This resource deck is intended to help advocates read the U.S. government (USG) MoUs for bilateral health funding. It is complemented by two documents:
- A primer for understanding how the transformative impact of the MoUs and their implications for Grant Cycle 8 planning / implementation: find it here
- A template for advocates to inform their internal analysis of priorities and their external engagement with stakeholders: find it here
Throughout the guide look for the 🔍 to know where to pay particular attention
This guide draws from a review of the nine MoUs (out of the 30 signed by early April) that have become publicly available. While the nine MoUs follow a consistent structure, there are important substantive differences from one to the next. Our analysis is based on a close review of the following MoUs: Kenya, Rwanda, Uganda, Mozambique, Nigeria, Ethiopia, Cameroon.
The MoUs should be understood as general blueprints that outline 5-year funding commitments for health by the US government (USG) and the recipient government. The MoUs call for the development of more detailed implementation plans, none of which had been made available at the time of writing.
The MoUs are broken into six sections: Objectives, Areas of Cooperation, Implementation Plan, Audit, Co-financing / Performance Benchmarks and Additional Terms. The briefing below highlights what to expect (and what may be missing) from the sub-sections.
If you need more details and data on how to connect this with Global Fund interventions,
here is where you can find the data you will need
Section 1: Objectives
This section includes annual epidemiological and process performance metrics to be targeted. These metrics are also referenced later in the audit section and in the Co-financing / Performance Benchmarks section.
- Outcomes, including 95-95-95 cascade for HIV; malaria deaths, TB deaths, polio cases, maternal mortality rate, and U-5 mortality rate.
- Process measurements, including people on ARVs, new infant and adult HIV diagnoses, % pregnant women on ARV, malaria prevalence, nets distributed, TB notification, TB treatment completion, polio vaccination, antenatal care visits and data quality accuracy.
- The 7-1-7 metric target for infectious disease outbreak response is included across all MoUs: this metric targets the detection of outbreaks within 7 days, informing of USG within 1 day, and initiation of a response within 7 days
Section 2: Areas of cooperation
The MoUs break cooperation areas into sub-sections, but notably, the MoUs do not break down funding levels by disease.
Each sub-section generally contains high-level budget lines for each year over the 2026-2030 period and a description of certain implementation targets and objectives. Tables highlight the respective funding levels to the area from the USG and domestic government over the course of the agreement.
Bilateral U.S. funding budgets until now were structured by diseases channels such as HIV, malaria, mother and child health, etc. The MoUs are not structured in that way, making them at times hard to read. The areas of collaboration are:
Surveillance and outbreak response
Describes USG support for national surveillance systems, including event detection, reporting timelines, coordination structures, training of field epidemiologists, and operational response procedures to outbreaks.
Laboratory systems
Details the focus and funding levels of USG support laboratory systems, including infrastructure upgrades, equipment and commodity provision, workforce training, accreditation processes, and specimen transport systems.
🔍 Look for gaps here and compare numbers with previous budgets
Frontline health workforce
Many MoUs contain specific budget lines / personnel numbers across key categories of the health workforce (e.g. community health workers, doctors, nurses). The MoUs generally indicate clear USG financial / policy support for community health workers (CHW); however, the MoUs also call for a clear shift over time of CHW salaries to domestically mobilized resources.
🔍 Look for gaps here and compare numbers with previous budgets
Commodities
This subsection concerns budgets for tests and medicines.[1] The level of detail provided in the MoUs varies greatly, in some cases, a budget line per disease area, on others a breakdown across treatment, prevention and more.
For context, the share of commodity purchases for key tests and medicines across Global Fund, USG, and domestic channels can vary greatly by product and by country.
- For example, the USG has historically funded nearly 90% of PrEP programs in sub-Saharan Africa
- See the annex for some examples of breakdowns of procurement share across U.S. bilateral aid, the Global Fund and domestic governments in past years.
- The abrupt termination of the USG procurement and supply chain grant, announced in early April, is creating a major risk of disruption in the flow of USG-supported commodities. See here for more information here on this risk.
🔍 Look for gaps here and compare numbers with previous budgets
Data systems / Digital Health
Explains the components and funding levels of health information system support provided by the U.S. Government, including digital platforms, interoperability, data collection and reporting processes.
Strategic Assistance (Strategic Investment and Technical Assistance)
Describes the provision and coordination of financial and technical support—including funding envelopes, implementing partners, planning processes, and alignment with government systems. This area typically represents the largest budget line, with varying levels of detail in how objectives and investment areas are articulated.
Section 3: Implementation Plans
Implementation plan
All MoUs stipulate that a detailed implementation plan should be developed within 90 days of signature. These implementation plans would presumably include more precise information on timing and mechanisms for areas of cooperation. As of mid-April, implementation plans were either unfinished or none had been made public.
❓ It is unclear if the implementation plan will only cover fiscal year 2026 (ending on September 31st 2026) or apply to a longer period.
The Joint Health Steering Committee
The MoUs create a Joint Health Steering Committee (JHSC), composed of USG officials and government officials, charged with implementation planning and oversight.
