Zambia’s Draft Memorandum of Understanding With the U.S. Government: What Do We Know? 

Health activists today released Zambia’s draft Memorandum of Understanding (MOU) with the U.S. government (USG). The deal would cover 5 years of funding for HIV, tuberculosis, malaria, maternal and child health, polio and measles vaccination, and pandemic surveillance. Negotiations over the MOU have been stalled for months; the deal was supposed to have been signed December 11, 2025.

USG officials are facing sharper criticism in response to revelations that Secretary of State Marco Rubio is intensifying threats that he will withhold life saving health funding unless the USG has greater access to Zambia’s mineral wealth. Specifically, The New York Times reported that the State Department’s Africa Bureau prepared a memo for Secretary of State Marco Rubio, which argues the USG must respond to stalled bilateral MOU negotiations with a willingness to escalate by denying Zambians lifesaving HIV prevention and treatment “on a massive scale.”¹ 

The State Department is threatening Zambia with an embargo on essential medicines in order to plunder its minerals. Zambia’s MOU text is the first we know of that explicitly ties exploitation of mineral wealth with agreeing to the USG’s MOU terms—in this case, via a separate “Bilateral Compact” ² which had been reported earlier.³ Zambia’s draft MOU, like all others, has been negotiated in secret.⁴ Such exploitative conditions have been described as a condition of other deals,⁵ but have not necessarily been included in actual MOU texts that we have had access to.

In addition to conditioning MOU funding access on secret mining deals, the MOU contains some of the worst terms of all bilateral MOUs negotiated thus far, including: 

• Substantial health funding cuts: A 53% funding cut for Zambia’s health priorities compared with FY24 funding levels for these health areas, of $1.012 billion over five years. In addition to this cut, in November, Zambia announced the US had first pledged it would receive $1.5 billion over a five-year period.⁶ $1.012 billion is a $488 million reduction in their envelope that was never been explained. Cuts are common in all MOUs, but not as severe as those proposed in Zambia’s deal. Where will all of the unspent money go? Already PEPFAR is refusing to spend $977 million that was appropriated but unobligated by the end of FY25.⁷ And Rubio is refusing to transfer all of CDC’s share of PEPFAR’s budget for FY26, potentially throwing its CDC-funded PEPFAR programs over a fiscal cliff.⁸  
• Unrealistic pace of health workforce expansion: Over 2026-2030, Zambia would be required to hire a total of 40,000 additional Zambian health workers, resulting in a 50% increase compared with the complement of all 81,000 currently funded health workers in the entire Zambian health system (MOU, p 38). If Zambia does not attain this goal, Zambia will face funding cuts and/or MOU termination. 
• Commodity funding cuts: The MOU also commits Zambia to a major increase in funding new laboratory and non-laboratory commodities, starting in 2026 with $55 million in new funding and expanding to $118.3 million in new funding by 2030 (MOU, p 36). The USG currently funds $175 million in laboratory and non-laboratory commodities (MOU, p 11); in 2026 this would drop to only $88.8 million (MOU, p 37). Even if Zambia’s increase in commodities funding materialized, it would not compensate for the massive, unjustified cut by the USG. 
• One-side USG data access: the MOU requires Zambia to share specimens and related data of “detected pathogens with epidemic potential” for 25 years, a duration no other country has accepted—based on what we have been able to see. Kenya, by contrast, rejected these terms and instead secured provisions based on existing pathogen sharing arrangements.⁹
• Excluding independent civil society from meaningful oversight and accountability: independent civil society groups are excluded from ongoing quarterly oversight over program implementation, through a body called the Joint Health Cooperation Steering Committee, or JHCSC (MOU, p 25 ). In prior years, civil society engagement in planning and in watchdogging program implementation was robust and meaningful, through PEPFAR country “COP” planning processes and through quarterly PEPFAR PoART (PEPFAR Oversight and Accountability Response Team) convenings.¹⁰ Despite claims contained in the “America First Global Health Strategy” that the USG will prioritize transparency, the USG has instead dismantled systems of oversight, excluded directly impacted communities from meaningful engagement, and shielded health deals governing access to lifesaving services from public scrutiny.   

By contrast, the MOU also contains a promise regarding “De-medicalization of Pre-exposure Prophylaxis (PrEP).” Specifically, funding is set aside for USG support to Zambia “in introducing and implementing a de-medicalized PrEP delivery model. This approach will expand PrEP delivery beyond traditional clinical settings by integrating services into community-based and private-sector platforms. A key component of this policy change will be the use of community health workers, private health facilities, community private pharmacies, to provide select HIV prevention services, including the administration of injectable PrEP.” (MOU, p 22 and 24.) This all-too-rare example of negotiators choosing to use their discretion, power and money to push for an agenda that advances evidence-based, ambitious prevention and treatment interventions stands in sharp contrast with the rest of the draft deal.

As Julius Kachidza, the chair of Zambia’s Civil Society Self-coordinating Mechanism, said, a massive cut in USG funding “would be apocalyptic. It could be quite a disaster, especially to me. And the majority of people living with HIV in Zambia.” Health GAP has been working for months with Julius and other Zambian AIDS advocates and human rights experts to fight back against the unacceptable MOU terms from this Administration, and to win a bilateral deal that safeguards the fight to defeat HIV and other pandemics in Zambia.

Activists are demanding: a rejection of deal conditioning funding access to mining, reversal of the 53% funding cut; revision of Zambia’s unrealistic co-financing obligations; rebuilding peer-led, community-based service delivery mechanisms that are essential for achieving epidemic control, particularly for key populations; and a commitment to including meaningful representation of independent civil society during MOU implementation planning as well as for ongoing quarterly oversight over program implementation, through the JHCSC.

1. No H.I.V. aid without more access to minerals: U.S. ponders ‘sticks’ against Zambia ↩︎
2. See page 32, “6.2 Conditionality: This MOU will be immediately terminated, and all funding associated with it immediately discontinued, if the Participants fail to reach agreement by April 1, 2026, to the Bilateral Compact proposed by the U.S. Secretary of State to the Zambian President on November 17, 2025 or if, at any point, the parties terminate negotiations or implementation of such a Bilateral Compact due to non-compliance.” The Bilateral Compact, which is also secret, includes all of Zambia’s foreign aid, as well as mining interests. ↩︎
3. See: US accused of ‘shameless exploitation’ over proposed Zambian health aid deal, Zambia pushed back on U.S. health funding deal to protect interests, government says, The Zambia-US deal raises ‘alarm,’ and U.S. delays Zambia health agreement as signing becomes contingent on mining deal ↩︎
4. The MOU and the Bilateral Compact are the subject of an Access to Information Act Request filed by the Chapter One Foundation and the LCK Freedom Foundation, and subsequently have appealed to Zambia’s Human Rights Commission, see: State’s silence over health deal with U.S. queried ↩︎
5. US ends R5.8bn health aid to Zimbabwe after minerals deal snub ↩︎
6. US to give Zambia $1.5B in new health sector grant for next five years ↩︎
7. Stopping PEFPAR’s deadly slowdown ↩︎
8. PEPFAR’s next quarter could be its last ↩︎
9. See: “2.1.2: The United States and Zambia shall negotiate a specimen sharing arrangement that includes the elements set out in Appendix 4 for the purpose of sharing physical specimens and related data, including genetic sequence data of detected pathogens with epidemic potential for either country within five (5) days of detection. Both participants intend this specimen sharing arrangement and agreed upon benefits to continue for twenty-five (25) years,” available here. ↩︎
10. 2023 Rough Guide to Influencing and Monitoring PEPFAR Country Programs ↩︎