Progress Without Programs: Reforming U.S. Department of Defense Global Health Engagement for Economic and Strategic Advantage

Introduction

The shuttering of the U.S. Agency for International Development and the complete overhaul of the United States’ $58 billion annual investment in foreign assistance is raising eyebrows in the Department of Defense. In particular, the global health engagement community of practice may not be immune to a similar fate if they don’t reflect on and adapt to the current operating environment.

Foreign assistance, in its broadest economic definition, includes all international support that results in commercial transactions and mutual benefits for both recipient and donor states. Such forms of U.S. support include philanthropic and charitable giving, official development assistance and development finance from the U.S. government, remittance from the United States, and the many forms of American private sector engagement and investment overseas. Department of Defense global health engagement can be a form of foreign assistance. Policy defines global health engagement as the “interaction between individuals or elements of the department and those of a Partner Nation’s armed forces or civilian authorities, in coordination with other U.S. government departments and agencies, to build trust and confidence, share information, coordinate mutual activities, maintain influence, and achieve interoperability in health-related activities that support U.S. national security policy and military strategy.” It is a long and broad policy definition. Like foreign assistance, global health engagement is characterized as misaligned with broader strategies, lacking funding transparency, and employed through a fragmented workforce. It leads to duplication and creates questions about substitution and attribution, resulting in recipient nation frustration, cost escalation, and lost economic opportunities.

The crescendo of dissatisfaction with disconnected official development assistance, coupled with the Department of Defense’s inability to articulate what global health engagement encompasses, contributes to a rise in alternative forms of partnership, particularly from China, which committed to escalating global health diplomacy efforts in September 2024. Still, Department of Defense efforts abroad continue to be underappreciated, leaving space for competitors like China to strengthen their alternative global health engagement-like approaches that achieve global influence through more seemingly transparent and project-oriented health assistance. It is time for a transformative approach to Department of Defense global health engagement efforts, which can reverse recent dampening trends by replacing its ineffective model with a “Progress Without Programs” framework. The framework rebuilds competitive American prosperity and economic resiliency in recipient states while reinforcing strategic objectives found in the National Security, Defense, and Military Strategies. The approach is further warranted given the recent dissolution of the U.S. Agency for International Development, providing a catalyst for such reform.

Problem Statement

The current global health engagement framework is outdated, fragmented, and ineffective in responding to modern health security, geopolitical, and economic challenges. Department of Defense global health engagement comprises multiple stove-piped agencies, components, services, and other stakeholders, often operationalizing plans to support their own command’s objectives without adequate coordination. The absence of a centralized accounting system for all assistance mechanisms creates confusion among providers and recipients. As a result, the department cannot adequately attribute successes, track progress, assess gaps, or address failures, nor can recipient nations effectively integrate and leverage the assistance into their security or development strategies. This lack of clarity undermines trust, reduces impact, and cedes influence on competitors.

Meanwhile, the People’s Republic of China is emerging as a dominant foreign assistance provider through its Belt and Road Initiative, offering well-defined, investment-driven, and infrastructure-focused health aid, known as the Health Silk Road. Unlike traditional Western health engagement models, which impose complex conditionalities, China’s apparent “no-strings-attached” approach positions it as an attractive alternative for many nations. China’s strategic investments in natural resources and critical infrastructure further exacerbate American vulnerabilities in security supply chains essential for health security.

Moreover, institutional inefficiencies in multilateral policy enforcement allow adversaries to exploit informal, unregulated markets, including illegal, unreported, and unregulated natural resource extraction. These shadow economies fuel corruption, criminal networks, and economic instability while also diminishing the United States’ economic leverage in recipient nations.

