What do countries receiving US foreign aid owe Washington? Since returning to power in 2025, the Trump administration has drastically changed the answer to this question, pursuing an ‘America First’ philosophy that is dramatically more transactional: the US will give you money, but you must give the US something valuable in return.
In the mineral-rich Southern African country of Zambia, for example, the US tried to negotiate an agreement under which the US would provide more than $1 billion in funding to fight diseases such as HIV and malaria. But Zambia would not only have had to contribute over $2 billion of its own money, but it would also have to hand over something potentially far more valuable: its citizens’ health data.
Zambia ended up signing a revised version of the agreement, but it is just one of dozens of similar arrangements struck under Trump’s America First Global Health Strategy, which has not only significantly reduced US foreign health funding but also increasingly conditioned it on countries’ willingness to give up health data. So far, 36 countries have signed deals under the new America First framework, although not all of them involve data sharing.
“The crux of the agreements hinges on the understanding from the US perspective that aid can no longer be just 'aid' as it was — there have to be tangible benefits that the US itself gets,” said Dr. Tatenda Chatikobo, who researches global health at Warwick University.
How have things changed?
For decades, Washington was the largest single foreign aid donor in the world, administering as much as $60 billion annually through the US Agency for International Development (USAID). These funds usually came with no specific quid pro quo or strings attached. The guiding idea was that the soft power of aid was itself a worthy objective.
But USAID was dismantled last spring by the Trump Administration as part of sweeping cuts led by the Department of Government Efficiency (DOGE). At the time, Marco Rubio argued that USAID didn’t align with the US’s foreign policy objectives under US President Donald Trump and that its aid strategy needed to more clearly benefit Americans.
Now, the US is not only dramatically reducing its aid allocations and encouraging recipient governments to put up more cash of their own, but also directly brokering more explicitly transactional deals in closed-door negotiations with individual countries.
“It represents a fundamental restructuring of the US global health relationship,” said Adam Wexler, who has researched the agreements at health policy organization KFF.
Why does the US want all this data? The US says it’s necessary in order to monitor how aid money is spent and ensure that programs meet their stated objectives. For example, its deal with Uganda says the data should be used to deliver and audit healthcare services.
But under that agreement, the US will also get access to nine of Uganda’s health data systems for seven years, including the system that manages individuals’ medical records.
Large datasets like these are incredibly valuable – the industry of buying and selling healthcare data is now worth billions as companies try to get their hands on data that can be used for medical research, pandemic preparedness, or training AI models.
“Looking at it as a simple 'data for aid' transaction is too simplistic,” said Chatikobo. “You have to look at the immense future value of that data.”
And that value isn’t being structured or shared fairly, say critics. The agreements do not give aid recipients a stake in revenues generated from using their data. Even the aid itself will in some cases run out before the data sharing obligations do: Rwanda is expected to provide data for 25 years but receive aid only for five.
Critics say these new arrangements are inherently coercive. In Uganda, for example, US aid was estimated to save around 170,000 lives per year. Could the government really say no to Washington’s new conditions?
“What the US shifted to under Trump is basically giving us your data or die. And that is an inherently coercive offer,” said Arthur Caplan, the former head of medical ethics for NYU’s population health department.
Moreover, there are concerns about data privacy and consent. Although citizens may have consented to share their data with their own governments, they have not agreed to do so for the US. That has caused an outcry in countries such as Kenya, whose high court suspended the implementation of an agreement with the US over data sharing concerns.
One fear is that although the data is largely anonymized, increasingly powerful AI tools can easily reverse that, leaving the people whose data is shared vulnerable to identification later on – something that experts have warned could violate countries’ health privacy laws. This is a special concern in countries where diseases like HIV are still stigmatized, Caplan said, and identification as an HIV patient could be life-changing.
Before the America First Global Health Strategy, the US provided health aid to over 70 countries. Under the new approach, just thirty-six deals have been signed so far, though Washington intends to conclude more in the coming months.
The US says these new arrangements provide a clearer benefit in exchange for US largesse, and that weaning recipient countries off of Washington’s support is good for everyone. Some African health officials have suggested similar views.
But who will really benefit most in the long run will remain an open and deeply controversial question.
“What we are seeing here is trying to solve a problem that in some ways is a genuine
problem,” says Chatikobo. “But is not really benefiting the people that are giving away that data.”
