The United States has begun signing bilateral agreements on global health cooperation under the State Department’s new “American First Global Health Strategy.” In the largest of those agreements, the United States will provide $2.1 billion over five years for Nigeria’s efforts to prevent and treat HIV/AIDS, malaria, and tuberculosis; advance maternal and child health; and prevent infectious disease outbreaks. The government of Nigeria, in turn, will commit an additional $3 billion of its own budget to the objectives outlined in the agreement. The United States has supported these public-health goals in Nigeria and many other countries around the world for decades. But the expansion of government-to-government agreements in health cooperation marks a sea change in approach, pivoting away from largely funding local and international NGOs to implement health programs and toward more direct engagement with partner country governments.
While many questions remain about how these agreements will be implemented, government-to-government engagement provides an opportunity for the United States to support partner country governments in delivering services to their citizens. The success of these approaches, however, will ultimately hinge on how they are carried out. As the State Department begins to implement these new agreements, and develops new policies to guide them, it should understand both the value and the vulnerability of such partnerships with foreign governments. Factors to consider include the importance of broad-based local ownership, transparency, proper risk mitigation, and adequate staffing, as well as the need for patience and a clear-eyed view of the strategic — and potentially harmful — interactions between political goals and people’s lives.
Such partnerships can support a range of mutual goals. Partner governments, at both the national and subnational levels, are crucial in delivering public services at scale (including but not limited to healthcare) and managing public goods. Supporting government systems instead of creating parallel processes can build public confidence in a government’s ability to deliver services, which in turn, can bolster a government’s legitimacy and reinforce the accountability of authorities to their citizens for fulfilling these roles. Channeling foreign assistance through governments can also create opportunities to strengthen the capacity and integrity of government financial systems as well as establish or reinforce democratic processes for community engagement and accountability, which can have benefits beyond the scope of the investment. Such arrangements also align with the desires of many partner governments who want to — and should — set the agenda for their development plans and negotiate as peers. Furthermore, ensuring government leadership and ownership over goals and means can be important for the success and sustainability of any U.S.-supported investments.
In addition, beyond its potential to enhance governance and public-service delivery, government-to-government cooperation can support U.S. foreign policy goals by strengthening bilateral ties, increasing U.S. influence, and countering the inroads of other countries. In other words, it can give the United States leverage. Former U.S. National Security Council Senior Director for Africa Judd Devermont recently lamented that “by directing almost all foreign assistance to NGOs and U.S. entities, we stepped back from a dialogue with African governments.” He noted that attempts to impose conditions on aid — to extend funding as a carrot in exchange for reforms or other policy choices — were relatively inconsequential to governments that had not been involved in the design or implementation of the aid package or the conditions. “In other words,” he said, aid “was unlikely to have much of a sustainable impact on our bilateral relationships because almost all our programming existed separately from African governments.”
Underutilized Approach
While the U.S. Agency for International Development (USAID) used to craft high-level agreements with many partner country governments, those agreements primarily outlined USAID’s activities toward shared objectives with funding that would ultimately go to third-party implementing partners.
To be sure, USAID’s implementing partners often coordinated closely and worked in tandem with government entities in support of their goals. For example, Pact, a Washington-based international NGO where one of us (Daphne) works, supported the birth-registration goals of Eswatini’s Civil Registration and Vital Statistics Department, co-designing a nationwide campaign that helped accelerate the government’s plans to reach full birth registration by 2030. In Zambia, Pact developed a curriculum and trained Ministry of Community Development and Social Services staff to deliver high quality HIV services to vulnerable children and adolescents, while also strengthening their backend administrative capacity to efficiently manage public funds.
Nonetheless, partner country governments were rarely the recipients of USAID funding — or in the driver’s seat for implementation. In fact, in 2024, only about 3 percent of USAID’s funding went directly to governments across 14 countries — and three quarters of that money went to just one country, Jordan.
Direct partnerships with governments have been more integral to other agencies that manage U.S. foreign assistance. The Millennium Challenge Corporation, for example, develops five-year “compacts” jointly with partner country governments to define U.S. investments in — and partner country contributions to — government-identified (and MCC approved) priorities for advancing economic growth. MCC’s approach is not fully government-to-government, however; while the receiving government directly manages all aspects of compact implementation, it does so through a separate, dedicated unit rather than existing government systems. Nor does MCC funding go through the government; instead, the government procures services for the compact and the U.S. government pays the implementor. MCC also represents a small proportion of U.S. foreign assistance — just 3 percent of U.S. expenditures on non-military foreign assistance in fiscal year 2024.
Use of government-to-government approaches has been limited by various factors. First, Congress restricts which countries are eligible for such investments, with a number of provisions. USAID, for example, could only fund governments that, among other things, were taking steps to ensure budget transparency, maintain robust financial management systems, protect civil society, pursue anti-corruption efforts, and eliminate human trafficking. Congress also requires MCC to select countries for compacts based on their record of good governance, economic policy, and social investment.