Policy Objectives

To address these challenges, we recommend a restructured approach to global health engagement under the banner of “Progress Without Programs,” emphasizing the following principles:

1. Greater Transparency and Coordination: Establishing a unified repository of all global health engagement to increase accountability and coordination, improve recipient nation planning, and maximize impact.
2. Decoupling global health engagement from Foreign Assistance: Eliminating less collaborative engagement while employing a “whole-of-society” approach focused on leveraging philanthropic, private sector, and remittance-driven investments for greater strategic impact.
3. Empowering global health engagement Practitioners: Strengthening their role in convening, coordinating, and catalyzing health engagement efforts rather than responding to isolated situations in haste and without attempt for unison.
4. Aligning Assistance with National Economic Interests: Shifting from a strictly Department of Defense global health engagement-driven programmatic aid to an investment-based approach that implores partnership to attain greater diplomatic and socioeconomic relationships that respond to both need and opportunity.
5. Countering Chinese Influence through Economic Statecraft: Developing competitive, transparent, and accountable Department of Defense-based health assistance strategies that reinforce the prominence of a largely independent private sector – supported by, but detached from, its public sector, as the best means by which any country achieves and sustains long-term socioeconomic resilience that best serves its population.

Case Study: Angola as a Model for Progress Without Programs

The U.S. Agency for International Development Country Development Cooperative Strategy for Angola (2014) took a new approach. Designed by the lead author, the strategy provides a successful early iteration of this model. The strategy features four lines of effort to drive sustainable development across multiple, interrelated sectors essential for Angola’s health and economic resilience:

• Strategic Alignment with Angola’s National Health Plan: U.S. Agency for International Development’s efforts supported, rather than replaced, Angolan-led initiatives.
• Tapered United States Programmatic Footprint – Foreign Service Officers transitioned from direct implementation of U.S.-designed and to serving as a convening authority between public and private sectors.
• Public-Private Partnerships – Oil and gas companies collaborated with the U.S. Agency for International Development on malaria control, maternal-child health initiatives, and public financial health system development.
• Peer-to-Peer Knowledge Transfers – The Angolan Ministries of Health and Finance leveraged technical expertise from the U.S. Agency for International Development, the Centers for Disease Control and Prevention and the Department of the Treasury, along with Duke University and the Financial Services Volunteer Corps, to fulfill its health financial accounts and governance structures that persist today.

Ten years after implementation, the following outcomes are maintained: 

• The United States’ influence increased despite reduced programmatic aid, proving economic resilience can be supported without traditional official development assistance programs.
• Angola’s 2024 Millennium Challenge Scorecard received a “green” rating for corruption control, a key signal of improved public financial management and governance.
• The Lobito Corridor Project, linking the Lobito port in Angola to Zambia through the Democratic Republic of the Congo, remains the largest U.S. infrastructure investment in Africa, directly challenging China’s Belt and Road Initiative.

Policy Recommendations

Key changes are required in policy across U.S. government agencies engaged in foreign assistance to facilitate “Progress Without Programs.” The recommendations below are a starting point for global health engagement reform, enabling economic and strategic advantage.

