After a year of dissolving the U.S. Agency for International Development (USAID), withdrawing from the World Health Organization (WHO), and reducing foreign assistance for health, the Trump administration is finalizing bilateral arrangements that will define the next era of U.S. global health engagement.

These memoranda of understanding (MOU), released under the America First Global Health Strategy, intend to transition the United States away from aid and toward jointly financed health agreements. The 29 countries that have signed MOUs as of April 13 face widely varying cofinancing provisions, raising questions about their capacity to meet spending benchmarks, achieve target health outcomes, and replace foreign assistance.

This interactive assesses the sustainability and scope of the cofinancing obligations under the MOUs. Toward this effort, we analyze the partner governments' recent and projected health spending, examine how U.S. funding is expected to change under the agreements, and evaluate the available text of the MOUs.

We will continue to update the interactive as new MOUs are signed and will track the public availability of their full texts. On March 12, Think Global Health (TGH) accessed five full texts released officially by the State Department through its Freedom of Information Act (FOIA) library. A week or so later, TGH and others noticed the texts were no longer available. On April 3, Public Citizen sued the department to produce the health-funding agreements under FOIA.

In a comment to the Washington Post on April 6, the State Department said the texts were originally published in error and that it will release the full batch of agreements once finalized. In the table below, TGH is providing hyperlinks to five texts from the FOIA library prior to removal and three additional texts obtained from partners. Their details are described throughout the analysis.

Overall, global health financing dropped 21% from 2024 to 2025, according to the Institute for Health Metrics and Evaluation (IHME). Further reductions are expected for multilateral organizations. Our analysis suggests that some countries, such as Liberia, could face significant year-over-year drops in U.S. funding for health alongside sharp increases in cofinancing expectations that exceed previous spending projections. Other agreements, such as Mozambique's, more closely reflect the country's spending capacity.

Accompanying press releases signal a shift in U.S. assistance toward health security and away from health areas that received earlier support, including family planning, maternal health, and children's health. Countries could choose to continue funding those areas independently, but may need to target spending on U.S. priorities to meet cofinancing requirements, adding further strain in arenas where health aid has been cut.

On April 7, Cambodia and Tajikistan signed MOUs with the United States, marking the first bilateral health agreements to be signed outside of Africa or Latin America. The same day, the United States signed a joint letter of intent with the Philippines, which indicates a forthcoming bilateral agreement.

Casting doubt on the ability to meet an upcoming deadline for completing the MOUs are unresolved negotiations—Zambia and Zimbabwe both rejected the proposed deals in late February, citing unfair and one-sided data-sharing commitments. Tension over the U.S.-Zambia negotiation escalated further by mid-March, as the U.S. Department of State threatened to withhold HIV funding provided through the President's Emergency Plan for AIDS Relief (PEPFAR) to pressure Zambia into granting access to critical minerals.

It marked the most explicit occasion of a new health MOU being used to push U.S. economic interests. Our analysis also found that Zambia faced steep cofinancing measures, which would have required the country to increase its domestic health spending by $1 billion over a five-year period.

How Much Do Countries Spend on Health?

While a handful of MOUs have been signed in Latin America and recently Asia, the majority reflect partnerships with African countries. African leaders have long promised to grow domestic health spending and systems-wide self-reliance, a sentiment that 46 African Union countries captured in the 2001 Abuja Declaration [PDF] to allocate 15% of their government budgets to health. As of 2024, African governments devote roughly 7% of their national budgets to health, on average.

So far, the 27 MOUs govern spending between 2026 and 2030 and total at least $20.1 billion

Consistent with long-standing domestic financing goals, the new bilateral agreements outline how the United States will transfer funding responsibility from nongovernmental organizations (NGOs) and other implementing partners, previously contracted with USAID, to recipient governments, who agree to increase their investment shares over the duration of the partnerships. So far, the 29 MOUs govern spending between 2026 and 2030 and total at least $20.2 billion, roughly 37% to be funded by the recipient governments over the next three to five years.

