The United States is accelerating a shift in how it delivers health assistance to Africa, signing new bilateral agreements with Madagascar, Sierra Leone, Botswana, and Ethiopia that together mobilize about US$2.3 billion over the next five years.
The memorandums of understanding (MoUs), signed on December 23, commit Washington to provide nearly US$1.4 billion, while the four African governments have pledged to contribute more than US$900 million from domestic resources. US officials say the arrangements reflect a move toward a more disciplined, results-driven aid model designed to deliver measurable health outcomes while encouraging greater national ownership.
The agreements extend a framework unveiled earlier this month with Kenya, Uganda, and Rwanda, confirming Africa’s central role in testing a new generation of US bilateral health partnerships. Unlike traditional aid programs, the model relies on clearly defined targets, strict implementation timelines, and formal monitoring mechanisms, with explicit consequences if commitments are not met.
According to the US State Department, the goal is to ensure American taxpayer-funded health assistance produces tangible results, while gradually reducing long-term dependency on external financing. The approach emphasizes government-to-government cooperation, tighter accountability, and stronger alignment with national health strategies.
The timing is particularly significant for countries such as Madagascar, where public health financing has recently come under pressure. The country’s 2026 budget allocates 5.4 percent of total public spending to health, down from 6.5 percent the previous year and well below the 15 percent target set under the Abuja Declaration, which calls on African governments to prioritize health in national budgets.
In practical terms, the new framework implies a relative reduction in direct US financial effort, combined with stricter co-financing requirements for partner countries. It also marks a departure from decades of aid delivery that relied heavily on multilateral institutions and international non-governmental organizations. Washington argues that while the US has invested more than US$175 billion in global health since 2001, a substantial share of that funding supported parallel systems that proved difficult to sustain once external financing declined.
By placing domestic resource mobilization at the center of the agreements, the US aims to push partner governments to strengthen their own health systems, improve public financial management, and take greater responsibility for long-term service delivery.
With the addition of Madagascar, Sierra Leone, Botswana, and Ethiopia, Africa has become the primary testing ground for this results-based bilateral aid model. US officials have indicated that the approach could be expanded to other countries, but only where governments are willing to meet tighter financial, institutional, and accountability requirements.
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As global development financing faces increasing scrutiny, the new agreements signal a broader recalibration of US health assistance one that prioritizes performance, sustainability, and shared responsibility over open-ended support.
