Africa: Human Rights Watch Challenges 'Terms' of U.S. Health Aid to African Countries

A new report by Human Rights Watch (HRW) has thrust Liberia into a growing international debate over health aid, data sovereignty, disease surveillance, and the future of global health partnerships after the organization alleged that the United States is conditioning critical health assistance on broad access to health information systems, pathogen samples, and compliance monitoring.

The report, released June 8, examines a series of bilateral health agreements signed between the United States and several African countries, including Liberia, following major changes to U.S. foreign assistance programs in 2025.

"The agreements show the US intends to condition vital health assistance for millions of people on acquiescence to troubling conditions," said Julia Bleckner, senior health researcher at Human Rights Watch. "After the sudden and devastating pullback from US assistance in 2025, governments are now being pressured to accept agreements with contingencies that jeopardize human rights."

Human Rights Watch argued that the agreements raise concerns about access to private health data, abortion-related monitoring, pathogen-sharing arrangements, and the possibility that countries negotiating from positions of financial vulnerability may have limited leverage to reject conditions attached to assistance.

The organization further stated that the agreements "require recipient countries to allow the US broad surveillance over their health systems" and warned that some provisions could undermine patient confidentiality and ongoing international efforts to establish more equitable pathogen access and benefit-sharing arrangements.

For Liberia, however, the controversy arrives against the backdrop of a healthcare system that continues to struggle with some of the highest maternal and child mortality rates in the region, persistent dependence on donor financing, shortages of trained personnel, and recurring disease outbreaks.

At the center of the debate is a purported Memorandum of Understanding between Liberia and the United States that has circulated publicly in recent days. The document has not been independently authenticated by the Daily Observer, and neither the Government of Liberia nor the U.S. Embassy in Monrovia had publicly confirmed its authenticity as of press time.

If authentic, however, the document outlines one of the most ambitious health-sector cooperation frameworks ever proposed between Liberia and a bilateral partner.

The reported agreement establishes detailed targets extending through 2030 covering HIV treatment, malaria reduction, laboratory strengthening, disease surveillance, maternal health, child mortality, healthcare staffing, pharmaceutical logistics, digital health records, and outbreak response systems.

Unlike many aid agreements that focus primarily on financial commitments, the leaked framework reportedly includes annual performance indicators, auditing provisions, co-investment obligations, workforce absorption targets, and data-sharing mechanisms.

Those features have become a focal point of debate because they raise two distinct questions simultaneously: whether Liberia is surrendering excessive control over sensitive health information and whether stronger accountability mechanisms might finally help address longstanding weaknesses in the country's healthcare system.

A system still under pressure

Recent health indicators illustrate the magnitude of the challenge.

According to the Liberia Demographic and Health Survey 2019-2020, the country's maternal mortality ratio stood at 742 deaths per 100,000 live births. More recent mortality estimates published by the Liberia Institute of Statistics and Geo-Information Services following the 2022 Population and Housing Census estimated maternal mortality at 854 deaths per 100,000 live births, infant mortality at 64 deaths per 1,000 live births, and under-five mortality at 93 deaths per 1,000 live births.

Those figures remain among the most sobering measures of health system performance because they reflect access to skilled care, functioning facilities, medicines, transportation, referral systems, and emergency response capacity.

The World Health Organization's Liberia Annual Report for 2024 also highlighted continuing challenges in child health and disease prevention. The report noted that more than half of suspected measles cases recorded during the year occurred among children under five years of age.

Malaria continues to impose a significant burden as well. Data from the U.S. President's Malaria Initiative show that community health workers increasingly serve as the front line of malaria diagnosis and treatment, particularly in remote areas where access to formal health facilities remains limited.

Donor dependence

The debate surrounding the reported agreement is inseparable from Liberia's reliance on international health financing.

Reporting by the Associated Press in 2025 indicated that U.S.-supported programs accounted for approximately 48 percent of Liberia's health budget. American-funded initiatives support HIV treatment, malaria control, maternal and child health services, laboratory systems, disease surveillance programs, and community health activities.

The U.S. Centers for Disease Control and Prevention (CDC) remains deeply embedded in Liberia's public health architecture. According to CDC program information, the agency supports laboratory strengthening, epidemiological training, disease surveillance systems, emergency operations centers, sample transport networks, infection prevention programs, and outbreak preparedness efforts across all fifteen counties.

