For decades, global health governance relied on aid flows, multilateral institutions, and shared norms of solidarity. Countries received funding, technical assistance, and essential commodities through organisations such as the World Health Organization (WHO), the Global Fund, USAID, and other multilateral mechanisms. This model prioritized collective risk management and assumed that global health security was a shared responsibility. However, recent shifts, including USAID restructuring, reductions in Official Development Assistance (ODA), the U.S. withdrawal from WHO, and the launch of the America First Global Health Strategy in September 2025, signal a move away from multilateralism toward a more transactional, bilateral, and security-oriented approach. Health data, surveillance, and digital infrastructure are increasingly treated as strategic assets rather than technical outputs.
The America First strategy reframes U.S. health assistance as a tactical instrument to prevent outbreaks, advance national interests through bilateral agreements, and promote American health innovation. While programs like PEPFAR continue to save lives, the strategy critiques previous global health financing for inefficiencies and dependency. It emphasizes government-to-government agreements, mandatory co-investment, performance-based funding, and integration of surveillance, data systems, and supply chains. This marks a broader reorientation in global health governance from shared stewardship to conditional partnerships, reshaping how power and influence are exercised.
Africa is a central focus in this transformation. The COVID-19 pandemic highlighted the continent’s dependence on imported medicines, vaccines, and diagnostics, prompting governments to treat health as an industrial policy priority. Yet, bilateral health agreements under the U.S. strategy raise questions about their compatibility with Africa’s push for domestic manufacturing and regulatory convergence, including efforts led by the Africa Medicines Agency. Agreements such as the Kenya–U.S. Cooperation Framework tie health financing to interoperable surveillance systems, real-time reporting, and long-term access to national health data platforms, positioning data infrastructure as a core deliverable rather than a technical by-product.
These arrangements create inherent asymmetries. African states often commit to granting sustained access to surveillance systems, laboratories, and digital health platforms, while reciprocal guarantees for vaccines, diagnostics, therapeutics, or technology transfer derived from shared data are frequently absent. In Kenya, civil society and lawmakers challenged the agreement’s compliance with national data protection and digital health laws, leading the High Court to suspend implementation. Similar patterns are reported in Liberia, Zambia, and Uganda, where bilateral agreements embed health cooperation within broader geopolitical and commercial negotiations, raising concerns over sovereignty, cybersecurity, and long-term governance.
The emergence of health data as a key strategic asset signals a shift in the geography of global power. Where influence was once exercised through aid volumes and technical assistance, it now flows through data control—who collects it, who sets interoperability standards, and who retains long-term access. African countries investing in digital health systems, national data warehouses, genomic surveillance, and interoperability frameworks become indispensable nodes in the global early-warning system for disease outbreaks. However, these investments also create vulnerability, as short-term financial incentives may come at the cost of long-term data sovereignty.
Civil society in Africa has raised alarms about the opacity of bilateral agreements, including weak legal alignment, secondary use provisions, and limited guarantees of reciprocal access to health technologies. In this evolving landscape, African governments must navigate not only declining aid but also the governance of health data to protect national sovereignty, public trust, and autonomy. Clear rules on data access, domestic legal supremacy, and alignment with regional and multilateral frameworks are critical. Without robust governance mechanisms, health data risks becoming a conduit for consolidating global power, potentially extending influence far beyond the lifespan of funding agreements.
