• Washington signed health MoUs with four African countries worth about $2.3 billion

• The US will provide nearly $1.4 billion, with partners funding over $900 million

• The deals extend a new results-based bilateral aid model

The United States on December 23 signed four new health memorandums of understanding with Madagascar, Sierra Leone, Botswana, and Ethiopia, covering a combined amount of about $2.3 billion over five years. Under the agreements, Washington will commit nearly $1.4 billion, while the partner countries have pledged to mobilize more than $900 million in domestic resources.

The accords expand a framework launched in early December 2025 with Kenya, Uganda, and Rwanda, confirming the acceleration of a new format of US bilateral health assistance in Africa. The model is built around a common structure, with clearly defined objectives, strict implementation timelines, and monitoring mechanisms that include explicit consequences in the event of non-compliance.

The US State Department says the approach is results-driven, aimed at ensuring that American health assistance delivers measurable outcomes while reducing long-term dependence by recipient countries.

The new funding comes at a critical time for some beneficiaries, notably Madagascar, which has recently cut public health spending. The finance law adopted last month allocates 5.4% of the national budget to health in 2026, down from 6.5% year on year and well below the 15% target set under the Abuja Declaration.

In practice, the strategy involves a relative reduction in US financial effort, stricter requirements for national co-financing, and a shift toward government-to-government agreements. This comes at the expense of multilateral mechanisms and the traditional role of non-governmental organizations. Washington argues that, despite more than $175 billion invested in global health assistance since 2001, a significant share of funding has supported parallel systems considered insufficiently sustainable.

With the inclusion of Madagascar, Sierra Leone, Botswana, and Ethiopia, Africa has become the main testing ground for this model, which could be extended to additional countries, subject to tighter financial and institutional commitments.

Olivier de Souza