Will African nations lose their leverage in an ‘America First’ health plan?

Health and development experts are concerned that African governments are losing their collective bargaining power under the United States’ new “America First” global health strategy as they sit alone across the negotiating table from the world’s most powerful nation. The U.S. State Department has sent roving teams to visit African countries to negotiate overarching bilateral health agreements, as opposed to leaning more heavily on funneling money through nongovernmental organizations to implement global health programing. A template of the agreements obtained by Devex outlines points under negotiation such as how funding responsibilities will shift from the U.S. to partner governments annually and ensures those governments commit to “co-investment” from their own budgets as opposed to using funds from other donors or multilateral organizations. But more controversially, it also includes decades-long requirements for African countries to share sensitive data with the U.S. The African continent has been working through the African Union to approach the global community as a bloc. While countries may not have much leverage on their own, they can benefit from the aggregate power of 55 countries. Examples of this include the African Continental Free Trade Area, African Medicines Agency, pooled procurement of medical supplies, and negotiations through the World Health Organization on the global pandemic agreement. But bilateral agreements with the U.S. move the continent away from this model, experts told Devex last week in Nairobi at the Africa Health and Development Annual Research Symposium. “I think that African countries need to be careful. We’ve been moving in a direction of trying to reduce fragmentation, because we recognize that our markets are relatively small individually,” said Dr. Sam Oti, senior program specialist at the International Development Research Centre. Oti called upon negotiators from African countries to speak with one another before they sit down at the table with the U.S. — the country spent $23 billion on international health assistance in 2023, making it the largest global health donor. “That they sort of come together continentally and agree on what is a minimum acceptable terms and conditions for Africa. I think this is critical. Otherwise, I think we are going to lose that collective bargaining power that we could have harnessed from [the continent’s population of over] 1 billion people,” Oti said. The State Department is initially starting its negotiations with Cameroon, Côte d’Ivoire, Democratic Republic of Congo, Eswatini, Ethiopia, Ghana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Rwanda, Tanzania, Uganda, and Zambia, according to the Africa Centres for Disease Control and Prevention, or Africa CDC. Knowing where the US stands While the “America First” global health strategy covers a wide gamut — including efforts to fight HIV, malaria, tuberculosis, polio, and measles — it also mentions leveraging U.S. foreign assistance to strengthen American military alliances, counter Chinese influence, and secure key minerals and rare earth elements that fuel the U.S. military and commercial sector. Last week in Kigali, U.S. State Department official Jeff Graham said the country envisions positioning American companies to lead in African markets, with African governments serving as “customers” of American products — noting that American companies are largely absent from the world’s fastest-growing consumer market. Dr. Seye Abimbola, associate professor of health systems at the University of Sydney, said at least it’s “gratifying” to see these levels of blunt honesty. “It is far more honest than anything the U.S. government has said about global health ever,” he said. “There’s something reassuring about that — we know the game we are in now. It’s a different thing from the charity case.” And knowing where the U.S. stands may help African countries in negotiations, he said. “Your hand is stronger when you know what the terms of the deal are, unlike when it is under the table,” Abimbola said. “On the other hand, I am also deeply aware of how strong the hand of the United States government is in that deal — and that is the part that bothers me.” Other health experts agreed, noting the vast power imbalance — one that could be countered by a continental approach of countries joining forces and deciding upon a strategy and certain thresholds under which to approach these negotiations. “As a continent, we can actually definitely negotiate with America,” said Dr. Anthony Mveyange, director of programs at the African Population and Health Research Center. “America is galvanizing its forces against China. … So can Africa do that? I think the onus is on us now to take advantage of that, coalesce ourselves, to really bring ourselves together and represent the needs of a huge Africa.” Yap Boum, deputy incident manager at Africa CDC, said during a press briefing on Thursday that his agency has engaged with countries before their meetings with the U.S. There will be another meeting to touch base with countries on these negotiations to determine how to move forward as a continent to ensure they get the best deals, he added. Africa CDC Director-General Dr. Jean Kaseya recently called upon ministers to share information on their ongoing negotiations with the U.S. ‘It’s our data, our blood’ One of the more contentious elements of these bilateral agreements is the requirement that African countries share data with the United States. A template of the agreements obtained