The United States has signed new global health memoranda of understanding (MOUs) with four African countries totaling nearly $2.3 billion in combined commitments as part of the Trump administration's America First Global Health Strategy.

The bilateral agreements with Madagascar, Sierra Leone, Botswana, and Ethiopia include approximately $1.4 billion in US assistance with more than $900 million in co-investment from the countries.

“Each MOU includes clear benchmarks, strict timelines, and consequences for nonperformance—ensuring US assistance delivers results against priority disease threats and reduces long-term dependence on US assistance,” the State Department said in a statement.

The Ethiopia agreement focuses on investment that addresses HIV/AIDS, tuberculosis, malaria, polio eradication, maternal and child health, and infectious disease preparedness. The arrangement includes ongoing support for the country's response to the Marburg virus.

In Southern Africa, Botswana’s agreement includes plans to modernize electronic medical records and disease surveillance systems.

The US plans to front-load more than $30 million to Sierra Leone in 2026 as part of the agreement in order to rapidly strengthen disease surveillance, laboratory capacity, health workforce, and data systems.

Madagascar’s agreement includes investments that target malaria, maternal and child health, and global health security while transitioning the infectious disease-focused community health workforce to national ownership.

These four agreements join a list of bilateral health memorandums signed under the America First Global Health Strategy, which was launched in September.

Kenya became the first country to sign such an agreement on December 4. However, within days of the signing, a Kenyan court suspended part of the health funding agreement until it hears a data privacy case filed by a consumer protection group.

Nigeria, Rwanda, Cameroon, Lesotho, and Liberia are the other African nations that signed on to the US-led initiative.

The US plans to sign multi-year bilateral health cooperation agreements with dozens of partner countries in the coming weeks.