Trump's US health aid overhaul meets reality in Mozambique

Key topics:Floods in Matola drive malaria, cholera and clinic strainUS aid cuts shift global health to bilateral funding dealsMozambique health system strained by staff cuts and funding gaps.By Janice Kew and Tavares Cebola.Floodwater stagnates in parts of Matola near Mozambique’s capital of Maputo, where clinics treat a familiar post-disaster mix: malaria, suspected cholera and children at risk from unsafe water. At the Matola II health center, staff are racing to contain outbreaks while catching up on tuberculosis and HIV treatments after months of flood disruption. The clinic, which sees roughly 400 patients a day, is also still reeling from last year’s abrupt US aid cuts that forced layoffs of community-health workers and disrupted disease-surveillance programs..“We were already struggling before the floods,” said Alarico Moisés Manjacaze, the clinic’s director. “Now we are trying to recover services with fewer people and more patients.”The strain visible in clinics like this across Mozambique reflects a far bigger shift underway in global health..Read more:.Trump’s foreign aid cuts shake NGOs and philanthropists.When Donald Trump returned to office in 2025, his administration rapidly dismantled much of the US foreign-aid system that for decades made Washington the world’s largest humanitarian donor, slashing billions of dollars in assistance programs across the developing world. The cuts forced some HIV clinics to scale back services, disrupted vaccination and disease-monitoring initiatives and left refugee agencies scrambling to replace lost funding.The suspension of programs also reduced disease-surveillance capacity and triggered layoffs, according to clinic staff and aid groups operating in Mozambique. At Matola II, the number of community-health workers has dwindled to fewer than 20 from more than 40 in the past year.Now, the US administration is rebuilding parts of that system around a more transactional model: bilateral health deals that offer reduced long-term support while pushing poorer countries to finance more of their own care systems — and, opponents say, increasingly tying cooperation to commercial goals..Mozambique has emerged as one of the clearest examples of that shift.One of more than 30 new US bilateral-health agreements signed under the America First global health strategy that commits almost $13 billion through 2030 — alongside a further $7.3 billion in contributions from 22 African nations — Maputo’s pact with the US is reshaping its dependence.The southern African country — home to vast offshore natural-gas reserves but also one of the world’s most aid-dependent health systems — signed a five-year, $1.8 billion accord that will support HIV and malaria programs while requiring it to sharply increase domestic health spending. It replaces far higher US support that exceeded $500 million annually and accompanies the abrupt halt of many surveillance programs last year.A place where cyclones and floods regularly batter fragile infrastructure — with damages of $764 million in the first quarter alone — Mozambique grapples with a large HIV burden and endemic malaria that stretch capacity in stable times. It’s also dealing with an Islamist militant insurgency in the north that has further displaced populations and disrupted care, compounding systemic strain. .Critics say the arrangement illustrates the imbalance many countries face after last year’s aid shock: accepting less generous funding on tougher terms because the alternative could be systemic collapse. Analysts and civil-society groups say the agreements are unfolding alongside broader US strategic and commercial interests in Africa, including energy, mining and logistics access.“This contract is part of a broader negotiation for Mozambique’s resources in terms of gas in the north and other logistics contracts that the US government is looking for,” said Jorge Matine, director for Maputo-based health-governance group Observatório Cidadão para Saúde.“If there’s any concern or problem in those negotiations, the health contract itself could be jeopardized,” he said. Mozambique’s government didn’t respond to numerous requests for comment..The new agreements mark a significant departure from the decades-old aid architecture dominated by the United States Agency for International Development multilateral agencies and large international implementing organizations.The strategy “is about giving countries ownership and sovereignty over their health systems,” US Under Secretary of State for Foreign Assistance Jeremy Lewin said at a Council on Foreign Relations event in April. “If we’re going to give foreign assistance for your healthcare architecture, it should be in coordination with the government. We should make them coinvest. We should make them have skin in the game. We should have a pathway to self-reliance.”.US officials say the model will reduce waste, cut reliance on expensive foreign contractors and encourage countries to build self-sustaining health systems. Others, however, argue the transition is being forced at a speed many fragile states cannot withstand.