Addis Abebe — The adage that “there are no free lunches in geopolitics—only postponed bills” captures a core reality of international relations: engagements that appear cost-free in the short term almost always carry deferred obligations.
The recently signed five-year health cooperation Memorandum of Understanding (MoU) between Ethiopia and the United States fits squarely within this logic, warranting scrutiny beyond its humanitarian framing.
When Ethiopia and the United States signed a new Bilateral Health Cooperation MoU in late 2025—committing a combined $1.46 billion to Ethiopia’s health sector—the official narrative was predictably benevolent. The agreement was presented as a vehicle for partnership, capacity building, pandemic preparedness, and “saving lives.” Such objectives are both legitimate and urgently needed in a country facing persistent public health challenges. Yet the language of goodwill and technical cooperation obscures a more consequential question: what, if anything, does Ethiopia cede in return?
Foreign assistance, particularly at this scale, is rarely neutral. Health financing increasingly intersects with governance standards, policy alignment, data sharing, and regulatory influence. The concern, therefore, is not the value of cooperation itself but the terms under which it unfolds. Does this MoU enhance Ethiopia’s long-term institutional autonomy, or does it embed external priorities into national health policy under the guise of technical support?
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Framed this way, the agreement invites a sober assessment of trade-offs rather than a reflexive celebration of funding levels. Public health partnerships can save lives and strengthen systems, but they can also recalibrate power relations. The critical issue is whether Ethiopia emerges from this arrangement with greater capacity to set its own priorities—or with obligations whose political costs will only become visible once the bill comes due.
At a moment when Ethiopia is stalled in political fragmentation, economic distress, and declining public trust in governance, the timing and substance of this agreement deserve scrutiny far beyond celebratory press releases.
America First Doctrine in Global Health Guise
The MoU is not an isolated act of benevolence. It is explicitly anchored in Washington’s America First Global Health Strategy, unveiled by the U.S. State Department in September 2025. This strategy is sincere about its primary objective: U.S. global health assistance must serve U.S. national interests first.
”Ethiopia enters this pact from a position of weakness: a battered economy, ongoing internal conflicts, humanitarian crises, and declining legitimacy of governance.”
In addition to Ethiopia, several African countries have signed bilateral health cooperation Memoranda of Understanding (MoUs) with the United States under the America First Global Health Strategy. In East Africa, Kenya became the first country to sign a bilateral health pact under the strategy, involving substantial U.S. funding and domestic co-investment. Rwanda subsequently followed with its own health cooperation agreement, while Uganda signed a multi-billion-dollar MoU that also includes co-investment commitments.
In West and Southern Africa, Nigeria entered into a health cooperation MoU with U.S. support and co-investment obligations. Cameroon signed a bilateral health MoU under the same framework, and Côte d’Ivoire concluded a five-year health cooperation agreement aligned with the strategy. Additional countries, including Lesotho, Liberia, and Mozambique have also either concluded similar agreements or are reported to be in the process of signing bilateral health deals under this U.S. global health framework.
The America First Global Health Strategy reframes health aid not as solidarity but as a strategic instrument to prevent outbreaks from reaching U.S. shores, advance American commercial interests, compete with China’s influence in Africa, and secure bilateral leverage through performance-based agreements.
In the words of U.S. Secretary of State Marco Rubio, global health diplomacy is meant to make America “safer, stronger, and more prosperous.” Ethiopia’s wellbeing, while not irrelevant, is clearly secondary. This context matters. Because what Ethiopia signed was not simply a health agreement; it was an alignment.
From Aid to Oversight: Ethiopia’s Health Sovereignty at Stake
Ethiopia enters this pact from a position of weakness: a battered economy, ongoing internal conflicts, humanitarian crises, and declining legitimacy of governance. In such circumstances, “partnership” risks becoming conditional compliance.
