Analysis of the Kenyan, Rwandan US-:health care agreement

Kenya was the first country to sign the US-EU healthcare agreement, followed shortly after by Rwanda. In this context, the question arises whether Rwanda and Kenya are entering into a relationship of dependency. This is an excellent question because it touches upon the core of many countries' strategic considerations in their dealings with global powers. This question addresses a central concern of nations like Rwanda and Kenya: sovereignty and the avoidance of neocolonial dependency. The following explains why both countries emphasize that they are not entering into a relationship of dependency, and the nuances involved: There are reasons often cited for the argument of "non-dependency." One of these is strategic agency. Rwanda and Kenya are known for their strong agency in their international partnerships. They are not passive recipients. They negotiate the terms, align programs with their national health strategies (e.g., Rwanda's community-based health system, Kenya's Universal Health Agenda), and often provide co-financing or in-kind contributions. Another frequently cited factor is the diversification of partners. Both countries do not rely solely on the USA. They maintain health partnerships with various organizations: the Global Fund, GAVI, the World Bank, the UK, the EU, China, and private foundations such as the Gates Foundation. This diversification prevents excessive dependence on individual donors. The strengthening of national capacities is emphasized. A central, though not always perfectly achieved, goal of these agreements is knowledge transfer, strengthening local health facilities, and building sustainable systems. The long-term aim is to create a resilient health system that requires less external support. Then there are also clear, goal-oriented agreements. Modern health agreements are often formulated as technical partnerships with specific, measurable objectives (e.g., reducing the HIV infection rate, improving laboratory diagnostics, strengthening pandemic preparedness). This differs from open-ended, blanket support, which could create dependencies. Of course, political sovereignty remains intact. Both countries retain full control over their entire foreign and domestic policy. While cooperation in health is significant, it is only one aspect of a multifaceted relationship that also encompasses trade, security, and diplomacy. The downsides and risks of dependency (the other side of the coin), which no one likes to talk about. One of these is financial dependency. For certain health problems (especially HIV/AIDS), US funding through PEPFAR is so extensive that a sudden withdrawal would trigger a severe crisis. This leads to a structural dependency in this sector, even if it is managed. Then there is the technical and protocol dependency. Long-term reliance on US-funded goods, training, and data systems can lead to difficult and costly changes in procedures and potentially crowd out other approaches or providers. Not to be forgotten are the influence and conditionality. Even if it is not overtly apparent, funding can be linked to subtle influence. Agreements may include stipulations regarding governance, reporting, or ideological alignment (e.g., past debates surrounding the "Mexico City Policy" on family planning). The partner country must manage these conditions. The distortion of local priorities must also be addressed. Large, vertical, disease-specific programs (such as HIV funding) can divert local health professionals and resources from other national priorities and subtly shape the health agenda in line with the donor's perspective. The specific positions of Rwanda and Kenya: Rwanda places particular emphasis on self-responsibility. The country is known for its results-oriented development aid model. It frequently directs partners to specifically address gaps in its clearly defined plans. The government contributes significantly to the health budget and closely coordinates all external aid to ensure it serves national objectives. This model is explicitly designed to avoid dependencies. Kenya has a larger and more complex health system, as well as a larger population. The country is actively working to gradually transition programs from donor to government funding (a process known as “transition planning”). However, due to the enormous need, donor funding remains essential in many areas, leading to a more complex dynamic of dependency. This is a very relevant and important issue. Every significant international agreement, especially one involving large sums of money and critical sectors like healthcare, carries risks along with its benefits. The new five-year, $2.5 billion healthcare cooperation agreement between the US and Kenya (signed at the end of 2025) represents a marked shift from the previous donor-funded model to a partnership between governments. While officials praise the agreement for promoting Kenyan self-reliance and strengthening the national health system, critics have raised several specific concerns that could lead to negative consequences. There is also the risk of potential deterioration of the agreement. The risks primarily concern sustainability, sovereignty, and equity: The financial crisis (sustainability). The framework agreement is a transitional model in which the US contribution