The United States and Eswatini have signed a five year health cooperation agreement worth $242 million, marking the latest step in the Trump administration’s reshaping of global health assistance around shared financial responsibility and domestic investment by recipient countries.
The agreement, signed on Friday and announced by the U.S. State Department, sets out a framework under which Washington intends to provide up to $205 million to support Eswatini’s health sector. The funding will focus on health data systems, disease surveillance and response, as well as HIV prevention and treatment programmes. In return, Eswatini has committed to increasing its own domestic health spending by $37 million over the same five year period.
According to the State Department, the memorandum of understanding reflects a shift away from traditional aid models towards partnerships designed to build long term sustainability. The deal also includes the delivery of lenacapavir, a U.S. manufactured HIV prevention drug, to Eswatini. The country has one of the highest HIV prevalence rates in the world, making continued access to prevention and treatment a central pillar of its public health strategy.
“The signing places Eswatini on a clear path to achieving the long term goal of an effective, sustainable, and efficient health system while underscoring a mutual commitment to safeguarding health gains, protecting American and Eswatini citizens alike,” State Department spokesman Tommy Pigott said in a statement.
The agreement with Eswatini follows a series of similar deals signed over the past month with Kenya, Rwanda, Uganda and Lesotho. U.S. officials say further bilateral health agreements with dozens of other countries that receive American health assistance are expected in the coming weeks. Together, these accords form part of a broader reorientation of U.S. global health policy.
In September, the Trump administration unveiled its America First Global Health Strategy, a policy that emphasises self reliance, accountability and shared investment by partner countries. Under the strategy, U.S. support is increasingly tied to commitments by recipient governments to expand domestic funding, strengthen governance and take greater ownership of their health systems.
Supporters of the approach argue that it reduces long term dependence on foreign aid and encourages governments to prioritise health spending. Critics, however, have warned that linking assistance to domestic investment targets could place pressure on poorer countries with limited fiscal space, potentially putting essential health services at risk if commitments cannot be met.
Eswatini’s government has not publicly commented in detail on how it plans to meet the additional $37 million spending pledge, though officials have previously signalled a desire to reduce reliance on donors in the health sector. The country has made notable progress in recent years in expanding HIV treatment coverage, largely with support from U.S. programmes such as PEPFAR.
The health agreement also comes against a more complex backdrop in U.S. Eswatini relations. In a separate deal announced in November, Eswatini received $5.1 million from the United States in exchange for agreeing to accept third country nationals deported by the Trump administration. That arrangement drew scrutiny from human rights groups and highlighted the increasingly transactional nature of some U.S. foreign agreements.
For now, U.S. officials are presenting the health pact as a model for future cooperation, combining significant American funding with firm expectations of local commitment. Whether the approach delivers the promised sustainability will be closely watched, both in Eswatini and across a continent where U.S. health assistance has long played a decisive role.