by Devex dictates that countries should send the U.S. data on pathogens causing new outbreaks found within their borders within five days, which is not currently the practice. This can aid American companies in developing vaccines, therapeutics, and diagnostics. The template suggests that these pathogen-sharing agreements be in effect for 25 years. While the global pandemic treaty was adopted in May, negotiations have continued around this point, which was unresolved because it’s so controversial. This controversy is a legacy of the COVID-19 pandemic, when there was widespread vaccine inequity. Low- and middle-income countries have asserted that when they share pathogen data, they should receive benefits from medical products created from their pathogen data, such as ensuring they have access to vaccines. Critics have argued that having separate bilateral agreements with the U.S. that dictate pathogen sharing with the U.S. could handicap the African continent’s negotiating position. African nations have negotiated in a bloc in their push for benefits. Separately, the template bilateral agreements also include a 25-year agreement for African governments to share other sorts of data with the U.S. that it can use to monitor “long-term performance” of the bilateral agreements, and so the U.S. Congress can review how money was spent. Journalist and author Emily Bass reported that countries “will be asked to sign a data sharing agreement that could provide the US with login credentials to a sweeping array of national systems for the next twenty five years.” Abimbola said he worries that these deals will move forward without populations understanding what’s been sold off — urging negotiators to be transparent with the public. “So that we all know what is being done in our name, because it’s our data, our blood. It belongs to us,” Abimbola said. “I’m from Nigeria, we have lots of oil that we sign off for pittance, and it bothers me that it’s likely that we will sign off our data and rights to specimens, etc., for a pittance.” He added that agreements should also have much shorter time limits than the 25 years outlined in the template, such as one or two years — so countries aren’t “signing away in perpetuity resources that will only increase in value over time.” Angela Wamola, head of sub-Saharan Africa at GSMA, a global organization that represents the mobile phone sector, said this is a moment when African countries should leverage the African Union Convention on Cyber Security and Personal Data Protection, or Malabo Convention, which outlines the continent’s position on data sovereignty. “We have a lot of data protection authorities in Africa, and this is an opportunity to empower them,” Wamola said. “If [the agreements include] data, then they are the rightful people to discuss what is sovereign, what can be cross-borderly shared for Africa, by Africa, to profit Africa — and then what can be used for the global good, in terms of global health management.” Some experts also noted that high-income countries have a heavy hand in determining how health care is delivered in other countries. For example, in the interest of quickly squashing outbreaks abroad before diseases reach American shores, the agreement template notes countries should detect new outbreaks within their borders within seven days and notify the U.S. government within one day thereafter — and then engage meaningfully with the U.S. on how the country quickly responds. “As long as the North is defining how patient zero is being treated, we are never going to have the equity partnership that we need to have,” said Dr. Evelyn Gitau, chief scientific officer at the Science for Africa Foundation. “The power imbalance … is going to continue being reproduced in this model.” The next chapter Despite these criticisms, the “America First” strategy has also received much praise for outlining a vision of leaning more heavily on direct relationships with governments, creating the potential to better integrate foreign aid into national health systems as opposed to creating parallel, siloed systems, which have long plagued the global health sector. The U.S. Department of State’s strategy was highly critical of the nongovernmental organizations that have traditionally played a large role in delivering its health aid, saying these organizations have high overhead costs. And some experts agree. “Those people in between — the brokers — we do away with them, and thanks to Trump for doing that for us,” Mveyange said. “Sometimes the system has its ways of cleaning itself.” But others argue that this blame is misplaced and that the U.S. Congress and previous administrations reasonably prioritized strong fiduciary and programmatic accountability mechanisms over national government partnerships, considering that as a safe way to get high-quality services running quickly. Now, local and international NGOs that once partnered with the U.S. government are trying to figure out the role they will play in the “America First” strategy, which, beyond prioritizing working directly with governments, notes that it will prioritize working with the private sector and faith-based organizations. And more broadly, experts at the Nairobi symposium agreed now is the moment to ensure there’s an increase in domestic funding for health priorities. “For far too long, our hands have been stretching out waiting for money,” said Mveyange. “We do have local resources, and we have seen this year, after Trump funding cuts, we have seen countries increasing budgets for ministers of health. And the question is: All these years, where were we?”