Over December, the United States signed bilateral health co-operation agreements with 14 African countries, setting out the parameters for aid in exchange for speedy information about new disease outbreaks – and, in some instances, clinched alongside trade deals profitable to US companies.

The fourteen countries, in order of when the agreements were signed, are: Kenya, Rwanda, Liberia, Uganda, Lesotho, Eswatini, Mozambique, Cameroon, Nigeria, Madagascar, Sierra Leone, Botswana, Ethiopia and Cote d’Ivoire.

Grant agreements still need to be crafted from the memorandums of understanding (MOU), which are characterised by vague disease targets and tight pathogen-sharing terms.

Notable absences are South Africa, Tanzania and the Democratic Republic of Congo (DRC) – all with high disease burdens that previously received significant grants from the US President’s Emergency Plan for AIDS Relief (PEPFAR). 

As previously reported, a US State Department spokesperson told Health Policy Watch that the US government “is still deliberating future health assistance to South Africa pending broader bilateral discussions”.

Several political spats between the US and South Africa – over Israel’s conduct in Palestine, the fate of white Afrikaans-speaking South Africans and the G20 –  have put any bilateral agreements on the back burner.

In early December, the US stated that it is “reconsidering ties” with Tanzania in light of the government’s “ongoing repression of religious freedom and free speech, the presence of persistent obstacles to US investment, and disturbing violence against civilians in the days leading up to and following Tanzania’s October 29 elections”.

This follows the shooting of hundreds of people protesting the outcome of the Tanzanian elections.

What’s happening with the DRC?

It remains unclear why the DRC has not yet clinched a deal with the US, as Rwanda did on 5 December, the day after it signed a peace accord with the DRC in the presence of US President Donald Trump in Washington.

Instead, the US and the DRC signed a “strategic partnership agreement” that will, amongst other things, “promote secure, reliable, and mutually beneficial critical mineral flows for commercial and defense purposes”. The DRC is one of the world’s most important sources of rare earth minerals, but China currently dominates the purchase and processing of the DRC’s minerals.

The US may be holding out on health aid to the DRC as it seeks better access to the country’s minerals. 

A similar scenario unfolded in Zambia, where the US announced on 8 December that two countries had committed to a plan to unlock “a substantial grant package of US support in exchange for collaboration in the mining sector and clear business sector reforms that will drive economic growth and commercial investment that benefit both the United States and Zambia”.

“We want to leverage US assistance to bring about reforms that will unleash business investment that enhances US access to critical supply chains and creates great jobs for the Zambian people,” said Caleb Orr, US Assistant Secretary of State  for Economic, Energy, and Business Affairs.

Until then, Zambia and the US had been set to sign their health MOU on 11 December, author Emily Bass reported.

“Access to the region’s natural resources and markets is central to America’s geopolitical ambitions and strategy, and supercedes every other consideration that has historically motivated health foreign aid including winning hearts and minds, saving lives and shoring up global health security,” argues Bass.

“The [State] Department’s public statement about the Zambia terms is a warning and an object lesson to anyone who thinks the way things were is the way they are going to be.”

Kenya recognised as key ally

By choosing Kenya as the first country to sign an MOU, the US was anointing it as its most-favoured state, and the official announcement reflects this. 

The US will provide up to $1.6 billion over the next five years for “HIV/AIDS, tuberculosis (TB), malaria, maternal and child health, polio eradication, disease surveillance, and infectious disease outbreak response and preparedness”. Kenya pledges to increase domestic health expenditures by $850 million.

However, Kenya’s High Court has frozen implementation of the MOU after two separate court challenges by the Consumer Federation of Kenya (COFEK) and local Senator Okiya Omtatah over concerns about patients’ data privacy and the bypassing of Parliament. The government has until 16 January to file its response, and the case will return to court on 12 February.

While Oluga Ouma, Principal Secretary of Medical Services, assured the media that the MOU contained no pathogen-sharing clauses, but clause 3 of the MOU commits the country to pathogen-sharing. 

Nigerian air strikes

In early December, Nigeria’s relationship with the US was on shaky ground after the US announced it would take “decisive action” against the “mass killings and violence against Christians by radical Islamic terrorists, Fulani ethnic militias, and other violent actors in Nigeria and beyond”.

