Pulse Check: The New U.S-Africa Health Deals - Into Africa

Podcast Summary: Into Africa – "Pulse Check: The New U.S-Africa Health Deals"
Host: Oge Onobogu
Guests: Dr. Doris Macharia (President, Elizabeth Glaser Pediatric AIDS Foundation), Dr. Steve Morrison (SVP and Director, Global Health Policy Center, CSIS)
Date: March 12, 2026

Episode Overview

This episode examines the transformative impact of the U.S. "America First Global Health Strategy" on Africa’s health sector. With the U.S. shifting from multilateral to bilateral aid, African nations face abrupt funding changes, threatening past health gains but also accelerating efforts toward health sovereignty, domestic investment, and new partnerships. Host Oge Onobogu explores these dynamics with leading voices in global health to understand what's at stake, how countries are adapting, and what the future might hold.

Key Discussion Points & Insights

1. Context: The End of "Golden Era" Health Aid

[00:05 – 02:51]

The U.S. has replaced multilateral health aid with bilateral, performance-based "compacts."
Abrupt funding cuts threaten progress on HIV/AIDS, child, and maternal health, particularly in aid-dependent nations.

Dr. Macharia on Losses at Stake:

"Behind every statistic is a child, a child whose future depends on uninterrupted treatment." [03:52]

2. The America First Global Health Strategy: What Changed?

[05:43 – 11:01]

"America First" means government-to-government deals with up-front co-investment requirements; less role for international NGOs.
Key surprise: U.S. kept the Global Fund as a major implementing partner.
Integrated programming: Merging HIV, TB, maternal/child health, etc., into unified packages.
Countries must now manage data and surveillance responsibilities directly.
24 compacts signed (as of early March 2026), representing $20B (37% from partner countries).

Dr. Morrison on the shift:

"It was a demolition of many of these programs... There was a race in the fall to get these compacts concluded." [06:31]
"These are three to five year [deals]... Some [countries] are seen as primary partners... Some expect to graduate sooner. Others are fragile... will stay longer." [08:47]

3. Impacts on African Public Health Policy

[11:01 – 15:45]

Compact structure gives governments more autonomy—but also greater responsibility and risks.
Shift to performance-based funding is unfamiliar; execution timelines are daunting.
The Accra Reset (Aug 2025), led by Ghana, marks increased African solidarity and a push for sovereignty after crisis-induced funding cuts.
Domestic resource mobilization (e.g., Abuja Declaration goal of 15% GDP, currently at 7–8%) is essential but challenging.

Dr. Macharia:

"There's support for government sovereignty and greater ownership... The current compacts are certainly more conditional, performance-based funding which is complex and quite new..." [11:56]

4. Pushback, Rejection, and Risk

[15:45 – 21:54]

Not all African countries have signed on—for instance, Zimbabwe rejected the compacts, citing lack of trust, sovereignty concerns, and new data/mineral conditionalities.
The new era exposes the risk of overdependence on external donors.
Withdrawal risk: Countries may be excluded suddenly for non-health reasons (as with South Africa and ICC/Gaza issues).
Increased financial and accountability burdens on African governments, many already grappling with debt.

Dr. Morrison:

"There was a cataclysmic set of events... The 25 year golden era of global health has ended." [17:12]
"There's a risk that the governments themselves... will not do so well. And then if we have a deterioration in quality of data, we won't know what we're achieving." [20:26]

5. Path Forward: Balancing Autonomy and External Aid

[21:54 – 26:45]

Dependency is uneven: Some countries rely heavily on U.S. aid (Mozambique, Malawi, Zimbabwe), others less so (South Africa, Kenya).
Building African institutions (e.g., African Union, African Medicines Agency) is key for sustainable sovereignty.
Sin taxes (alcohol, tobacco, sugar) and donor diversification (beyond U.S.) are needed strategies.

Dr. Macharia:

"African institutions must be supported. So it's not just about supporting programs, but supporting institutions that actually get the job done..." [23:58]

6. Sustainable Health Financing: Towards Innovation

[26:45 – 35:33]

Innovative models: National health insurance (Ghana, Rwanda, Kenya); the AIDS Trust Fund (Zimbabwe) for HIV programs.
Lessons from other countries—Thailand, Brazil, Vietnam—show the value of sustained commitment and systems-building.
Corruption and accountability concerns resurface as funding is handed over to national systems.
U.S. appropriations gap: Lack of transparency on allocated versus requested funds; plans for Innovation, Rainy Day, and Performance Funds remain in flux.
U.S. internal discord (State vs. HHS, OMB) and withdrawal from WHO adds uncertainty.

