After dismantling the main US body for delivering foreign assistance last year, the Trump administration is again offering hundreds of millions of dollars to African countries to support their healthcare structures and help fight disease.
But the new deals come with conditions attached and as a result, face resistance from some governments.
When the initial agreement was signed by Kenya's President William Ruto in Washington last December, US Secretary of State Marco Rubio said he hoped it would be the first of many.
"We hope to sign, I don't know, 30, 40, how many? Fifty? Well, this is number one. We'll always remember this one… and we think we've picked the perfect partner," Rubio declared.
But even this landmark deal with Kenya, worth $2.5bn (£1.9bn), has been delayed by activists who went to court to block it, although cabinet ministers did finally approve it last month.
Shortly after taking office, President Donald Trump ordered the closure of the US Agency for International Development (USAID) amid accusations of wastefulness, in the process decimating health programmes in some African countries that relied on American funding.
The State Department's new global health strategy requires recipient governments to share responsibility by increasing their own health spending, with the goal of building durable systems that can eventually be self-reliant. It is, for example, contributing $1.6bn to the overall deal with Kenya, external - with the East African nation pledging $850m over five years.
The Trump administration hopes that partnering with national leaderships will improve on traditional donor-NGO relationships which it says created dependency, led to parallel delivery arrangements and sucked up aid dollars in overhead costs.
"Our aid to those countries will not just be dollars distributed to an NGO who then will go into the country and impose programmes," Rubio told a congressional committee last month.
"Not only are we treating the acute situations on the ground of people that are sick, we are helping them build the capacity and the capability to do this for themselves."
But the result is a shift away from a model of global cooperation anchored in the World Health Organization (WHO), to direct agreements with individual governments that are tied to US strategic and commercial interests.
The US withdrew from the WHO early this year saying it was unfair that Washington provided so much more funding than other countries and alleging that the organisation mismanaged the Covid-19 crisis, lacked transparency, and was susceptible to political influence.
Controversially, the American bilateral deals come with an explicit promise to prioritise US pharmaceuticals and medical firms to develop and deliver treatments.
"Our global health foreign assistance programme is not just aid - it is a strategic mechanism to further our bilateral interests around the world," says the policy document.
Thirty-two countries had accepted the health Memorandums of Understanding (MOU) by mid-May, in Latin America, the Caribbean and at least 20 in Africa. But some - such as Ghana, Zimbabwe and Zambia - have resisted signing up, citing different reasons.
In Zambia, Foreign Minister Mulambo Haimbe criticised what he described as an American effort to link health funding to US economic interests by connecting the deal to a separate agreement giving Washington access to critical minerals.
"Our [US] colleagues looked at it from the perspective that [the two deals] must be taken as a package to be negotiated and concluded at one particular time," he told the BBC, saying the Zambian government wanted to discuss them separately on their own merits.
"The US felt that there is need for there to be a preferential treatment in the use of critical minerals. And the framework was to reflect that," he added.
The State Department stopped short of explicitly linking the two when questioned by the BBC but offered a robust "America First" response.
"The Trump administration has made clear, US foreign assistance is not charity - rather it is strategic capital to be wisely invested to advance US interests - and we expect all of our allies and recipient nations to take seriously American strategic and commercial priorities," a department spokesperson said.
Last month provided further evidence of this readiness to tie health financing to American priorities - with the announcement that the US would withdraw completely from funding HIV/Aids programmes in South Africa.
An administration official connected the move to Pretoria's "failure to make demonstrable progress on policy requests", including apparently the treatment of the white-minority Afrikaner community. US claims that a "white genocide" is taking place in South Africa have been widely discredited.
For some African countries who were negotiating the bilateral MOUs, it was concerns over US access to health data which set alarm bells ringing. This included patients' information as well as biological resources known as pathogens - organisms that cause disease such as viruses, bacteria and parasites.