“The sudden steep cuts last year created health crises that put governments between a rock and a hard place when negotiating,” said Suerie Moon co-director of the health center at the Graduate Institute of International and Development Studies.The Department of State didn’t respond to requests for comment.Some governments have also balked at provisions requiring expanded access to health-program data, procurement systems and financial reporting, with detractors warning the need could give Washington outsized leverage over national systems and sensitive public-health information.The new agreement also represents a significant reduction in funding even before inflation and rising disease burdens are considered..With Mozambique in financial distress and organizations such as the World Bank saying the gas-rich nation’s debt is unsustainable, it’s difficult to see where the nation’s contributions will come from, Matine said.“If we see how dismantled the systems are, it means restarting again and these funds will only help to reorganize the system, not really provide the health services,” he said.Fátima Mimbire, a project manager at Maputo-based advocacy group N’weti, said the biggest risk is losing funding altogether if the government cannot increase spending to the required levels..Read more:.Trump permanently halts healthcare aid to South Africa, sparking HIV crisis.The rollout is happening quickly, with fewer US staff overseeing a larger portfolio, raising risks around coordination and delivery, said Jocilyn Estes of the Center for Global Development in Washington.“The theoretical case for cost savings is real,” she said. “But theory and practice are different animals. The State Department is designing these agreements at breakneck speed with a fraction of the workforce that previously managed a much smaller government-to-government aid portfolio.”.South Africa, which has the world’s largest HIV burden, may not even be offered a deal. Kenya’s agreement has faltered over data-sharing concerns. The US has already ended health aid to Zimbabwe after it rejected a similar pact as undermining sovereignty.Even before the US slashed support -- and other western countries including the UK, France and Germany followed -- most African nations fall well short of global benchmarks for domestic health spending.The World Health Organization recommends allocating at least 15% of public expenditure to health, yet many remain in the single digits, constrained by debt burdens, volatile export revenues and currency pressures — with more than 30 countries spending more on debt servicing than on healthcare.Africa Centres for Disease Control and Prevention, which initially backed direct funding to governments after the 2025 USAID cuts, now says bilateral deals must align with regional priorities. WHO Director-General Tedros Adhanom Ghebreyesus has emphasized that such agreements are sovereign decisions that can coexist with multilateral systems..Even with the recent promise of funding, Mozambique is still working out how to implement spending, said Mauro Cuna, senior project manager at Acasus, which is advising the government.Others argue the timeline itself is a risk.“Three to five years is an extremely short time frame for a country to transition out of aid,” said Gavin Yamey, the director of the Center for Policy Impact in Global Health of Duke University in Durham, North Carolina. Rapid transitions risk financing gaps that can lead to a resurgence of diseases such as malaria and HIV..Read more:.The Economist: Trump woos African leaders while slashing aid and policy focus.The debate underscores a broader question facing global health: whether the push for speed, efficiency and national ownership can coexist with the realities of fragile systems and repeated shocks, such as the current outbreak of Ebola affecting eastern Africa.At the clinic level, the trade-offs are already visible.Nearly six months after the bilateral accord was signed, health workers at Matola II said they have yet to see any real effect — underscoring the long gap between international funding deals and changes on the ground.“We just wait for the new agreement to make an impact,” Manjacaze said, as groups of staff sat under trees between shifts at the clinic..Floodwater still pools outside parts of the building and staff are trying to restore services with a fraction of the outreach workforce they once had while thinking about what awaits them beyond 2030, when the US program ends.“This is a time for our government to start preparing itself,” Manjacaze said. “We’re currently walking alone after those cuts. But there is a lesson — we need to start preparing ourselves so that at the end of this agreement, if there isn’t financing to carry on, we’re ready and have staff for all areas.”.© 2026 Bloomberg L.P..Sign up for your early morning brew of the BizNews Insider to keep you up to speed with the content that matters. The newsletter will land in your inbox every morning on weekdays. Register here.Support South Africa's bastion of independent journalism, offering balanced insights on investments, business, and the political economy, by joining BizNews Premium. Register here.If you prefer WhatsApp for updates, sign up to the BizNews channel here.

Trump's US health aid overhaul meets reality in Mozambique

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