of up to US$1.6 billion over five years (until 2030) will gradually decrease. Kenya commits to increasing its health spending by US$850 million to cover costs, including healthcare staff salaries and supplies. The risk is that if Kenya's economic growth or its ability to meet the US$850 million commitment weakens, the health system could face a financial crisis after the US funding ends. This would result in a sudden and drastic decline in services, particularly in programs such as HIV/AIDS (PEPFAR) and malaria. Data and pathogen sovereignty. The agreement provides for the exchange of health data and biological samples/pathogens with the US for surveillance and biosecurity purposes. The risk is that critics fear this could lead to “digital colonialism” or a loss of national sovereignty over highly sensitive health data and biological materials, especially if the fine print (which is not always public) prioritizes US access and commercial interests over data protection and the participation of Kenyan citizens. It's worth noting that Kenyan officials have publicly stated that only anonymized, aggregated data will be shared and that Kenyan data protection laws will be strictly adhered to. However, the lack of full disclosure of all technical details has raised concerns. Lack of participation in innovation. There are concerns that the agreement does not explicitly guarantee Kenya access to, or co-ownership of, medical products, vaccines, or research results based on pathogens and data shared by Kenya. The risk is that this could lead to an “exploitative” arrangement, where Kenyan resources drive global health innovation, but Kenyans do not benefit commercially or clinically from the final products. The agreement is part of a global health strategy based on the “America First” principle, which may link development aid more directly to US foreign policy and domestic priorities (e.g., restrictions on family planning programs that include abortions). The risk is that this could introduce an ideological component that could limit local healthcare decision-making and restrict the scope of services provided to what complies with US directives, thereby potentially compromising comprehensive care. Implementation and governance issues. The shift from NGO-funded to direct government funding (G2G) aims to reduce waste, but simultaneously shifts a greater financial and operational risk directly to Kenyan government agencies (KEMSA, SHA, etc.). The risk lies in rampant corruption. If existing weaknesses in public financial management, procurement, or the integration of healthcare personnel are not fully addressed, the G2G model could lead to new forms of inefficiency or delays, directly impacting the availability of vital medicines and services. Conclusion: The agreements are structured as Memoranda of Understanding (MOUs) or framework agreements, meaning they are generally not legally binding treaties under international law, but rather political commitments. The agreement with Kenya represents a broader and more ambitious partnership, underscoring Kenya's status as a key US ally in East Africa and its proactive role in global security (e.g., in Haiti). It includes stronger incentives for Kenya's financial independence and data sovereignty safeguards based on domestic demands. In contrast, the agreement with Rwanda is modest—effectively a reduction in funding disguised as cooperation—and focuses on combating key infectious diseases, given the already strained health systems resulting from previous PEPFAR pauses. Both agreements illustrate the US shift toward bilateral, interest-driven aid rather than multilateral initiatives like the WHO. Analyses suggest that life-saving measures beyond strategic advantages receive little attention. Future agreements (e.g., with Zambia for US$1.5 billion) could follow Kenya's example for larger partners. The statement that Rwanda and Kenya “will not enter into a dependency relationship” reflects a key strategic intention and a negotiated reality, not necessarily a guaranteed outcome. This is true at the political and strategic level. Both countries actively shape these partnerships to preserve their sovereignty, diversify their portfolios, and leverage external financing to build self-reliance. At the practical, sectoral level, dependencies do exist. In certain healthcare programs or technical areas, a sudden withdrawal by the donor would be disastrous. The relationship is asymmetrical and requires careful and continuous management from the recipient countries. Essentially, they are walking a tightrope. They are utilizing the vital resources and expertise of a powerful partner to improve the health and security of their populations, while consciously implementing measures and safeguards to ensure that the partnership promotes, rather than hinders, their long-term development. Direct G2G financing is intended to increase accountability and transparency by channeling funds through official government channels. In summary, the agreement could have negative consequences if the transitional model fails (due to a lack of Kenyan funding) or if the governance clauses (regarding data, sovereignty, and benefit-sharing) are implemented in a way that disadvantages Kenya. Should I look for current information on the implementation of the agreement or on the existing control mechanisms?