The US is the largest donor to global health; current government proposes significant cuts to funding
The United States (US) is by far the world’s largest donor to global health, spending a total of US$9.4 billion on health official development assistance (ODA) in 2015, according to Organisation for Economic Co‑operation (OECD) data. This represents almost half (49%) of all health ODA provided by OECD donor countries.
The US spends more of its development assistance on global health than any other donor. In 2015, the US allocated almost 30% of its total ODA to global health programs, the same share as in previous years. US government funding on global health sharply increased during the tenure of President George W. Bush and President Barack Obama (see details below). However, this may change in the current administration.
In the president’s fiscal year (FY) 2018 budget request released in May 2017, the administration proposes drastic cuts to global health across the board (approximately US$2.5 billion, 27% of funding to global health). The House of Representatives’ (House) Appropriations Committee rejected most of the overall cuts in its State-Foreign Operations (SFOPs) and Labor, Health and Human Services (LHHS) appropriations bills in July 2017. Some sectors, however, still face cuts—albeit to a lesser degree than in the president’s request. These include global health security, family planning (FP), and reproductive health (RH). The House SFOPs, for example, proposes a US$114-million reduction to specific FP and RH budget lines as compared to the president’s proposed complete elimination of them.
Note: This profile uses OECD data to track US global health funding that has been disbursed up to calendar year 2015. This funding has been reported as ODA. However, it also takes totals included in the relevant FY2017 and FY2018 appropriations bills for a more current assessment of the US context. These bills align with the US’s fiscal year (October-September) and refer to amounts appropriated rather than dispersed. They also include ODA- and non‑ODA-eligible funding to global health.
In general, FP and RH funding is threatened: In January 2017, the new administration reinstated and expanded the ‘Mexico City Policy’ (also known as the ‘Global Gag Rule’). This policy blocks federal funding for non-government organizations (NGOs) that provide abortion information, counselling or referrals, or advocate for such services. The House SFOPs seeks to codify this policy in law. Further, neither the president’s request nor the House bill includes funding for the United Nations Population Fund (UNFPA). In March 2017, the current administration invoked the ‘Kemp-Kasten amendment’ to withhold funding to UNFPA that had been allocated for FY2017. This amendment proscribes the application of funding in support of “coercive abortion or involuntary sterilization”, in which, the administration argues, UNFPA is involved. The Senate Appropriations Committee's SFOPs, passed on September 7, 2018, maintains some provisions around family planning, including Kemp-Kasten, but seeks to repeal the Mexico City Policy, and restores funding to UNFPA. Further, its LHHS includes an overall US$1.7 billion increase from FY2017 levels, from US$77.7 billion to US$79.4 billion.
The US launched several large interagency global-health initiatives under President George W. Bush. These included the President’s Emergency Plan for AIDS Relief (PEPFAR), set up in 2003 as the umbrella program for all US HIV/AIDS activities. PEPFAR’s goals align with global goals to deliver an AIDS-free generation, which have been set by the Joint United Nations Programme on HIV/AIDS (UNAIDS) in its new 2016-2021 Strategy. PEPFAR is the largest initiative undertaken by any country in history to address a single disease: Between FY2004 and FY2017, the US provided almost US$73 billion through PEPFAR. Its FY2017 budget alone stood at US$6.8 billion. PEPFAR is also the cornerstone of US global health activities: About two-thirds of US funding for global health is channeled through the initiative. PEPFAR is particularly important to the global HIV response: According to the Kaiser Family Foundation (KFF) and UNAIDS, the US accounted for 70% of international assistance to HIV from donor governments in 2016. PEPFAR covers bilateral funding for HIV/AIDS and tuberculosis (TB) programs, as well as US contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and UNAIDS. The US provided PEPFAR bilateral support for HIV/AIDS in 41 countries in 2016, including the 15 focus countries identified in PEPFAR’s first phase, as well as regional programs in Africa, the Americas, Asia, the Caribbean, and Europe.
Another key initiative is the President’s Malaria Initiative (PMI), launched in 2005. PMI is an interagency initiative led by the United States Agency for International Development (USAID), which focuses on 19 focus countries in Africa and the Greater Mekong region. It is governed by the President’s Malaria Initiative Strategy 2015-2020, and works with PMI‑supported countries and partners to reduce malaria mortality and morbidity. Overall, the US is the largest funder of global malaria efforts, including bilateral programs: According to KFF data, bilateral malaria funding amounted to US$952 million in FY2017, a sharp increase from US$198 million in 2004, the year before PMI was launched. The US provides bilateral malaria support to more than 30 countries through the PMI and other activities.
