I’ve become a little obsessed with where the Accra Reset and the America First Global Health Strategy meet. Both call for greater country ownership, though they approach it from different directions. Earlier this week, I wrote about the question that matters most to me: will these efforts strengthen health systems, or shift financial and operational risks onto governments without accounting for each country’s resources and readiness?
This week in New York gave us a clearer view of both agendas.
At the Accra Reset’s Full Circle event, President John Dramani Mahama launched A Sovereign Future for Health. The room was packed. His message was direct: “No Ownership Without Control.” Countries cannot truly own health programs if donors and global institutions still decide the priorities, hold the data and determine how money moves. He also insisted that governments must answer to their own people for how they use that control.
Three days later, at the U.S. Chamber of Commerce organized event for the first anniversary of America First. I was in the room for its launch last year. This time, the room was full and the conversation felt different. State shared more detail. Also new this time: CDC Director Dr. Erica Schwartz addressed the room, and Caroline Vik joined from the U.S. International Development Finance Corporation.
The America First train is moving. The question now is whether it is headed toward the kind of sovereignty countries are asking for.
What State put on the table
State reported 35 signed bilateral health agreements, with $14 billion in U.S. commitments and more than $10 billion in partner-country co-investment. It did not meet its original timetable for completing agreements with the countries receiving most U.S. health assistance by the end of 2025. Still, 35 agreements after a dramatic year amount to a major change in how U.S. global health programs will operate. And all under impressive timing!
Brad Smith offered the clearest picture I have heard yet of the planned transition. Across the country plans presented, partner governments would fund more than half of combined spending by year five. Government-to-government funding would reach roughly 60%. Countries would take on more than 80% of the health workers covered by these plans and purchase about 60% of commodities locally. He stressed that the pace will vary by country.
State also made a more concrete case for integration. Smith described separate HIV, TB and malaria teams traveling to reach the same people, and a clinic where staff entered information from one paper register into two different data systems. Combining services and removing duplicate reporting could free up time and money for care. It must also preserve the outreach and community relationships that bring people into care.
Jeff Graham emphasized protecting the health gains of the past 25 years. Smith said plainly that State expects the transition to improve outcomes. I welcomed that commitment. GHSD is already receiving country data for roughly 30 to 35 indicators, and Smith expects usable baselines by year’s end. We need to see those results, including what happens to prevention, treatment continuity and people who are hardest to reach.
The country speakers were at times presented as proof that the strategy is working. Their remarks also showed how much implementation still requires. Dr. Ouma Oluga described Kenya’s progress toward government-to-government funding, along with court cases and parliamentary scrutiny. Dr. Kelechi Ohiri explained Nigeria’s effort to bring partners around one plan, one budget and a joint annual review. Dr. Mebratu Massebo said Ethiopia has already budgeted and disbursed its 2026 co-investment commitment.
Programming note: State co-hosted the event with the U.S. Chamber of Commerce, which does a very effective job of bringing companies and governments together. Naturally, the role of the private sector was a major theme throughout the program. Abbott, BD, Gilead, Merck, Palladium, Pfizer, Roche and Zipline sponsored the event. I appreciated hearing from country leaders alongside them, but civil society and other non-state actors were largely absent from the program.
Sovereignty asks donors to change, too
The Accra Reset brings a challenge that reaches beyond the U.S. agreements. Its new report calls for one national health plan, one costed investment plan, one public budget framework and one country-led platform to coordinate partners. Donors would align their funding and reporting with that system.
That is a meaningful test. A government cannot set priorities freely while every funder maintains a separate plan, budget and reporting calendar. The Accra proposal asks donors to give up some control over how programs are designed and managed.
It also asks countries to invest more of their own resources. That responsibility is real. So are debt payments, narrow tax bases and the cost of borrowing. I think we can all agree that domestic financing cannot become a polite phrase for donor withdrawal. The report calls for managed transitions that protect essential services while national capacity grows. Families should not inherit the financing gap through higher out-of-pocket costs.
The regional agenda may be just as important. Countries need to work together on surveillance, reference laboratories, regulation, emergency response, procurement and manufacturing. As William Menson and I argue in our PLOS Global Public Health article, bilateral agreements can clarify responsibilities, but they cannot by themselves finance or govern functions that cross borders.