The MoU commits Ethiopia to extensive data sharing, integration of health surveillance systems, and adherence to strict performance benchmarks, while granting the United States significant leverage over the continuation of funding. Under the agreement, the health systems of signatory countries are expected to be fully digitalized, with comprehensive data shared with U.S. authorities. This digitalization encompasses detailed patient information, tracking individuals from the moment of admission to their discharge, raising concerns over data sovereignty and privacy.
Another provision obliges signatory countries to share physical biological specimens within five days in the event of a pandemic. Such samples may be used by the U.S. Centers for Disease Control (CDC) or private pharmaceutical companies engaged in vaccine development. In practice, this creates a scenario in which Ethiopia could be effectively required to purchase vaccines exclusively from U.S. companies during health emergencies, limiting national procurement autonomy.
”The essential question is not whether Ethiopia should cooperate with the United States—it should—but on whose terms, with what safeguards, and at what cost.”
The MoU further provides for U.S. health professionals to work directly within the ministries of signatory countries. While intended to support technical capacity, this arrangement risks prioritizing U.S. strategic interests over local health priorities. Under these conditions, Ethiopia’s health system risks becoming a node within America’s global health surveillance and strategic competition framework, raising critical concerns about sovereignty, policy autonomy, and the long-term implications of external oversight in domestic public health.
Emerging Regional Precedent: Lessons from Kenya
Skeptics need look no further than Ethiopia’s neighborhood. In December 2025, Kenya’s High Court suspended a $2.5 billion health agreement signed between the Kenyan government and the United States, citing data privacy risks, constitutional violations, the absence of parliamentary oversight, and threats to national sovereignty. The court held that public health agreements cannot circumvent democratic accountability or compromise state autonomy.
One of the petitioners, the Consumer Federation of Kenya (Cofek), warned that Kenya risked surrendering strategic control over its health system “if pharmaceuticals for emerging diseases and digital infrastructure (including cloud storage of raw data) are externally controlled.” The High Court agreed, barring implementation of the agreement until the case is fully adjudicated.
This ruling raises an uncomfortable question for Ethiopia: was the MoU subjected to meaningful parliamentary debate or public scrutiny? If not, the country may already have crossed a dangerous threshold—normalizing executive-level foreign commitments that reshape national systems without democratic consent.
Consequences of Compliance
Supporters of the Ethiopia–U.S. health MoU emphasize the country’s urgent need for resources—and that need is undeniable. Yet necessity does not excuse naivety. The U.S. “America First” framework openly critiques dependency while embedding American priorities within partner countries’ systems. This is not a decolonization of aid but a recentralization under a different flag, where strategic influence accompanies assistance.
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More concerning is the apparent willingness of Prime Minister Abiy Ahmed’s administration to accept these terms without adequately safeguarding Ethiopia’s policy space. In a nation whose history is defined by resistance to external domination, such acquiescence risks being perceived not as pragmatism but as policy surrender. Critics argue this posture is dangerously unbalanced—not because cooperation is inherently wrong, but because unconditional alignment undermines national sovereignty.
Sovereignty in health extends beyond funding: it requires ownership of data, authority to set priorities, control over financing, and accountability to citizens rather than donors. Aid that compromises these principles carries long-term costs, regardless of benevolent rhetoric. “Dollars can fund clinics. They can also reprogram states.”
The essential question is not whether Ethiopia should cooperate with the United States—it should—but on whose terms, with what safeguards, and at what cost. If strategic sectors continue to be mortgaged under the guise of reform or partnership, without transparency, accountability, or national consensus, the price will be paid not only in policy autonomy but also in public trust. Once sovereignty is traded for dollars, reclaiming it becomes far costlier. History is unforgiving to governments that mistake short-term relief for long-term interest. AS
Editor’s Note: Yirgalem Addisu is an independent public health researcher with academic training in health systems and population health. His research interests include health governance, health systems security and emergencies, and policy-making in low-income countries. Yirgalem can be reached at [email protected].
Disclaimer: The views and opinions expressed in this article are that of the writer’s and do not necessarily reflect the editorial of Addis Standard.