US Health Aid Offers Face Resistance in Africa
In April, Ghana declined a proposed $109 million health agreement with the United States, citing concerns over data protection.
Following the dismantling of the primary US agency responsible for foreign assistance last year, the Trump administration has renewed offers of hundreds of millions of dollars to African countries aimed at strengthening healthcare infrastructure and combating disease.
However, these new agreements include conditions that have led to resistance from several governments.
When Kenya's President William Ruto signed the initial agreement in Washington last December, US Secretary of State Marco Rubio expressed optimism about future deals.
"We hope to sign, I don't know, 30, 40, how many? Fifty? Well, this is number one. We'll always remember this one and we think we've picked the perfect partner," Rubio declared.
Despite the landmark $2.5 billion (£1.9 billion) deal with Kenya, it faced delays due to activist-led legal challenges, although Kenya's cabinet approved it last month.
Shortly after assuming office, President Donald Trump ordered the closure of the US Agency for International Development (USAID), citing inefficiency, which significantly impacted health programs in African countries dependent on American funding.
The State Department's new global health strategy mandates recipient governments to increase their own health spending to build sustainable systems capable of self-reliance. For example, the US is contributing $1.6 billion to the Kenya deal, with Kenya pledging $850 million over five years.
The Trump administration aims to improve upon traditional donor-NGO models, which it argues foster dependency, create parallel delivery systems, and incur high overhead costs.
"Our aid to those countries will not just be dollars distributed to an NGO who then will go into the country and impose programmes," Rubio told a congressional committee last month.
"Not only are we treating the acute situations on the ground of people that are sick, we are helping them build the capacity and the capability to do this for themselves."
This approach represents a shift from a global cooperation model centered on the World Health Organization (WHO) to direct bilateral agreements with governments aligned with US strategic and commercial interests.
The US withdrew from the WHO earlier this year, criticizing the organization for disproportionate US funding, mismanagement of the Covid-19 crisis, lack of transparency, and political influence.
Controversially, the American bilateral agreements include explicit commitments to prioritize US pharmaceutical and medical companies in developing and delivering treatments.
"Our global health foreign assistance programme is not just aid - it is a strategic mechanism to further our bilateral interests around the world," states the policy document.
By mid-May, 32 countries had accepted the health Memorandums of Understanding (MOUs), including nations in Latin America, the Caribbean, and at least 20 in Africa. However, countries such as Ghana, Zimbabwe, and Zambia have resisted signing, citing various concerns.
In Zambia, Foreign Minister Mulambo Haimbe criticized what he described as an American attempt to link health funding to US economic interests by coupling the health deal with a separate agreement granting Washington access to critical minerals.
"Our [US] colleagues looked at it from the perspective that [the two deals] must be taken as a package to be negotiated and concluded at one particular time," he told the BBC, emphasizing Zambia's preference to discuss the agreements separately.
"The US felt that there is need for there to be a preferential treatment in the use of critical minerals. And the framework was to reflect that," he added.
The State Department did not explicitly confirm the linkage when questioned but emphasized an "America First" stance.
"The Trump administration has made clear, US foreign assistance is not charity - rather it is strategic capital to be wisely invested to advance US interests - and we expect all of our allies and recipient nations to take seriously American strategic and commercial priorities," a spokesperson said.
Last month, the US announced it would completely withdraw funding for HIV/AIDS programs in South Africa, linking the decision to Pretoria's failure to meet policy requests, including issues related to the white-minority Afrikaner community. Claims of a "white genocide" in South Africa have been widely discredited.
Concerns over US access to health data, including patient information and biological samples such as pathogens, have alarmed some African countries during MOU negotiations.
A Kenyan court initially suspended the country's deal after legal challenges demanding protection of patient privacy.
Arnold Kavaarpuo, executive director of Ghana's Data Protection Commission, told the BBC that Ghana objected to the deal over similar concerns.
"We had concerns around the scope and breadth of data that was being required," he said.
"It was us generating data and passing it on to the US authorities, and there were no real reciprocal measures when it comes to the protection of Ghanaian data and Ghanaian sovereignty.
"And so from our perspective," he added, "once the data left the Ghanaian borders, we had no control over what becomes of it."
Zimbabwe also cited concerns about medical data sharing, presumably with US pharmaceutical companies, as a reason for rejecting a deal.
