The United States government has concluded a series of new health cooperation agreements with nine African nations, marking a significant transformation in its approach to global health engagement. The accords, described by Washington as promoting “mutual benefit” and “self-sufficiency,” represent a recalibration of aid priorities under President Donald Trump’s administration and signal a decisive shift from traditional development assistance models.
Agreements have so far been formalised with Kenya, Nigeria, Rwanda, Uganda, Cameroon, Eswatini, Lesotho, Liberia and Mozambique. The new framework conditions health aid on bilateral negotiations, a departure from the previous multilateral structure overseen by the United States Agency for International Development. Analysts from the Center for Global Development have noted that these arrangements combine reduced funding commitments with expectations for increased national co-financing and a move toward direct government-to-government assistance.
Official figures indicate that these compacts collectively represent a 49 per cent reduction in annual United States health spending across participating countries compared with 2024. For many African states that have historically depended on US funding for public health, the shift poses both opportunities and risks. While Washington maintains that the approach seeks to promote local ownership and efficiency, critics argue that it could exacerbate existing inequalities in health systems already strained by past aid cuts.
In Nigeria, which previously received approximately $2.3 billion in United States health assistance between 2021 and 2025, the new agreement is valued at just over $2 billion. The arrangement places notable emphasis on Christian faith-based healthcare providers, a point that has drawn concern among civil society organisations in a country with a nearly equal division between Muslim and Christian populations. The Nigerian government has pledged to mobilise $2.9 billion in domestic resources to complement the American contribution, part of what it describes as a broader commitment to sustainable healthcare financing.
The United States State Department has framed the Nigerian compact as recognition of Abuja’s reforms to protect religious minorities, noting that it includes dedicated funding for Christian healthcare institutions. It further affirmed that the president and secretary of state reserve the authority to suspend any programme not aligned with what it termed the “national interest.”
In Mozambique, the new agreement allocates over $1.8 billion to support HIV and malaria programmes, critical components of the country’s public health infrastructure. Lesotho, among the poorest nations globally, secured an arrangement valued at approximately $232 million, while Eswatini reached a deal under which the United States will provide up to $205 million to strengthen disease surveillance and data systems. Eswatini has committed to increase its own health expenditure by $37 million as part of the accord.
Rwanda and Uganda, both of which have separate agreements with Washington to receive deported migrants from the United States, have also signed health deals under the new framework. Rwanda’s compact totals $228 million, including $158 million in US funding, while Uganda’s $2.3 billion agreement allocates $1.7 billion in American support. The State Department has denied any direct connection between these health pacts and the migration arrangements, although officials have acknowledged that political considerations may influence negotiations.
South Africa, historically one of the largest recipients of American health funding, has not signed a new agreement. Diplomatic tensions have intensified following the United States’ decision to withdraw over $436 million annually that had previously supported South Africa’s HIV prevention and treatment programmes. This development follows President Trump’s announcement of his intent to end financial assistance to Pretoria, citing unsubstantiated claims of discrimination against the country’s white minority.
The transformation of the United States’ global health engagement represents a wider philosophical shift away from traditional aid paradigms toward transactional, conditional partnerships. This realignment raises pressing questions about the long-term sustainability of health systems in many African nations that have relied heavily on external financing. Yet, within this complex landscape, several African governments have framed the new arrangements as opportunities to advance greater fiscal autonomy and assert national priorities in health policy.
While the debate over the merits of this new model continues, the continent’s response reflects a nuanced and pragmatic recalibration. Many policymakers across Africa view these agreements not solely as reductions in aid but as a signal to invest more deliberately in domestic health resilience and to redefine relationships with major donors on more equal footing.
As the global health architecture continues to evolve, the success of these new arrangements will depend on whether they foster long-term capacity building and inclusive health outcomes across the continent.