PMI focus countries:
Angola, Benin, Democratic Republic of the Congo, Ethiopia, Ghana, Guinea, Kenya, Liberia, Madagascar, Malawi, Mali, Mekong region, Mozambique, Nigeria, Rwanda, Senegal, Tanzania, Uganda, Zambia, Zimbabwe
US ODA to health has a clear focus on bilateral programs: According to OECD data, US$7.5 billion, or 80% of the US’s total health ODA in 2015 was provided bilaterally. This spending pattern mirrors the PEPFAR and PMI approach to HIV/AIDS, TB, and malaria programming. According to government data, 80%, or US$5.5 billion, of PEPFAR funding in FY2016 was implemented bilaterally for HIV and TB programming; the remainder went to the Global Fund and UNAIDS. In line with the priorities outlined above, bilateral health ODA in 2015 focused on HIV/AIDS (56%, or US$4.2 billion), followed by RH care (9%, US$655 million), malaria control (9%, US$654 million), and FP (8%, US$632 million).
US support for maternal, newborn and child health (MNCH) has increased over time, with a focus on immunization and nutrition (for more information, see Deep Dive: Nutrition). In FY2017, total appropriated funding amounted to US$1.4 billion, comprising US$1.3 billion for MNCH and US$153 million for nutrition. This is up from US$730 million in FY2006. USAID has 24 priority countries for MNCH (see box), primarily located in Africa and South and Central Asia. In the past, RH and FP have been integral to US efforts in MNCH, but funding to this area is likely to see significant cuts due to the aforementioned Mexico City Policy.
USAID’s MNCH focus countries:
Africa: DRC, Ethiopia, Ghana, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Nigeria, Rwanda, Senegal, South Sudan, Tanzania, Uganda, Yemen, Zambia
Asia: Afghanistan, Bangladesh, India, Indonesia, Myanmar, Nepal, Pakistan
In 2015, the US channeled 20%, or US$1.9 billion, of its health ODA multilaterally. In absolute terms, this makes the US the largest donor to global-health multilateral organizations. However, 20% is below the share that donor countries allocate on average to multilateral health programs (55% in 2015). This is mainly due to the US’s immense bilateral global health investments.
The key recipient of multilateral health ODA in 2015 was the Global Fund (67% of US multilateral health ODA). The US is the Global Fund’s largest single donor, with contributions totaling US$13.0 billion from 2001 to 2016, almost a third of all contributions received for that period (US$37.3 billion), according to Global Fund data. This is in line with US legislation: The US law authorizing PEPFAR provides that the US may not give more than one-third of the Global Fund’s total contributions. For the 2017-2019 funding period, the US has pledged US$4.3 billion, an increase from the US$4.0 billion pledged for 2014 to 2016. Additionally, the US has committed to match one dollar for every two dollars pledged by other donors through September 30, 2017.
The US is the third-largest donor to Gavi, the Vaccine Alliance (Gavi), after Norway and the United Kingdom. Total contributions to Gavi amount to US$1.4 billion from 2000 to 2015. The US pledged US$800 million in direct contributions for 2016 to 2020, according to organizational data. The president’s FY2018 budget request proposed a US$15-million increase for Gavi, which was the only global health funding increase in the budget request. The House Appropriations Committee approved this increase in its SFOPs appropriations bill. The US is also the largest public donor to the Global Polio Eradication Initiative (GPEI). According to GPEI data, the US has contributed US$2.9 billion since 1985. Total enacted funding for polio in FY2017 was US$233 million. This supports multilateral contributions, such as to the World Health Organization (WHO) and the UN Children’s Fund (UNICEF), as well as bilateral programming.
Congress decides funding levels; multiple government departments and agencies are involved in the design and implementation of US global health programs
Overall policy direction for global health comes from the president and the White House. Several governmental departments and agencies participate in the decision-making and implementation of the US’s global health cooperation. These include:
State Department: According to KFF, in FY2015, the most recent year with complete data, the State Department’s global health funding was US$6 billion. Most of the State Department’s global health work is overseen by the Office of the US Global AIDS Coordinator (OGAC), headed by Ambassador Deborah Birx. OGAC manages the implementation of PEPFAR and all HIV/AIDS-related activities (even if implemented by another department or agency, see box below). In the past, the Bureau of Population, Refugees and Migration has provided support for RH and FP, especially through UNFPA. The State Department provides policy direction for USAID.
PEPFAR implementing institutions include USAID, the Department of Health and Human Services (Centers for Disease Control and Prevention, Health Resources and Services Administration, and National Institutes of Health), the Department of Commerce, the Department of Defense, the Department of Labor, and the Peace Corps.
USAID: In FY2015, USAID managed US$3.3 billion in global health funding. USAID’s global health programming is coordinated primarily by the Bureau of Global Health, which supports the work of the five geographic bureaus: Bureau for Africa, Bureau for Asia, Bureau for Europe and Eurasia, Bureau for Latin America and the Caribbean, and Bureau for the Middle East. USAID leads on PMI through the US Global Malaria Coordinator, appointed by the president, and implements it jointly with the Centers for Disease Control and Prevention (CDC). The agency is also a main implementer of PEPFAR programs, and responsible for other global health-related programs such as MNCH, nutrition, family planning and reproductive health, other infectious diseases, nutrition, and water and sanitation.
