Alarm bells ring as US rolls out transactional strings for health deals

The Trump administration’s “America First” global health strategy has made it clear that when it offers a country financing to strengthen its health systems, its ultimate goal is to secure something in return — something not always related to health outcomes, such as gaining a competitive edge over China, securing minerals, strengthening military alliances, or accessing data. The new strategy has a focus on direct bilateral government deals, cofinanced with those governments, and aims to leverage faith-based organizations and the private sector, as opposed to funneling money through nongovernmental organizations. In U.S. negotiations with Zambia and Nigeria, it made explicit the nonhealth goals it wants to achieve in return for health aid. In Zambia, mining sector reforms are at the heart of negotiations — which are still ongoing, whereas in Nigeria, the signed deal focuses specifically on protecting Christians from violence. To some who think U.S. health aid should exclusively focus on health outcomes and align with priorities of partner governments, this type of arrangement raises alarms. Additionally, there are concerns that privileging certain groups runs counter to efforts to achieve health equity. Tying aid to broader geopolitical interests in Zambia’s minerals negotiations evokes a troubling precedent, Desta Lakew, group director for partnerships and external affairs at Amref Health Africa, told Devex. “Africa is not a commodity source; it is a co-investor in its own health future. With debt servicing consuming a large share of budgets, these deals must integrate fiscal sustainability and governance safeguards, not create parallel systems or dependency,” she said. “True partnership means mutual accountability, respect for sovereignty, and alignment with African-led strategies. Anything less risks undermining the very reforms we seek to achieve.” But others think the U.S. is taking a rational approach that can still exist within efforts to support African nations achieving greater health sovereignty, and that elements of these transactional relationships have always existed — albeit via a more subtle approach during previous administrations. The U.S. expects to sign dozens of bilateral health agreements in the coming weeks, with expectations they will evolve into more detailed plans before implementation begins in April. A handful of countries have already signed. The catch The Trump administration’s “America First” global health strategy notes that the African continent “contains several of the largest deposits of key minerals and rare earth elements needed as inputs into advanced technologies that fuel critical military and commercial applications.” Democratic Rep. Gregory Meeks, a ranking member of the U.S. House Foreign Affairs Committee, published a statement Friday calling the Trump administration's conditioning of the provision of health assistance on access to Zambia’s critical minerals a “very troubling trend” and “evokes a colonial mindset.” “President Trump is pursuing an approach that mirrors the worst practices of China and Russia, treating African countries as sources of commodities rather than as partners,” he said. In early December, the American Embassy in Zambia released a statement saying the U.S. “aims to unlock a substantial grant package of U.S. support in exchange for collaboration in the mining sector and clear business sector reforms.” U.S. Assistant Secretary of State for Economic, Energy, and Business Affairs Caleb Orr called Zambia’s business regulatory environment “slow, unpredictable, and opaque.” While in Zambia this month, Orr met with the country’s Ministry of Mines and Mineral Development, as well as the California-based mining company KoBold Metals, which is developing what it says will be one of the world’s largest copper mines. Orr also visited Kansanshi Mine, owned by Canadian company First Quantum Minerals, which is the largest integrated metallurgical processing facility in Africa. The U.S. Trade and Development Agency announced in September that it awarded funding to Metalex Africa Zambia Limited, a subsidiary of Texas-based Metalex Commodities Inc., to conduct a feasibility study on the expansion of a Zambian facility that extracts and processes copper and cobalt to diversify U.S. supply chains to access these critical minerals. Another key part of the “America First” global health strategy is using health aid to counter Chinese influence. Chinese companies have reportedly invested over $3.5 billion in Zambia’s mining sector over the past 26 years. But not everyone is raising an alarm about the U.S. integrating sectors such as mining into health deals. Dr. Mark Dybul, former executive director of The Global Fund to Fight AIDS, Tuberculosis and Malaria, said during a Devex Pro event last week that dynamics like these aren’t new, but are now just more public. And the U.S. isn’t the only country with its eyes on Africa’s minerals. Dybul said it’s “incredibly naive and dangerous” to ignore the movements of autocratic governments and other players on the continent operating in ways that exhibit a “horrific breach of sovereignty” for the countries with the mineral