Which African countries signed the US health deal?

What this document is

The Memorandum of Understanding on Health Cooperation is an agreement between the US Department of State and the Federal Republic of Nigeria, which the text defines as the federal, state and local governments together. It was signed in Abuja on December 19, 2025 and covers April 1, 2026 to December 31, 2030.

The text states that it is not an international agreement and does not create legal rights or obligations (§6.9). It is a five-year plan with funding conditions, not a treaty.

How US health support worked before

Support ran mainly through implementing partners that delivered programmes on the ground, largely outside government systems. The MOU plans to move that support onto Nigerian government systems and sets out a phased approach for existing partner contracts (§5.5).

The change follows the US America First Global Health Strategy, released on September 18, 2025. It replaced that model with five-year, government-to-government agreements that pair US funding with domestic co-financing, data access and audit rights. Nigeria's is one of 24 African MOUs signed so far.

What the US funds in Nigeria today

The 2026 plan for laboratory support totals $74.8 million once lab-worker salaries are included: $70.3 million for commodities and $4.4 million for workers (§2.2.3, Appendix 1).

Nigeria's own reform agenda

The MOU sits on top of the Nigeria Health Sector Renewal Investment Initiative, a reform to improve accessibility, affordability, quality, accountability and efficiency on the way to universal health coverage. It runs through a Sector-Wide Approach that aligns government agencies and development partners under one plan, one budget and one reporting framework.

On December 12, 2023, Nigeria signed the Health Sector Renewal Compact, uniting all 36 state governors and the FCT Administration behind the initiative. Frontline primary care is financed through the Basic Health Care Provision Fund, mandated by the National Health Act 2014.

The baseline

Nigeria's commitment is measured against its 2025 domestic government health spending: the US contribution is scheduled to fall as Nigeria's spending rises above that baseline. Outbreak response starts from a low base.

Data note: the baseline for notification within one day is illegible in the source scan and is not shown. 7-1-7 means detect within 7 days, notify within 1 day, respond within 7 days.

Timeline

1. September 18, 2025US releases the America First Global Health Strategy.
2. December 4, 2025Kenya signs first.
3. December 19, 2025Nigeria signs the MOU and its specimen-sharing agreement.
4. January 18, 2026Nigeria's specimen-sharing agreement enters into force.
5. February 24, 2026US Embassy announces Zimbabwe's withdrawal from talks.
6. April 1, 2026MOU activities begin.
7. April 2026Ghana declines its proposed agreement.
8. July 1, 2026Tanzania signs a $3.1 billion agreement.
9. September 2026US health funding to Zimbabwe ends.

The money: a crossover in 2027

The US plans $1.95 billion in yearly allocations across 2026 to 2030, plus a separate $124.7 million management and operations line that is not spread by year. That brings its total to $2.08 billion. Nigeria commits $2.98 billion of new funding, counting only money it raises itself, including loans, and not donor grants (§5.1.1).

• US yearly funding falls 53% between 2026 and 2030. Nigeria's new funding rises 145% over the same years.
• If Nigeria falls short of the schedule, the US may prorate its funding in a straight line. The MOU's own example: a $125 million shortfall in 2030 could cut US support by $100 million, roughly 80 cents per dollar missed.
• The combined five-year total is $5.05 billion. The US Embassy called Nigeria's the largest co-investment under the strategy to date.

Shares: Consilium analysis of MOU Appendix 1 figures. The US total includes the $124.7 million management and operations line, which the yearly figures spread across the period only in the MOU's totals.

The people: a four-year handover

The US pays for frontline health workers in full in 2026. Nigeria takes over a quarter of the positions each year and funds all of them by 2030. Salaries flow through government systems on state and local pay scales. States recruit and deploy staff, and the federal government sets recruitment numbers.

In 2026 the US funds 13,936 community health workers, 5,574 community health practitioners, 2,862 nurses, 1,103 pharmacy workers and 284 doctors (Appendix 3). US funding for these workers falls from $23.6 million to $5.7 million by 2030, while Nigeria's rises from $32.8 million to $80.3 million. Lab workers are handled separately.

Data note: the MOU reports different totals. Section 2.4.3 lists 25,696 FTEs, the cadre tables in Appendix 3 sum to 23,759, and Appendix 1 gives 22,867 for 2026. Lab FTEs are 1,937 in §2.2.3 and 1,198 in Appendix 1. The chart uses the Appendix 3 cadre tables.

