U.S. Cuts Health Aid and Ties It to Funding Pledges by African Governments

The State Department is negotiating agreements with countries across the developing world to provide billions of dollars in health aid, an effort intended to replace the system of global health assistance that had for decades been offered through the now-dismantled U.S. Agency for International Development.

Over the past month the U.S. has signed agreements with 16 African countries to provide more than $11 billion in health aid over the next five years, and is negotiating dozens more deals with governments in Asia and Latin America as well as Africa.

The new commitments represent a steep drop in the health aid that the United States contributed before President Trump ordered a review of foreign assistance on his first day in office last year. According to an analysis by the nonprofit Partners in Health, health funding under the agreements would drop by 69 percent to Rwanda, 61 percent to Madagascar, 42 percent to Liberia and 34 percent to Eswatini, where a quarter of adults live with H.I.V.

Nevertheless, the deals are being welcomed by governments and some analysts in Africa as a significant shift that could increase country autonomy and make health systems stronger and less reliant on international largess. Others, however, say the agreements were negotiated with countries that had no leverage and demand conditions that are unattainable, especially in places where people are most in need of help.

The deals are guided by the administration’s global health strategy, announced in September, which emphasizes health spending that it says serves to make the United States safer and more prosperous. In Zambia, where negotiations are stalled, Washington is seeking to tie access to U.S. health funding — on which Zambia relies heavily to run a huge H.I.V. treatment program — to the signing of a separate deal for U.S. access to the country’s vast mineral resources. The proposed deal cuts Zambia’s health funding from the United States by more than 50 percent.

Jeremy Lewin, acting under secretary of state for foreign assistance, humanitarian affairs and religious freedom, said the agreements are the first phase of a reimagining of a failing and dysfunctional foreign aid system.

“That system was failing American taxpayers who were going to fund this in perpetuity,” Mr. Lewin said in an interview with The New York Times. “It was failing countries who didn’t have control over their own health sovereignty and their own health destinies. And it was failing patients, because ultimately we can only reach so many people with our foreign assistance funding and the thing that’s going to produce the best health outcomes for people in these countries is going to be for their national governments to build the capacity to take care of those populations.”

The overall large drop in the funding deals contrasts sharply with a push from Congress, where the House voted overwhelmingly on Wednesday to maintain funding for global health near the level it was in past years. The Senate will take up the bill later this month; the legislation proposes $9.4 billion in global health funding for the 2026 fiscal year, more than twice the $3.8 billion the administration had said it intends to spend.

The administration’s new mode of providing health aid differs significantly from the previous funding model. Now U.S. support is being conditioned on a cofinancing commitment from the partner country — Washington will give Nigeria about $2 billion over five years, for example, if the Nigerian government increases its current health budget by $3 billion in that period. In many cases, the new commitments that governments are making represent a large hike in their health spending — and it’s not clear, in countries with faltering economies and huge debt burdens, where those funds will come from.

“We will be punished sorely if the terms of the agreement aren’t met,” said Gift Trapence, who chairs a network of H.I.V. organizations in Malawi. “Yet Malawi is already struggling to finance its health system.” U.S. funding to Malawi will be cut by 35 percent.

The agreements frame the U.S. support as a direct exchange with the African governments, reducing or eliminating the role of nongovernmental organizations. Mr. Lewin and others at the State Department have been harshly critical of the large aid organizations — known as “implementing partners” — that the United States contracted to do much of the global health work it funded in the past.

Under that system, U.S.A.I.D. contracted those organizations to deliver goods and services in partner countries, sometimes working with the local health ministry, while other times acting independently. Trump administration officials have repeatedly characterized those organizations as a development mafia, saying they charged exorbitant overhead fees and were more preoccupied with ensuring their own survival than with helping countries end their reliance on foreign aid.

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Under the new deals, more funds will go directly to governments to deliver services, and when they need the support of partners, they will choose them with the United States and have clarity about their budgets. The lack of transparency around those budgets, and the ability of implementing partners to set heath agendas, have been points of frustration for recipient governments in the past.

“There’s nothing not to like here,” said Ebenezer Obadare, a Nigerian analyst of African politics at the Council on Foreign Relations. “If there is any part of this that does not work for any African government, they are entitled to walk away.”

