Although the United States’ bilateral health memorandums of understanding (MOUs) with 35 countries are due to come into effect on Thursday (1 October), the start of the US fiscal year, the money will not flow yet – as countries have until Friday to submit their final 2027 budgets.

And while US officials have hailed the agreements as promoting countries’ self-reliance, Ghana’s President said his country refused to sign an MOU as the terms were “humiliating” and would compromise his country’s sovereignty.

The US has committed around $14 billion for the MOUs, in terms of its America First Global Health Strategy, which replaces grants from the now-defunct US Agency for International Development (USAID) and the US President’s Emergency Plan for AIDS Relief (PEPFAR).

However, country teams have until Friday (2 October) – the day after the start of the US government fiscal year –  to submit new documentation of “budget allocations, organisational charts and commodity procurement plans” for the 2027 fiscal year, according to author Emily Bass, who has been tracking the MOUs closely.

Clearly, the MOUs are not on track for implementation, and countries will have to wait – again – for their funds.

Initially, the MOUs were due to kick in on 1 April, but that would have given most countries mere weeks to develop complex budgets. So the US State Department made bridging finance available until 30 September – and it is likely to make yet another arrangement for bridging finance.

Meanwhile, US State Department’s senior advisor for global health security and diplomacy, Brad Smith, said the 35  countries “have committed in aggregate to increase their domestic health spending by more than $10 billion”.

Speaking at an event on the sidelines of the UN General Assembly (UNGA) last week, Smith said that the America First Global Health Strategy had been launched “with a clear premise: American leadership, paired with the ingenuity of the private sector and true partnership with recipient nations, could usher in a new era of global health assistance focused on improving health outcomes while simultaneously increasing country ownership and self-reliance.” 

‘Humiliating’ terms

However, Ghanaian President John Mahama told another UNGA side event a few days’ later that his Cabinet had rejected an MOU with the US, describing its terms as “humiliating”.

“We flagged several things in the compact. One, it says that we shall give the United States our pathogen profile…And then it also says we should give our medical records. I mean, who takes another country’s medical records?” Mahama told an event hosted by the Council on Foreign Relations in New York last Friday.

“And then it says we would have to put up a certain amount of money as part of the programme into healthcare. And then it also says that any medication or medical products that shall be brought into our country, our Food and Drugs Administration has absolutely no right to inspect. I mean, it was humiliating,” he added.

Zimbabwe and Namibia have also refused the terms offered by the US, the main sticking point being US demands for sensitive health data.

Intermingled minerals and health deals

The US is particularly intent on getting access to critical and rare earth minerals, which China has a monopoly over, and some of the health MOUs have been intermingled with negotiations over access to such minerals.

Shortly before the International AIDS Conference in July, acting US global AIDS co-ordinator Jeff Graham told a briefing on the America First Global Health Strategy that “there are no critical minerals mentioned in any MOU”.  

But several of the MOUs – notably with Cameroon, the Democratic Republic of Congo (DRC), Guinea, Madagascar, Malawi and Rwanda – were signed along with deals that offer the US favourable terms to access their minerals.

Kenyan President William Ruto met Rubio last week to discuss “how critical minerals opportunities in Kenya can position the country as a key player in the sector while presenting opportunities for US firms to provide value addition”, according to the US Bureau of African Affairs.

Nigeria and the US also signed a minerals deal alongside UNGA last week.

Zambia is struggling to find a way to secure US aid without agreeing to punishing terms. Dr Lloyd Mulenga, Zambia’s National HIV programme coordinator, told Health Policy Watch in July that he was unable to divulge why his country had been able to proceed with an MOU.

However, earlier in the year, The New York Times reported on a leaked memo from the US State Department’s Africa Bureau to Secretary of State Marco Rubio, which posited: “We will only secure our priorities by demonstrating willingness to publicly take support away from Zambia on a massive scale.”

Dr Mike Reid, PEPFAR’s former chief science officer, resigned as a result of the extractive terms being imposed on Zambia, explaining in a Substack post: “When life-saving health assistance, often beyond the immediate capacity of partner countries, is conditioned on unrelated commercial or strategic objectives, something essential is lost.” 

Sovereignty – for who?

Earlier in the week, Mahama co-hosted an UNGA side event to report on progress on the Accra Reset, an initiative he launched to help African leaders to respond to the massive and immediate cuts to health aid implemented by the Trump administration. 

The Accra Reset has since evolved into a global platform pushing for the reform of global health and aid institutions, based on empowering countries and regions.

Given the Trump administration’s stated support for national sovereignty, a key reason for its withdrawal from UN forums including the World Health Organization (WHO), the Accra Reset should have been a natural ally.

However, the US has not engaged with the initiative. Rather, it has alienated Mahama – who is culturally aligned with US conservatives.

Furthermore, the US pathogen asks in the MOUs directly undermine African countries’ sovereign rights – something that the WHO talks on a pathogen access and benefit sharing (PABS) system are currently stuck on.

Meanwhile, the Trump administration has refused any further aid to South Africa, the country with the largest HIV population in the world, primarily over its measures to address apartheid-era racial injustice and its case against Israel at the International Court of Justice.

South Africa’s Minister of Science, Technology & Innovation, Blade Nzimande, told a media briefing this week that said the country had lost $152 million [R2.5bn] when Trump withdrew funding.

“Collaborative biomedical, health, and clinical trial programmes, particularly those focused on HIV/Aids and tuberculosis”, had suffered most, said Nzimande.

 However, he added: “Our co-operation with China is increasing in leaps and bounds in terms of science, technology and innovation”.

Meanwhile, as Bass notes: “Continued foreign aid from the US government for health has to reach countries. This to work. Everyone needs this to work.

“[The] State Department can rally this support by sharing the real calendar, reflecting on lessons learned from the past year and moving on from tallying signed MoUs to transparent updates on the number and contents of approved implementation plans, and public health outcomes in the countries where [America First Global Health Strategy Fiscal Year 2027] money finally starts flowing.”