Trump Administration Replaces PEPFAR Model With Bilateral Compacts Tying African Health Aid to Mineral Access, Specimen Sharing, and Steep Cofinancing

Details

On September 18, 2025, the U.S. Department of State released the America First Global Health Strategy (AFGHS), a 36-page document that replaces the dominant model of U.S. global health engagement—NGO-implemented programs funded primarily through USAID and PEPFAR—with a system of bilateral memoranda of understanding (MOUs) negotiated directly between the State Department and partner-country governments. The strategy describes U.S. health foreign assistance as not just aid, but "a strategic mechanism to further our bilateral interests." The new framework cuts annual U.S. health funding to recipient countries by an average of 49% relative to FY24, requires recipient cofinancing, and obligates partner governments to extensive multi-year sharing of health data and biological specimens.

By April 2026, more than two dozen MOUs had been signed across Africa, Latin America, and Asia, with implementation set to begin. Three of those agreements—covering the Democratic Republic of Congo, Guinea, and the proposed deal with Zambia—have been linked publicly to U.S. critical mineral access. The Zambia negotiation, reported in detail by The New York Times on April 25, 2026, is the most explicit example: a leaked State Department memo proposed withholding the HIV treatment that 1.3 million Zambians receive through PEPFAR unless Zambia signs a bundled health-and-minerals deal by April 30, 2026.

Background: The 2025 Foreign Aid Collapse

AFGHS was developed against the backdrop of an aid collapse the administration itself created. Within hours of taking office in January 2025, President Trump issued an executive order pausing all foreign aid; the Department of Government Efficiency (DOGE), run by Elon Musk, then oversaw the dismantling of USAID, cancelling—per The New Yorker—more than 80% of the agency's programs and cutting basic health-care access for some 95 million people. According to KFF analysis, the pause was followed by:

• Dissolution of USAID, which had obligated 60% of PEPFAR's bilateral assistance
• Cancellation of 86% of USAID awards, including 71% of HIV-related awards
• Cancellation of more than 60% of State Department awards
• A limited waiver for "lifesaving HIV services" that excluded most prevention activities
• A FY26 budget request seeking $2.9 billion for bilateral PEPFAR—a $1.9 billion reduction from prior levels

The disruptions were severe. A survey of PEPFAR partners found 71% reported cancellation of at least one work category and over 60% reported staff reductions. The International Epidemiology Databases to Evaluate AIDS consortium estimated that funding disruptions had caused over 120,000 deaths globally by November 2025, including more than 13,000 child deaths—an early tally that subsequent accounting has revised sharply upward (see below). An Imperial College London model projected that just the three-month early-2025 disruption would cause 37,400 excess deaths by 2060. PEPFAR data released in April 2026—the first public update in 16 months—showed new HIV diagnoses fell 13% at clinics that were not interrupted and nearly 30% at clinics that were, with roughly 24% of frontline health workers no longer supported.

The Death Toll: From Projection to Accounting

By mid-2026, the mortality estimates had hardened from models into a running count—and become the subject of a public dispute between the researchers doing the counting and the man who oversaw the cuts.

In December 2025, the Center for Global Development updated its "lives lost" estimate, calculating 500,000 to 1 million deaths per year based on actual outlay cuts (670,000 to 1.6 million based on obligations), using standard cost-effectiveness benchmarks of $3,457 per life saved for global health spending and $17,837 for humanitarian and food aid. The documented disruptions behind those figures include 2.3 million people losing antiretroviral treatment support, 2.4 million people in Yemen losing food assistance, stock-outs of HIV drugs, antimalarials, and therapeutic food, and rising malnutrition mortality in Nigeria, Somalia, and refugee camps. Boston University infectious-disease modeler Brooke Nichols maintains a tracking dashboard estimating deaths from halted HIV/AIDS, tuberculosis, malaria, malnutrition, and maternal-child health programs; Harvard's T.H. Chan School of Public Health has stated that the shutdown "has led to hundreds of thousands of deaths"; and a Lancet-published model projects that the cuts could cause more than 14 million deaths by 2030, including 4.5 million children under five, if defunding persists.

Atul Gawande—USAID's assistant administrator for global health from 2021 until he stepped down the week the administration ended foreign assistance—has become the most prominent voice attaching a number to the realized toll. Having told Democracy Now in November 2025 that hundreds of thousands had already died, citing Nichols's tracking work, he said on The New Yorker Radio Hour on July 10, 2026 that an estimated 700,000 people have now died as a result of the cuts. The episode aired days after DOGE was formally terminated on its July 4, 2026 sunset date, which was written into Trump's original executive order creating it.

