 3 million community health workers globally — who often serve as a critical, and sometimes only, line of medical contact, especially for people in poorer countries. And the vast majority of these workers do not receive any salary at all. Before Trump, USAID-funded NGOs did employ and pay a massive number of local health workers. But this model also led to a kind of parallel health care system, Bonnifield said, where NGOs — with their big budgets and better salaries — would inadvertently “poach from the public sector.” The result was a bifurcated health sector. While USAID was very effective at combatting specific diseases like HIV or malaria, these programs were effectively siloed from countries’ broader primary health care systems, which often went underfunded. Many people knew where to get their HIV meds, but struggled to find a primary care doctor.“People want to go to a health care center, and they want to get all of their support in one stop,” Ratevosian said. “They want to get tested for HIV, they want to pick up their malaria medications, they want to get checked for high blood pressure, just like anyone else wants to in any other country in the world.”The art of the global health dealBut even though USAID was never perfect, its wholesale destruction instantly put millions of people’s lives at risk, thrusting local health workers into a panic around the world.Odera remembers the chaotic day the agency laid off its health staff — including a clinic providing HIV care and anti-retroviral therapies — in Mathare, one of Kenya’s largest slums. “I feared for my life,” said Odera, who still relied on USAID to keep her own HIV in check. “I was asking myself, ‘What will happen five years from now, if I’m not taking drugs? I still have small kids, who I’m educating, and if I die now, what will happen to my children?’”Hundreds of thousands of people around the world did die in the immediate aftermath, from hunger or preventable diseases, unable to access previously USAID-funded resources. In the following months, however, elements of USAID’s work experienced a groggy rebirth, culminating in September with the release of a new “America First” global health plan, parts of which read oddly familiar to progressive reformists who favor localization. Suddenly, it seemed, the Trump administration was ready to make a deal: As part of an untested new strategy, the US would enter into “multiyear bilateral agreements” directly with recipient countries, offering up to billions of dollars of support in exchange for the promise to progressively increase their own domestic health spending to varying degrees. Kenya’s was the first to be negotiated in December, followed by Uganda, Sierra Leone, Ethiopia, and others soon after. As of March, the US had negotiated bilateral deals with 27 countries across Africa and Central America.View LinkAt first glance, “of course we were excited,” said Peter Waiswa, a Ugandan health systems researcher and associate professor at the Makerere University School of Public Health. Not only was US global health aid on the rise but for the first time, local authorities would take center stage. “From a systems perspective, there’s no alternative to government in terms of doing a public good,” Waiswa said. “And so that was exciting that maybe at last, the [Ugandan] government will have a little bit more to be able to deliver.”But this is the Trump White House’s global health strategy after all, and the State Department has made no secret of advancing its own interests in shaping bilateral deals.For one thing, the White House expects recipient countries to share health data and biological specimens with the US government. This is ostensibly put forth as a means of quickly identifying and quashing disease outbreaks as they arise, which might sound like a benign addendum — it is generally good when countries share health data with one another. But advocates have raised alarms over whether the data-sharing terms will abide by local privacy laws, and, moreover, whether African nations will actually benefit from any health innovations gleaned from the data, such as when African countries struggled to access Ebola treatments developed from their own citizens’ health data.Allan Maleche, executive director of the Kenya Legal & Ethical Issues Network on HIV and AIDS, said that the biggest concern is about who controls that data, and eventually profits off of it: “What are the consent and limitations safeguards when you share data across borders?”In December, dozens of organizations signed a letter addressed to African heads of state raising objections to the data sharing requirement. Kenya’s health deal with the US is currently on hold until a data privacy lawsuit proceeds through that country’s court system. And Zimbabwe ended talks with the US about health aid in February over similar concerns. Another emerging risk is that the agreements could come with increasingly strict geopolitical strings attached. In Zambia, the US State Department has refused to sign over lifesaving aid unless the country agrees to fork over its vast mineral reserves to American businesses. “It is effectively not really a health strategy, but a security and economic strategy,” Mihir Mankad, director of advocacy and global health policy at Doctors Without Borders, told me. Other countries on the president’s bad side, such as South Africa, have been excluded from the negotiations altogether, severely disrupting their responses to public health crises.“They pick winners and losers every single day,” Ratevosian said. “They punish people who don’t subscribe to their beliefs, and that is carried over to foreign assistance — and that’s a recipe for danger.”The risky, radical future of foreign aidOdera, the community health worker, is choosing to not care about those concerns right now, because for the first time in a long time, she feels optimistic. She’s frustrated that Kenya’s agreement with the US has gotten caught up in the courts. “Anything that improves the health security of our country is good for me,” Odera said, who is convinced that soon enough, with money going into the Kenyan government’s hands, the benefits will trickle down to local health workers like herself. All she’s asking for is a minimum wage, which in Kenya, is about $120 per month.It will take months, maybe years, to see if that materializes. And as hopeful as Odera is, even she worries there’s a risk that, without proper oversight, the money could easily be lost to mismanagement. For what it’s worth, studies on the effects of bilateral aid on corruption have had mixed results, with some researchers finding little association between the two, and others finding a significant risk, especially when aid doesn’t come with anti-corruption requirements. Under the previous USAID model, despite the Trump administration’s claims, evidence shows that corruption was rare. Well-resourced NGOs tend to have established systems for keeping their accounting in order, for example, even in very fragile contexts like Afghanistan, where audits by USAID found that only about 0.4 percent of funds ever strayed from their intended purposes. The Trump administration fired the USAID watchdog charged with monitoring corruption back in February of last year. And every global health expert I spoke with for this story agreed that in the long run, moving more money into local hands is a good thing. US presidents have been trying and mostly failing to do so for years. But nobody has ever dared to do it so quickly — and for good reason. Yes, the NGO industrial complex was flawed. But it also played a crucial role in making HIV a much less deadly disease around the world and helped make it the safest time in history to be a child. It often found ways to protect those who face discrimination or live on the margins, including women and LGBTQ people, even when their governments chose not to. And we very well may miss it when it’s gone. “If there is an advantage to the abruptness [of the Trump administration’s changes], it’s that people have to take it seriously immediately,” said Mankad of Doctors Without Borders. “But if there’s a disadvantage, it’s that the bottom could fall out right away.”In a perfect world, there would be no need for NGOs. There would be no need for foreign aid. Odera and other local health workers like her would earn the salaries they deserve without having to rely on often capricious aid flowing from the powers that be in Washington, DC. But we don’t live in that world. And so far, it’s entirely unclear whether the Trump administration’s blustery, bullying approach will even come close to ushering in the vision of a world without a need for foreign aid, one in which people like Odera can thrive. But for many people in the poorest nations, the road ahead could be deadly — or at least very rough. For many of these countries, the co-investment that Trump’s deals require may be far too expensive to sustain, and the logistics too complicated to organize overnight.Even so, this structural shift is probably permanent. Future US administrations may eventually bring more NGOs back into the fold to backstop local governments and help ensure the continuation of care for those who need it — but the era of largely bypassing recipient governments is rightfully, incontrovertibly coming to an end. “It aligns with where the momentum is elsewhere in global health, and what the demands of African countries have been for some time,” Bonnifield said. “It will be hard to come back from this.”