Under the MOUs, some countries face more demanding funding expectations than others. Nigeria and Botswana pledged to fund the largest shares of MOU spending, 59% and 78%, respectively. Despite committing to coinvest a substantial $3 billion, Nigeria expects to increase its health spending as a proportion of its national budget only marginally, from 5% [PDF] as proposed in its 2025 budget to at least 6% [PDF] from 2026 to 2030.

Botswana, conversely, already has strong baseline health spending, reaching more than 15% of its government budget in 2023. The memoranda's additional expectations raise concerns that the deal could strain a system already heavily committed to health financing, especially considering economic pressures from their shrinking diamond industry. Botswana's agreement—akin to Panama's—is two years shorter than the others. The condensed timeline means that Botswana will absorb health-system financial responsibility sooner than other African countries, but it also reflects a mutual belief in Botswana's higher economic capacity: the country by far has the highest gross national income (GNI) of any African MOU partner as of April 13.  

Other countries—Burundi, Dominican Republic, Eswatini, Guatemala, Madagascar, Malawi, and Mozambique—have committed to modestly increasing their health expenditures relative to 2025 spending baselines. Each proposes to finance less than a quarter of the MOU packages. Although these coinvestment expectations fall short of the America First Global Health Strategy's goal [PDF] to transition most partner countries to full self-reliance through the agreements, they account for country-level fiscal constraints.

Malawi, for example, allocated only 3% of its 2023 budget to health, meaning its lower cofinancing expectation could permit a more gradual and realistic transition to self-reliance. Mozambique, meanwhile, allocated more than double Malawi's share—roughly 8% of its national budget—to health, yet it signed a cofinancing commitment five times lower than Malawi's. The smaller cofinancing share could be explained by the country's exceptionally high debt-repayment obligation: in 2025, 97.2% of Mozambique's gross domestic product (GDP) was owed in public debt, the highest of all MOU partner countries.

Not All MOUs Are Created Equal

Eight MOU draft texts—for Cameroon, Ethiopia, Kenya, Liberia, Mozambique, Nigeria, Rwanda, and Uganda—provide details on annual funding commitments that are not available in the U.S. State Department press releases announcing the deals. For each, the cofinancing expectations increase by year relative to a 2025 baseline, with the U.S. contributions decreasing correspondingly.

Some countries expecting to increase their total health coinvestments—combined domestic and U.S. spending—will experience budget fluctuations each year under the MOUs, which could disrupt program continuity.

Health coinvestments from Ethiopia, Nigeria, Rwanda, and Uganda are modestly larger in 2030 than in 2026. But while Nigeria's and Uganda's total health budgets rise steadily before flattening at their tail ends, coinvestments in Ethiopia and Rwanda will fluctuate. Ethiopia's health budget will peak in 2028 and drop steadily through 2030, while Rwanda's will more than double from 2026 to 2027, only to decline sharply.

Liberia's coinvestment packages are similarly volatile, dropping 35% from 2028 to 2029 before elevating once again in the agreement's final year. Kenya, conversely, expects to see a more substantive rise in its annual investment by the end of the MOU, growing $135 million from its 2026 contribution. The rationale for these annual fluctuations is unclear.

Liberia and Mozambique, however, expect overall declines in annual health spending—even as both increase their domestic contributions. If the countries follow the MOU terms, Liberia's combined health spending will shrink 6% by 2030, while Mozambique's will drop 17%. Reductions in total yearly funds over the agreements' lifetime could limit the countries' abilities to meet health outcomes and security benchmarks unless explicit cost-cutting plans are in place.

Some commitments detailed in the MOUs diverge from country-level spending projections provided by IHME and forecast through indicators such as GDP, debt, development assistance for health, and government health expenditures. These discrepancies have implications for the feasibility of the domestic spending pledges.

Among the eight available full texts, Cameroon, Liberia, Nigeria, and Uganda stand out as partners facing particularly high cofinancing expectations, as their MOU domestic commitments outpace the health budget growth projected by IHME. If these countries are to achieve their stipulated health-spending growth, they could need to either transfer some funding responsibilities to other donors or reallocate resources from other national priorities. Ethiopia, Kenya, Mozambique, and Rwanda, meanwhile, face cofinancing expectations that are slightly below IHME projected growth, suggesting higher likelihoods of smooth implementation.

