As the US ties global health cooperation to strategic interests such as data and critical minerals, African countries are pushing back to secure more equitable and sustainable terms
The United States (US) rolled out its new global health agenda — the America First Global Health Strategy (AFGHS) — in September last year. Since its introduction, the US has entered into agreements with over two dozen countries in Africa and Latin America. The strategy seeks to address shortcomings in development assistance for health. It signals that US health cooperation is increasingly being structured through bilateral arrangements, in which geopolitical considerations — from access to pathogen information and health data to critical minerals — play a prominent role. While the US is expanding bilateral arrangements, the trajectory of the AFGHS has yet to be shaped, as it unfolds at a time when African countries are beginning to adopt a more assertive posture in multilateral global health negotiations, slowly positioning themselves to negotiate on more equitable terms.
US engagement in global health had shifted considerably over the past year, most notably with its withdrawal from the World Health Organization (WHO) and the severe restructuring and funding cuts to the United States Agency for International Development (USAID) and the President’s Emergency Plan for AIDS Relief (PEPFAR). These initiatives, often working alongside multilateral bodies, have extensively funded large-scale programmes addressing HIV, tuberculosis (TB), malaria, and vaccine coverage across low- and middle-income countries (LMICs). They have, however, been criticised for a lack of integration into national health systems and for creating siloed health data systems and parallel supply chains. In this context, the AFGHS is positioned as a remedy to address these concerns.
The AFGHS aims to mitigate these issues by gradually transitioning away from foreign aid dependency towards co-financing arrangements and time-bound bilateral contracts. It emphasises greater national ownership and self-reliance, with a strong preference for public-private partnerships. Since its launch, the US has entered into 26 bilateral arrangements with countries in Africa and Latin America. Collectively, these agreements include US$20.4 billion in new funding, with US$7.7 billion as co-investment from recipient countries. Most of these countries were previously recipients of aid from USAID and PEPFAR.
The AFGHS aims to mitigate these issues by gradually transitioning away from foreign aid dependency towards co-financing arrangements and time-bound bilateral contracts. It emphasises greater national ownership and self-reliance, with a strong preference for public-private partnerships.
Uganda serves as a relevant example of how the new strategy is being operationalised. Under a five-year cooperation agreement valued at approximately US$2.3 billion, the partnership focuses on strengthening infectious disease outbreak surveillance and response mechanisms, advancing the country’s health digitalisation efforts, and supporting Uganda’s health workforce. It aims to shift responsibility for health financing to the national government, thereby building a resilient and self-reliant health system.
Apart from addressing long-standing developmental concerns, these agreements reveal a major policy shift, signifying what may become a new era in US engagement in global health. Health cooperation under the AFGHS is increasingly intertwined with geopolitical considerations, with negotiations coinciding with parallel discussions on critical minerals and data access. Several of these agreements have been paused, challenged, or entered into renegotiation.
A prominent example is the agreement signed with the Democratic Republic of Congo (DRC). Facing recurring outbreaks of Ebola and mpox, the country requires sustained health assistance — including an integrated national disease surveillance system and high-quality laboratory networks — to combat these emerging health threats. While negotiations on the agreement had been underway for months, the final memorandum of understanding (MoU) was signed only in late February, following the conclusion of a strategic partnership agreement ensuring the flow of critical minerals from the DRC to the US.
This insistence on securing the supply of critical minerals and linking it with health assistance is not surprising. The AFGHS document frames US health assistance in Africa as a counterbalance to China’s footprint and interests in the region.
Washington’s intent to strengthen its partnerships with mineral-rich African countries demonstrates its effort to diversify supply chains and reduce its dependency on China for critical minerals. This insistence on securing the supply of critical minerals and linking it with health assistance is not surprising. The AFGHS document frames US health assistance in Africa as a counterbalance to China’s footprint and interests in the region. Notably, critical minerals have become vital strategic assets in global supply chains, with applications in emerging technologies, the energy transition, and national security. The US National Security Strategy (NSS), released in December 2025, outlines their importance. Africa holds approximately 30 percent of global critical mineral deposits, making it a site of geopolitical rivalry between the US and China. China has heavily invested in Africa’s mining operations and accounts for refining about 70 percent of lithium and cobalt, and 90 percent of rare earth elements and graphite.
The AFGHS agreement with Guinea followed a sequence similar to that of the DRC, where the MoU followed a partnership agreement on critical minerals. This underscores how critical minerals have emerged as a focal point in health assistance negotiations. While, in the last two months, the supply of rare earth minerals from the DRC to the US has been initiated, the partnership over critical minerals is currently being challenged in court in the DRC over its constitutional validity, as it provides Washington preferential access to Congolese mineral reserves and enables direct US oversight in the management of the country’s mining sector.