Musk, who boasted of feeding USAID "into the wood chipper" and recently became the world's first trillionaire, maintains that there is no evidence a single person died from the cuts. Forbes reported on July 1, 2026 that Musk escalated these claims in a series of posts—including endorsing the assertion that "not a single" child died—even as studies linked the cuts to child deaths, and journalists and researchers publicly rebutted him. New York Times columnist Nicholas Kristof, whom Musk accused of "lying through his teeth," answered with a July 1, 2026 opinion column, "U.S.A.I.D. Cuts Killed People. That's the Truth.", inviting Musk to accompany him to Africa to see the consequences firsthand. And in a June 29, 2026 essay for The Bulwark, "Yes, the Cuts to USAID Have Killed", Lauren Dobson-Hughes assembled a study-by-study accounting: more than 500,000 children already dead as a result of the cuts, roughly 200,000 more child deaths in 2025 than in 2024, and—after child mortality was halved between 2000 and 2023—the first reversal of that three-decade decline. The essay, drawing on the Lancet modeling, CGD analyses spanning 37 countries, and Gawande's documentation, also named individual victims: Jane Naboi, who starved in a Kenyan refugee camp; one of Yagana Bulama's twins in Nigeria, dead of malnutrition; one-year-old Mohammad Omar in Afghanistan; and Nada and Omer, who starved in Sudan. By the same literature's estimate, USAID had saved 92 million lives over the prior two decades. (The Kristof and Dobson-Hughes pieces are opinion essays, but the mortality figures they marshal come from the peer-reviewed and institutional studies cited above.)

This accounting matters for AFGHS because the strategy formalizes, rather than reverses, the funding levels that produced it: the bilateral compacts lock in cuts averaging 49% against FY24 for five years, and the death-toll literature is the baseline against which the transition's feasibility claims are being judged.

The MOU Framework

AFGHS reorganizes the surviving programs around bilateral five-year compacts (2026–2030) that, per the State Department's own announcements, aim to transition partner countries toward "self-reliance." KFF's tracker and Think Global Health's analysis document the architecture:

• Total commitments: At least $20.2 billion across 29 MOUs spanning 2026–2030, with roughly 37% to come from recipient governments
• Average reduction: 49% decrease in annual U.S. health spending vs. FY24 (Center for Global Development)
• Steep country-level cuts: Per Partners in Health analysis, funding drops 69% to Rwanda, 61% to Madagascar, 42% to Liberia, and 34% to Eswatini, where roughly a quarter of adults live with HIV
• Cofinancing penalty: Uganda's MOU, for example, allows the U.S. to reduce funding at a 2:1 ratio if Uganda misses its annual domestic spending commitments
• Largest agreement: Nigeria signed a $5.1 billion five-year MOU, of which Nigeria pledges $3.0 billion in new domestic health spending
• Notable exclusions: Maternal and child health and family planning are absent from press releases for 16 of the early agreements; malaria was missing from Côte d'Ivoire's deal despite the disease accounting for roughly 12.6% of premature deaths there

Of the MOUs signed, only Kenya's, Uganda's, and Liberia's are publicly available—citizens of the other signatory countries cannot read what their governments agreed to. Common provisions include obligations to share pathogen and biological specimens within five days of a U.S. request, a 25-year specimen sharing duration with up to ten non-U.S. third parties allowed access to the data, and recognition of FDA Emergency Use Authorizations as the basis for authorizing health products domestically. There is no reciprocal U.S. data-sharing obligation in any of the fourteen MOUs analyzed by Discourse Channel.

Mineral Linkage: DRC, Guinea, and Zambia

In three cases, U.S. critical mineral access has been bundled with health or peace cooperation:

Democratic Republic of Congo (December 4, 2025): The U.S. brokered the Washington Accords for Peace and Prosperity between the DRC and Rwanda, ending—nominally—the M23-driven conflict in eastern Congo. On the same day, the U.S. and DRC signed a separate Strategic Partnership Agreement giving American firms preferential access to Congolese cobalt, copper, lithium, and uranium. President Trump described the U.S. as obtaining "a lot of the mineral rights from the Congo." A health MOU with the DRC was signed in late February 2026, after the minerals partnership. A collective of Congolese lawyers filed a constitutional challenge at the DRC Constitutional Court on January 21, 2026, arguing the agreement violates Article 214 of the constitution, which requires legislative ratification of treaties amending domestic law.

Guinea (February 5, 2026): At the State Department's Critical Minerals Ministerial, Guinea signed a bilateral critical minerals MOU focused on bauxite and iron. According to Health Policy Watch, Guinea's separate health MOU was conditional on the prior minerals agreement—a sequencing pattern that mirrored the DRC.