However, on 20 December, the two countries signed an MOU committing the US to giving Africa’s most populous state nearly $2.1 billion, while Nigeria committed to increasing domestic health expenditures by almost $3 billion.

“The MOU was negotiated in connection with reforms the Nigerian government has made to prioritize protecting Christian populations from violence and includes significant dedicated funding to support Christian health care facilities with a focus on expanding access to integrated HIV, TB, malaria, and maternal and child health services,” according to the US State Department announcement about the MOU.

Five days later, the US launched air strikes against Islamic militants’ bases in northern Nigeria with the buy-in of the Nigerian government.

Digitisation, disease surveillance

The US will give Rwanda $158 million over the next five years, while its government will increase domestic health investment by $70 million.

Liberia will get up to $125 million and will increase domestic health expenditures by almost $51 million.

Almost $2.3 billion in US aid is heading to Uganda and the Ugandan government has  “pledged to co-invest over $500 million” in health.

 “The agreement will further Uganda’s national health digitalization effort, as well as provide support for faith-based health care providers and for health care services to the Ugandan military, which is assisting with a number of key operations in the region,” according to the US State Department.

Lesotho, the tiny southern African state that declared an emergency after its economy was shattered by Trump tariffs last year, will get up to $232 million and it has undertaken to invest $132 million in its HIV/AIDS response. 

Eswatini, which has the highest HIV rate in the world, will get $205 million to “improve public health data systems, modernize disease surveillance and outbreak response technology, provide access to HIV antiretroviral medications, and scale up access to highly effective HIV prevention interventions”, according to the US State Department.

Eswatini will increase domestic health expenditures by $37 million.

Mozambique stands to get $1.8 billion to “expand cutting-edge solutions such as the HIV/AIDS prevention drug lenacapavir and drive advancements in malaria prevention efforts”. Mozambique commits to increasing its domestic expenditure on healthcare by nearly 30% over the next five years to “improve maternal, newborn, and child health” including the elimination of mother-to-child HIV transmission of HIV. 

According to the MOU with Cameroon, the US will provide nearly $400 million in health assistance while Cameroon has committed to increase its own health expenditures by $450 million. The focus of the agreement is on “global health cooperation, including funding frontline health commodities and health care workers, strengthening laboratory networks, and modernizing data systems with secure, interoperable digital tools that enhance disease surveillance and outbreak preparedness”.

Agreements with Madagascar, Sierra Leone, Botswana, and Ethiopia were signed over two days shortly before Christmas.

In Ethiopia, the US will invest $1.016 billion and that country $450 million, for  HIV/AIDS, tuberculosis, malaria, polio eradication, maternal and child health, and infectious disease preparedness and response, including ongoing support for the Marburg response. 

Ownership of HIV service delivery

Botswana’s MOU focuses on that country taking more “ownership of HIV clinical and community service delivery”, with $106 million from the US and $380 million from Botswana.

“The MOU will modernize electronic medical records and disease surveillance systems, including US supported networking infrastructure that may leverage American satellite-based technologies to strengthen outbreak preparedness while advancing U.S. technological leadership,” according to the US State Department.

In Sierra Leone, the United States will “front-load more than $30 million in 2026 to rapidly strengthen disease surveillance, laboratory capacity, health workforce, and data systems”.

“By 2030, Sierra Leone will assume responsibility for most commodity costs, workforce, and laboratory expenses, significantly reducing long-term US burden,” according to the US State Department.

The US aid for Madagascar focused on “malaria, maternal and child health, and global health security, while transitioning the infectious disease-focused community health workforce to national ownership”.  The US has committed more than $134 million in and Madagascar,  $41 million.

On 30 December, the last agreement for the year was signed between the US and Cote d’Ivoire. It involves up to $487 million from the US with a $450 million buy-in from the country.

“This assistance is focused on stopping outbreaks early – before they spread across borders.  It strengthens epidemic surveillance and laboratory systems, modernizes health supply chains and data systems, and reinforces frontline health systems so outbreaks are detected faster and contained sooner,” according to the State Department.

All agreements are over five years and provide opportunities for US companies to provide logistics, data, and supply-chain support.

The MOUs have been concluded in haste as countries’ PEPFAR bridging finance runs out in March, and the new MOUs are supposed to kick in on 1 April. However, MOUs still need to be reached with many countries previously part of PEPFAR, while the 14 signed MOUs need to be translated into concrete contracts.