Department for Health and Human Services (HHS): HHS mainly works domestically, but does have a global function through the Office of Global Affairs (OGA). OGA is led by the assistant secretary of global affairs, and coordinates with other global health actors in government, the private sector, and international agencies. Most of HSS’s global health engagement is executed through four agencies: Centers for Disease Control (CDC), National Institutes of Health (NIH), Food and Drug Administration, and Health Resources and Services Administration . The two primary ones are:.
- CDC: CDC is an operating division of HHS and is the largest government agency working in the field of disease control and prevention, and health promotion, with US$416 million contributed in FY2015 for global health efforts. In 2007, the Center for Global Health (CGH) was established to drive CDC’s work globally. CGH has four divisions: 1) Division of Global HIV/AIDS, 2) Division of Parasitic Diseases and Malaria, 3) Division of Global Health Protection, and 4) Division for Global Immunization. CDC’s Office of Infectious Diseases (OID), comprising three national centers, also participates in US global health efforts. The CDC implements PEPFAR and PMI programs.
- NIH: This collection of 27 research institutes makes up one of the world’s top global health research institutions. NIH conducts basic research on diseases and disorders for improved diagnosis, prevention and treatment. It is a PEPFAR implementing agency, and leads on the US’s malaria research and development (R&D) activities. In FY2015, NIH received US$596 million for HIV and malaria-related research activities. Other areas of US global health engagement do not receive specific, pre-defined funding levels.
Department of Defense (DOD): The DOD received US$19 million in US global health funding for HIV and malaria in FY2015. It conducts a wide range of US global health activities, including humanitarian assistance and disaster relief and care delivery. The department also plays a critical role in disease surveillance, health-systems capacity building through military and international training, and in US global health R&D efforts (for more information, see Deep Dive: Global Health R&D).
Congress: ultimately decides on global health funding levels through multiple appropriations bills’ funding several departments and agencies. Through its oversight and authorization role, Congress also shapes policy orientation. Over 15 congressional committees oversee US global health engagement. This includes the House and Senate Committees on Foreign Affairs and the Health Subcommittee of the House Committee on Energy and Commerce, which presides over, for example, public health, biomedical research and development, health information technology, and HHS, including CDC and NIH. The Senate Committee on Health, Education, Labor, and Pensions oversees measures relating to education, labor, health and public welfare. The Appropriations Committees of both chambers are important for setting funding levels. In addition, around ten caucuses (informal congressional groups, see box below) focus specifically on issues related to global health.
Global health caucuses:
Congressional Global Health Caucus, Congressional HIV/AIDS Caucus, Tuberculosis Elimination Caucus, Congressional Caucus on Malaria and Neglected Tropical Diseases, Senate Caucus on Malaria and Neglected Tropical Diseases, House Hunger Caucus, and Senate Hunger Caucus.
For a more comprehensive list of departments, agencies, and other institutions involved in US global health funding and programming, see KFF, The US Government Engagement in Global Health: A Primer, http://files.kff.org/attachment/report-the-u-s-government-engagement-in-global-health-a-primer (2017).
- US Department of State, Congressional Budget Justification, Department of State, Foreign Operations, and Related Programs (FY2018)
- US Senate, Committee on Appropriations, State, Foreign Operations, and related Programs appropriations bill FY2018 (September 2017)
- US House of Representatives, Committee on the Appropriations, State and Foreign Operations appropriations bill FY2018 (July 2017)
- House of Representatives, Committee on the Appropriations, Labor, Health and Human Services, and Education, related agencies appropriations bill, Full draft FY2018 (July 2017)
- US President’s Emergency Plan for AIDS Relief (PEPFAR), Fact Sheet 2016
- PEPFAR, PEPFAR Funding (2017)
- Kaiser Family Foundation (KFF), The US Government and Global Maternal & Child Health Efforts (August 2017)
- KFF, The US Government and Global Polio Efforts (August 2017)
- KFF, What Could US Budget Cuts Means for Global Health?, Updated Issue Brief (July 2017)
- KFF, The US President’s Emergency Plan for AIDS Relief (PEPFAR) (August 2017)
- KFF, Global Health Policy, Kaiser Daily Global Health Policy Report (July 2017)
- KFF and UNAIDS, Donor Government Funding for HIV in Low- and Middle-Income Countries in 2016 (July 2017)
- KFF, UNFPA Funding & Kemp-Kasten: An Explainer (May 2017)
- KFF, The President’s Malaria Initiative and Other US Government Global Malaria Efforts (April 2017)
- KFF, The US Government Engagement in Global Health: A Primer (January 2017)