The exact processes and make up of Joint Health Steering Committees are not clarified; many MoUs push down the details onto ToRs, to be developed at a later date. For example: Cameroon’s MoU calls for a ToR for the JHSC to be developed by June 30th 2026, Uganda’s by April 1st, and no timeline in Nigeria.
🔍 What to pay attention to:
- What does the MoU say about the timing of developing a ToR for the Joint Health Steering Committee?
- What does the MoU say about the frequency of joint steering committee meetings?
Section 4: Audit
This section contains plans for the monitoring and validation of the reporting including co-financing and commodity deliveries. The MoU may highlight plans for evaluating metrics or for defining and tracking health expenditures.
🔍 Check if your MoU highlights the entity responsible for carrying out the audit (e.g. either third parties or the government itself).
Section 5: Co-financing and Performance Benchmarks
This is where the MoU outlines expectations of co-financing by governments.
First, see the examples of Mozambique and Cameroon:
The calculation of co-funding by domestic governments covers all domestic health expenditure. It is not limited to the scope of health funding for interventions that fall in cooperation areas. However, two considerations must be kept in mind:
- The funding targets must be additional funding (compared to the baseline year listed in the MoU)
- The additional funding must not be from external channels such as Global Fund or development banks
The stakes of meeting metrics are high, because MoUs include language linking performance benchmarks to additional funding or penalty.
🔍 Check here to fill out the proposed top-level funding for the template
🔍 Check here to fill out the penalty/bonus language in the template
Section 6: Additional terms
This section may contain minimal text or contain a lot of detail that would fit in other sections in other MoUs. The MoUs contain a standard confidentiality clause regarding information exchanged. However, this paragraph also highlights that “either Participant may make this MOU itself public”.
Further considerations
- Details on disbursement channels and/or selection of implementing partners can be found across different sections; and the information provided varies from country to country. The USG has highlighted that its intention is to eventually channel the aid as government-to-government funding (bilateral), but in some cases language is included indicating that parts of the programs may be implemented by third parties. In some program areas, there is more specificity: e.g. USG support for Human Resources for Health (HRH) would be flow through Nigeria government payment systems.
- The MoUs may include some information on what entities should lead on procurement and supply chain, as well as terms for procurement of locally manufactured products. For example, Nigeria’s MoU aims for 30% of commodities to be sourced from Nigerian manufacturers.
- Though there is clear instruction for the creation of Joint Health Steering Committees (JHSC), there does not appear to be guidance on its coordination with the Global Fund’s CCM; moreover, timelines for the creation of JHSC suggest they would only form after the CCMs have submitted their funding requests
- The MoUs point to the importance of the calculation of performance metrics and domestic resource mobilization, but with little or no details regarding methodologies and transparency regarding the application of penalties or bonuses.
Notes Targets and Baseline Years
The year chosen as the baseline for funding and epidemiological targets can be important if there was a noticeable change in either the epidemiological situation of any of the three diseases or domestic health funding. Most MoUs we saw use 2025 as a baseline, but some mention 2024; if for example there were epidemiological or funding changes between 2024 and 2025, the use of 2024 as a baseline would make it harder to meet the domestic funding targets, and 2025 easier. Similarly if there was a sharp increase in malaria deaths, HIV infections or a drop in TB case-finding between 2024 and 2025 (which is likely because 2025 was impacted by the U.S. freezes and cuts), the use of 2024 as a reference year could make outcome targets harder to meet than picking 2025.
Global Fund tools for mapping program area and commodity investments
As part of their efforts to avoid redundancies through coordinated planning, visibility on investments across program areas has long been a point of emphasis for the USG and the Global Fund. The Global Fund has provided template planning documents with tables that would capture funding channels across key areas and commodities for each of the three diseases. The Global Fund requests CCMs to submit these funding landscape tables that include funding tables for each disease by Global Fund module and by core area of the NSP. Funding request tables may also include projections of commodity procurement for certain intervention areas. . Of note, the funding request documents that are ultimately made available on the Global Fund website may not capture the final version (i.e. post-TRP review and post-approval) of the funding plan; moreover, changes to grants that are made during the cycle would not show up in these documents. And finally, the projection of funding streams from domestic governments and USG support may evolve over the time horizon of grant cycle 8. Those caveats aside, the tables are useful tools, especially if they are regularly updated.
Where to find these documents?
- Go to https://data.theglobalfund.org/
- Put the country name in the search bar; this will take you to the country page.
- The country page provides information on GC7 PRs and contact information for the Global Funds Secretariat’s country-level Fund Portfolio Manager, as well as contact information for the CCM focal point.
- For the programmatic tables, click on the access to funding tab. Scroll down the page to find the “Documents” subsection, and click on the 2023 funding request.
- The folder you download should contain several documents, download the excel files labeled FundingLandscapeTable and ProgrammaticGapTable.
- Explore the Tables!
Need more information? Check out our Key Resources’ Page on US MoUs