Across Africa, health is not merely a policy priority but a fundamental determinant of life, livelihood, and human security.
Yet in 2026, the very meaning and practice of “health cooperation” have become increasingly contested — not primarily within clinics and communities, but in national capitals, foreign ministries, and regional multilateral institutions.
A new generation of United States bilateral health agreements, advanced under the banner of the “America First Global Health Strategy,” has ignited intense and polarising debate across the continent.
Some governments have embraced these arrangements as a means to address urgent health financing gaps; others have rejected them outright.
What is at stake extends far beyond funding, medicines, or technical support.
At its core, the contestation revolves around national sovereignty, institutional dignity, and the future of African ownership and control over public health governance.
Under this America first global health framework, Washington has pursued a series of bilateral health Memoranda of Understanding (MOUs) with African governments, offering targeted financial support for priority health challenges. These include the fight against HIV and Aids, malaria, tuberculosis, maternal and child mortality, as well as national and regional preparedness for pandemic outbreaks.
Countries across east, west, and southern Africa — including Kenya, Rwanda, Uganda, Nigeria, Cameroon, Côte d’Ivoire, Lesotho, Liberia, Mozambique, and Ethiopia — have either signed these agreements or are engaged in active negotiations.
While such initiatives respond to genuine and pressing needs within under-resourced African health systems, the structural design and accompanying conditions of these deals have emerged as a source of deepening unease.
These bilateral health arrangements have not been universally welcomed or accepted.
In Zimbabwe and Zambia, governments have publicly declined substantial health assistance packages worth hundreds of millions of US dollars, citing principled concerns over national sovereignty and potentially inequitable or intrusive terms.
Zimbabwe chose not to proceed with bilateral negotiations on a proposed US$367‑million MOU after raising concerns over provisions that would grant external actors access to sensitive national health data, alongside legitimate fears of diminished sovereign control over the direction and governance of its own health systems.
In Zambia, negotiations stalled following public and official pushback against stringent data‑sharing clauses, as well as widespread perceptions that broader strategic and commercial interests were being advanced under the rhetorical cover of health cooperation.
These high‑profile rejections are not isolated or idiosyncratic decisions; they reflect a broader and intensifying continental trend: a rising African awareness and resistance to external assistance framed with non‑health‑related political or economic strings.
The Africa Centres for Disease Control and Prevention has publicly articulated significant reservations regarding provisions related to data and pathogen sharing in certain external health pacts, warning of the risks associated with inadequate governance, unauthorised use, or potential exploitation of sensitive national health information. Civil society organisations, health practitioners, and policy analysts across the continent have criticised such approaches as structurally lopsided, lacking transparency, and inconsistent with the ideals of sovereign partnership and mutual respect.
On the surface, bilateral health cooperation represents a seemingly laudable response to the daunting burdens facing health systems across Africa.
Yet when situated within the ideological and strategic framework of “America first,” such initiatives increasingly resemble transactional geopolitical instruments rather than expressions of multilateral solidarity or altruistic development assistance.
The US strategy deliberately shifts emphasis away from longstanding multilateral platforms — most notably the World Health Organisation (WHO), which has traditionally embodied shared global norms and collective governance — and toward direct state‑to‑state deals that prioritise American regulatory preferences, strategic priorities, and access to health data.
This shift raises meaningful and legitimate concerns on several interrelated grounds.
First, it risks replacing the ethos of global health solidarity with rigid and often coercive conditionality.
Historically, much Western development assistance has incorporated implicit or explicit political and economic conditions, ranging from market access requirements to regulatory alignment and governance conditionalities.
When a major global power ties health funding to access to national disease surveillance systems, demands for domestic policy reform, or alignment with external commercial and geopolitical goals, such arrangements risk replicating and entrenching unequal power relations under the benign language of partnership.
Second, such narrowly bilateral approaches carry tangible risks for pan‑African health governance.
*Mafa Kwanisai Mafa, is a Pan-Africanist political commentator based in Gweru, Zimbabwe.