-
CENTRES
Progammes & Centres
Location
The AFGHS illustrates a new era in which US global health engagement is increasingly shaped by commercial incentives, geopolitical calculations, and controlled access to American innovation
The beginning of 2025 and Donald Trump’s second term as US President brought abrupt changes to the global health landscape, most notably the dismantling of the United States Agency for International Development (USAID) and steps to withdraw from the World Health Organization (WHO). In September this year, the administration released the America First Global Health Strategy (AFGHS), a document providing insight into the US’s approach to global health. Recent initiatives signal a recalibration of US engagement toward an interest-driven, commercially-aligned approach that leverages technological innovation, public-private partnerships, and diplomacy to advance US economic priorities.
A core pillar of the AFGHS is the emphasis on a commercial diplomacy agenda, which aligns health security with the advancement of US economic interests. Along with the suspension of foreign aid to multilateral health initiatives and the withdrawal from the WHO, it marks a shift toward a more transactional era in global health—one in which public–private partnerships underpin economic development, and American innovation is increasingly deployed to achieve foreign policy objectives. Co-financing commitments with partner governments and milestone-based payments underpin these public-private sector partnerships.
Along with the suspension of foreign aid to multilateral health initiatives and the withdrawal from the WHO, it marks a shift toward a more transactional era in global health—one in which public–private partnerships underpin economic development, and American innovation is increasingly deployed to achieve foreign policy objectives.
In line with this approach, the US intends to use autonomous logistics, robotics, and AI to advance health goals. One of the US’s first major global health funding initiatives since Trump took office in January 2025 was the announcement of a US$150 million grant over three years to Zipline International Inc., an American autonomous delivery system company, to finance healthcare operations in five African countries (Rwanda, Ghana, Nigeria, Kenya, and Cote d’Ivoire). Zipline currently operates in these five countries and was instrumental in maintaining Ghana’s supply chain in the aftermath of USAID disruptions. The multimillion-dollar US State Department commitment aims to set up new Zipline hubs or permanent drone delivery infrastructure to deliver medical commodities. The collaboration is expected to increase the number of hospitals and healthcare facilities that Zipline serves by threefold and will provide greater access to blood, vaccines, medications, and other medical supplies.
The WHO and the World Economic Forum have highlighted the benefits of drones in healthcare. The delivery of medical supplies by drones creates an alternative health-system supply chain that can be extremely useful during emergencies, support patients in remote regions lacking in transport infrastructure, dramatically shorten delivery times, reduce costs, and potentially lower the environmental impact of healthcare deliveries—especially when powered by electric motors. In this case, the new Zipline partnership in Africa is poised to act as a viable alternative to Chinese-backed debt-financed infrastructure exports.
There are, however, concerns about the true impact of drone delivery and its potential to exacerbate existing fragilities in African healthcare systems. Over-reliance on drones could undermine local workforce participation, exacerbate brain drain, reduce the quality of care in underserved regions, and overlook community-defined needs that require the presence of healthcare workers. Thus, while drones hold the potential to transform healthcare systems and last-mile delivery, it is necessary to ensure that they serve the best interests of partner countries and create resilient health systems, rather than merely advancing the economic priorities of partners.
The delivery of medical supplies by drones creates an alternative health-system supply chain that can be extremely useful during emergencies, support patients in remote regions lacking in transport infrastructure, dramatically shorten delivery times, reduce costs, and potentially lower the environmental impact of healthcare deliveries—especially when powered by electric motors.
The revamped health security agenda also reflects an effort to recalibrate US engagement in line with strategic interests. Notably, the US leveraged pharmaceutical tariffs under national security measures to pressure countries and to incentivise domestic manufacturing, and has more recently begun leveraging existing global health platforms to advance US innovations. Considering the latter, the US President's Emergency Plan for AIDS Relief (PEPFAR) is increasingly being positioned as an instrument to promote US-developed health technologies. This is evident in the administration’s evolving response to tackling HIV/AIDS, where the Global Fund to Fight AIDS, Tuberculosis, and Malaria has been framed as a ‘critical partner’ and a channel for deploying American health commodities. A new partnership between PEPFAR (run by the US Department of State), the Global Fund, and Gilead Sciences – announced in September 2025 – aims to deliver at least two million doses of Gilead’s new HIV drug, lencapavir, at cost to ten high-burden countries, with the first doses already reaching Eswatini and Zambia.
Further, Gilead granted royalty-free voluntary licenses to six generic drug manufacturers to enable the production and sale of affordable generic versions of the drug to 120 Low- and Middle-Income Countries (LMICS), including African countries. Collectively, these manoeuvres are intended to stimulate early demand for an American innovation but also to reinforce African manufacturing ecosystems that could integrate into US-led supply chains.
