The United States is reshaping development policy again with 14 bilateral pacts with African states so far setting out the parameters for aid in exchange for speedy information about new disease outbreaks – part of the ‘American First Global Health Strategy’, reports Africa Confidential.
The latest multimillion-dollar deals are with Ethiopia, Madagascar, Botswana and Côte d'Ivoire, while the most lucrative are with Nigeria and Kenya, worth $2.1bn and $1.5bn respectively.
The agreements follow the blueprint of prioritising programmes offering treatment and prevention of HIV/Aids and TB and malaria, as well as infectious diseases.
That is standard Western development spending and will be a near like-for-like replacement for much of work done by the USAID agency, which was shuttered weeks after Trump’s inauguration in January.
But there will still be losers.
Organisations such as the Red Cross are reporting that funding for sexual and reproductive health programmes has been dramatically reduced. Several of the agreements have caveats that explicitly promote Washington’s policy interest.
Besides promoting private sector medicine that already dominates most health provision across Africa, most notably, Nigeria’s is based on a “strong emphasis on promoting Christian faith-based healthcare providers”, according to a State Department statement, which adds that the US “expects Nigeria to continue to make progress ensuring that it combats extremist religious violence against vulnerable Christian populations”.
Health Policy Watch reports that the 14 countries – in order of their signings –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 Pepfar.
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 “promote secure, reliable, and mutually beneficial critical mineral flows for commercial and defence 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 … 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 US and Zambia”.
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. In a statement, it said it would provide up to $1.6bn over the next five years for “HIV/Aids, TB, malaria, maternal and child health, polio eradication, disease surveillance, and infectious disease outbreak response and preparedness”.
Kenya has pledged to increase domestic health expenditures by $850m, but its 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.
An MOU was also signed committing the US to giving Nigeria nearly $2.bn, while Nigeria committed to increasing domestic health expenditures by almost $3bn.
Rwanda will get $158m over the next five years, while its government will increase domestic health investment by $70m: Liberia will get up to $125m and increase domestic health expenditures by almost $51m, and almost $2.3bn is heading to Uganda, where the government has “pledged to co-invest more than $500m” in health.
Lesotho will get up to $232m and will invest $132m in its HIV/Aids response.
ESwatini, with the highest HIV rate in the world, will get $205m to “improve public health data systems, modernise disease surveillance and outbreak response technology, provide access to HIV antiretroviral medications, and scale up access to highly effective HIV prevention interventions”, with its government upping domestic health expenditures by $37m.
Mozambique will get $1.8bn from the US, and nearly $400m will be given to Cameroon, which has committed to increase its own health expenditures by $450m.
In Ethiopia, the US will invest $1.016bn and that country will fork out $450m for HIV/Aids, TB, 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 is to get $106m from the US and $380m from the country’s government, and in Sierra Leone, the US will “front-load more than $30m in 2026 to strengthen disease surveillance, laboratory capacity, health workforce, and data systems”.
In Madagascar, the US has committed more than $134m and that country’s government will cough up $41m.
On 30 December, the US and Cote d’Ivoire signed a deal for $487m from the US with $450m from the African country.
All agreements are over five years and provide opportunities for US companies to provide logistics, data, and supply-chain support. They are also all geared towards ensuring that individual governments assume responsibility for the health service delivery to citizens, with a tapering off US funds from the second year of the five-year agreements.
The MOUs have been concluded in haste as countries’ Pepfar bridging finance runs out on 31 March, and the new MOUs are supposed to kick in on 1 April.
However, MOUs still need to be reached with many countries that were previously part of Pepfar, while the 14 signed MOUs need to be translated into concrete contracts.
See more from MedicalBrief archives:
US seeks Africa data access in new aid agreements
US ending WHO funding may harm African polio, HIV/Aids and malaria programmes