What specific MOUs or state‑to‑state public health agreements have U.S. states signed with foreign governments since 2015?

1. What the documents actually are — federal MOUs under America First, not state‑level agreements

The agreements described across official State Department press releases and related reporting are multiyear, five‑year bilateral health cooperation Memoranda of Understanding signed by the U.S. federal government with partner national governments, not by U.S. states like California or Texas; the State Department framed these as the central vehicle for operationalizing the America First Global Health Strategy ^{[1] [2]}.

2. Which countries are named in the public reporting so far

Public State Department and allied outlets explicitly list an initial cohort of African partners: Kenya (first signing announced in Washington), Rwanda, and an extended roster that includes Botswana, Cameroon, Côte d’Ivoire, Ethiopia, Eswatini, Lesotho, Liberia, Madagascar, Mozambique, Nigeria, Rwanda, Sierra Leone and Uganda, with other signings reported as “dozens more anticipated” ^{[2] [4] [3] [5]}. Separate State Department items and the ShareAmerica summary repeat the same country list as MOUs signed “to date” ^[3].

3. What the MOUs say they will cover — scope and gaps in public detail

According to the State Department and secondary analysis, these compacts are framed as five‑year plans focused on transitioning programs from U.S. assistance to partner‑country ownership, with program areas described broadly as health commodities, frontline health workers, data systems, disease surveillance and outbreak response, laboratory systems and a flexible strategic assistance category ^{[6] [7]}. However, the KFF tracker and policy analysts note that many granular details — specific financial breakdowns, data‑sharing or specimen rules, and complete text of the MOUs — are not yet publicly available, limiting independent assessment ^{[6] [7]}.

4. Timing and political context that shaped the recent agreements

These federal MOUs began appearing in late 2025 as the State Department rolled out a new America First Global Health Strategy; the signings coincided with the U.S. executive branch’s move to withdraw from the World Health Organization, which government statements used to justify a shift toward “direct, bilateral” engagements rather than multilateral WHO channels ^{[1] [8] [9] [10]}. The administration’s framing emphasizes co‑investment and reduced U.S. financial commitments over time ^{[1] [6]}.

5. Critiques, risks and alternative readings in the reporting

Policy analysts at the Center for Global Development warn that the early MOUs amount to reduced U.S. health spending in each country relative to FY24 levels (roughly a reported average 49 percent reduction) and flag risks that health assistance could be tied to non‑health priorities, creating transactional pressures that could undermine public‑health outcomes — concerns underscored by reporting on negotiation delays tied to broader commercial or political interests ^[7]. Proponents argue the model drives sustainability and country ownership, but key terms remain opaque to independent observers ^{[6] [3]}.

6. What is not supported by the available sources — subnational signings and full MOU texts

The available reporting and trackers in the provided sources do not document any U.S. state (for example, California, New York, Texas) entering into formal public‑health MOUs with foreign national governments since 2015; instead, the materials show federal Department of State MOUs beginning in late 2025 and do not publish full MOU texts or exhaustive program details, a gap acknowledged by KFF and analysts ^{[6] [7]}. If subnational agreements exist, they are not covered in these sources and therefore cannot be credited or denied here.