Zambia and the United States finally signed a bilateral health aid agreement on Thursday – after a 10-month delay as the US pushed for better access to the country’s minerals and changes to mining and agricultural regulations in exchange for health aid.

In 2024, 84% of Zambia’s HIV programme was funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR) – and 1.3 million Zambians are on antiretroviral medicine to keep their HIV in check.

But Zambian Minister of Foreign Affairs Mulambo Haimbe told reporters at the signing ceremony that the country is negotiating a separate critical minerals agreement with the US

“There was this [agreement] on health and another on critical minerals, and we were saying that these need to be decoupled, and this has been done,” Haimbe said, adding that the minerals agreement is still being negotiated.

Zambia is one of the world’s biggest copper producers and also has large deposits of lithium and cobalt.

In terms of the health memorandum of understanding (MOU), the US “intends to provide more than $1.5 billion over the next five years to support priority health programs in Zambia including HIV/AIDS, tuberculosis, malaria, maternal and child health, disease surveillance, and infectious disease outbreak response and preparedness”, according to the US Mission In Zambia.

The Zambian government has pledged to increase its domestic health expenditures by $975 million over five years.

Zambia’s civil service will also take over frontline health care workers currently supported by the US government, and the country will also take over procuring health commodities.

The US funding will also support the scale-up of Zambia’s health data systems, including ensuring the “interoperability of key programmatic data for HIV/AIDS, TB, malaria, and disease outbreaks tracked at scale over the long term”.

Transactional demands

Last December, the US announced that it had reached agreement with Zambia on “a plan that aims to unlock a substantial grant package of US support in exchange for collaboration in the mining sector and clear business sector reforms.”

However, while the US signed several MOUs with other African countries around this time, a deal with Zambia did not materialise. 

The MOUs are part of the US State Department’s “America First Global Health Strategy”, which is based on making the US “safer, stronger, and more prosperous” – including by enabling US companies access to business opportunities in healthcare delivery.

In February, Zambia acknowledged that part of the proposed health aid deal with the United States “does not align with the country’s interests”.

In March, The New York Times reported that the US was planning to use health aid as a bargaining tool to force the country to give it access to critical minerals.

It quoted a leaked memo from the US State Department’s Africa Bureau to Secretary of State Marco Rubio, stating: “We will only secure our priorities by demonstrating willingness to publicly take support away from Zambia on a massive scale.”

Following this leak, Dr Mike Reid, PEPFAR’s chief science officer, resigned in protest at Zambia’s treatment.

“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,” Reid wrote in a Substack post shortly before resigning.

Crippling effect on HIV services

Zambian Health Ministry leaders have detailed the chilling effects on their health services following changes to US foreign aid after Donald Trump became president in January 2025.

These include a “drastic decrease in the HIV care workforce”, clinic closures, the cessation of “most HIV prevention services”,  “disrupted logistics, supply chains, [and] data systems”, and the “ interruption of key services such as HIV testing, laboratory diagnostics, and surveillance systems”.

“Electronic medical record systems, which had been run with PEPFAR support, became inaccessible, including in clinics that had implemented a fully digital workflow without paper-based records on-site,” the health ministry leaders noted in the journal, Open Forum Infectious Diseases.

“This occurred because data clerks were terminated and typically instructed to return laptops to the implementing partner’s headquarters; others left computer hardware on-site but without the opportunity to transfer passwords, accounts, or informatics skills to other staff.”

The Ministry leaders also modelled the impact of the disruptions, noting that just three months’ worth of disrupted services would cause an additional 34,550 deaths and 54 863 new HIV infections.