The commodities: from the US to Medipool

The US pays for all commodities in 2026: $133.2 million, made up of malaria ($67.1 million), HIV and TB ($62.8 million) and maternal and child health ($3.3 million). Its share of commodity funding falls from 69% in 2026 to 26% in 2030, while Nigeria's rises from 31% to 74%.

• Medipool. The US intends to move to Nigeria's pooled procurement system once Medipool has procured at least $50 million of commodities with Nigerian funds.
• Local manufacturing. A 30% procurement priority for locally made antimalarials, antibiotics and bed nets, with Nigeria covering any price differences.
• Supply-chain standards. GS1 track-and-trace for US-funded commodities by 2028, and ISO-standard warehouses by 2027.

Data, labs and outbreaks

• Electronic health records in 20% of facilities in 2026, rising in steps of 20 points to 100% by 2030.
• Systems. The lab information system, SORMAS outbreak surveillance and the national health logistics system are due in 2026. The M-Supply warehouse system covers 45 warehouses by 2029.
• Lab handovers. Diagnostic network and accreditation support move to Nigeria by January 2027, equipment calibration by September 2027, external quality assurance by September 2028, and sample transport by 2030.
• Data-system funding. US support falls from $60 million to $22 million, while Nigeria's rises from $13.8 million to $33.8 million.
• Outbreak response. Full 7-1-7 compliance from 33% to at least 85%, with quarterly reports through NCDC.

Services and insurance

• Reach. 500 local government areas are targeted, with 24-hour maternal and child services and a hub-and-spoke model of three spoke facilities per hub.
• Insurance. US support for 350,000 pregnancy-related services and 100,000 newborns by 2030, plus health insurance enrolment covering 500,000 person-years for people with HIV or TB.
• Faith-based providers. About 10% of US funding, roughly $208 million, to the extent US law allows.
• Strategic funding. US strategic investment and technical assistance falls from $205 million to $133 million, while Nigeria's rises from $186 million to $455 million.

How Nigeria compares

By dollars, Nigeria's $3.0 billion is the largest co-financing among the African MOUs. By share of total funding, Botswana's three-year MOU is higher, followed by Nigeria and Tanzania.

Source: ONE breakdown of African MOUs as of September 10, 2026. Shares are a Consilium analysis of ONE's rounded figures.

What to watch

A detailed implementation plan is due within 90 days of signing. The Ministerial Oversight Committee is set to meet quarterly, and the US plans to fund national surveys in 2027 and 2029 to measure outcomes (up to $10 million for the two cycles).

How to read the tags

Of the 35 items tracked here, 15 are tagged Commits, 14 Plans and 6 Aim. The firmest language covers standards, systems, the tax exemption and US audit access. The largest financial items are only worded as plans, yet they carry the sharpest consequences.

Tags follow the MOU's own verbs: "commits" is Commits; "plans", "intends", "expects" and "should" are Plans; "aim" is Aim. Where a sentence mixes verbs, the main verb decides. The MOU is not legally binding (§6.9).

Scorecard

Deadlines, 2026 to 2030

If Nigeria misses

1. Spending shortfall. The US may prorate its funding in a straight line, about 80 cents per dollar missed in the MOU's 2030 example (§5.1.1).
2. Performance shortfall. A joint review of root causes comes first. The US may then substantially reduce or end funding in one or more areas (§5.2).
3. Data or audit failure. Failure to provide requested data or access could change or end planned assistance (§4.6, §4.7).
4. Either side can leave. Either participant may discontinue cooperation, with best efforts to give one year's notice (§6.3).

The upside

If Nigeria meets all process and outbreak-response metrics for 2027 or 2028, it becomes eligible for a performance incentive of up to $75 million a year, subject to available funds (§5.3).

What the US must deliver

US funding is "subject to the availability of funds" (§6.8). The US also plans to fund national surveys in 2027 and 2029 (up to $10 million). If the US does not meet its commitments, Nigeria may revise its co-investment terms (§5.1.1).

Ten contested areas

Every card follows the same order, so no side gets more space. Tap a card to open it.

Health data accessWhat the US can see, for how long, and under what safeguards.