Ethiopia's and Rwanda's MOUs break from the six other texts in their calls for sharp domestic-spending increases concentrated toward the very end of the agreement. Ethiopia is expected to more than triple its domestic spending commitment from 2027 to 2028, after which its spending levels out.

Of the $70.6 million domestic-spending commitment, Rwanda will spend 88% in the final two years. This nonlinear rate of growth could create delayed funding obstacles and have the counterintuitive effect of delaying domestic increases in health spending that were expected to occur in the absence of the MOU. By contrast, Cameroon, Kenya, Liberia, Mozambique, Nigeria, and Uganda plan to raise their coinvestment shares in a gradual, linear fashion throughout the lifecycle of the agreements.

Disease Area Funding in the MOUs

Over the last two decades, U.S. foreign assistance for health has had broad priorities in Africa, including HIV/AIDS, tuberculosis (TB), malaria, global health security, family planning, reproductive health, and maternal and child health. Two issues—HIV/AIDS and maternal and child health—remain objectives across the new bilateral agreements according to an analysis by the Kaiser Family Foundation (KFF) of available information, including State Department press releases and the available full texts.

Press releases for the early bilateral agreements signed before April 13 omit some long-standing health priorities. Malaria, which previously received the second highest proportion of U.S. health assistance and has historically been funded across all African partner countries, was notably absent from the Ivory Coast's agreement, which attributes 12.63% of premature deaths to malaria—roughly six times the global average.

Both Uganda and Mozambique, in their full MOU texts, have set the ambitious goals of significantly reducing maternal mortality by 2030—Uganda by almost 40% and Mozambique by 50%. Tracking progress toward these thresholds will be prudent given the uncertain future of investments in family planning and reproductive health as well as the recent reinstatement and expansion of the Mexico City Policy. As of April 13, maternal and child health is not listed as a priority in the press releases for 16 agreements.

Despite a U.S. legacy of delivering development assistance to address TB, the disease is not mentioned in the available information for 18 agreements. The eight full texts somewhat reinforce these findings, as the agreements for Rwanda and Liberia do not reference TB even once, despite outlining implementation plans for other diseases.

Kenya's and Mozambique's texts mention TB, but neither covers health outcomes nor spending benchmarks. Those omissions could hinder progress and accountability for existing TB programs. The other texts, by contrast, outline both health outcome benchmarks and health strengthening proposals for this disease area.

Securing funding for TB care will be important for Lesotho and Burundi, where, according to IHME, the infectious disease accounted for 8.2% and 5.8% of premature deaths in 2023, respectively. The current gap between disease burden and health assistance for noncommunicable disease—which account for more than 30% of premature deaths across the initial group of partner countries—will likely persist under the new agreements, with the funding area receiving no meaningful mentions in the available texts.

As countries move toward implementation, the eight full texts indicate that the process will be government-dominated. Notable exceptions include Uganda's and Nigeria's plans to incorporate faith-based organizations in health-care delivery; Mozambique's to continue to involve NGOs in HIV responses; and Cameroon's to extend current implementing partner contracts for a limited period during the transition. Detailed implementation plans for each MOU were expected [PDF] by March 31, 2026.

At the end of March, the State Department reportedly changed how the United States would procure and deliver health products by emailing a plan to cease its partnership with private contractor Chemonics by the end of May. The reported emails did not outline clear transition guidelines, which could cause delays in partner countries' supplies.

The remaining transition plans have yet to be made public, and transparency of such activities will enable a thorough evaluation of the feasibility and implications of each newly formed partnership.

Until details are confirmed, uncertainties persist around preparing countries' health systems to distribute and maintain new funding after 2030, particularly for countries whose MOU terms do not lead to full self-reliance.

EDITOR'S NOTE: This tracker was originally published on March 3, 2026. We will update it regularly as new information emerges about the health MOUs.