Interestingly, US realignment has not amounted to a complete retreat from multilateral global health platforms; instead, it is indicative of an interest-driven engagement strategy. This is underscored by Washington’s US$4.6 billion pledge to the Global Fund in early November – a figure lower than the $6 billion pledge made by President Joe Biden in 2022 but nonetheless significant. Reaffirmation of the 1:2 matching requirement attached to the pledge positions the US to shape health finance-sharing dynamics at a time when other donors, such as the European Commission and Japan, have yet to announce their commitments. This also comes at a time when several other European countries, including the UK, are scaling back their commitments, thereby cementing the US influence on the Global Fund’s architecture.
Interestingly, US realignment has not amounted to a complete retreat from multilateral global health platforms; instead, it is indicative of an interest-driven engagement strategy.
South Africa
Strained political ties between the US and South Africa have increasingly spilled over into the health domain, highlighting how foreign policy issues shape health decision-making. The suspension of PEPFAR funding as soon as Trump assumed office in January 2025 occurred against a backdrop of tensions linked to allegations of discriminatory treatment of Afrikaners by the South African government and imposition of tariffs on South African exports. Although the country – with the world’s largest HIV burden – welcomed the US decision in October to allocate US$115 million for six months under a PEPFAR Bridge Plan, it remains excluded from receiving lencapavir doses under PEPFAR-The Global Fund-Gilead initiative. Jeremy Lewin, US Under Secretary for Foreign Assistance, Humanitarian Affairs, and Religious Freedom, stated that the US-funded doses of the American-made drug will not be supplied to South Africa and called on the country to fund its own doses. This signals a shift in which access to American health innovations is increasingly mediated by political considerations. With the US boycotting the Johannesburg-hosted G20 in November and uncertainty surrounding South Africa’s invitation to the 2026 summit in Washington, concerns have grown over whether South Africa may face further exclusion from future US HIV grants.
Latin America
This selective exclusion extends beyond South Africa and reveals a broader incoherence in the AFGHS. While South Africa will not receive lencapavir doses from the PEPFAR-The Global Fund-Gilead initiative, it will benefit from the voluntary licensing agreement Gilead has agreed to, while most of Latin America lacks access to this mechanism. Gilead agreed to grant licenses to six manufacturers, including 3 Indian companies, to enable the production and sale of affordable generic versions of the drug in 120 LMICS, including South Africa. However, the denial of a Phase III clinical trial waiver by India’s Central Drug Standard Control Organisation (CDSCO) to Hetero Lab Ltd (an Indian generic drug manufacturer) will contribute to a delay in the availability of the generic version. This means that while South Africa will eventually access the lower-cost generic version of lencapavir, Latin American countries remain excluded from the initial US allocation and possibly from a clear supply of generics.
This exclusion of Latin American countries is striking, given that four of them — Argentina, Brazil, Mexico, and Peru — took part in lencapavir’s clinical trials. Structural barriers now impede these countries from accessing the drug affordably, despite having contributed to its development.
This exclusion of Latin American countries is striking, given that four of them — Argentina, Brazil, Mexico, and Peru — took part in lencapavir’s clinical trials. Structural barriers now impede these countries from accessing the drug affordably, despite having contributed to its development. Further, licensing restrictions prevent generic drug manufacturers from exporting the drug outside of the 120 authorised countries, exacerbating the situation. Reportedly, Gilead is exploring alternative pricing methods such as tiered pricing for Latin America, but it could be argued that the exclusion of the region is indicative of a return to the longstanding US pattern of neglecting regional partners’ health needs.
The incoherence of AFGHS is highlighted by the geopolitical framing of the approach. It positions global health as a tool to counter China’s influence. Yet Latin America – a region where China has considerably expanded its health diplomacy efforts – remains largely excluded from the US’s approach to addressing HIV. By excluding Latin America from voluntary licensing, the strategy exposes a core contradiction: it claims to counter China, yet its uneven implementation leaves key regions where China’s influence is expanding unaddressed.
The AFGHS, along with the suspension of funding for critical global health activities, thus reflect a shift in the US approach to global health from developmental assistance objectives to a strategy where political, economic, and technological considerations are intertwined. Drone delivery initiatives highlight the potential for US and African partners to utilise cutting-edge technologies to improve healthcare; yet they also underscore the risks of bypassing opportunities to create resilient health systems. Selective distribution of lencapavir illustrates how access to US-based innovations is increasingly mediated by political alignment, benefiting some countries while excluding others. Ultimately, the approach demonstrates how innovation, commercial diplomacy, and strategic multilateralism are being harnessed to serve national interests, even as the promise of equitable, globally coordinated health security remains contested.
Lakshmy Ramakrishnan is an Associate Fellow with the Centre for New Economic Diplomacy at the Observer Research Foundation.
The views expressed above belong to the author(s). ORF research and analyses now available on Telegram! Click here to access our curated content — blogs, longforms and interviews.
Lakshmy is an Associate Fellow with ORF’s Centre for New Economic Diplomacy. Her work focuses on the intersection of biotechnology, health, and international relations, with a ...
Read More +
PREV