A government spokesman noted there were no guarantees that drugs or vaccines developed from the pathogens would be accessible to Zimbabweans, pointing out that the WHO already has a system for data sharing and benefit distribution during pandemics.
African countries have previously shared medical data through existing programs such as USAID and Pepfar, America's primary HIV/AIDS initiative.
The US maintains that sharing data and specimens is essential for scientific progress and mutual cooperation.
A State Department spokesperson stated that the requested materials are aggregated and de-identified data that have been used for years in infectious disease control.
Nelson Aghogho Evaborhene, a PhD fellow in global health governance at Roskilde University in Denmark, explained that the context has shifted.
"It was an unequal relationship, but it was quite tolerable politically," he said, "because you could sell it to the domestic population as an altruistic need to improve health service.
"But now it has changed significantly, because it's more about very transactional leverage."
Many African nations have also learned from the Covid-19 pandemic, which highlighted the importance of pathogen data but left the continent struggling to access vaccines.
Aggrey Aluso, executive director of Resilience Action Network Africa (Rana), stated:
"I think one of our biggest opportunities as Africa is the fact that we have important information that can help build the global health security ecosystem."
Rana and over 50 civil society groups signed an open letter warning African leaders that US terms do not align with African national or regional interests, a perspective shared by South Africa.
"Frankly speaking, no nation on Earth that respects itself should accede to [two requests]," South Africa's Health Minister Dr. Aaron Motsoaledi told the BBC.
"That [the US] will get their pathogen if there's any pandemic or epidemic in their area.
"And they'll also provide them with a genome for life. But the US is going to give them money for five years."
Ebola Outbreak Highlights Challenges of Bilateral Aid
The debate over health diplomacy intensified recently with a new Ebola outbreak in the Democratic Republic of Congo (DR Congo).
DR Congo was among the first countries to accept the new American health agreements, and the US claims the deal is aiding Kinshasa's response to the crisis.
However, humanitarian workers and former US health officials argue that significant US aid cuts to DR Congo and the WHO have weakened frontline responses.
Amadou Bocoum, DR Congo country director for the international humanitarian organization Care, reported having to lay off 36 workers, a third of his staff, following USAID cuts that affected community mobilization, health education, and Ebola prevention.
"When this new Ebola came, the staffing was not there, and the emergency stock that we also used to have was also not there," he said.
"With proper funding, we would have had prepositioned stock and begun distributing critical supplies like PPE from day one, but instead, we started with nothing and lost 10 days."
Critics argue that dismantling USAID hindered the speed and scale of Ebola detection and response, emphasizing the agency's role in logistics, supplies, and local outreach.
"I just cannot imagine that if you still had the full slate of health partners that the US government was funding in Congo up until [the cuts] shut most of that down, that no-one would have seen that an unidentified viral haemorrhagic fever was spreading," said Jeremy Konyndyk, who led USAID's response to the 2014 West Africa Ebola epidemic.
The US denies that its cuts have impaired current efforts, asserting that the new arrangements are more "aligned and effective," and highlighting a $270 million contribution to combat the epidemic.
The administration's strategy also encourages national governments to increase their own health spending, although progress in Africa has been limited despite commitments made in 2001.
Experts warn that the Ebola outbreak underscores the risks of a bilateral approach to global health.
"Bilateral relationships ignore collective challenges," said Dr. Kevin DeCock, former director at the US Centers for Disease Control (CDC) with extensive infectious disease experience.
"Global health, by definition, is transnational, crosses borders, does not concern just one country. Global health problems require global approaches, and no country can go it alone."
Some analysts advocate giving the administration's new strategy a chance.
In an article for the conservative think tank American Enterprise Institute, Brett Schaefer and Roger Bate acknowledged the risks of moving away from multilateral systems, especially the WHO withdrawal.
"This is not the end of American leadership in global health," they wrote. "It is the start of a test - of whether influence is better exercised through conditional engagement, parallel institutions and results-driven partnerships than through deference to an organisation that has struggled to learn from failure."
Despite Secretary Rubio's enthusiasm at signing the first MOU months ago, adoption of bilateral agreements in Africa remains uneven and contentious.
Tanzania recently joined the partnership, but with several African nations declining, the future extent of America's reshaped global health strategy remains uncertain.