Even for potentially eligible countries, however, USAID significantly underutilized government-to-government approaches. The concerns about the potential for corruption contributed to risk aversion. Furthermore, there weren’t sufficient U.S. staff skilled in developing and maintaining government partnerships. Working with partner country governments requires different skills, with both parties needing to negotiate as peers, balance power, contend with their own domestic constituencies, and navigate conflicting systems. With the recent dismantling of USAID and the significant decrease in U.S. government personnel managing foreign assistance, this shortage is now even more acute.
Of course, channeling foreign assistance through government is not a silver bullet, and it matters how the support is designed and implemented. Examining the few examples where government-to-government partnerships were used in the past provides helpful lessons. For instance, in Malawi, USAID paid for agreed-upon milestones, which led to more oversight and paid for results. In partnership with Malawi’s Ministry of Finance and two district health councils, the United States empowered local healthcare providers and district council staff to enhance access to — and improve the quality of – health-service delivery in areas like HIV, TB, maternal and child health, nutrition, and family planning, as well as to strengthen the health system itself through support for improvements to human resources, governance, and financial management.
By contrast, most direct government funding to Jordan was provided annually as direct budget support ($845 million in 2024), which is more a demonstration of geostrategic support for a key ally than it is an investment in development progress. With the exception of Jordan, this type of direct support was historically used only exceptionally and usually on a short-term basis in few other strategic countries such as Ukraine, Egypt, and Georgia. The U.S. government-to-government partnership with Jordan supported important water-sector reforms, among other objectives, given the country’s severe water scarcity. However, while there were nominal conditions that the government of Jordan was to meet before the United States would transfer the funds, it was effectively a rubber-stamp process because the funding to Jordan was codified in U.S. law and therefore had to be spent. It was, in effect, unconditional support, which reinforced Jordan’s aid dependence and disincentivized important reforms that could bolster Jordan’s future economic growth and stability.
The Risks
While concerns about the potential risks of government-to-government partnerships have been painted with far too broad a brush, it is certainly the case that they are not the right choice everywhere. In some places, the host government may lack the technical or administrative capacity to deliver services effectively. Public financial-management systems may not adequately protect from waste or diversion, especially at the scale of funding being proposed through the current MOUs; they might even be designed to obfuscate corruption. In countries with diverse populations, governments might privilege certain groups over others and marginalize underserved communities. In cases where the government is well-intentioned but lacks capacity, the government-to-government partnership may invest in strengthening these systems. In other cases, concerns about good governance may be a non-starter.
Furthermore, the U.S. government should not want — and Congress should not allow — direct funding of fragile, undemocratic, or predatory governments that are not investing in their citizens. In some of those cases, working at the subnational level may be a way to partner with governments even where there are concerns about the central government. In other cases, the State Department may continue to rely on local non-governmental organizations, with support, as necessary, from international partners.
Pivoting to more government-to-government funding could also introduce additional risks. Working largely with or through government (or any single partner) concentrates risk compared to investing in a more diverse portfolio of partnerships. Risk diversification and management is especially important to withstand the repercussions of external shocks like natural disasters, conflict, and economic instability. If, for some reason, the partnership slows or stalls, it is harder to pivot to maintain crucial services. The political nature of a government-to-government relationship can further complicate program management. Decisions to scale back or pivot away from underperforming work can end up being politically weighty, as the partnership with Jordan — mandated by Congress to support a strategic partner regardless of performance or risk — has shown. The United States then needs to balance the cost to the bilateral relationship against subpar sectoral outcomes.
Conversely, there may be strong political incentives to cut off government-to-government funding in the event that the bilateral relationship, the operating environment, or governance deteriorates. For instance, MCC’s model requires that it curtail its partnerships with governments that demonstrate a deteriorating policy or governance environment, or that make inadequate progress on the policy conditions of the compact. MCC has revoked eligibility or halted compacts in the middle of implementation in several countries for these reasons. However, MCC typically finances infrastructure and other capital investments that underpin economic growth. When U.S. assistance supports ongoing health services, like antiretroviral treatment, HIV testing, or maternal and child healthcare, turning the aid taps on and off puts ordinary citizens’ health — in some cases, their very lives — at stake, raising deep ethical questions.
Moreover, there are invariably differing perspectives on the use of aid conditionality. Both government officials and outside advocates may call for cutting off aid to a particular country for a variety of reasons, including human rights violations, policy positions that diverge from U.S. geopolitical interests, the diversion of aid for unauthorized or corrupt purposes, or an unfavorable policy environment. Recently, for example, the United States announced that collaboration in the mining sector is a key factor in the completion of the global health memorandum of understanding with Zambia, which is consistent with the Trump administration’s approach to use foreign aid to advance American commercial interests. Given that host governments are juggling domestic constituencies and the priorities of other countries with which they have relationships, it remains an open question whether aid conditionality from the United States, alone, would actually lead to behavior change. Nevertheless, there will be times when the United States will determine it is important to cut off aid anyway, whether for moral, legal, budgetary, or strategic reasons.
