Guinea is less dependent on US funding than many other African countries. As a result, the impact of changes in global health funding on Guinea (and countries like it) is often neglected. In December 2025, Delphin Kolié (Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Guinea) interviewed several key actors involved in the design and implementation of US-funded health interventions in Guinea. This blog draws on these interviews and brings you their perspectives and some of their concerns about the upcoming bilateral agreement on global health between Guinea and the USA. Interviewees consistently described the shift from multilateral to bilateral cooperation as an application of the “law of the jungle”, where the strongest actor sets the rules and isolation is used to increase vulnerability.
Guinea’s reliance on US funding
Over the past decade, Guinea’s health system has relied heavily on household out-of-pocket payments, (for 56% of total health expenditure), and on external funding (23%). Government health spending per capita (8 to 12 USD per person per year in 2019 to 2023) is almost matched by external aid per capita (around 10 USD per person since 2021). USAID funding has played a strategic role (accounting for 17% of external funding, authors’ own calculations, based on IHME data, 2022), supporting key programmes, such as malaria control (40%) and global health security (21%), and contributing significantly to disease surveillance, community health services and operational capacity.
Impact of withdrawal of US funding in 2025
Since early 2025, the withdrawal of US bilateral DAH (development assistance for health) funding has resulted in an estimated annual loss of more than 23 million USD for Guinea (authors’ own calculations, based on IHME database 2022, constant 2022 US dollars). Temporary adjustments were made, often with the support of remaining partners, but were insufficient to absorb the shock. The operational consequences were immediate and severe. Malaria research activities, including test efficacy studies, were suspended. Supply chains for essential inputs (medicines and long-lasting insecticidal nets) were disrupted. Seasonal malaria chemoprevention campaigns were interrupted, and several community-based activities were halted. The abrupt interruption of support to community health workers has weakened malaria testing, routine data reporting and district-level coordination mechanisms, which are central pillars of Guinea’s health strategy.
Beyond the financial impact, this situation has revealed deeper changes in the governance of global health cooperation. The unprecedented uncertainty created by political changes in the United States and the “America First” strategy has challenged the foundations of global health cooperation, including how it is structured, negotiated and sustained.
Concerns about the upcoming bilateral agreement with the USA
In Guinea, the Memorandum of Understanding (MoU) with the US government has been revised and is currently in the process of being signed. Interviewees worried that the fragmentated negotiation process may weaken regional solidarity, preventing shared learning and reducing collective bargaining power in West Africa. For many local actors, the negotiation of this MoU appears to be a survival strategy especially given that it is occurring a year after the sudden US funding cuts. It does not reflect a genuine partnership.
Another major challenge concerns domestic co-financing. Under the new arrangements, Guinea’s financial contribution is expected to rise rapidly, from 0% in the first year to 25% in the second, and 100% by the fifth year. However, Guinea has struggled to meet previous commitments on domestic co-financing. According to interviewees, the Guinean government spent less than half of what it committed in domestic co-financing between 2021 and 2023. For 2024 to 2026, no disbursement of domestic co-financing has yet occurred (despite substantial commitments from the Guinean government). As one respondent noted, this partly explains the US decision to draw down its health funding to Guinea. It also raises questions about the responsibility of the State itself. More practically, the rapid increase in domestic co-financing in the MoU does not seem to take account of the national budget realities in Guinea or the State’s ability to meet previous co-financing commitments. Without credible fiscal reforms and sustained political commitment, accelerated co-financing is unlikely to materialise.
Concerns were also raised about implementation arrangements. Most operational responsibilities remain with US-based organisations, such as Chemonics for medicine procurement and PMI-REACH (CRS) for programme implementation. Although the revised framework allows for greater involvement of national non-governmental organisations, many grey areas remain, particularly regarding decision-making power. It is not clear that the new arrangements will lead to genuine national ownership of programmes.
Moreover, political volatility in the United States further increases uncertainty, as changes in administration can quickly alter priorities, funding levels and conditions. Important questions remain about what will happen to these programmes when new administrations with different political or ideological views take office.
Guinea’s experience raises a broader question for global health. As cooperation shifts from multilateral platforms towards bilateral agreements, there is a growing risk that power imbalances will deepen, collective approaches will weaken, and countries with limited negotiating capacity will be left exposed. In this evolving landscape, the challenge is no longer only about securing funding, but about preserving equity, solidarity and shared responsibility in global health governance.