Dr. Morrison:

"There is no magic bullet. This is a period in which finance ministers are... under a lot of pressure... The other thing we have to bring into this is the difficult issue of corruption and accountability." [29:25]

7. Beyond Donor-Recipient: Building Equitable Partnerships

[35:33 – 41:06]

Short, medium, and long-term approaches needed:
- Short-term: Sustain critical services and support ministries.
- Mid-term: Ensure successful transitions, include multi-sector partners.
- Long-term: Ministries must deliver on MOUs, prioritize mother-child transmission (PMTCT), data capabilities, and new prevention tools.
Community health workers' pay and welfare spotlighted as key to system resilience.

Dr. Macharia:

"We have to continue supporting people living with HIV and AIDS services across the board and support the Ministry of Health." [36:35]
"PMTCT... must be in the domestic budget line item... That’s going to be important." [38:30]

8. Lessons Learned & Looking Ahead

[41:06 – End]

The disruption forces long-needed reforms toward accountability, efficiency, and national ownership.
Need for more leadership and clarity from the U.S. side (call for an Assistant Secretary for Global Health; coherence in funding and strategy).
The "golden era" built lasting African expertise that now underpins local innovation and resilience.

Dr. Morrison:

"We have to change, there's no question about this. There's no restoration of the status quo ante." [41:38]
"These centers of excellence that have emerged through this investment, they're not going away... that's what gives me a lot of hope." [49:00]

Notable Quotes & Memorable Moments

Dr. Macharia:
- "If we sustain our commitment and protect the systems that have supported us... we can get to a generation of zero pediatric HIV infections. That is amazing. And that can be done in the next five years." [45:41]
- On African authors and self-reliance:
  "Ndambisa Moyo... has really lent her voice very unapologetically in terms of self reliance on the African continent, but really supporting African institutions to lead the way." [46:36]
Dr. Morrison:
- "The people that I think deserve the greatest kudos are President Mahalakhana for pushing forward and bringing others along on the Accra reset. That is a very pivotal moment..." [47:30]

Important Timestamps

Setting the stage on global health aid changes: 00:05–02:51
Impact of funding cuts on children & health ecosystems: 02:51–05:43
Structure of America First Health Strategy explained: 06:14–11:01
Accra Reset & African health sovereignty: 11:20–15:45
Rejection of compacts (Zimbabwe) & risks: 16:04–21:54
Building health security & responsible transition: 22:12–26:45
Innovative domestic resource mobilization: 27:11–29:13
Corruption, accountability, and U.S. internal struggles: 29:25–35:33
Stages of partnership adaptation: 36:26–41:06
Lessons and hope for the future: 41:38–49:32

Recommendations & Closing Thoughts

Books and Authors for Inspiration:
- Farah & Di, Ndambisa Moyo (advocating African self-reliance), classics by Ngũgĩ wa Thiong'o, Chinua Achebe.
Musical Reflections on Hope: Not verbally named, but music and new African voices suggested as inspirations.
Key Hope: The durable expertise and innovations born from decades of health investment, and a new generation of African leadership reshaping continental health policy for a sustainable future.

Summary prepared by Into Africa Podcast Summarizer.

Episode Overview

Key Discussion Points & Insights

1. Context: The End of "Golden Era" Health Aid

[00:05 – 02:51]

The U.S. has replaced multilateral health aid with bilateral, performance-based "compacts."
Abrupt funding cuts threaten progress on HIV/AIDS, child, and maternal health, particularly in aid-dependent nations.

Dr. Macharia on Losses at Stake:

"Behind every statistic is a child, a child whose future depends on uninterrupted treatment." [03:52]

2. The America First Global Health Strategy: What Changed?

[05:43 – 11:01]

"America First" means government-to-government deals with up-front co-investment requirements; less role for international NGOs.
Key surprise: U.S. kept the Global Fund as a major implementing partner.
Integrated programming: Merging HIV, TB, maternal/child health, etc., into unified packages.
Countries must now manage data and surveillance responsibilities directly.
24 compacts signed (as of early March 2026), representing $20B (37% from partner countries).

Dr. Morrison on the shift:

"It was a demolition of many of these programs... There was a race in the fall to get these compacts concluded." [06:31]
"These are three to five year [deals]... Some [countries] are seen as primary partners... Some expect to graduate sooner. Others are fragile... will stay longer." [08:47]

3. Impacts on African Public Health Policy

[11:01 – 15:45]

Compact structure gives governments more autonomy—but also greater responsibility and risks.
Shift to performance-based funding is unfamiliar; execution timelines are daunting.
The Accra Reset (Aug 2025), led by Ghana, marks increased African solidarity and a push for sovereignty after crisis-induced funding cuts.
Domestic resource mobilization (e.g., Abuja Declaration goal of 15% GDP, currently at 7–8%) is essential but challenging.

Dr. Macharia:

"There's support for government sovereignty and greater ownership... The current compacts are certainly more conditional, performance-based funding which is complex and quite new..." [11:56]

4. Pushback, Rejection, and Risk

[15:45 – 21:54]

Not all African countries have signed on—for instance, Zimbabwe rejected the compacts, citing lack of trust, sovereignty concerns, and new data/mineral conditionalities.
The new era exposes the risk of overdependence on external donors.
Withdrawal risk: Countries may be excluded suddenly for non-health reasons (as with South Africa and ICC/Gaza issues).
Increased financial and accountability burdens on African governments, many already grappling with debt.