What It Will Take to Succeed
Beyond the broader policy issues, ensuring a successful government-to-government partnership requires a number of standards be met, including:
• Inclusive local leadership and engagement, throughout the partnership. The United States should engage host country governments as equal partners in determining the goals, terms, and content of the agreement, with involvement from all relevant line ministries and various levels of government, civil society, and the private sector. For instance, local NGOs may help ensure that historically underserved communities are included; such organizations can also provide essential oversight and accountability. Working with subnational governments may be important, too; they are closer to the communities they serve and last-mile delivery happens locally. There is widespread consensus, supported by experience and evidence, that foreign aid investments are most effective and most likely to be sustained when there is local ownership, from a range of stakeholders, over goals and processes. MCC’s compacts, for instance, require local stakeholder engagement during the development phase and are governed by a local steering committee made up of government, civil society, and private-sector representatives.
• Transparency: Local ownership and leadership is not possible without transparency into the process and contents of the agreement. For these agreements to strengthen the accountability relationship between the receiving state and its people, citizens there must be informed about their governments’ commitments. Furthermore, these agreements are funded with U.S. taxpayer dollars, so they should be approved by Congress. American citizens also have the right to understand what their taxes are funding.
• Adequate staffing. Negotiating and overseeing a government-to-government partnership requires skilled personnel dedicated to relationship management. Unlike aid programs in which the United States buys services from outside partners, which is more akin to a client-agent model, government-to-government agreements should be rooted in equal partnership and a nuanced understanding of the political dynamics in the host country. These relationships cannot operate on autopilot once signed; they demand ongoing engagement to refine approaches, continue negotiations, and navigate inevitable challenges that can spill over to other aspects of the geostrategic relationship. These diplomatic functions are best suited for U.S. government staff, even as some functions like milestone verification might continue to be outsourced to external partners.
• Oversight over government financial and procurement systems. In contrast to awards with international nonprofit and for-profit contractors that have built extensive compliance systems to meet federal requirements, government-to-government agreements rely on partner government systems, which have not been purposefully built to align with the requirements of federal grants and contracts. Effective oversight of the use of U.S. funding requires U.S. government staff or qualified third-party monitors.
• Complementary development programs to strengthen the receiving government’s institutions. The long-term durability of transitioning from foreign aid to systems that are funded and managed by the receiving government on its own may sometimes require investments in the capacity of the host government. Strategic investments in domestic resource mobilization, anti-corruption, and financial accountability and transparency — when done in genuine partnership with the partner country government and other local stakeholders — may help accelerate the transition away from U.S. government-funded assistance.
• Operational policy that governs how U.S. government staff develop and implement government partnerships. USAID’s former operational guidance (no longer available online) included an entire chapter outlining the roles, responsibilities, and processes for different types of government-to-government arrangements. In contrast, the State Department’s Foreign Affairs Manual provides little direction on channeling assistance through governments. As the State Department’s new policy on government-to-government partnerships takes shape, it will need to be accompanied by formalized guidance on the practical, day-to-day implementation of these programs to ensure consistency and accountability.
• Transition planning. In many of the countries where the United States is currently signing memorandums of understanding, governments will, in some cases, need to work in tandem with the international and local NGOs that have been supporting service delivery to allow for a responsible transition. Alternatively or additionally, receiving governments may wish to contract out certain services (as most governments do); international or local NGOs could be among those considered for this role. In some cases, international partners like INGOs may continue to help strengthen the capacity of local NGOs, government, and/or private partners, in alignment with these local actors’ priorities, during this transition period.
• Time and patience. Building direct government relationships takes time. Yet, the State Department in September indicated a desire to enter into and begin implementing multiple new partnerships in just six months or less. Such a short timeline for developing these agreements and their implementation plans may not allow sufficient time to assess whether government systems can manage funding effectively and accountably — or what support might be needed. A compressed timeline also precludes meaningful local engagement, including with local civil society and private-sector actors, on the scope and content of the agreement. Meanwhile, as noted above, history has shown that local ownership of aid goals and processes are critical for sticking power — and that externally imposed policy reforms, agreed to quickly and under pressure, have little chance of success.
At a moment when Global South leaders are increasingly asserting their right to shape their development paths, the U.S. shift toward more government-to-government engagement offers a genuine opportunity to move toward a model of foreign aid that can reinforce bilateral relations and better strengthen local systems to deliver. There can be enormous value in these approaches, but much remains unclear, and political and practical elements create ethical and functional vulnerabilities. Successful partnerships will require both sides to account for domestic constituencies and stakeholders, and it will necessitate built-in processes that prioritize transparency, meaningful local ownership, and accountability.
