The America First Global Health Strategy promises something African health advocates have demanded for decades: ownership. Through time-bound bilateral compacts, countries co-finance health programs with the US, gradually taking over as American funding tapers. By year five, they're supposed to own and sustain these systems themselves.

But what if ownership without authority is just dependency with a new face?

In this episode, we sit down with Nelson Aghogho Evaborhene, PhD fellow in Global Health Governance at Roskilde University, to unpack how these compacts actually work. Nelson has written several major analyses of the AFGH, and his conclusion is stark: these agreements transfer responsibility to African governments without transferring commensurate control over technology, data, procurement, or even the political conditions under which funding continues.

We explore Nigeria's $3 billion compact and its religious conditionalities, the South Africa precedent where funding was cut for political reasons despite strong performance, how bilateralism fragments the continental institutions Africa has been building, and why—even with full domestic financing—health systems remain vulnerable to collapse if they can't produce what they need.

Reading: Nelson's articles

Rebalancing Risk and Responsibility Under the America First Global Health Strategy

The America First Global Health Strategy and the Dilemma of Pan-Africanism

America First and the Fragmentation of Global Health: How Africa can Reimagine Its Agency

Protecting global health in the era of the America First Strategy

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