In addition to critical minerals, access to health data and pathogen information has also been included in negotiations. The MoU signed with Kenya has been paused and is now under litigation after objections were raised over clauses that grant the US access to pathogen information and patient health data. A US$1 billion agreement with Zambia is being renegotiated, as it entails the sharing of the country’s health data for 10 years despite the memorandum’s five-year validity period, and is contingent on collaboration with the US in the mining sector. The agreement with Zimbabwe raised similar concerns and was described as ‘asymmetrical’, as it included unrestricted US access to health data without reciprocity, no guarantees on benefit-sharing, and demands for access to minerals, particularly lithium.
The AFGHS agreement with Guinea followed a sequence similar to that of the DRC, where the MoU followed a partnership agreement on critical minerals. This underscores how critical minerals have emerged as a focal point in health assistance negotiations.
Some agreements also include clauses enabling health programmes to be paused or terminated if they fail to align with US national interests. The agreement with Nigeria — a US$5.1 billion health cooperation package over five years — accords primacy to Christian faith-based healthcare service providers and underscores US expectations that Nigeria address alleged religiously motivated violence against Christian communities. These examples illustrate how the AFGHS is being operationalised in a manner that links health cooperation negotiations with broader geopolitical objectives — particularly critical minerals and data governance — raising questions about the sustainability of these arrangements.
These arrangements raise concerns about the fragmentation of the African continent’s bargaining power and the weakening of its regional surveillance and response mechanisms. Agencies such as the Africa Centres for Disease Control and Prevention (Africa CDC), an autonomous body with coordinating authority, have been sidelined from the bilateral health arrangements. To ensure continental coordination, Africa CDC is engaging separately with US policymakers; however, the risk of creating parallel systems that hamper regional coordination persists.
Further, with data emerging as a strategic resource in global health, there are concerns that data shared by African countries may be accessed by US pharmaceutical companies, used to develop new drugs or technologies, and subsequently sold back to the originating countries at prices higher than those in US markets. Such an outcome would undermine efforts led by African institutions to develop regional manufacturing capacity and reduce inequities in pharmaceutical markets.
The most recent draft text of the PABS was rejected by African countries, as it obliges member states to share pathogen information in a timely manner without guaranteeing commensurate benefits. While minimal provisions for vaccines, therapeutics, and diagnostics (VTDs) are obligatory during pandemics, the draft does not impose a legal obligation on pharmaceutical companies to supply VTDs during a public health emergency of international concern (PHEIC).
These developments are further complicated by negotiations over the annex to the WHO Pandemic Agreement — the Pathogen Access and Benefit-Sharing (PABS) mechanism. Countries such as Zimbabwe, which have been active in the PABS negotiations, have expressed concern about how bilateral agreements on pathogen information-sharing and access to benefits will align with, or potentially conflict with, the PABS framework once it is finalised.
The most recent draft text of the PABS was rejected by African countries, as it obliges member states to share pathogen information in a timely manner without guaranteeing commensurate benefits. While minimal provisions for vaccines, therapeutics, and diagnostics (VTDs) are obligatory during pandemics, the draft does not impose a legal obligation on pharmaceutical companies to supply VTDs during a public health emergency of international concern (PHEIC). Instead, it leaves access and benefit-sharing negotiations to individual countries, the WHO, and pharmaceutical manufacturers, thereby significantly weakening member states’ bargaining power and undermining the principle of equitable health outcomes.
Previous analyses of the AFGHS have highlighted the strategy’s emphasis on a commercially driven approach, in which US technological innovation and public-private partnerships play a central role. The recent agreements reveal another dimension — namely, how health cooperation is increasingly intertwined with broader geopolitical considerations aimed at safeguarding US interests.
At the same time, an emerging theme across these negotiations is the resistance of African countries to the creation of a system in which health benefits are discretionary or inequitably distributed. This signals a transformation in the global health order, with African countries asserting their interests in both bilateral and multilateral forums. In this context, the AFGHS illustrates how the contours of global health governance are evolving to balance public health objectives with strategic considerations. Its trajectory will depend not only on US geopolitical priorities, but also on how effectively African countries leverage their position to secure equitable and sustainable healthcare arrangements.
Lakshmy Ramakrishnan is an Associate Fellow with the Centre for New Economic Diplomacy at the Observer Research Foundation.
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Lakshmy is an Associate Fellow with ORF’s Centre for New Economic Diplomacy. Her work focuses on the intersection of biotechnology, health, and international relations, with a ...
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