What the text says

The US and Nigeria intend to negotiate a data-sharing arrangement (Appendix 5, which reads "See attachment") for exchanging performance data and for accountability to the US Congress. The MOU expects a five-year term, renewable for another five, in compliance with laws on personal data (§2.5.2).

Critics

Ghana's president said its compact required transferring a pathogen profile and medical records, and that Cabinet flagged several provisions before rejecting it. The US template keeps data terms in force for a decade after cancellation, according to an analysis by researcher Emily Bass. ProPublica reports that Uganda gave the US direct access to nine health data systems for seven years.

Defenders

The State Department says the agreements share only aggregated, de-identified data of the kind used for years against HIV, malaria and TB, that sharing is consistent with each country's laws, and that no personally identifiable information is received.

What remains unclear

Nigeria's data-sharing agreement has not been published, so its scope, duration and safeguards are unknown. The MOU's five-plus-five-year wording differs from the longer terms reported for other countries.

Sources: Graphic OnlineEmily BassProPublica

Specimen sharingPathogen samples going to the US, and what comes back.

What the text says

A separate agreement, signed on December 19, 2025 and in force since January 18, 2026, requires Nigeria to begin sharing specimens and related data within five days of a US request, or on a timeline agreed case by case. Nigeria may share sequencing data through a public database instead of, or in addition to, direct sharing. The MOU itself says Nigeria plans to negotiate such an arrangement (§2.1.2); it was already signed.

Critics

Zimbabwe's government said its country would supply the raw materials for scientific discovery without any assurance that resulting vaccines, tests or treatments would reach its people.

Defenders

ProPublica found that Nigeria's is the only one of six published specimen agreements that commits the US to facilitate priority access to, and donation of, medical products developed from the specimens. In the other five, the US prioritises its own needs first. The State Department says every agreement includes benefit-sharing provisions.

What remains unclear

Duration. The MOU expects five years renewable for five (§2.1.2), while the US template runs 25 years, and a lawsuit reportedly alleges up to 25 years for Nigeria. How the priority-access wording would be enforced is also unclear.

Data note: the full text of the specimen-sharing agreement is not yet confirmed by Consilium; excerpts and ProPublica's analysis were used.

Sources: US State DepartmentProPublicaAssociated PressEmily Bass

Drug regulationWhether local oversight of medicines is weakened.

What the text says

Guided by the NAFDAC–US FDA mutual recognition framework, Nigeria intends to rely on its regulatory directive on reliance to accelerate evaluation of relevant applications (§2.1.2, §2.3.2).

Critics

Ghana's president said its compact barred the Food and Drugs Authority from inspecting medicines and medical products brought in under the programme.

Defenders

Nigeria's text refers to speeding up evaluations. It does not, on its face, waive inspection.

What remains unclear

Whether "reliance" reduces local inspection in practice. Ghana's compact text has not been published, so its claim is the government's account and cannot be checked.

Sources: Graphic OnlineNigeria MOU

Co-financing and affordabilityWhether Nigeria can fund the ramp-up.

What the text says

New Nigerian spending rises from $345 million in 2026 to $845 million in 2030, counting only funds Nigeria raises itself, including loans (§5.1.1). Shortfalls allow prorated US cuts.

Critics

Ghana's president objected to the counterpart-funding requirement. In Nigeria, opposition figure Atiku Abubakar questioned the government's capacity to meet its commitments, citing the Health Minister's statement to lawmakers that ₦36 million of ₦218 billion appropriated for the ministry's headquarters capital projects was released in 2025 (as reported by Vanguard).

Defenders

The US Embassy describes Nigeria's commitment as the largest co-investment under the strategy so far and a sign of national ownership. The State Department says it took steps to ensure required investments were realistic and achievable.

What remains unclear

Which budget lines count, how much comes from states, how much is borrowed, and how the ₦36 million figure sits within the wider health budget.

Sources: US Embassy NigeriaVanguardProPublica

Minerals for medicineWhether health aid is tied to access to resources.

What the text says

The Nigeria MOU text contains no reference to minerals.

Critics

Zambia's foreign minister said in May that Washington had made a critical-minerals deal conditional on the health agreement. Zimbabwe's government made a similar claim about its own talks.