Zambia (proposed, deadline April 30, 2026): The Zambia case is structurally different and more aggressive. Rather than minerals deal first, health MOU after, the State Department's leaked memo proposed using ongoing HIV/AIDS funding as direct leverage to compel mineral concessions. As Think Global Health put it, this marked the most explicit occasion of a health MOU being used to push U.S. economic interests.

The Zambia Case

According to the New York Times reporting, the proposed Zambia compact has three components, all required for partial restoration of HIV aid:

1. Health: $1 billion over five years (versus the $1.5 billion the U.S. had pledged to Zambia in November 2025, and less than half of pre-2025 levels), conditional on Zambia committing $340 million in new domestic health spending.
2. Minerals: Preferential American access to Zambian copper, cobalt, lithium, and rare earths.
3. MCC restructuring: Conversion of a 2024 Millennium Challenge Corporation $458 million agriculture grant into leverage for mining sector regulatory reform.

A draft Memorandum of Understanding released by health activists shows additional Zambia-specific terms: 10-year health data sharing (despite five years of funding), 25-year specimen sharing without guaranteed Zambian access to research products, a requirement to hire 40,000 additional health workers over 2026–2030 (a roughly 50% expansion of Zambia's currently funded health workforce), and the exclusion of independent civil society from quarterly oversight committees that previously involved community organizations.

The leaked Africa Bureau memo to Secretary Rubio described the approach as the "potential use of sticks." It recounted that the U.S. had already suspended health funding talks in December 2025 when Zambia was not engaging on minerals, and that the State Department subsequently notified Zambia it would cancel a planned debt-relief deal worth hundreds of millions of dollars. According to the memo, Zambia's mines minister reversed course within days and provided U.S. technical experts unprecedented access to the country's mining database. The memo argued that if Zambia refused to sign by the deadline, sharp public cuts would demonstrate to other recipient countries the seriousness of America First conditions.

NYT reporting from April 25, 2026 documented the on-the-ground impact of the 2025 cuts already in effect: at Mpongwe Mission Hospital in northern Zambia, advanced HIV cases jumped from one or two per month in early 2025 to 28 in January 2026 and 28 in February. About 100,000 Zambians stopped taking medication during the upheaval, with 40,000 not yet re-engaged. Programs eliminated or scaled back include index testing (which had identified 70% of new infections), community medication distribution, voluntary medical male circumcision, dedicated services for vulnerable populations, community health worker outreach, genetic sequencing for outbreak tracking, and most pre-exposure prophylaxis.

The State Capacity Argument

The framework's defenders argue that the underlying premise is correct, even if the methods are contested.

Donor dependency was never sustainable. Several decades of PEPFAR built parallel NGO-run delivery systems alongside, rather than within, recipient countries' health ministries. According to Foreign Policy reporting, thousands of Zambian health workers were employees of U.S.-funded NGOs, not the Ministry of Health, and Zambia's government had not taken over essential medicines procurement, supply chain management, or salary payments despite years of "localization" rhetoric. When the 2025 cuts hit, Ministry employees in Ndola had to ask laid-off NGO data clerks to come back and teach them passwords for the patient-records system.

African governments have committed to greater health spending. In the 2001 Abuja Declaration, African Union members pledged to allocate 15% of national budgets to health. As of 2024, average health spending stood at roughly 7%. Whatever the merits of the AFGHS specifically, the broader call for African countries to meet long-stated domestic financing commitments is not a partisan or American invention.

Direct government funding can work. Foreign Policy's reporting on Zambia's Southern Province documented that Mahatma Gandhi Memorial Clinic and other facilities maintained continuity of HIV services through the 2025 disruptions. Since 2019, the U.S. CDC had channeled PEPFAR funding directly to provincial governments rather than NGOs in four Zambian provinces. The administration has cited this model as proof that government-to-government delivery is viable and that the AFGHS structure is realistic.

Critics generally accept the localization premise. Senator Shaheen's letter opposing the Zambia coercion does not call for indefinite NGO-led delivery; it asks the State Department not to weaponize the transition. Conor Savoy, former USAID foreign policy lead now at the Center for Global Development, wrote that the administration's instinct to demand a return on foreign assistance "is not wrong"—he objected specifically to "coercion dressed in the language of strategy." The dispute is about implementation: whether localization can be achieved by abrupt cuts to standing programs, secret terms, and 25-year extractive conditions, or whether it requires a longer phaseout, transparent benchmarks, and reciprocal commitments.

