American aid to Africa comes with more strings attached

Following an order via WhatsApp, autonomous drones operated by Zipline, an American company, can drop blood, vaccines and essential medicines by parachute to any of 15,000 clinics across Ghana, Ivory Coast, Kenya, Nigeria and Rwanda. The firm’s expansion is being underwritten by a new kind of American aid deal, worth $150m, that requires domestic co-investment. The performance-based contract is a welcome shift away from how aid has traditionally been given, says Caitlin Burton, the head of the company’s African operation.

Zipline is one beneficiary of a new approach to American health aid to Africa that evolved after USAID was forced shut a year ago. Since September the Trump administration has been on a deal-making spree, signing bilateral health agreements worth about $11bn with the governments of more than a dozen African countries. The aim is to conclude many more. “America First” global-health strategy eschews needs-based grants implemented by NGOs in favour of transactional deals that advance American commercial, security and ideological interests.

In agreements running for five years America promises to purchase items such as drugs and vaccines, in some cases worth billions of dollars, and pay for some health workers. The deals emphasise preventing HIV, TB, malaria and polio, and improving surveillance and reporting of disease outbreaks. In return, African countries are expected to buy American products, grant America access to their health data and align policies to the administration’s health agenda.

Whatever total the new deals reach, it is likely to be a fraction of what America used to spend on aid. A recent analysis of eight of the deals by the Centre for Global Development in Washington finds that on average the countries face a 49% fall in American health spending compared with 2024 in the first year of these deals. In subsequent years support is scheduled to dip steeply before tapering off.

The process is “chaotic and fast-moving”, says Oge Onubogu of the Centre for Strategic and International Studies, an American think-tank, and is likely to produce clear winners and losers in Africa. Countries that are large, rich in minerals or strategically located will have more leverage. Others may face worse conditions.

One deal in Zambia, for example, hinges on the passage of another agreement offering America access to minerals. In Nigeria, a religiously diverse country of 230m people, a $2.1bn agreement has drawn a backlash over America’s emphasis on delivering care through Christian health-care providers. In Kenya a deal worth $1.6bn is awaiting review following concerns over the lack of parliamentary consultation and worries that the government could breach data-protection laws by offering access to patients’ health records. Lawrence Gostin of Georgetown University in Washington says the transactional approach jettisons a long history of global aid based on “compassion and caring”.

The requirements for co-investment should prompt African governments to boost health spending, which has long been insufficient in much of the continent. Kenya’s $1.6bn package requires it to increase its own spending by $850m. Nigeria must add $3bn to its health budget over five years. In principle, that is a good thing. The worry is that the need to get critical health funds from America may force some cash-strapped countries to take out costly loans to afford their contribution.

The money also comes with ideological strings. American rules announced on January 23rd will limit access to abortion and restrict spending on efforts to promote diversity, equity and inclusion. These are an expansion of the “global gag rule” that has typically been imposed by Republican administrations and rescinded by Democratic ones. Earlier versions prevented family-planning funds going to foreign groups that provide or discuss abortion, and mainly affected providers of contraception.

The first Trump administration broadened the rule to cover all health assistance delivered by foreign NGOs. The new one covers all non-military aid streams, including humanitarian disaster relief and economic aid. It applies to any organisation that gets American funding, a category assumed to include national governments.

Governments may yet be exempted from those rules. Even then it will be hard to show they have not indirectly supported clinics offering abortion or contraception, which adds to red tape and gives America leverage to withhold funds. Beth Schlachter of MSI, a reproductive-rights charity, says that during George W. Bush’s presidency the more limited rule was associated with a 14% decline in contraceptive use in 26 African countries, and a 40% increase in abortions, most of them unsafe.

More immediately, applying ideological conditions to aid is likely to stymie efforts to deliver swift help to those who urgently need it, such as the 300,000 people who face the threat of cholera after being displaced by floods across southern Africa. In its drive to put America first, the Trump administration risks losing trust that could be hard to regain. ■