1. Centralizing and Enhancing Health Engagement Transparency
   • Establish a digital platform under the Department of State that consolidates all U.S. foreign assistance health engagement data, including the Department of Defense, private sector, philanthropic, and government contributions.
   • Reinforce real-time reporting of United States contributions to recipient nations, ensuring that American health aid is visible, quantifiable, and comparable to other donors.
   • Develop standardized impact measurement tools to assess the long-term benefits of United States health assistance in recipient countries.
2. Elevating the Role of Global Health Engagement Practitioners.
   • Expand the mandate of personnel to act as health engagement liaisons as well as program implementers for greater asymmetry toward achieving interoperability.
   • Equip personnel with the resources and authority to facilitate private sector engagement, government outsourcing, and strategic economic partnerships.
   • Enhance collaboration between the military health system and embassies’ economic sections to align global health engagement activities with the United States’ trade and investment strategies.
3. Expanding the role of the National Guard Bureau State Partnership Program
   • Leverage the National Guard’s dual military-civilian role to serve as a catalyst for integrating civilian health capabilities.
   • Incentivize states to incorporate civilian engagement into their global health engagement efforts, including state and local governments, academic institutions, and private industry.
   • Align global health engagement activities with combatant command campaign plans, United States trade policy, and private investment initiatives, ensuring recipient nations build self-sustaining health economies.
4. Reinforcing Recipient Nation efforts to consolidate ‘One Sector, One Plan’ approaches where governments, health partners, and the private sector agree to a single, costed, national health plan and related ‘investment case’ with emphasis on health security
   • Revive the United States National One Health Framework to guide interagency coordination, surveillance and research investments for greater transparency, accountability, and foreign reporting.
   • Reduce bureaucratic inefficiencies by eliminating duplicative reporting structures and aligning all joint, interagency, intergovernmental, multinational, plus commercial health assistance initiatives under a single governance mechanism.
   • Leverage universities, think tanks, and research institutions to provide technical assistance in health data management and governance reform.
5. Strengthening Economic Statecraft and Market Governance
   • Prioritize trade partnerships and foreign direct investment over U.S. government-only health assistance programs to foster long-term economic resilience in recipient countries.
   • Establish incentives for domestic health sector businesses to invest in emerging markets by providing risk-mitigation frameworks and regulatory support.
   • Expand joint venture health opportunities between the Department of Defense and local businesses to reinforce partner nation industry, create jobs, and reduce economic reliance on adversarial powers.
6. Enhancing Oversight to Counter illegal, unreported, and unregulated Supply Chains
   • Strengthen monitoring mechanisms to track and eliminate illegal, unreported, and unregulated health resource exploitation, particularly pharmaceuticals, and counterfeited supplies.
   • Leverage digital technologies and open-source artificial intelligence to enable leapfrogging more traditionally cost- and time-intensive knowledge transfer gaps, as well as electronic health supply chain monitoring and compliance with international trade and labor standards.
   • Implement stricter trade policies that penalize companies and entities engaging in exploitative or illegal economic activities.

Expected Outcomes

Four strategic outcomes are anticipated with implementing the “Progress Without Program” model across DoD global health engagement:

• Increased Strategic Influence: By ‘crowding in’ private and public health sector entities without foreign or military aid stimulus, the United States demonstrates new partnership power in pursuit of greater, long-term socioeconomic and security resilience. This generates a greater sense of American authenticity to save lives, alleviate suffering, and achieve greater health security via sweat equity when compared to more monetary transactional approaches employed by adversaries seeking a shorter-term advantage.
• Economic Growth and Stability: Redirecting global health engagement toward trade, investment, and governance helps resolve more acute health sector issues while concurrently working with recipient nations to develop stronger public financial management and self-sustaining health systems, private health enterprise and greater outsourcing potential, and reduced aid dependency.
• Stronger Institutional Partnerships: Full alignment of multi-sectoral health assistance strategies with recipient nations’ priorities will enhance defense and diplomatic relationships, fostering mutual trust.
• Greater National Security and Economic Competitiveness: Countering illegal, unreported, and unregulated counterfeit medicines, their supply chains, and the criminal networks that take advantage of their efficiencies reaffirms health sector rules-based order for domestic firms and their risk-return evaluations along with upstart health-related entrepreneurs seeking legitimate market opportunity.

Conclusion

The “Progress Without Programs” model represents a fundamental shift in Department of Defense global health engagement. The model replaces ineffective and disjointed assistance that often falls short of meeting strategic and operational objectives with a transparent, investment-driven approach that reinforces American health, economic, and strategic interests. By restructuring the department’s role, enhancing transparency, and aligning assistance with recipient nations’ security and development strategies, as well as the combatant command campaign plan, the United States can regain its competitive edge. The department can establish a more resilient, economically empowered global health partnership network that better represents the contribution of global health engagement to American security, strength, and prosperity. Implementing these reforms will not only bolster the department’s influence but also contribute to a strengthened rules-based international order through which American intellectual property, innovation, and therapies can regain market share and assure the United States’ health security.

(Disclaimer: The views expressed in this article are those of the authors and do not reflect the official position of the US Government, the US Department of Defense, or any other portion of the US Government)