Leverage and Constraint: African Agency under the America First Global Health Strategy

Nelson Aghogho Evaborhene on the latest attempt to present strategic allocation as technical reform. 

As Washington recasts its global health agenda, the America First Global Health Strategy (AFGHS) has been framed as a recalibration designed to enhance sustainability, national ownership, and efficiency in global health cooperation. It responds to longstanding concerns about aid dependence, fragmentation, and weak domestic accountability by prioritizing time-bound bilateral health compacts, accelerated domestic co-financing, and clearer transition pathways away from external support.

In principle, these objectives are neither novel nor objectionable. African policymakers have long called for stronger national systems and reduced reliance on donor funding, a position reinforced during the Accra Reset hosted by Ghana in August 2025 following retrenchment. Yet in practice, the AFGHS has produced sharply uneven outcomes across the continent. To date, at least fourteen African countries have entered bilateral health compacts, with total commitments exceeding US$7 billion. Some countries have secured large, flexible, and politically insulated agreements, while others face rigid benchmarks, compressed timelines, and heightened exposure to funding volatility and service disruption.

This divergence is not explained by differences in health need, epidemiological burden, technical performance, or administrative capacity. They reflect a deeper shift in how health assistance is allocated. Alignment now produces flexibility. Misalignment produces exclusion. African agency under the AFGHS is real, but conditional, uneven, and increasingly detached from health system performance.

The strategy is therefore not merely a technical adjustment to aid architecture. It is a political reordering of global health cooperation, where financing is subordinated to broader bargaining priorities, continental institutions are marginalised, and national health systems assume greater responsibility while absorbing greater risk.

Alignment, Leverage, and the New Aid Hierarchy

Uganda illustrates how strategic alignment converts into advantage under the AFGHS. It is neither the strongest health system nor the most fiscally stable, yet it secured one of the largest compacts: nearly US$2.3 billion in U.S. funding with over US$500 million in domestic co-investment. The agreement explicitly supports faith-based providers and health services linked to the military. This outcome reflects Uganda’s role as a regional security anchor. Its forces are central to peacekeeping, counterterrorism, and stabilisation across East and Central Africa, including corridors tied to critical minerals. Within this bargain, flexibility, lenient benchmarks, and sustained engagement become politically viable.

This alignment persists despite domestic political deterioration. Ahead of recent elections, authorities in Kampla restricted civic space, expanded military jurisdiction over civilians, and limited communications. These developments raised concerns about democratic integrity, yet they did not disrupt health cooperation. Alignment insulated the partnership from governance costs.

Kenya presents the inverse case. It has capacity but limited leverage. It signed the first compact, a five-year framework worth about US$2.5 billion, including US$1.6 billion from the U.S., yet the terms proved rigid. Co-financing was front-loaded, and data-sharing provisions triggered constitutional challenges. In late 2025, Kenya’s High Court suspended parts of the framework after civil society groups argued it violated constitutional and data protection standards. Kenya is a valued partner, but not indispensable. Unlike Uganda, which anchors U.S. regional security operations, Kenya’s contribution to peacekeeping in Haiti did not translate into bargaining power.

Zambia illustrates a different pathway to influence leverage through friction. In May 2025, the U.S. suspended roughly US$50 million in health aid, citing mismanagement of antiretroviral drugs. Later that year, negotiations over Zambia’s health compact stalled over U.S. demands for access to strategic minerals. The delay generated political pressure and service uncertainty, but it also created leverage. By slowing the process, Zambia forced health financing into a broader economic and geopolitical negotiation. Under the AFGHS, countries that can tolerate uncertainty and bargain with strategic assets gain influence, while those reliant on uninterrupted assistance face exposure and conditionality.

Eswatini and Liberia offer a stark contrast that exposes how alignment outweighs scale and need. Eswatini, a small state of approximately 1.25 million people, accepted U.S. deportees in November 2025 under a controversial third-country deportation programme despite legal challenges and human rights objections. The government received US$5.1 million in exchange for accepting up to 160 deportees. Shortly thereafter, Eswatini entered a US$242 million compact, including US$205 million in U.S. funding and US$37 million in domestic co-investment.

