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From Partnership to Conditional Health Sovereignty: U.S.–Africa Bilateral Health MOUs, with Uganda as a Case Study

By Fanilo Andriamamantena and Stuart Ssebibubbu

Under the America First Global Health Strategy, the United States is advancing bilateral health Memoranda of Understanding (MOUs) with African countries that link cooperation to financing commitments, performance targets, and data-sharing obligations.^[1] While these agreements are presented as instruments of partnership and transition to domestic ownership, they raise a deeper question: do they strengthen African health self-reliance or condition it on terms defined by external strategic priorities?^[2]  As such, they require scrutiny not only as financing instruments but also as governance arrangements.

Regional responses have not been uniform, with some countries challenging or halting these arrangements,^{[3] [4]} while Uganda’s public and unusually detailed MOU provides the clearest basis for examining its structure and implications. This note argues that the Uganda MOU poses two main risks: first, the weakening of data and specimen sovereignty; and second, the reproduction of financial dependency through an insufficiently defined transition model.^[5]

The Governance Logic of the MOUs

These bilateral MOUs appear to be structured asymmetrically, placing substantial operational and financial responsibilities on partner countries while preserving broad U.S. discretion over audit, performance assessment, and the continuation of funding.^[6] This creates an uneven governance arrangement in which essential cooperation may remain contingent on externally defined benchmarks, with implications for financing predictability, policy autonomy, digital dependence, and control over African health data as illustrated in the Ugandan case.

Data and Specimen Sovereignty: The Uganda Case Study

The Uganda MOU clearly commits U.S. investment to enhancing national data and disease surveillance systems. However, a detailed review uncovers a notable governance gap. The agreement provides limited clarity on the U.S.’s responsibilities regarding data privacy, regulatory oversight, and long-term operational costs of maintaining these advanced systems.

• Digital Coloniality and Extractive Practices

The lack of legal clarity risks reinforcing “digital coloniality.” This concept describes a governance gap in which data generated by African populations, often at great personal risk during epidemics, is collected to benefit external actors without meaningful reciprocity.^[7]

The America First strategy makes health aid contingent on the rapid transfer of:

• Genomic Sequences: real-time data on emerging pathogens.
• Biological Specimens: physical samples of viruses or bacteria.
• National Health Data: patient records and epidemiological trends

• The 25-Year Data Sharing Agreement

Perhaps the most striking feature of the Uganda-U.S. arrangement is the 25-year Data Sharing Agreement. This sub-agreement grants the U.S. secure, uninterrupted access to Uganda’s health information systems, including direct login credentials and real-time data availability.^[8]

This 25-year mandate raises three specific governance alarms:

• Temporal Duration: A quarter-century commitment outlasts multiple political administrations, effectively locking in data access regardless of future Ugandan policy changes.

• Third-Party Dissemination: The agreement allows for the sharing of this data with third-party entities without explicit consent from the country partner for each instance.^[9]

• Absence of Benefit-Sharing: There are no enforceable mechanisms to ensure that vaccines, diagnostics, or therapies developed using Ugandan data are made available to the Ugandan public at an affordable cost.

Financing Transition: The Co-Investment Paradox

The Uganda MOU is framed as a co-investment arrangement, a term that suggests an equitable sharing of the financial burden. However, the numbers tell a story of continued, and perhaps deepened, structural dependency.

• The Fiscal Scale

The U.S. has committed up to USD 1.7 billion in support over the framework period. In exchange, Uganda is expected to increase its domestic health expenditure by more than USD 500 million.^[10] While this is presented as a transition to domestic ownership, the scale of external funding remains so massive that the transition remains uncertain.

When donor aid constitutes over 50% of the Uganda national health budget,^[11] its ability to independently set priorities may be constrained. This echoes the historical experience of PEPFAR-funded programs, where external funding covers over 95% of HIV/AIDS services in some African countries.^[12] If the U.S. were to exercise its unilateral termination right, the Ugandan health system would face significant system disruptions.

• Operational Blind Spots

Furthermore, the MOU lacks operational specificity. It does not clearly demonstrate how Uganda will finance its health system once the five-year framework concludes. Crucial details are missing, such as:

• Commodity Costs: Who pays for the supply chain of life-saving drugs once the co-investment ends?