But Dr. Musoba Kitui, the Nairobi, Kenya-based regional director for a health rights advocacy group, said it was absurd to suggest that this was a fair negotiation between nations. After the United States abruptly froze funding to Kenya a year ago, “the health system was on its knees, and that vulnerability made it very likely that the state would sign on to any conditions, just to get some money into the Ministry of Health,” he said. Kenya’s funding from the United States will decline by 20 percent.

The deals have been negotiated under intense time pressure and with limited transparency. In Cameroon, the heads of key government health departments were unsure talks were even taking place until they learned a deal had been signed. In Kenya, the deal was negotiated with the Kenyan Treasury, and senior figures in the health ministry did not know its content until it was signed.

The compacts mean governments should be able to better integrate their health systems instead of having H.I.V. services run through one channel of U.S. funding, and malaria services another, said Dr. Kitui, who works with Ipas Africa Alliance. But what’s lost is the kind of solidarity that U.S.A.I.D. used to provide for marginalized communities — for women and girls, for people living in informal settlements or rural areas whose needs are often neglected by government. U.S.A.I.D. funded projects that provided health care to queer communities in places such as Uganda where homosexual activity is criminalized or persecuted.

Dr. Kitui said there is deep concern that the new deal could restrict abortion access, overriding national policies on reproductive health. A 1973 U.S. law prohibits the use of American foreign assistance funds to pay for abortion as a method of family planning, or to motivate or coerce any person to practice abortion. While abortion in Kenya is legal only when deemed necessary for the life or health of the pregnant woman, in practice medical personnel interpret this broadly and include the ways mental health can be undermined by an unwanted pregnancy.

Now, though, any aspect of the Kenyan health system that is getting U.S. funding support — such as the national medication supply chain — would theoretically be prohibited from supporting abortion, such as by stocking medications.

The new agreements will do more government-to-government transfer in countries where there is perceived to be greater transparency, and will continue to rely on “implementing partners” in places where accountability is weaker, Mr. Lewin said. The “implementing partner” model was developed in part because of concern about high levels of corruption in some developing countries’ governments, and fear of theft or waste of resources that were U.S. taxpayer contributions.

“We don’t see any way to make sure how this money is being used,” said Olivia Ngou, the director of Impact Santé Afrique, a health advocacy organization in Cameroon — a country with high corruption and an opaque, autocratic government.

Mr. Lewin said the new system will have strict audit requirements, and that if theft or graft is detected, the funding deals could be suspended or terminated.

Some of the negotiations have tied in explicit U.S. economic and foreign policy goals to the new health spending. The deal with Nigeria obliges the government to take steps to protect Christian victims of Muslim violence. (It says nothing about protecting Muslim victims; the majority of those who suffer at the hands of militant Islamist groups such as Boko Haram are themselves Muslim.)

A high court in Kenya has suspended implementation of the agreement while it evaluates concerns that several clauses violate Kenyan law. Under scrutiny are a provision that requires Kenya to send pathogen samples to the United States for 25 years — decades after the terms of the deal expire — and another that gives the United States access to national health data. (Other agreements made public also have this requirement.)

Terms for the sharing of pathogen samples was a key sticking point in negotiations for the global “pandemic treaty,” signed last year. African countries as a bloc demanded a requirement in that deal that if they shared information on pathogens, such as a virus causing a pandemic, they would also receive guaranteed access to any vaccines or treatments derived from those samples. The demand reflected frustration that Africa had largely been shut out of access to Covid shots for more than a year after they began to be widely used in industrialized countries, even though samples from Africa had contributed heavily to vaccine development.

In Madagascar, the loss of U.S. aid over the past year has crippled an already weak health system. The United States supplied most of the malaria tests and treatments in the country, and much of the contraception — all of which has been in short supply.

“We see easily treatable cases of simple malaria evolving to become severe and in some cases fatal,” said Laura Cordier, director of Pivot, a Malagasy rural health organization. The new deal for U.S. funding has come more quickly than people in the country expected, she said, but a reduction of two-thirds in that funding is harsh news. “We were already trying to do the impossible with not enough,” she said.

Stephanie Nolen is a global health reporter for The Times.

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