The United States has signed a five-year health cooperation agreement with Eswatini valued at $242 million, reinforcing the Trump administration’s push to recast global health assistance around domestic responsibility and long-term self-reliance.
Under the memorandum of understanding, signed on Friday, Washington intends to provide up to $205 million in health support, while Eswatini has committed to increasing its own health spending by $37 million over the duration of the agreement, according to the US State Department.
From aid to shared responsibility
The agreement forms part of President Donald Trump’s ‘America First Global Health Strategy’, unveiled in September, which seeks to move away from open-ended foreign aid towards models that require recipient countries to invest more heavily in their own health systems.
US funding under the Eswatini deal will focus on health data collection, disease surveillance, outbreak response, and HIV prevention and treatment. Eswatini, a small southern African kingdom, has one of the world’s highest HIV prevalence rates and has long relied on external assistance, particularly from the US, to sustain its public health programmes.
State Department spokesman Tommy Pigott said the agreement marked a turning point in bilateral health cooperation. ‘The signing places Eswatini on a clear path to achieving the long-term goal of an effective, sustainable, and efficient health system,’ he said, adding that it underscored a mutual commitment to safeguarding health gains and protecting citizens in both countries.
HIV focus and new treatments
A key element of the agreement is the inclusion of lenacapavir, a US-made long-acting HIV prevention drug, which will be delivered to Eswatini as part of the package. The drug is seen by health specialists as a potential breakthrough, particularly in countries where daily medication adherence has proved difficult.
US officials argue that combining new medical innovations with stronger national health systems will improve outcomes while reducing long-term dependency on donor funding. Eswatini’s increased budgetary commitment is intended to ensure that gains made under the agreement can be sustained beyond the five-year timeframe.
Part of a broader Africa rollout
The Eswatini agreement follows a series of similar health cooperation deals signed by Washington in recent weeks. Over the past month, the US has concluded comparable arrangements with Kenya, Rwanda, Uganda and Lesotho, signalling a coordinated effort to standardise its approach to global health partnerships across Africa.
The State Department said similar bilateral health agreements with dozens of other countries that receive US health assistance are expected to be finalised in the coming weeks. Together, they are designed to operationalise the new strategy by embedding fiscal responsibility and local ownership into health programming.
Balancing ambition and risk
While the new model has been welcomed by some policymakers as a more sustainable framework for development assistance, critics have raised concerns that tying aid to domestic spending targets could place strain on public finances in lower-income countries. There are fears that failure to meet funding commitments could disrupt essential services, particularly in countries facing economic volatility.
For Eswatini, the agreement presents both opportunity and pressure. Increased domestic investment could strengthen its health infrastructure and improve resilience, but it also requires sustained fiscal discipline amid broader social and economic challenges.
Wider diplomatic context
The health pact comes against the backdrop of evolving US–Eswatini relations. In a separate agreement announced in November, Eswatini received $5.1million from Washington in exchange for accepting third-country nationals deported by the Trump administration, highlighting the increasingly transactional nature of some aspects of US foreign policy.
As Washington expands this model across Africa, the Eswatini agreement will be closely watched as a test case for whether tying aid to domestic investment can deliver both stronger health outcomes and lasting system reform.