• Workforce Transitions: How will large numbers of frontline health workers, currently paid via donor-funded NGOs, be integrated into the national civil service?

• Logistical Capacities: There is no assessment of whether the national infrastructure can handle the high-tech surveillance systems once U.S. contractors depart.

Without these details, the MOU does not resolve the structural dependency and may instead reconfigure it. This continues to create a parallel health system, one that is high-tech and data-rich for the donor, but structurally fragile and unfunded for the host.

Policy Implications:

The Uganda MOU, as currently structured, does not meaningfully advance African health sovereignty. By prioritising data access arrangements over equitable partnership, these frameworks risk institutionalising a new cycle of dependency. To address this, future bilateral global health agreements must be built upon the following five pillars of Sovereign Safeguards:

1. Transparency and Parliamentary Scrutiny

National health is a matter of national security. All MOUs should be subject to parliamentary approval before they take effect. This ensures that the long-term consequences of 25-year data deals are debated in the public eye, rather than decided in closed-door negotiations.^[13]

2. Enforceable Benefit-Sharing

Agreements involving specimen and data access must include legally binding commitments. If African data leads to a commercial breakthrough, the partner country should be assured a fair share of the research outcomes. This could include free access to any resulting intellectual property, no royalty obligations, or more affordable pricing for the medical products developed from the research.

3. Institutionalised Technology Transfer

Sustainable self-reliance requires the transfer of technology, not just the provision of aid. MOUs must include specific timelines for the transfer of diagnostic manufacturing, vaccine production technology, and genomic sequencing capacity to local African institutions.

4. Public Control of Digital Infrastructure

Data-sharing arrangements must guarantee that African countries retain ultimate governance. This includes kill switches for data access in the event of a privacy breach, as well as strict limits on third-party dissemination. National health data should reside on national servers, with the U.S. granted viewing rights rather than ownership rights.

5. Alignment with Multilateral PABS Rules

Bilateral agreements should not be used to undermine global equity. They must be consistent with the Pathogen Access and Benefit-Sharing (PABS) framework currently being negotiated under the WHO Pandemic Agreement.^[14] African nations must ensure that bilateral America First deals do not dilute their collective bargaining power at the WHO.

Conclusion

The America First Global Health Strategy, as operationalised through these asymmetric MOUs, risks prioritising external security interests over domestic public health priorities. A unified African stance, led by the Africa Centres for Disease Control and Prevention (Africa CDC), is urgently needed. Only through collective negotiation can African nations guarantee that global health collaborations truly transfer power, technology, and health security to the continent.

References :

1. Cullinan K, ‘Africa Is Stuck Between Global Pathogen-Sharing Talks And Conflicting US Bilateral Agreements – Health Policy Watch’ (1 December 2025) <https://healthpolicy-watch.news/africa-stuck-between-global-pathogen-sharing-talks-and-conflicting-us-bilateral-agreements/> accessed 17 March 2026
2. David W, ‘Understanding the US-Uganda Health MoU: Balancing Aid with Privacy, Sovereignty, and Data Risks’ (Lawpointuganda, 11 December 2025) <https://www.lawpointuganda.com/post/understanding-the-us-uganda-health-mou-balancing-aid-with-privacy-sovereignty-and-data-risks> accessed 17 March 2026
3. ‘From Dependency to Sovereignty – HHR Journal’ <https://www.hhrjournal.org/2025/02/26/from-dependency-to-sovereignty/> accessed 19 March 2026
4. ‘Joint Statement on Uganda-USA Bilateral Health Cooperation MOU .Pdf’ <https://www.finance.go.ug/sites/default/files/2025-12/JOINT%20STATEMENT%20ON%20UGANDA-USA%20BILATERAL%20HEALTH%20COOPERATION%20MOU.pdf?> accessed 17 March 2026
5. Lay K and correspondent KLG health, ‘Rising Anger over “Lop-Sided” and “Immoral” US Health Funding Pacts with African Countries’ The Guardian (27 February 2026) <https://www.theguardian.com/global-development/2026/feb/27/rising-anger-over-lop-sided-immoral-us-health-funding-pacts-africa-countries> accessed 18 March 2026
6. Musoke R, ‘Uganda: Inside Uganda’s Landmark Health Agreement With Washington’ The Independent (Kampala, 9 March 2026) <https://allafrica.com/stories/202603090342.html> accessed 17 March 2026
7. Sekalala S and others, ‘America First, Africa Last? Health Data Deals and the New Scramble for Pathogens (2026) 6 PLOS Global Public Health e0005974 <https://doi.org/10.1371/journal.pgph.0005974> accessed 24 March 2026
8. Sekalala S and Chatikobo T, ‘Colonialism in the New Digital Health Agenda’ (2024) 9 BMJ Global Health <https://doi.org/10.1136/bmjgh-2023-014131>
9. Syam N and Tellez VM, ‘The US Bilateral Specimen Sharing Agreement in the Proposed PEPFAR MOUs Would Leave African Countries More Vulnerable in the Next Pandemic.’
10. Wiyeh A and others, ‘A Critical Juncture in Global Health: Leveraging Historical Institutionalism to Examine PEPFAR Dependency and Inform the Development of Self-Reliant Public Health Systems’ (2025) 5 PLOS Global Public Health e0004440 <https://doi.org/10.1371/journal.pgph.0004440> accessed 5 February 2026

