Since his return to the White House last year, President Donald Trump has systematically gutted USAID, the government agency that oversees US efforts to improve health and education and fight poverty around the world. Most contracts were canceled, its budget was cut, and what was left of the agency’s functions were folded into the State Department. The Trump administration’s argument: USAID had become bloated, inefficient, and not valuable use of taxpayer money.
But the administration has not abandoned foreign aid – it has reshaped it. Washington is channeling foreign aid through bilateral deals, many of which promise the US something in return. The 19 bilateral health agreements signed in Africa in the last year include only a fraction of the assistance distributed largely through USAID, and require many recipient governments to co-finance programs themselves. For example, in Nigeria, the US has offered about $2 billion in aid over five years – but only if the government raises its own health spending by $3 billion over the same period. Across the 26 countries around the world that have signed bilateral agreements so far, recipient governments are expected to cover roughly 37% of the nearly $20 billion total package.
The administration’s new model also ties aid more directly to US interests. In Zambia, negotiations linked health assistance to a separate push for access to critical mineral resources — a significant departure from the old approach of aid for development and humanitarianism. Post-USAID funding is allocated less by universal development goals than by whether the country serves “America First” interests.
The upside. This shift is being presented by the administration as a move away from dependency and toward sovereignty. For some African governments, that argument has appeal. Many have long objected to an aid system in which foreign NGOs shaped spending priorities and captured large administrative budgets. Direct government-to-government arrangements could, in principle, give ministries more control and better integrate HIV, malaria, and primary care services into national systems.
The risks. In many countries, co-financing demands are arriving at a time of weak growth, high debt, and already constrained budgets. For example, Liberia, and Uganda face particularly high financing requirements. Under the requirements, Liberia needs to increase its own health spending by 23% by 2030 to meet the projected terms of the agreement, at a time when GDP growth has stagnated around 5% since 2023. That raises the prospect that governments will either fail to meet the terms, divert money from other priorities, or accept shoddy standards.
In Africa, America is not absent post-USAID. But it is more selective and transactional. Over the past year, the US’s foreign-aid policy has transformed from soft power into hard leverage. Washington has not exited African health financing, but it has rewritten the contract.
