*This article originally appeared on NPR.

Since inauguration night, President Trump has cut billions of dollars in global health aid, upending everything from HIV clinics to Ebola containment efforts. Throughout this time, one question has loomed over the Trump administration’s abrupt actions: What will be the future of U.S. foreign aid?

On Thursday, the State Department sought to answer that question, releasing a 35-page document that outlines how the Trump administration plans to proceed with global health work.

“We must keep what is good about our health foreign assistance programs while rapidly fixing what is broken – and this strategy lays out a plan to do just that,” said Secretary of State Marco Rubio in a letter accompanying the document.

In a call with reporters on Thursday, a senior administration official who spoke on the condition of anonymity called it a “landmark” strategy.

“This is a roadmap. This is a strategy document that allows us to go and negotiate with countries,” the official said.

What’s in the roadmap? 

The document spells out what the U.S. plans to do more of — and less of — in the global health arena.

“Change number one,” the senior administration official said, “[is] it’s the first time that we’re really bringing the recipient countries of health foreign assistance to the table, giving them skin in the game and ownership.”

The U.S. plans to work directly with the governments of lower income countries to build up their national health systems. The goal for this year is to reach individual agreements with the countries that receive the majority of U.S. global health assistance, with implementation starting by April 2026.

According to the document, the ultimate goal is to wean countries off foreign aid and reduce “the culture of dependency.”

This vision largely severs the longstanding work of the U.S. with international aid groups and multilateral organizations, like the World Health Organization. The strategy document says global health programs “have become inefficient and wasteful” and points the finger at the nongovernmental organizations (NGOs) that have received the bulk of funding from Congress over the years.

The document suggests that NGOs rely on “perverse incentives” that encourage them “to self-perpetuate rather than work towards turning functions over to local governments.” However, it does suggest the U.S. could work closely with faith-based organizations to roll out global health programs, emphasizing their broad reach. The document singles them out because of their trust within the community and their ability to continue operating independently since they can rely on tithing and private donations.

The second change, the official at the press conference highlighted, is: Integration.

The strategy aims to stop the traditional approach of creating disease specific programs — such as PEPFAR, the President’s Emergency Plan for AIDS Relief, or the President’s Malaria Initiative. Rather, the new U.S. plan is to merge different global health programs and data systems and analytics into one unified system. On the Thursday press call, the official who spoke on the condition of anonymity said this would be both cost-effective and delivers better results. The official also said there would be an integrated financial incentive and data incentive system for “positively measuring self-reliance.” Specific details on an incentive system were not shared.

Finally, the document lays out two areas where the U.S. will concentrate its global health spending: frontline health care workers and procuring commodities, such as medications and diagnostic test kits. At the same time, the plan says, the U.S will “rapidly decrease” all other types of funding, such as technical assistance. In the past, technical assistance has been a significant part of U.S. foreign aid work in which specialists provide guidance and support as a way to build up local know-how.

Throughout the document, U.S. engagement in global health is presented as a way to counter China’s influence abroad and boost U.S. health care and pharmaceutical companies by increasing their access to emerging markets.

What’s the reaction?

Max Primorac, a senior researcher at the Heritage Foundation and author of the section on foreign aid in its Project 2025 report, calls the administration’s strategy “a breath of fresh air.”

“I think the American taxpayer is going to be happy. I think the HIV/AIDS health community should be happy. And I think the Africans will be happy, because it really is focused on success as an outcome,” he says, adding that success in foreign aid can only be achieved by empowering recipient countries.

“[This strategy is] one that empowers people on the ground. It’s one that is highly sensitive to taxpayer equities in an era of constrained budgets, but it’s also one that recognizes that you don’t alleviate poverty and you don’t stabilize regions through financial transfers. We tried that. It does not work,” Primorac says, referring to the grant-based program structure of foreign aid that the administration has moved away from.

Instead of financial transfers, which typically take the form of aid to a non-profit group, Primorac says the administration is pivoting to a more business-like model of investments in countries with the expectation that it will produce returns.

While some in the world of global health also welcomed the document, others have expressed confusion and frustration.

“This seems to be the first kind of logical strategy we’ve seen from [the administration]. That’s great. And this is a huge change, I think, from what we’ve seen the past few months,” says Elisha Dunn-Georgiou, the CEO of the Global Health Council, a nonprofit group that advocates for global health priorities and has sued the Trump administration for the release of funds appropriated by Congress.

Dunn-Georgiou says many elements of the vision presented by the State Department have long been part of the U.S. approach to foreign aid, such as working closely with recipient governments and moving toward a more integrated approach.

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