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^[1] Ronald Musoke, ‘Uganda: Inside Uganda’s Landmark Health Agreement With Washington’ The Independent (Kampala, 9 March 2026) <https://allafrica.com/stories/202603090342.html> accessed 17 March 2026.

^[2] ibid.

^[3] Kat Lay and Kat Lay Global health correspondent, ‘Rising Anger over “Lop-Sided” and “Immoral” US Health Funding Pacts with African Countries’ The Guardian (27 February 2026) <https://www.theguardian.com/global-development/2026/feb/27/rising-anger-over-lop-sided-immoral-us-health-funding-pacts-africa-countries> accessed 18 March 2026.

^[4] ibid.

^[5]Joint Statement on Uganda-USA Bilateral Health Cooperation MOU, ’ <https://www.finance.go.ug/sites/default/files/2025-12/JOINT%20STATEMENT%20ON%20UGANDA-USA%20BILATERAL%20HEALTH%20COOPERATION%20MOU.pdf? accessed 17 March 2026.

^[6]Nirmalya Syam and Viviana Munoz Tellez, ‘The US Bilateral Specimen Sharing Agreement in the Proposed PEPFAR MOUs Would Leave African Countries More Vulnerable in the Next Pandemic’.

^[7]Sharifah Sekalala and Tatenda Chatikobo, ‘Colonialism in the New Digital Health Agenda’ (2024) 9 BMJ Global Health <https://doi.org/10.1136/bmjgh-2023-014131>.

^[8] Waboga David, ‘Understanding the US-Uganda Health MoU: Balancing Aid with Privacy, Sovereignty, and Data Risks’ (Lawpointuganda, 11 December 2025) <https://www.lawpointuganda.com/post/understanding-the-us-uganda-health-mou-balancing-aid-with-privacy-sovereignty-and-data-risks> accessed 17 March 2026.

^[9] Kerry Cullinan, ‘Africa Is Stuck Between Global Pathogen-Sharing Talks And Conflicting US Bilateral Agreements – Health Policy Watch’ (1 December 2025) <https://healthpolicy-watch.news/africa-stuck-between-global-pathogen-sharing-talks-and-conflicting-us-bilateral-agreements/> accessed 17 March 2026.

^[10] Joint Statement on Uganda-USA Bilateral Health Cooperation MOU (n 5).

^[11]From Dependency to Sovereignty – HHR Journal’ <https://www.hhrjournal.org/2025/02/26/from-dependency-to-sovereignty/> accessed 19 March 2026.

^[12] Alison Wiyeh and others, ‘A Critical Juncture in Global Health: Leveraging Historical Institutionalism to Examine PEPFAR Dependency and Inform the Development of Self-Reliant Public Health Systems’ (2025) 5 PLOS Global Public Health e0004440 <https://doi.org/10.1371/journal.pgph.0004440> accessed 5 February 2026.

^[13] Musoke (n 1).

^[14] Sharifah Sekalala and others, America First, Africa Last? Health Data Deals and the New Scramble for Pathogens’ (2026) 6 PLOS Global Public Health e0005974 <https://doi.org/10.1371/journal.pgph.0005974> accessed 24 March 2026.