A significant shift in US global health policy under President Donald Trump has sparked discussion across Africa, as Washington replaces large multilateral aid programs with bilateral health agreements subject to harsher requirements.
Supporters within the US administration argue that the new approach encourages accountability and pushes partner countries toward self-reliance. Critics, however, warn that the agreements may transform Africa’s public health environment, raising issues about sovereignty, equity, and long-term viability.
Across the continent, governments are evaluating the benefits of new financing against the commitments outlined in the agreements. With at least 17 African countries already confirmed as signatories, the effort has rapidly become one of the most significant developments in US-Africa health cooperation in recent years.
The accords are part of the Trump administration’s “America First” strategy to foreign assistance, which prioritizes bilateral agreements above conventional multilateral channels like USAID and the World Health Organization.
According to Reuters and other outlets, the US claims that the model allows for more accurate performance tracking, better value for American taxpayers, and stronger national ownership of health-care programs.
The framework provides African nations with multi-year US support to tackle HIV, malaria, TB, maternal mortality, and other key health problems. In exchange, countries must boost their domestic health spending, reach particular criteria, and, in some situations, agree to extended data-sharing agreements.
While U.S. officials frame this as a partnership model designed to reduce long-term aid dependency, public health advocates say the structure shifts more financial risk onto already stretched African health systems.
1. Kenya
Kenya became the first African country to join in December 2025, securing a package valued at more than $1.6 billion.
The pact compels Nairobi to dramatically increase its own health budget in addition to US help, ushering in a new co-financing model that Washington seeks to replicate overseas.
Kenyan officials have touted the contract as an opportunity to build domestic health capabilities and minimize dependency on unpredictable external cash.
However, several civil society organizations have called for greater transparency regarding the memorandum’s long-term duties.
2. Rwanda
Rwanda swiftly joined the program, consistent with its long history of close health cooperation with Western partners. The agreement focuses heavily on infectious disease control and health system strengthening.
Analysts believe Kigali’s participation matches the organization’s overall approach of utilizing targeted partnerships to advance health outcomes. However, regional analysts point out that the full financial and data-sharing ramifications of the agreement will only become obvious over time.
3. Liberia
Liberia’s membership is viewed as especially significant given its post-Ebola emphasis on pandemic preparedness.
The country has relied largely on international health assistance, thus the shift to co-financing is a significant policy change.
Liberian officials have welcomed the prospective funding boost, but health advocates warn that meeting the agreement’s domestic spending goals will require careful budgetary planning.
4. Uganda
According to Reuters, Uganda’s contract may provide up to $1.7 billion over five years, making it one of the largest country packages under the initiative.
In exchange, Kampala is anticipated to increase its own health-care spending by almost $500 million.
Government officials say the money will go toward HIV and malaria programs, but budget specialists warn that the compulsory domestic contributions could put a strain on Uganda’s already tight economic situation.
5. Lesotho
Lesotho joined the effort as part of Washington’s larger Southern African engagement agenda. The small kingdom has always relied on donor support for HIV treatment programmes, so the bilateral approach represents a significant policy shift.
According to health experts, the deal’s success will be highly dependent on Lesotho’s ability to sustainably build up domestic health financing while without crowding out other essential public spending.
6. Eswatini
Eswatini, which has one of the world’s highest HIV prevalence rates, signed onto the framework in hopes of stabilising long-term treatment funding. US assistance remains critical to the country’s HIV response.
While officials hailed the accord, several regional analysts caution that the co-financing requirements may be difficult for a small economy with little budgetary reserves.
7. Mozambique
Mozambique’s participation demonstrates its persistent need on external assistance to manage infectious diseases and develop its poor health system. The bilateral agreement is likely to focus significantly on malaria and HIV programs.
However, policy analysts warn that Mozambique’s sensitivity to financial pressures may hinder its capacity to satisfy the agreement’s domestic funding pledges.
8. Cameroon
Cameroon joined the new compact as part of the programme’s expansion into Central Africa. Malaria and maternal mortality continue to be major public health issues in the country.
According to observers, the deal should give useful finance stability, but doubts remain about governance safeguards and how performance goals will be implemented.
9. Nigeria
Nigeria’s accord received special notice after AP News reported that it places a high priority on faith-based health services. Given Nigeria’s religious variety, the clause has provoked controversy among civil society organizations concerning inclusivity.
Federal officials have defended the cooperation as a practical step toward improving healthcare delivery at scale. Nonetheless, analysts believe implementation specifics would be closely monitored given Nigeria’s complex federal health organization.
10. Madagascar
Madagascar signed one of four memorandums issued by Washington in late 2025. The agreement focuses on infectious disease control as well as overall health-care support.
For Antananarivo, the transaction provides an opportunity to receive reliable external investment. However, economists warn that continued domestic co-financing will be critical to ensuring program durability.
11. Sierra Leone
Sierra Leone joined the program as part of its attempts to build post-Ebola health resilience. The country continues to prioritize pandemic preparedness and maternal health.
Health policy experts believe the deal will assist to stabilize financial flows, but they emphasize the significance of transparency in data-sharing provisions.
12. Botswana
Botswana’s participation reflects the country’s ongoing transition away from relying heavily on donors and toward greater domestic ownership of health programs. The country has historically had high HIV treatment coverage.
Analysts think Botswana may be better positioned than many counterparts to meet the co-financing criteria, though long-term sustainability will still rely on economic growth.
13. Ethiopia
The US State Department announced a four-country tranche, which included Ethiopia. The accord comes as Addis Abeba works to repair and stabilize its health system after years of internal strife.
Observers observe that Ethiopia’s vast population implies that implementation will be actively monitored, notably in terms of financing flows and accountability criteria.
14. Côte d’Ivoire
According to the Associated Press, Côte d’Ivoire obtained approximately $480 million as part of its arrangement with Washington. The funds are intended to go toward HIV, malaria, and maternal health programs.
Ivorian officials have welcomed the collaboration, but regional health activists believe close monitoring will be required to ensure equal program delivery.
15. Burkina Faso
According to reports, the agreement, which focuses on boosting basic healthcare systems, disease surveillance, and community-level medical access, comes as rivalry for influence in the Sahel heats up, with shifting alliances and security realignments reshaping regional dynamics.
The US Department of State will assist Burkina Faso with up to $147 million over five years to combat HIV/AIDS, malaria, and other infectious diseases, as well as improve disease surveillance and outbreak response.
16. Republic of Niger
The health contract includes $107 million in US support over five years, with Niger contributing $71 million from its own budget.
The funding will be used to build local health systems, increase epidemic surveillance, boost malaria prevention, and promote maternity and child health, all while working to avoid disease transmission that could endanger Americans.
The US Embassy in Niger noted that the agreement focuses on direct bilateral cooperation, reducing administrative expenses and allocating cash directly to frontline services.
Officials view the arrangement as a model for multi-year health collaborations under President Trump’s policy, which aims to ensure sustainable and autonomous health systems in the Sahel.
17. Congo
The arrangement will last from 2026 to 2031 and will combine $900 million in US support with $300 million in Congolese government domestic spending that will be gradually increased.
It aims to address some of the country’s most pressing public health issues, including as HIV/AIDS, tuberculosis, malaria, maternal and child health, polio eradication, epidemiological monitoring, workforce development, and disaster preparedness.
Congo expressed confidence that the agreement would improve healthcare results while enhancing regional impact, putting the country as a hub for disease surveillance and fast response in Central Africa.