Resistance and Litigation

Several recipient countries have rejected or paused MOUs over sovereignty concerns:

• Zimbabwe walked away from its proposed deal in late February 2026, with Information Secretary Nick Mangwana stating Zimbabwe would not provide the raw materials of scientific discovery without guarantees of access to derived products. The U.S. ended Zimbabwe's R5.8 billion health aid almost immediately afterward.
• Kenya's MOU has been partially suspended by court order as activists pursue two High Court challenges over patient data and pathogen-information sharing.
• South Africa has not been offered an MOU at all. Diplomatic relations broke down after Trump's 2025 executive order suspending research funding to South Africa over what the administration characterized as "white genocide" claims that researchers and South African officials disputed.
• The DRC's minerals partnership faces a constitutional challenge filed by Congolese lawyers in January 2026.
• Africa CDC, the African Union's continental health agency, has been sidelined from the bilateral arrangements and is engaging separately with U.S. policymakers, raising concerns about fragmentation of regional surveillance and bargaining power.

Congressional Response

PEPFAR has historically been one of the most bipartisan-protected U.S. foreign aid programs—it survived a proposed $400 million rescission in July 2025 with Republican votes. Reaction to AFGHS, and especially to the Zambia coercion, has split along familiar lines but with notable Republican unease:

Senate Democrats: On April 16, 2026, Senator Jeanne Shaheen (D-NH), ranking member of the Foreign Relations Committee, joined by Senators Chris Coons (D-DE) and Brian Schatz (D-HI), wrote to Secretary Rubio calling the Zambia approach a "disturbing break from the long held bipartisan support for PEPFAR." They urged Rubio to reject what they characterized as economic coercion.

House Republicans on Foreign Affairs: Defended the negotiating posture on social media, arguing Zambia is free to walk away and that the U.S. should not be expected to fund the entire health systems of countries that grant priority access to Chinese supply chains.

State Department position: Declined to comment on the Zambia memo, calling it a deliberative diplomatic discussion. Secretary Rubio has publicly framed AFGHS as eliminating "dependency, ideology, inefficiency, and waste."

The broader indictment of Rubio's stewardship: In a July 8, 2026 opinion essay for Foreign Policy, Amanda Klasing, national director of government relations and advocacy at Amnesty International USA, argued that Rubio—as acting USAID administrator and secretary of state—"must be seen as the chief architect of the Trump administration's assault on the rules-based order." Klasing noted the reversal from Rubio's Senate record, when he declared that "[t]he United States must remain adamant in the defense of human rights," to a tenure in which he rarely mentions rights except, in her words, "to impugn them as part of some so-called woke agenda," and has instead adopted the slogan: "We are not here to play social worker. We are here to win." The essay is advocacy commentary, but it situates AFGHS within an 18-month pattern—USAID's dismantling, gutted human rights reporting, collapsed refugee admissions—that human rights organizations attribute directly to Rubio's leadership.

What's at Stake

Three trajectories are possible from the deadline:

1. Zambia signs the deal. Antiretroviral treatment continues for 1.3 million Zambians at reduced funding, with extensive data, specimen, and mineral concessions. The compact becomes a template for future negotiations elsewhere, and the use of health aid as a minerals lever becomes normalized.

2. Zambia refuses; aid is fully cut. Zambia takes over purchasing antiretroviral drugs, lab chemicals, and HIV tests itself—a transition Zambian health officials describe as one they are unprepared to make. The Global Fund, also reliant on U.S. contributions and cutting its own budget, cannot fully fill the gap. The pattern of advanced AIDS cases now appearing in northern Zambian hospitals likely accelerates.

3. A renegotiated deal. Health activists have argued Zambia could secure better terms—a five-year cap on data sharing co-terminus with funding, pathogen sharing under the WHO Pandemic Agreement's benefit-sharing framework, and non-exclusive mineral access that does not lock out other partners. Several recipient governments have signaled appetite for collective negotiation through the African Union to avoid being individually outmaneuvered.

The longer-term question raised by AFGHS is not whether U.S. global health engagement should evolve—the bipartisan answer to that is yes. It is whether evolution can be accomplished through abrupt cuts, secret terms, and the conversion of decades-old humanitarian programs into leverage for unrelated commercial and strategic objectives—or whether the resulting damage to recipient health systems, U.S. credibility, and the bipartisan coalition that built PEPFAR is itself a strategic loss. The answer is no longer hypothetical: by mid-2026, the research consensus—contested only by Musk himself—was that the funding collapse underlying the strategy had already cost hundreds of thousands of lives.