The relationship intensified following the Ebola epidemic of 2014-2016, which exposed profound weaknesses in health infrastructure but also accelerated investments in surveillance and public health preparedness.

CDC reports indicate that all 93 health districts in Liberia now have at least one graduate of the Frontline Field Epidemiology Training Program, a milestone widely viewed as a significant improvement in outbreak detection capacity.

The data question

Human Rights Watch's strongest concerns focus on health data.

The organization argues that the agreements create pathways for extensive data access without clearly defining safeguards governing retention, secondary use, patient consent, third-party access, or future commercialization.

The leaked Liberia document appears to envision nationwide expansion of electronic medical records, laboratory information systems, disease surveillance databases, logistics management systems, and a national health data warehouse.

If implemented, such systems would dramatically improve the government's ability to track diseases, monitor treatment outcomes, manage commodities, and respond to outbreaks.

At the same time, they would generate large volumes of valuable health information.

Globally, health data has become increasingly important not only for healthcare delivery but also for pharmaceutical research, vaccine development, epidemiological modeling, artificial intelligence applications, and public health planning.

Human Rights Watch argues that agreements involving data sharing should contain stronger protections and greater transparency regarding how information may ultimately be used.

Pathogen samples and global debates

The report also raises concerns about pathogen-sharing arrangements.

Human Rights Watch said several agreements reference mechanisms through which countries provide biological samples and related data associated with pathogens possessing epidemic potential.

The issue has become increasingly sensitive internationally since the COVID-19 pandemic renewed debates over who benefits when countries share pathogens that later contribute to scientific discoveries, vaccines, diagnostics, or treatments.

HRW argues that some of the bilateral agreements may conflict with ongoing World Health Organization efforts to negotiate a more equitable pathogen access and benefit-sharing framework.

The organization noted that developing countries have historically expressed concerns that they often provide critical biological materials while receiving limited access to resulting products.

Accountability and performance

Yet the same provisions drawing criticism from rights advocates may be viewed differently by some public health practitioners.

If authentic, the Liberia agreement appears unusually focused on measurable outcomes.

The framework reportedly establishes targets for HIV treatment coverage, viral suppression, malaria mortality, childhood immunization, laboratory performance, disease detection timelines, outbreak notification requirements, and workforce development.

It also appears to link continued support to auditing, performance reviews, and progress toward agreed benchmarks.

Supporters of such approaches often argue that donor-funded programs should be evaluated against measurable results rather than simply expenditure levels.

Critics, however, caution that excessive external oversight can undermine national ownership and create pressure on governments to prioritize donor reporting requirements over locally determined priorities.

The regulatory dimension

Another aspect likely to attract attention is a reported provision involving recognition of approvals issued by the United States Food and Drug Administration.

Supporters could argue that reliance on FDA approvals may accelerate access to medicines and reduce regulatory bottlenecks.

Others may question whether such provisions could create advantages for certain pharmaceutical suppliers relative to competitors approved through alternative regulatory pathways.

The broader issue is one of regulatory sovereignty--how countries balance efficiency, safety, access, and independence in health product regulation.

Unanswered questions

Many questions remain unresolved. The most immediate is whether the leaked document accurately reflects the final agreement.

Additional uncertainty surrounds any supplementary arrangements involving data sharing, specimen access, privacy protections, and implementation mechanisms that may not be publicly available.

Human Rights Watch has called on governments to ensure transparency and involve civil society organizations and multilateral health institutions in deliberations surrounding such agreements.

"Governments negotiating health assistance agreements with the United States face difficult choices," Bleckner said. "They should be wary of terms asking them to sign away their populations' rights and push for the inclusion of civil society representatives and multilateral global health organizations like the Global Fund in deliberations."

For Liberia, the discussion arrives at a moment when policymakers continue to confront difficult realities: high maternal mortality, continuing infectious disease risks, dependence on donor financing, and the long-term challenge of building a health system capable of sustaining itself.

Whether the reported agreement ultimately becomes a model for strengthening healthcare delivery or a source of concern regarding data governance and national sovereignty may depend not only on its final terms but also on how it is implemented, monitored, and explained to the public.

This article originally appeared on Liberian Observer