In the waning days of 2025, the United States embarked on an unprecedented restructuring of its global health engagement, unveiling a suite of negotiated health agreements with at least nine African nations. These accords mark a significant departure from Washington’s traditional model of multilateral and grant-based development assistance, pivoting instead to bilateral, transactional pacts linked to mutual expectations, co-financing, and strategic national interests. This shift has reverberated across health systems in Africa, stimulating intense debate about the future of international health cooperation and its implications for populations long reliant on U.S. funding.
Under what the U.S. government terms the “America First Global Health Strategy”, health assistance is no longer dispensed primarily through conventional foreign aid channels such as the United States Agency for International Development. Instead, direct government-to-government agreements are negotiated with each partner country, emphasising negotiated commitments, performance benchmarks, and shared resource contributions. This strategic recalibration positions health cooperation as a tool of diplomatic leverage, dovetailing with broader foreign policy objectives while signalling a retreat from the conventional international aid architecture.
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Historically, U.S. health assistance in Africa was anchored in expansive, long-term funding vehicles such as the President’s Emergency Plan for AIDS Relief and the President’s Malaria Initiative. These programmes, active for nearly two decades, were credited with saving millions of lives and substantially reducing the burden of infectious diseases across sub-Saharan Africa. However, recent funding upheavals have disrupted this status quo, with widespread cuts that have already eroded the capacity of key health programmes.
Under the new framework, nine African nations, including Kenya, Nigeria, Rwanda, Uganda, Mozambique, Eswatini, Cameroon, Liberia and Lesotho have signed bilateral health pacts with the United States. These agreements are structured explicitly around negotiated terms rather than traditional aid disbursement formulas and reflect the Trump administration’s broader priority of transactional diplomacy. Officials describe the approach as designed to enhance self-sufficiency and eliminate ideology and waste from assistance.
The scale of this transformation is stark. According to analysts at the Washington-based Centre for Global Development, annual U.S. health financial support under these new pacts is down by nearly 49 per cent compared with 2024 levels.
Nigeria and Faith-Linked Support
Nigeria, Africa’s most populous country, exemplifies the evolving nature of these agreements. Between 2021 and 2025, the United States provided approximately $2.3 billion in health assistance to Nigeria, predominantly through USAID. Under the new five-year health pact, U.S. support is anticipated to exceed $2 billion, with Nigeria expected to contribute an additional $2.9 billion of its own resources toward strengthening its health system. The agreement places particular emphasis on Christian faith-based healthcare providers, a provision that has generated scrutiny given Nigeria’s religiously diverse population. The U.S. State Department has framed this focus as aligned with Nigeria’s stated reforms to protect religious communities from violence.
While the State Department denies that such conditions are tied to unrelated diplomatic pacts such as agreements for receiving third-country deportees from the United States, critics argue that political considerations may influence both sides of the negotiation table.
Broader Impacts Across the Continent
For other signatories, the new agreements offer mixed prospects. Mozambique’s health pact is set to channel more than $1.8 billion into combating HIV and malaria, addressing critical gaps left by previous funding cuts. In Lesotho, a country with some of the most challenging health indicators globally, the U.S. pledged over $232 million. The tiny kingdom of Eswatini secured up to $205 million to bolster disease surveillance, public health data systems and outbreak responses, with the government agreeing to raise domestic health spending by $37 million.
Uganda’s pact, reportedly valued at nearly $2.3 billion, similarly underscores the scale and ambition of these deals, reflecting broader efforts by the government to shore up public health systems amid funding volatility.
Yet these agreements surface stark contrasts within the region. South Africa, previously among the largest recipients of U.S. health aid, was conspicuously absent from the list of signatories following escalating diplomatic disputes with Washington. The dismantling of USAID support has resulted in the loss of more than $436 million annually for HIV treatment and prevention programmes in South Africa, jeopardising both jobs and hard-won public health gains.
The Diplomacy of Dollars and Expectations
Beyond the financial contours, the new health pacts signal an evolving nexus between health cooperation and geopolitical diplomacy. The Trump administration’s approach emphasises defined benchmarks, timelines and enforceable performance criteria, designed to incentivise accountability but also to ensure that U.S. resources yield measurable outcomes. This contrasts with the broader development models of previous decades, which often integrated technical assistance, multilateral partnerships and humanitarian contributions.
Substantial debate has accompanied these policy shifts. Supporters argue that direct, government-to-government negotiations encourage greater ownership and sustainability, reducing dependency on external aid while aligning incentives for both donor and partner. Critics counter that this model risks undermining long-standing public health infrastructures and marginalising the role of multilateral institutions and civil society organisations that have been integral to epidemic control and health system strengthening. This is especially salient amid cuts to disease-targeted initiatives, where funding freezes and restructuring have already begun to strain service delivery.
A Crossroads for Health and Development
As 2025 draws to a close, the implications of the U.S.–Africa health pacts extend far beyond bilateral agreements. They reflect broader global trends in development financing, where traditional foreign aid is increasingly subjected to geopolitical calculation and demands for reciprocal commitments. European partners, for example, have also shifted aid priorities in recent months, redirecting significant budgets toward defence and regional interests, underscoring that aid is evolving within a competitive global landscape.
For African nations navigating these transitions, the challenge lies in balancing the immediate needs of their health sectors with the longer-term goals of self-reliance and economic growth. Strengthening domestic health financing, improving governance, and expanding equitable access to services will be vital components of that journey — whether in partnership with the United States or through broader global cooperation frameworks.
Ultimately, these new pacts raise fundamental questions about the future of international health aid: Can mutual, transactional agreements replace decades of multilateral engagement without sacrificing health outcomes? And will these arrangements deliver the sustained investment required to achieve resilient health systems across Africa? As implementation begins in earnest in 2026, the answers to these questions will shape the next chapter of global health diplomacy.