Dr. Morrison:

"There was a cataclysmic set of events... The 25 year golden era of global health has ended." [17:12]
"There's a risk that the governments themselves... will not do so well. And then if we have a deterioration in quality of data, we won't know what we're achieving." [20:26]

5. Path Forward: Balancing Autonomy and External Aid

[21:54 – 26:45]

Dependency is uneven: Some countries rely heavily on U.S. aid (Mozambique, Malawi, Zimbabwe), others less so (South Africa, Kenya).
Building African institutions (e.g., African Union, African Medicines Agency) is key for sustainable sovereignty.
Sin taxes (alcohol, tobacco, sugar) and donor diversification (beyond U.S.) are needed strategies.

Dr. Macharia:

"African institutions must be supported. So it's not just about supporting programs, but supporting institutions that actually get the job done..." [23:58]

6. Sustainable Health Financing: Towards Innovation

[26:45 – 35:33]

Innovative models: National health insurance (Ghana, Rwanda, Kenya); the AIDS Trust Fund (Zimbabwe) for HIV programs.
Lessons from other countries—Thailand, Brazil, Vietnam—show the value of sustained commitment and systems-building.
Corruption and accountability concerns resurface as funding is handed over to national systems.
U.S. appropriations gap: Lack of transparency on allocated versus requested funds; plans for Innovation, Rainy Day, and Performance Funds remain in flux.
U.S. internal discord (State vs. HHS, OMB) and withdrawal from WHO adds uncertainty.

Dr. Morrison:

"There is no magic bullet. This is a period in which finance ministers are... under a lot of pressure... The other thing we have to bring into this is the difficult issue of corruption and accountability." [29:25]

7. Beyond Donor-Recipient: Building Equitable Partnerships

[35:33 – 41:06]

Short, medium, and long-term approaches needed:
- Short-term: Sustain critical services and support ministries.
- Mid-term: Ensure successful transitions, include multi-sector partners.
- Long-term: Ministries must deliver on MOUs, prioritize mother-child transmission (PMTCT), data capabilities, and new prevention tools.
Community health workers' pay and welfare spotlighted as key to system resilience.

Dr. Macharia:

"We have to continue supporting people living with HIV and AIDS services across the board and support the Ministry of Health." [36:35]
"PMTCT... must be in the domestic budget line item... That’s going to be important." [38:30]

8. Lessons Learned & Looking Ahead

[41:06 – End]

The disruption forces long-needed reforms toward accountability, efficiency, and national ownership.
Need for more leadership and clarity from the U.S. side (call for an Assistant Secretary for Global Health; coherence in funding and strategy).
The "golden era" built lasting African expertise that now underpins local innovation and resilience.

Dr. Morrison:

"We have to change, there's no question about this. There's no restoration of the status quo ante." [41:38]
"These centers of excellence that have emerged through this investment, they're not going away... that's what gives me a lot of hope." [49:00]

Notable Quotes & Memorable Moments

Dr. Macharia:
- "If we sustain our commitment and protect the systems that have supported us... we can get to a generation of zero pediatric HIV infections. That is amazing. And that can be done in the next five years." [45:41]
- On African authors and self-reliance:
  "Ndambisa Moyo... has really lent her voice very unapologetically in terms of self reliance on the African continent, but really supporting African institutions to lead the way." [46:36]
Dr. Morrison:
- "The people that I think deserve the greatest kudos are President Mahalakhana for pushing forward and bringing others along on the Accra reset. That is a very pivotal moment..." [47:30]

Important Timestamps

Setting the stage on global health aid changes: 00:05–02:51
Impact of funding cuts on children & health ecosystems: 02:51–05:43
Structure of America First Health Strategy explained: 06:14–11:01
Accra Reset & African health sovereignty: 11:20–15:45
Rejection of compacts (Zimbabwe) & risks: 16:04–21:54
Building health security & responsible transition: 22:12–26:45
Innovative domestic resource mobilization: 27:11–29:13
Corruption, accountability, and U.S. internal struggles: 29:25–35:33
Stages of partnership adaptation: 36:26–41:06
Lessons and hope for the future: 41:38–49:32

Recommendations & Closing Thoughts

Books and Authors for Inspiration:
- Farah & Di, Ndambisa Moyo (advocating African self-reliance), classics by Ngũgĩ wa Thiong'o, Chinua Achebe.
Musical Reflections on Hope: Not verbally named, but music and new African voices suggested as inspirations.
Key Hope: The durable expertise and innovations born from decades of health investment, and a new generation of African leadership reshaping continental health policy for a sustainable future.

Summary prepared by Into Africa Podcast Summarizer.