Defenders

A US official said Zimbabwe's MOU focused solely on health and contained no provisions on critical minerals, explicit or implicit. Zambia said the two agreements must be judged separately.

What remains unclear

No such link is reported for Nigeria. Whether parallel trade or resource talks touch Nigeria is not addressed in the public record.

Sources: Equity AxisallAfricaCiti Newsroom

TransparencyWhat has been published, and what has not.

What the text says

The MOU allows either participant to make it public (§6.4). Its main text and Nigeria's specimen-sharing agreement are now published by the US State Department, and the MOU is also hosted by Public Citizen.

Critics

Public Citizen sued the State Department for related records. Atiku Abubakar has called for full publication, including data-sharing and specimen-sharing agreements.

Defenders

The State Department describes its approach as protecting sensitive negotiations and has since published several texts.

What remains unclear

Nigeria's data-sharing agreement and implementation plans remain unpublished. No public reporting on National Assembly review has been located.

Sources: Public CitizenProPublicaVanguard

The courtsLegal challenges in Kenya, DRC and Nigeria.

What the text says

The MOU states that it is governed by consultation between the participants (§6.10) and consistent with each side's applicable law (§6.6).

Critics

Kenya's High Court froze implementation after two challenges over patients' data privacy and the bypassing of Parliament. Lawyers in the DRC have challenged that country's MOU. In Nigeria, a lawyer sued in March, alleging violations of the constitutional right to privacy and religious discrimination through prioritised funding for faith-based facilities. That suit is pending.

Defenders

Kenya's government argued in court that it cannot reach the highest attainable standard of health on its own.

What remains unclear

Outcomes, and whether a ruling in one country would affect others. Kenya's court allowed implementation to proceed in May while it considers the case.

Sources: ProPublicaHealth Policy Watch

Legal weight and funding certaintyWhat the MOU binds, and what can change.

What the text says

The MOU "is not an international agreement and does not give rise to legal rights and obligations" (§6.9). All activities are subject to the availability of funds (§6.8).

Critics

KFF estimates five-year US funding across MOU countries at 34% below historical levels. The Center for Global Development notes that even if countries meet targets, US funding could be affected by shifting congressional priorities or future disruptions.

Defenders

Before funding is adjusted for missed programme targets, the MOU provides for a joint review of root causes (§5.2), and it allows adjustments for national emergencies (§5.4).

What remains unclear

How the audit access in section 4 interacts with Nigerian law, and how disputes would be resolved beyond consultation.

Sources: KFFCenter for Global Development

Faith-based funding and the Helms clauseWho delivers services, and what US law restricts.

What the text says

About 10% of US funding, roughly $208 million, is allocated to faith-based service providers to the maximum extent permitted by US law (§2.6.2). Nigeria must allow verification that no US funds are used for abortion as a method of family planning (§4.5).

Critics

A pending Nigerian lawsuit alleges religious discrimination in prioritising faith-based facilities.

Defenders

The State Department said the agreement was negotiated in connection with Nigerian reforms to protect Christian populations from violence.

What remains unclear

How providers are selected, and whether other faiths or secular providers are disadvantaged.

Sources: ProPublicaNigeria MOU

Bilateral deals and collective bargainingWhether country-by-country agreements weaken a shared African position.

What the text says

Each MOU is a separate bilateral agreement between the US and one government.

Critics

Analysts argue that bilateral deals lock in individual relationships and prevent bloc-level bargaining, while the WHO's pathogen access and benefit-sharing system is still under negotiation. Zimbabwe called its offer a departure from the multilateral frameworks it champions.

Defenders

Governments that signed, such as Kenya, argued that they cannot reach their health goals without the funding.

What remains unclear

Whether the bilateral terms will set precedents that weaken collective African positions in multilateral talks.

Sources: Global Health UnfilteredPLOS Global Public HealthProPublica

Items still being verified

• The full text of Nigeria's specimen-sharing agreement, and the duration of specimen and data sharing (five plus five years in the MOU, 25 years in the US template).
• Nigeria's data-sharing agreement, which has not been published.
• Frontline-worker totals, which differ across the MOU's tables (25,696, 23,759 and 22,867).
• The MOU's outcome-metrics table, which is illegible in the source scan.
• The statuses of Zambia and Namibia, which are disputed in the sources.
• The ₦36 million capital-release figure, reported second-hand.