The America First Global Health Strategy (AFGHS), launched in late 2025, shifts US aid from multilateral financing to bilateral, incentive-based agreements that require partner countries, particularly in Africa, to co-invest domestic resources toward self-reliance by 2030. Presented as a bold $18 billion expansion, the initiative is framed as a renewed commitment to country-led development, an approach the United States began moving away from in the last decade. On paper, the figures appear appealing to governments.

However, on closer inspection, these agreements reveal two key issues: high conditionality for limited return, and weak alignment with development effectiveness principles. Assessed directly against the four core principles of development effectiveness – country ownership, focus on results, inclusive partnerships, and transparency and mutual accountability. These agreements raise significant concerns, pointing away from traditional grant-based support and towards a more transactional, conditional, and strategically aligned model.

First, the agreements require significant conditions, both in co-financing and beyond the health sector, raising immediate concerns around country ownership and transparency and mutual accountability. Governments are expected to mobilise substantial domestic resources, sometimes matching or exceeding US contributions, while agreeing to provisions on data sharing, governance reforms, and broader alignment:

1. Mozambique, committed to increasing its national health budget by nearly 30 percent over five years.
2. Botswana, is expected to co-finance approximately $381 million, covering 78 percent of its agreement, despite declaring a public health emergency following US funding cuts.
3. Kenya’s High Court suspended its agreement over concerns around data protection and lack of parliamentary oversight.
4. Zimbabwe rejected its deal outright, citing sovereignty infringement risks.
5. Zambia has entered renegotiations over bundled provisions linking health financing to regulatory reform and expanded access to its mineral sector. Internal US discussions referenced the “use of sticks”  ”, including threats to withhold existing HIV funding to compel agreement.

Second, the agreements raise serious concerns that reduced and more conditional funding may undermine the ability to deliver strong and focused results, ultimately weakening service delivery outcomes rather than strengthening them. Despite large headline figures, US support has declined sharply. Across 23 countries, annual US health assistance has declined from approximately $16.3 billion under previous programmes to just under $3 billion under AFGHS arrangements, a reduction of roughly 82 percent. While total deal values appear substantial, they combine US contributions with domestic financing, masking a sharp contraction in direct US support.

Third, by concentrating engagement at the state level and extending conditions beyond health, these agreements undermine the principle of inclusive partnerships. This shift narrows the range of actors involved in health delivery, moving away from the broader ecosystem of multilateral institutions, NGOs, and local civil society that has historically underpinned US support, and risks sidelining key delivery partners. It also calls into question the US claim to be the most “generous nation” on earth, particularly given its failure to meet the 0.7 percent UN ODA target since 1970 and its shift toward smaller, more conditional forms of support.

If this model represents the future of US–Africa health cooperation, its effectiveness remains uncertain. For the 31 countries yet to engage, negotiations must anchor in development effectiveness principles, with stronger country ownership, greater transparency, and a clear focus on health outcomes. Governments should push for fewer, more targeted conditions and more predictable budget support aligned with national priorities.

Without such adjustments, these agreements risk entrenching a more transactional model, defined by reduced financing, expanded conditionality, and uneven power dynamics — not an expansion of solidarity, but a redefinition of it.

Acknowledgments:
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Special thanks go to Teta Mukulira for her work on the graphics and for collecting/analysing the underlying data and this accompanying article.

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