This creates a practical role for the United States and other donors. They can back country plans while investing in Africa CDC, regional procurement, regulatory capacity and reliable markets for products made in Africa. Exactly on this point, DFC made a useful point at the Chamber event: financing a factory depends on a credible commitment to buy what it produces. Sovereignty requires more than a ribbon cutting. It requires buyers in year ten.
Are donors ready for an Accra Reset?
Accra asks donors to align with country plans, budgets and reporting systems. That will require more than asking governments to co-invest. Donors will have to change how they make decisions, move money and measure success.
The Global Fund is an immediate test. State said it is moving most commodity procurement through the Fund, giving it a central role in how the new U.S. agreements work. Yet I have heard much more detail about how State expects countries to change than about how the Fund will adapt.
This week, the Global Fund welcomed the Accra Reset. Its executive director, Peter Sands, cautioned that “accelerating the pathway to health sovereignty should not be equated with a retreat from global solidarity.” What would that mean in practice? Will the Fund align its grants with national plans while maintaining independent oversight? Will it support regional purchasing and manufacturing? And how will it protect community-led services when national programs fail to reach people?
Government ownership is not the same as public ownership. People living with HIV, key populations, women, adolescents, health workers and community organizations need a role in planning and monitoring these transitions. The Global Fund can help bring those voices together with governments and other donors, so country-led plans reflect the people who use the services and can change course when someone loses access.
The Accra Reset also offers global institutions a pointed test: Commit, Collaborate, Consolidate or Close. It leaves open which institution should do what. For the Fund’s donors and Board, that raises a practical question: which functions should the Fund continue to lead, which should it share with country and regional institutions, and where should it step back as those institutions grow stronger?
I’m watching the Global Fund’s leadership search closely because it could give us a chance to hear some answers. The Fund expects to publish the names and biographies of four or five shortlisted candidates next week. They will meet Board members in early October, and the Board expects to choose a new executive director at its October 28–30 meeting in Geneva. As I’ve said before, that leaves very little time for people outside the Board to hear the candidates’ plans, ask questions and build confidence in the choice. The Fund still had time to make room for that conversation.
The countries outside the room
The discussion offered little insight into what happens in countries without agreements. Zimbabwe is one urgent example: U.S.-supported health programs there are set to end at the close of September. Our analysis projects about 75,000 additional HIV infections within a year if PEPFAR support ends completely and no government or international support replaces it. That is a scenario we can still work to prevent.
South Africa’s absence from the conversations at both the Accra Reset and U.S. events felt strange to me. It has the world’s largest HIV epidemic and funds most of its own response. As U.S. support winds down there, the immediate questions concern treatment, prevention, community services and the workers who connect people to care. A transition plan has to account for countries without an agreement, too.
Overall, I left the Chamber more encouraged than I did a year ago. Officials offered numbers, country leaders described the work ahead, and State tied the transition to health outcomes. The Accra Reset made clear why outcomes are only part of the test. Countries and communities also need authority over the decisions that determine whether progress lasts.
The MOUs have made America First a working reality. Now the United States, other donors and the Global Fund must show how their practices will change. We should judge this transition by whether medicines remain available, health workers get paid, regional institutions grow stronger and families stay connected to care without taking on new costs.
Those are the receipts I want to see.
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What i love about this analysis, Jirair, is its novelty. You have triangulated Accra, America First, and Global Fund. That strikes me as a very useful way of thinking. I would dig further on two subdomains. First, the metrics. Seems to me that America First has more metrics/data emphasis than Accra. Is this your perspective? Is it something Accra could take on board. I know they have a recommendation along this line but not much else? Second, NCDs. Both America First and Global Fund are about the traditional foci in global health: HIV, malaria, and TB, and also in the case of AF maternal, newborn and children’s health. But with 2/3 or more of deaths from NCDs, and GLP-1s available to do something about NCDs, countries must take a broader view. How do you see this disjunction? Anyway, great piece and thank you.
Jirair, thanks for this very detailed reporting from these two key events at UNGA, and your analysis on the important questions that remain. Also noteworthy is that you are feeling more positive about the work that has been done in the past year by both the Accra Reset and America First.