U.S. Bilateral Health Agreements with African Countries: Balancing Health Cooperation, Economic Interests, and African Sovereignty

By Musa Nji, Enowbachem Agbortanyi and Larissa Ntoubia

Executive Summary

The recent U.S-Africa bilateral health agreements represent a major change in terms of government-to-government funding, co-investment and performance-based execution. Although such arrangements will help to maintain key health programs and enhance epidemic preparedness, they have spawned increased concern among African countries on issues to do with data sharing, policy conditionality, and connection to other economic interests, such as mining and strategic resources. withdrawals or resistance by Zimbabwe, Zambia and Kenya serve to point to growing uncertainty on the topic of sovereignty and national control over health assets.

This short paper maintains that in the absence of tougher protection these agreements will turn health cooperation into asymmetric alliances that will reduce policy autonomy, bind the policy into dependency, and create external forces into strategic sectors. It also gives recommendations that can be implemented to make sure that health partnerships are equitable, transparent, and focused on long-term development and sovereignty in Africa.

Key Messages

• The bilateral health agreements between the U.S. and Africa are transforming the global health financing by co-financing and models of government-led implementation.
• While they offer critical health system benefits, they introduce risks related to data sovereignty, policy autonomy, and external influence
• Evidence suggests linkages between health agreements and broader strategic interests, including access to natural resources and mining sectors.
• Uneven adoption including withdrawals by Zimbabwe and resistance from Zambia and Kenya reflects growing concern over the terms of engagement.
• Without stronger safeguards, these agreements risk entrenching dependency and weakening African sovereignty.

Overview of U.S.-Africa bilateral health agreements

The existing U.S.-Africa bilateral health agreements fall under the America First Global Health Strategy to change U.S. global health assistance to multi-year, government-to-government agreements that focus on co-financing, quantifiable outcomes, and national delivery.  As of March 2026, at least 27 agreements including Cameroon, Nigeria, Burkina Faso amongst others have been tracked in Africa, with a wide transition to this new model of health financing and partnership.

These agreements have priority areas including HIV/AIDS, tuberculosis, malaria, maternal health and child health, and epidemic preparedness. However, implementation has been uneven. Zimbabwe withdrew from negotiations citing data concerns, while Zambia and Kenya resisted aspects of the agreements linked to data access, biological resources, and broader economic interests. These developments highlight growing concerns over sovereignty and national control.

Consequently, these agreements are progressively being perceived as not just health partnerships but as strategic pacts influencing ownership of health finances, data and biological resources. The essence of the issue to which this brief refers is, then, whether such bilateral arrangements are indeed assisting African health-system ownership, or whether they risk further asymmetric dependence by tying vital health financing to requirements that further extend the external range of action over national policy space and strategic health resources.

Health system benefits and cooperation opportunities.

In terms of health systems, these deals present a significant chance to maintain large scale external assistance at a moment when most African nations are still heavily dependent on donor funding of critically needed disease initiatives and programs. They can stabilize priority services and avoid disruptions in the face of bigger changes in the global health funding by focusing on the areas including HIV/AIDS, tuberculosis, malaria, maternal and child health, and epidemic preparedness

U.S. health initiatives have made a contribution throughout history that highlights the potential impact. The Presidential Emergency Plan on AIDS Relief (PEPFAR) has helped millions of people to receive HIV treatment, empowered 7.8 million HIV-free babies to be born, and empowered over 342,000 direct health workers to work all over the world. These results indicate how sustained external funding is transformative in fortifying health systems and enhancing health in populations. Moreover, the move to government-to-government financing and co-investment may enhance national ownership and domestic integration of health programs. Such a strategy can lessen the fragmentation of donor-driven initiatives and enhance institutional capacity in the public health systems, which is recommended in the global ideas of strengthening health systems on country-level.

These advantages, however, are conditional upon how the agreements are designed and executed. The same characteristics that are designed to enhance sustainability, such as co-financing requirement, performance standards, and centralized implementation can also burden national systems when not supported by national capability. In this way, although the agreements are unambiguously offering good health prospects, their long-term contribution will be determined by whether they solidify national ownership or bring new types of dependency and foreign control.

Sovereignty and Security Implications

The emerging U.S.–Africa bilateral health agreements raise significant sovereignty and security concerns, particularly in relation to data control, biosecurity, and strategic influence over national health systems. While these partnerships provide opportunities for enhanced technical assistance and financial support, their design may introduce asymmetries that compromise African countries’ control over critical health resources. These concerns can be understood across three interrelated dimensions:

Data Sovereignty

The issue of health data governance poses a serious challenge to sovereignty. Many agreements involve the sharing of epidemiological data and genomics data among different states, often through a digital platform that may be hosted outside the nation’s borders. This poses a serious issue of digital sovereignty, where a nation may end up losing control over population health data to another foreign nation. Many African states lack strict laws to govern the use of data, making them vulnerable to exploitation by foreign powers. According to the Data Policy Framework, African states have a serious mandate to localize data and protect it from foreign exploitation for the betterment of their nation’s innovation and planning.

