Last month, Zambia pushed back on a proposed $1 billion-plus US health agreement, saying key provisions did not align with national interests. Zimbabwe also suspended talks over what it called a “clearly lopsided” $367 million deal. In Kenya, a $1.6 billion agreement remains frozen after the High Court halted implementation pending review.
This is not a run of isolated disputes. It is an argument over what global health partnership should look like in 2026 — and who sets the terms.
The new compacts flow from the “America First” global health strategy unveiled last year. Their premise is straightforward: shift from US-managed delivery toward host government ownership. On paper, that evolution is overdue. African public health capacity has grown. Governments want more control. The strategy correctly recognizes that dependency on donor-run parallel systems is not sustainable.
It also acknowledges real problems. Commodity diversion has been a genuine issue, with repeated scandals involving stolen or resold donated medicines. The heavy reliance on US-funded NGOs hiring parallel staff for specific programs — to meet US reporting requirements — created vertical systems that often distorted national priorities. Co-financing requirements, meanwhile, are not novel; they have been embedded in key assistance programs for years. These new agreements should build on that momentum, not present co-investment as a fresh imposition.
Channeling funds through African government systems can work. In northern Uganda, USAID’s post-conflict reconstruction work was implemented through local government structures, backed by independent monitoring and support for domestic revenue. The result was improved service delivery and stronger accountability. But it took years. Unwinding entrenched systems responsibly takes time too.
The friction now is not about the concept of transition. It is about the conditions attached — and the speed demanded.
In Zambia, sources told Reuters that the health compact was linked to a separate mining collaboration proposal advanced by Secretary of State Marco Rubio, with a deadline attached. Zimbabwe has raised concerns about provisions requiring long-term sharing of biological resources and data without guaranteed reciprocal access to resulting vaccines or treatments. As Jean Kaseya, head of the Africa CDC, has put it: Africa wants to own its data — and its future. Ten-year data-sharing arrangements embedded in five-year agreements create obvious asymmetries for governments trying to build domestic pharmaceutical and research ecosystems.
Then there is the money. Analysis by the Center for Global Development suggests signed agreements represent, on average, roughly a 49% drop in annual US support compared with 2024 levels, with countries expected to fill the gap within five years. For governments already grappling with debt stress and tighter fiscal space, that is a steep and compressed adjustment. Transition to integrated national systems requires careful sequencing, budget planning, and political buy-in. It cannot be rushed to meet an arbitrary deadline.
The risk is that a strategy meant to promote ownership ends up functioning as leverage. Health compacts framed explicitly within geopolitical competition — particularly with China — risk eroding decades of goodwill. Since 2001, the US has spent more than $200 billion on global health, saving millions of lives. That legacy is real. But if life-saving assistance is seen as contingent on mining concessions or market access, the dynamic shifts quickly from partnership to pressure.
There is still time to recalibrate. Health agreements should stand on their own merits, delinked from extractive or trade concessions. Data governance needs to be genuinely reciprocal, with co-ownership and guaranteed access to resulting innovations — ideally structured through the Africa CDC. Transition timelines should include built-in review points to assess fiscal feasibility and adjust expectations based on country capacity. And accountability must come paired with technical support. Dismantling oversight infrastructure without replacing it feels punitive. Support without accountability invites waste. Durable partnerships require both.
The broader ambition — moving beyond donor dependency toward national ownership — is sound. But Zambia, Zimbabwe, and Kenya are not rejecting partnership. They are contesting the terms. At a moment of intensifying geopolitical competition across Africa, Washington faces a choice: treat these objections as resistance, or as feedback on how to build a more balanced compact.
If the goal is genuine ownership, then listening is not a concession. It is the strategy.
Daniele Nyirandutiye manages the emerging markets portfolio at Desmos and a former USAID and White House official.