reserves. “We can’t be blind to what’s happening in the world,” he said. “We are losing out to autocratic states that don’t have to care about rule of law.” Dybul says the key is ensuring the U.S. engages in ways that enhance country sovereignty, not undermine it. This includes supporting countries with developing legal, regulatory, and other ecosystem frameworks that help build level playing fields for the private sector — helping some countries improve their ability to decide how and whom they want to work with in the private sector. Additionally, with the continent’s rapid population growth, it’s essential to create jobs, he said. While there’s been a constant push to keep international development siloed from other sectors, with “never the twain shall meet” — this disregards the realities of the world, he said. “Let’s focus on the positive pieces here and build the ecosystem that allows that vibrancy, the enormous opportunity,” Dybul said. Singled out The U.S. also announced a five-year bilateral health memorandum of understanding with Nigeria — Africa’s most populous nation — on Saturday, which intends to commit nearly $2.1 billion to expand essential preventative and curative services for HIV, tuberculosis, malaria, maternal and child health, and polio. Nigeria has also committed to increasing its domestic health expenditures by nearly $3 billion over that term. It’s the largest coinvestment any country has so far made under the “America First Global Health Strategy,” according to the U.S. State Department. But this deal has a “strong emphasis on promoting Christian faith-based health care providers.” “The MOU was negotiated in connection with reforms the Nigerian government has made to prioritize protecting Christian populations from violence and includes significant dedicated funding to support Christian health care facilities,” the press release stated. It noted that Nigeria has 900 faith-based clinics and hospitals, which currently serve more than 30 % of the population. “As with all foreign assistance, the President and Secretary of State retain the right to pause or terminate any programs which do not align with the national interest, and the Trump Administration expects Nigeria to continue to make progress ensuring that it combats extremist religious violence against vulnerable Christian populations,” the State Department press release said. Amref Health Africa’s Desta Lakew said she welcomes any investment in health systems, but this deal raises questions about sovereignty and alignment with Africa’s own priorities. “Conditioning health assistance on religious affiliation or political reforms risks fragmenting national health strategies and bypassing continental frameworks like the AU’s Agenda 2063 and Africa CDC’s New Public Health Order,” she said. “Health partnerships should strengthen universal access — not privilege one group over another —because equity is the foundation of public health.” The Nigerian government’s press release on the new deal didn’t mention a focus on Christians, but mentioned areas such as improving laboratory systems, supporting front-line health care workers, and strengthening data systems. It noted that it will commit to allocating at least 6% percent of annual federal and state budgets to health — which has already been appropriated for next year. The “America First” strategy emphasizes that it wants to leverage faith-based organizations, and some Christian groups have been consulted in the process and asked to submit proposals. Some Christian groups have also advocated that their role be more clearly outlined in these agreements, which the Nigeria agreement did. In late October, Trump called Nigeria, in a post on Truth Social, a “COUNTRY OF PARTICULAR CONCERN,” saying “thousands of Christians are being killed. Radical Islamists are responsible for this mass slaughter.” “We stand ready, willing, and able to save our Great Christian population around the World!,” he wrote. He ordered the military to prepare for action in Nigeria. The Trump administration has even enlisted American singer Nicki Minaj to publicly speak about the persecution of Christians in Nigeria. The Nigerian government has disputed the claims that Christians are persecuted. Christians comprise about 43% of the nation’s population. Nigeria has experienced conflict, atrocities, and attacks on civilians for over 15 years due to various nonstate militants, including Boko Haram, and a complex set of issues. But this widespread violence has brutalized civilians in general, not exclusively Christians. Both churches and mosques have been burned. This isn’t the only African country where the Trump administration has focused on one group. In South Africa, Trump has alleged a “white genocide” against Afrikaners and has moved to welcome them into the U.S. as refugees. South Africa recently arrested seven Kenyans working illegally on processing Afrikaner refugee applications for the U.S. The bilateral health deal in Nigeria is unlike those signed previously. It marks a change from the agreement in Kenya, for example, which more broadly encompassed the entire population and didn’t appear to explicitly dictate which implementing partners the Kenyan government must use to carry out programming. .