Liberia presents a different picture. With a population of roughly 5.7 million, its health system continues to recover from the Ebola epidemic. Maternal mortality remains among the highest globally, and child mortality strains national capacity. Yet Liberia secured approximately US$124 million in support, focused largely on infectious diseases, surveillance, and outbreak response, roughly half the scale of Eswatini’s compact. Other large, high-capacity states illustrate that scale and technical performance do not automatically translate into bargaining leverage.

Outliers: when need and capacity buy nothing

Two cases sit conspicuously outside the AFGHS engagement map: South Africa and the Sahelian junta states, comprising Burkina Faso, Mali, and Niger. Their exclusion is analytically revealing.

South Africa carries one of the highest HIV burdens globally and has long been a cornerstone of U.S. global HIV programming. It also possesses the continent’s most advanced public health infrastructure, robust regulatory capacity, and substantial domestic health financing. Under any needs-based or performance-oriented framework, it would be a priority partner. Yet South Africa has not been invited.

This exclusion unfolds amid a high-profile legal and diplomatic confrontation. In December 2023, South Africa brought a case against Israel to the International Court of Justice, accusing it of genocide in Gaza, a claim the court found plausible and continues to adjudicate. These proceedings, alongside President Trump’s public accusations alleging genocide against white citizens in South Africa, sharply deteriorated bilateral relations. U.S. HIV funding was suspended, and the United States subsequently boycotted the G20 summit hosted by Johannesburg.

Burkina Faso and Mali illustrate a related dynamic through a different pathway. Following military coups and the deterioration of relations with Western governments, both states adopted postures of strategic realignment toward Russia, including deepening security cooperation and expelling Western military forces. They also implemented reciprocal measures, including suspending U.S. visa privileges. Despite high communicable disease burdens and fragile health systems, none of the Sahelian junta states have been positioned for flexible or expanded engagement.

Marginalization of continental institutions

If bilateralism defines the current phase, coordinated regional mechanisms offer the clearest counterbalance. Yet under the AFGHS, continental institutions have been structurally sidelined. U.S. legislative proposals explicitly prohibit health compacts with the African Union and its affiliated entities, including Africa CDC, a stance reinforced by Washington’s withdrawal from several multilateral institutions including the WHO. The result is fragmentation by design.

This shift has generated concern among analysts, who warn that it creates space for parallel delivery and surveillance systems that may not integrate with Africa’s existing epidemiological networks or regulatory structures. Vertical bilateral platforms risk duplicating data systems, fragmenting reporting standards, and weakening continental early warning mechanisms. 

The marginalization of Africa CDC is particularly consequential at a moment when African countries are calling for a new, more resilient public health order. While AU leaders continue to assert the centrality of Africa CDC, this exposes a core dilemma in pan-Africanism: the tension between pragmatic national bargaining and collective continental capacity.

The end of health neutrality

Across these cases, a consistent pattern emerges. High capacity does not ensure flexibility. High need does not ensure protection. High performance does not guarantee stability. What matters is alignment with U.S. interests beyond health.  The AFGHS thus signals the end of health neutrality as an organising principle. 

Yet. this shift is not “irrational”. As Okereke observes, it “reflects a reality that Africans have long known: aid is never neutral.” What is new is the attempt to present strategic allocation as technical reform. Governments are urged to improve performance and increase investment while the true determinant of support lies elsewhere. The result is a governance trap: countries internalize risk without gaining commensurate influence and remain accountable for outcomes they do not fully control.

The reality is that global health has been absorbed into power politics. For African countries, the central question is no longer how to perform better within existing systems, nor how to revive a depoliticized order that never truly existed, but how to negotiate influence within them.

Nelson Aghogho Evaborhene is a PhD Fellow in Global Health Governance at the Centre for Interdisciplinary Study of Pandemic Signatures, Roskilde University.

Photo by mk_photoz