The United States government has formalised a series of new health agreements with at least nine African countries, signalling a profound shift in its approach to international health assistance. The deals, which reflect the priorities of the Trump administration, move away from traditional aid models towards a framework built on negotiation and mutual benefit, often resulting in reduced financial support from Washington.
A Transactional Turn in Global Health Funding
These compacts, established under a new global health framework, make American assistance contingent on direct negotiations between the US and the recipient nation. Countries including Kenya, Nigeria, Rwanda, Uganda, Cameroon, Eswatini, Lesotho, Liberia, and Mozambique have signed agreements so far. The Trump administration champions this "America First" strategy, arguing it promotes self-sufficiency and cuts ideological waste from international programmes, replacing a network of previous agreements managed by the now-dismantled United States Agency for International Development (USAID).
This policy shift has already had severe consequences, with US aid cuts crippling health systems across the developing world. Many African nations relied heavily on this funding for essential programmes, including outbreak response. According to the Center for Global Development, a Washington think tank, the new deals combine US funding reductions, ambitious co-financing expectations, and a move to direct government-to-government aid. Their analysis indicates annual US financial health support to these nations has fallen by 49% compared to 2024 levels.
Deal Details: Nigeria's Faith Focus and a Lifeline for Others
The specifics of the pacts vary significantly. In Nigeria, Africa's most populous country with a slight Muslim majority, the deal places a "strong emphasis" on supporting Christian faith-based health care providers. The US State Department stated the agreement was connected to Nigerian reforms to protect Christian populations from violence. The new five-year pact commits over $2 billion from the US, while Nigeria is expected to raise $2.9 billion domestically. This follows approximately $2.3 billion in US health assistance to Nigeria between 2021 and 2025.
For other signatories, the deals offer crucial support following devastating aid cuts. Mozambique will receive over $1.8 billion for HIV and malaria programmes. Lesotho secured a deal worth over $232 million, while Eswatini will get up to $205 million for public health data and disease surveillance, in exchange for increasing its own health spending by $37 million.
Notable Absences and Controversial Linkages
South Africa's absence from the list of signatories is particularly striking. The nation, which has one of the world's highest HIV prevalence rates, has lost most of its US funding—including $400 million in annual support—amid disputes with the Trump administration. The dismantling of USAID also ended over $436 million in yearly financing for HIV treatment and prevention in South Africa.
Further controversy stems from the fact that at least four of the countries with new health compacts—Rwanda, Uganda, Eswatini, and Cameroon—have separate agreements with the US to accept third-country deportees. While the State Department denies any direct linkage between the health and deportation deals, officials acknowledge that broader political considerations can factor into negotiations. Rwanda's $228 million health pact includes $158 million from the US, and Uganda's nearly $2.3 billion deal involves up to $1.7 billion in American support.
This new chapter in US-Africa health relations underscores a definitive pivot towards transactional diplomacy, where development assistance is increasingly intertwined with the domestic political and immigration priorities of the Trump administration, leaving recipient nations to navigate a landscape of reduced funding and heightened conditionality.
