Agree one African standard for payment, review and exit terms in aid deals

Why this matters

Twenty-four African countries have signed US health deals worth $23 billion in total. Their governments are to pay $9.1 billion of that, or 39%. The share varies widely: under 4% in Mozambique and 7% in Malawi, against 59% in Nigeria and 79% in Botswana. In each deal the government's share rises every year as the US share falls. A government that cannot keep up risks losing services its people now depend on.

These payments compete with interest on debt. Interest took 24.3% of Kenya's revenue in 2023 and 35.8% of Malawi's in 2024. The Organisation for Economic Co-operation and Development (OECD) expects aid for health to fall by between 29% and 46% from 2024 to 2026. Governments are promising more of their budgets just as other money for health shrinks and interest bills stay high.

The deals can also carry terms that have nothing to do with health. Zambia's draft linked health aid to a deal on critical minerals. On 25 September its foreign minister said that link had been set aside, and the United States has since agreed to drop the data clauses as well. In Kenya, the High Court suspended the deal because it broke Kenya's data laws.

Africa CDC, the African Union's public health agency, has offered to help any country that renegotiates. It has also proposed a meeting of all African health ministers with the US government. Help to one country at a time still leaves each to bargain alone. A model agreement would give every government the same starting text.

Four levels of action

1. 1

   What Africa asks of the world

   Governments that fund programmes on a shared-payment basis, starting with the United States, should publish the full texts of their deals and accept the African standard. The International Monetary Fund (IMF) should count these payment promises when it sets spending limits in its loan programmes.

   Who

   The US Department of State and other funding governments; the IMF

   When

   IMF and World Bank Spring Meetings, 12 to 17 April 2027

2. 2

   What the African Union does

   The AU Commission and Africa CDC collect and compare every signed deal with finance ministries. They draft a model agreement that ties each year's payment to what the budget can bear. It requires publication and regular review, and it sets out how a country can leave. Africa CDC's rules on health data are attached. Finance ministers endorse the draft, and AU leaders adopt it.

   Who

   The AU Commission, Africa CDC and African finance ministers

   When

   Draft by December 2026; adoption at the AU summit in February 2027

3. 3

   What regional groups do

   Finance ministers in the Economic Community of West African States (ECOWAS), the East African Community and the Southern African Development Community (SADC) compare their members' payment schedules. No member should accept terms that undercut its neighbours. The standard is published openly, so Burkina Faso, Niger and Madagascar can use it. They have US deals but are suspended from AU meetings.

   Who

   ECOWAS, the East African Community and SADC

   When

   By January 2027

4. 4

   Which country goes first, and why

   Zambia goes first. Its $1.5 billion deal is waiting to be signed, and the United States has agreed to drop the data clauses and the link to minerals. Zambia can write the standard's clauses into its text before it signs. No country that has already signed can do that.

   Who

   Zambia's Ministry of Finance and Ministry of Health

   When

   Before signing, and by 31 December 2026

Before another country can do this

• A payment schedule checked against the country's plan for managing its debt.
• The finance ministry at the table beside the health ministry.
• Publication of the deal, or approval by parliament.
• A data protection law, so the rules on health data can work.

What does not carry over from the first country

• Zambia is negotiating late, so it can learn from 24 African countries that have already signed.
• The minerals link in Zambia's draft gave its objections public weight that other countries lack.

Who else is ready

Has this worked before?

On 22 November 2023, the African Group at the UN, led by Nigeria's ambassador, won a vote in a General Assembly committee on cooperation over tax. The vote was 125 to 48. One text, tabled for all African states, opened talks on global tax rules at the UN, where Africa's numbers count. Source (opens in a new tab)

African Union: the UN vote on international tax cooperation

First steps

1. African Unionthe AU Commission and Africa CDC collect and compare every signed deal with finance ministries by the end of November 2026. Finance ministers endorse a draft in January 2027, for adoption in February.
2. Regional groupsfinance officials in ECOWAS, the East African Community and SADC check members' payment schedules against their debt plans by January 2027.
3. Zambiathe finance and health ministries write the draft clauses into the revised text before signing, and by 31 December 2026.

Who acts, and with what

Who leads

The AU Commission with Africa CDC and African finance ministers; Zambia as the first country to use the standard

Instrument

A model agreement drafted by January 2027 and adopted at the AU summit in February 2027

How progress is checked

The standard's clauses appear in Zambia's signed deal and in deals that are renegotiated

Signal to change course

Three or more governments miss scheduled payments without renegotiating their deals

What stands in the way

Governments that have signed may not want to reopen their deals. Funders may offer better terms to countries that break ranks. The standard needs finance ministers as well as health ministers.

Cost and money

The cost of drafting the standard is not yet known, and it would fall on the AU Commission's budget. The money it would govern is large: $24.1 billion across the 35 US health deals alone.

Who else contributes

What each audience can do