Under-the-Radar Deals and Strong Demands: Changing Strategies in U.S. Foreign Aid -

In November of last year, officials from Lesotho, located in the mountainous regions of eastern South Africa, met for three hours in the capital, Maseru, to discuss matters with representatives from the Trump administration.

Earlier that year, the US unexpectedly halted funding for healthcare initiatives in Lesotho as part of a larger reduction of billions in international aid. For this small nation of 2.4 million—combating the world’s second-highest rate of HIV and the fourth-highest rate of tuberculosis—this withdrawal posed a significant risk to many lives.

Read: Lesotho’s healthcare system devastated by US funding cuts

To secure future financial aid, the US requested reciprocal commitments. Unlike past US aid, which was offered with few conditions, documents reviewed by Bloomberg outlined specific expectations set by the Trump administration.

These requirements included preferences for US partnerships, technologies, equipment, and supplies; acknowledgment of US drug regulatory approvals by Lesotho; and tax exemptions for companies involved in US-funded projects.

The US also sought access to Lesotho’s medical data for 25 years, later shortened to five years.

Officials from Lesotho faced a tight deadline to finalize the agreement—a situation that Mokhothu Makhalanyane, a member of the ruling Revolution for Prosperity party, characterized as coercive. “The US effectively confined ministers in a room and pressured them with a deadline,” he stated.

A month later, the US Embassy in Lesotho announced that the acting US Charge d’Affaires and the finance minister of Lesotho had finalized an agreement. The US committed $232 million in health assistance over five years, contingent on Lesotho also contributing $132 million. This represented a notable reduction in support; previously, Lesotho received approximately $150 million in health aid in 2024 alone.

Parliamentarians expressed significant concerns regarding the deal’s processing. There had been no prior debate on the memorandum of understanding, nor did either government publicize it post-signing. As the document remains undisclosed, uncertainties linger about who will oversee its implementation, whether it impacts existing international agreements, or if it violates privacy laws. The deal’s constitutionality is also questioned due to a lack of parliamentary endorsement.

More than a year after the dismantling of the United States Agency for International Development, this scenario highlights how the Trump administration seems to be utilizing foreign aid to advance its geopolitical aims and how smaller nations are responding.

Other countries in the region have reported unprecedented conditions linked to US aid. Eswatini agreed to accept third-party nationals deported from the US, while Zimbabwe and Zambia claimed that US health assistance was linked to access to mineral resources. (Both nations declined the offer, and the US ambassador to Zambia denied that aid would be withheld.) According to the US State Department, 32 nations have entered into such agreements.

A State Department spokesperson stated that “cordial” discussions had taken place with officials from Lesotho’s foreign, health, and finance ministries, as well as the country’s National Aids Commission. The spokesperson added that none of the signed memorandums required that signatories provide “preference” to US companies for acquiring medical goods, equipment, or data services.

“This MOU aims to uphold Lesotho’s sovereignty and accelerate its journey toward self-sufficiency in addressing HIV/AIDS,” remarked the State Department.

Some demands from the US either disappeared or were softened in the final memorandum, as indicated in documents reviewed by Bloomberg. However, when the document circulated among a select group of senior politicians, two appendices regarding data sharing were redacted, raising further questions about the agreements made.

“There is this anxiety: What is the US planning to extract from Lesotho?” stated Sebabatso Ntlamelle, coordinator for health, education, and social development at the Lesotho Council of Non-Governmental Organisations.

Health Minister Selibe Mochoboroane consented to an interview with Bloomberg regarding the agreement but canceled at the last moment, explaining that what should have been a 30-minute meeting had extended throughout the day. He then suggested a virtual discussion but failed to follow through before leaving his post in late April. Finance Minister Retšelisitsoe Matlanyane deferred inquiries to Mochoboroane, while new Health Minister Mamokete Ntsekhe and Prime Minister Sam Matekane’s office did not respond.

Mochoboroane shared some insights about the pressures Lesotho faced in late March while defending the agreement in parliament. “It is true that America proposed bringing dangerous criminals into Lesotho,” he acknowledged. “But we rejected that.”

Prior to the advent of the memorandums, US foreign health aid agreements were largely characterized by transparency and accountability, according to Brian Honermann, deputy director of policy at amfAR, a US-based nonprofit focused on ending the HIV/AIDS epidemic. Under the new US guidelines, information within these agreements—and details about the partner countries’ progress—will typically remain confidential. “This creates a scenario where both parties with access to the data have an interest in portraying the MOUs as successful without external oversight,” Honermann noted.

Under the five-year agreement with Lesotho, the US will gradually reduce its health funding as the African nation’s contributions increase. Should Lesotho fail to meet its financial obligations, the US reserves the right to cut or entirely withdraw funding. This situation places Lesotho in a precarious position; struggling with slumping exports, the additional funds it has pledged are roughly equivalent to a year’s worth of its health budget.

Lesotho’s income sources are quite limited, primarily reliant on sales of mohair from one of the largest angora goat herds globally; water it sells to South Africa; diamonds; and a struggling textile sector. Ntlamelle, the NGO coordinator, foresees that budget cuts will be necessary to meet the agreement’s terms.

“If it’s not accounted for in the budget, there will be $30 million to $40 million a year that will need to be found,” she commented. “This is a financial commitment our country cannot shoulder.”

These challenges are widespread across the continent, as nations face the decline of US aid, noted Emily Wong, an associate professor at the African Health Research Institute. “The resources currently available are drastically lower than what was provided by the US previously,” she remarked.

There is increasing concern among nonprofits in Lesotho that the current US political climate may affect who receives medical care. Past US funding in the sector prioritized vulnerable groups, including sex workers, unmarried mothers, and LGBTQ+ individuals—often subject to discrimination in state-run facilities. These groups are noticeably absent from the signed memorandum, and an analysis of similar agreements by nonprofits suggests that family planning initiatives have largely been omitted.

While Lesotho has made strides in recent years regarding the rights of marginalized communities, nearly 40% of healthcare is managed by the Christian Health Association of Lesotho, which does not provide services that conflict with its religious beliefs. Under the new funding structure, Tampose Mothopeng, executive director of the LGBTQ+ rights group People’s Matrix, raises concerns that these communities may face increased obstacles in accessing healthcare.

“Now, the MOU and its executive orders are cornering Lesotho into compromising our values, our constitution, and our national regulations. They are attempting to reshape the world according to their vision,” Mothopeng stated.

Makhalanyane, the politician, remains doubtful about the deal’s ability to advance Lesotho’s health objectives.

“This arrangement undermines and complicates the government’s structures rather than reinforcing them,” he asserted. “It feels like outright bullying.”