Biosecurity and Pathogen Sharing

Also, the provisions regarding the sharing of pathogens included in the agreements have biosecurity implications. Global health cooperation requires the prompt sharing of biological materials. However, the unequal sharing of benefits may put African countries at a disadvantage. The COVID-19 pandemic experiences have shown how African-derived information and biological samples have contributed to global health benefits without access to developed technologies. The World Health Organization has recognized the need to ensure fair access to pathogens and benefit-sharing. However, the agreements need to ensure that African countries have control over biological resources and access to benefits proportionate to their contribution.

Policy autonomy and external Influence

The strategic implications of outside influence on national health systems are considerable. However, funding and technical assistance may influence national health priorities, often at the expense of local needs. This can result in a kind of “policy dependency” wherein national health priorities are more closely aligned to outside interests than to local needs. In fact, the Brookings Institution states: “External sources of finance for the continent have an implicit policy influence, constraining local decision-making. In Africa today, growing partnerships have the potential to limit local decision-making capacity. In the long term, this may limit the autonomy of national health systems and the ability of local governments to address emerging health challenges independently.

In sum, while U.S.–Africa health agreements offer important opportunities for strengthening health systems, they also pose significant sovereignty and security risks. Addressing these requires robust national regulatory frameworks, stronger regional coordination through bodies such as the Africa CDC, and the negotiation of more balanced agreements that prioritize data protection, equitable benefit-sharing, and policy independence.

Economic and Development Implications

External health financing and fiscal commitments

Current U.S. bilateral health agreements with African countries reflect strategic economic interests of external partners and redefines how financial resources are allocated and used. Although this funding is provided in the form of grants, it is accompanied by indirect fiscal obligations, including co-financing requirements, long-term operational costs, and commitments to sustain donor-initiated programs. For instance, within the next five years the US Department of states together with the Congress plans to provide about $400 million in health assistance to Cameroon. On the other hand Cameroon has committed to increase its own health expenditures by $450 million. This can create fiscal pressures or further reinforce dependence on external financing, potentially constraining national budgetary flexibility.

In addition, procurement structures within these agreements may favor foreign contractors, limiting opportunities for domestic private sector participation and reducing potential spillover effects for local economic development. Across subSaharan Africa, health systems already import between 70% and 90% of health products, reinforcing dependence on external manufacturers and weakening the potential for domestic firms to capture value added, create jobs, and build regional health product markets. This raises important concerns about the extent to which such partnerships contribute to sustainable, inclusive growth beyond the health sector, particularly when procurement rules are not aligned with national industrial and employment boosting objectives.

Conditionality and potential influence on domestic policy priorities

While U.S. health partnerships deliver clear development benefits, emerging evidence suggests that some bilateral health agreements are negotiated alongside, or in parallel with, resource and mining-related engagements. This raise concerns that health financing may be leveraged to advance U.S. economic and geopolitical priorities.

U.S. funding tied to measurable domestic co-financing commitments, performance benchmarks, and governance conditions, constrain the policy space of African states and may not align with national health and development strategies. U.S. linking billions of dollars in health financing to large increases in domestic health budgets and specific performance targets, shift substantial fiscal and administrative burdens onto partner states while preserving U.S. discretion over continued funding and program direction. Although these agreements could improve accountability and efficiency, they also condition African health sovereignty on donor defined priorities. Over time, this may constrain policy autonomy and reduce national ownership of development agendas.

Policy Recommendations

1. African governments should adopt and enforce robust legal frameworks governing health data and genomic information, including restrictions on cross-border data transfer, mandatory local storage, and clear rules on ownership and access. This will ensure that health data remains a strategic national asset rather than an externally controlled resource.
2. African governments should formally separate health cooperation agreements from negotiations on mining, natural resources, and strategic sectors. This “firewall” approach will prevent the implicit or explicit bundling of health financing with mineral access or economic concessions, thereby safeguarding national sovereignty and negotiating integrity.
3. All bilateral health agreements should be subject to public disclosure, independent review, and parliamentary approval. This will strengthen democratic accountability and ensure that provisions related to data sharing, conditionality, and external influence are scrutinized before implementation.
4. African Union and Africa Centers for Disease Control and Prevention should establish standardized negotiation guidelines and model clauses for external health partnerships. A coordinated continental approach will strengthen Africa’s collective bargaining power and reduce fragmented, country-by-country agreements that weaken negotiating positions.
5. African governments should embed U.S. bilateral health agreements within comprehensive national financing frameworks to ensure alignment with domestic priorities and long-term fiscal sustainability. This can be done by integrating external health funding into national budgets, medium term expenditure frameworks, and national health strategies, while clearly identifying recurrent cost obligations associated with externally funded programs.

Conclusion

The bilateral health agreements between the U.S and Africa stand out as an important milestone but without stronger governance safeguards, these agreements risk evolving into instruments of external influence that extend beyond the health sector into broader economic and geopolitical domains. Stronger safeguards and coordinated African action are essential to ensure these partnerships remain equitable and aligned with long-term development priorities.