I must confess that I have been a fan of the USA President Donald Trump. I viewed him as a leader who could make the world a better place and regarded him as one of the most powerful global leaders of our time. Today, however, that belief is clouded by serious doubts. The direction taken by President Trump on key issues—including US global health aid, immigration policies, the imposition of trade tariffs on countries that disagree with his policies, growing digital tensions with Europe, and the recent war of words with South Africa over claims of “white genocide,” despite clear evidence that no such genocide exists—suggests that the hope once placed in him now deserves critical reassessment.
At the centre of these concerns is the dismantling of the United States Agency for International Development (Usaid). For decades, Usaid played a critical role in supporting health systems, strengthening civil society organisations (CSOs), and improving development outcomes across Africa, including Malawi. Usaid funding helped save millions of lives, much of this success coming from close collaboration with CSOs. Although Usaid had its challenges, it represented a partnership-based approach to development. Its sudden restructuring and absorption into an “America First” global health framework has disrupted services and dismantled systems that took years to build.
What is emerging now is no longer aid in the traditional sense. It is a transactional model based on explicit give-and-take arrangements. Under the new US global health strategy, health financing is tied to broader US strategic interests that are often unrelated to health outcomes. These include access to minerals, competition with China, military cooperation, religious protection clauses, and access to data. The message is clear: there is no free lunch.
The shift is evident in new bilateral health agreements with countries such as Kenya, Uganda, and Liberia, as well as in ongoing negotiations with Zambia and Nigeria. In most cases, US funding has been reduced compared to previous years, while partner governments are expected to contribute more from their own budgets. In Zambia, health aid discussions have reportedly been closely linked to mining sector reforms, while in Nigeria, health support has been tied to commitments related to the protection of Christians from violence.
This approach effectively turns health aid into a bargaining tool. Health systems risk becoming instruments in wider geopolitical and ideological struggles. For countries that rely heavily on external health financing, this development should be deeply worrying.
Another major concern is the shift toward strict government-to-government funding that sidelines CSOs. The Kenya–US health agreement, which channels funding directly through government systems, is a clear example. US officials have defended this approach by criticising what they describe as the “NGO industrial complex,” arguing that NGOs waste resources on administration. While concerns about efficiency and accountability are legitimate, this narrative ignores the vital role CSOs play.
In countries like Malawi, where government systems are often overstretched and susceptible to political interference, CSOs are indispensable. Excluding them from implementation and oversight creates serious accountability gaps and increases the risk of resource abuse.
The notion that accountability can exist without empowered and independent CSOs is unrealistic. Effective monitoring and evaluation require strong, independent voices. With Usaid dismantled and CSOs weakened, the implications for transparency and accountability are troubling.
A health aid system that marginalises CSOs and treats aid primarily as a tool for political bargaining is poorly designed and unlikely to succeed. Ultimately, it risks harming the very people it is meant to help.
