United States - Global health
At a glance
The US is the largest donor to global health
In 2020, the US was by far the world’s largest donor to global health, spending a total of US$10.5 billion in official development assistance (ODA) on the sector, according to data from the Organisation for Economic Co-operation and Development (OECD). This represented 41% of all health ODA provided by OECD Development Assistance Committee (DAC) donor countries. In 2020, the US spent 29% of its development assistance on global health, more than any other donor.
The US spent a total of US$7.8 billion on bilateral health ODA in 2020 (including earmarked contributions to multilateral organizations). This represented 75% of its ODA to health. The US’ bilateral health ODA in 2020 focused on sexually transmitted disease (STD) control, including HIV/AIDS (63%, or US$4.9 billion, a 26% increase from 2019), malaria control (9%, or US$708 million; a 24% decrease), reproductive health care (6%, or US$494 million; a 15% decrease), and COVID-19 control (6%, or US$436 million; emerging for the first time in 2020 due to the COVID-19 pandemic). Spending on infectious disease control — the second-highest funded health sub-sector in 2017 — plummeted by 83% over the course of three years to US$114 million in 2020. This steep decline represents the period of relative calm between three major health events, namely the Ebola (2015), Zika (2016), and COVID-19 epi/pandemics (2020). In addition, COVID-19 control was considered a separate funding pool from infectious disease control in 2020, due to the urgency given to and the large amount spent on addressing the pandemic.
The other 25% of the US’ health ODA was channeled as core funding to multilaterals. The largest disbursement in 2020 went to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund; US$2.1 billion, or 20% of global health ODA). The US pledged US$4.7 billion to the Global Fund for 2020-2022. The US is its largest total donor and will host the Global Fund’s ‘Seventh Replenishment Conference’ in fall 2022. In 2020, the US also disbursed US$272 million (3%) to Gavi, the Vaccine Alliance (Gavi). The US pledged US$1.2 billion in direct contributions for 2020-2023, an increase of US$200 million over its 2015-2018 pledge. The US is the second-largest total donor to Gavi after the UK.
Although global health has always been a cornerstone of US global development programming, ODA to health is expected to increase further in the years ahead. The approved US government spending package for Fiscal Year (FY) 2022 includes US$9.8 billion for global health programs (including US$700 million for global health security). This represents an increase of 7%, or US$634 million, over FY2021. In addition, President Joe Biden’s FY2023 budget proposes US$10.6 billion toward global health (including US$995 million for global health security and emerging threats), representing an increase of 8%, or US$746 million, in FY2022. Almost all of this increase is tied to global health security or the Global Fund.
US global health funding focuses on HIV/AIDS, infectious diseases, and maternal and child health; funding concentrates on flagship interagency initiatives
The US’ main global health priorities are controlling the HIV/AIDS epidemic, fighting infectious diseases, and preventing child and maternal deaths. According to the Kaiser Family Foundation (KFF), funding from the US accounted for 76% of international assistance to HIV from donor governments in 2020. The US is also the largest funder of global initiatives to combat malaria.
The President’s Emergency Plan for AIDS Relief (PEPFAR), which covers bilateral funding for HIV/AIDS and tuberculosis (TB) programs, as well as US contributions to the Global Fund and Joint United Nations Programme on HIV/AIDS (UNAIDS), channels about two-thirds of all US funding for global health. In FY2022, PEPFAR disbursed US$7 billion (including US$5.4 billion for bilateral HIV programming and US$1.6 billion for multilateral efforts, including the Global Fund and UNAIDS). PEPFAR funding in FY2022 was enacted at US$4.4 billion, excluding emergency funding, and the Biden Administration proposed level funding for FY2022.
The US’ efforts against malaria are achieved primarily through the President’s Malaria Initiative (PMI), an interagency initiative led by United States Agency for International Development (USAID). In FY2022, US bilateral malaria funding amounted to US$775 million. The Biden administration’s FY2023 budget proposes to up this funding to US$780 million. In October 2021, PMI released a five-year ‘End Malaria Faster’ strategy for 14 African countries, following the WHO’s approval of a groundbreaking malaria vaccine.
PMI Focus Countries
Angola, Benin, Burkina Faso, Burma, Cambodia, Cameroon, Cote d’Ivoire, the Democratic Republic of the Congo, Ethiopia, Ghana, Guinea, Kenya, Liberia, Madagascar, Malawi, Mali, Mekong region, Mozambique, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Tanzania, Thailand, Uganda, Zambia, and Zimbabwe
As with most other donors, COVID-19 has emerged as a focus of the US’ ODA, although it also fits with the US’ emphasis on infectious disease control. Former President Donald Trump’s Administration was criticized for its relatively minor role in the international response to COVID-19. Biden reversed Trump’s pledged withdrawal from the World Health Organization (WHO) and announced that the US would repay missed dues and increase funding. In March 2021, Biden signed the American Rescue Plan into law, which included US$11 billion for the global COVID-19 response. US$3.5 billion was allocated to the Global Fund and US$5.2 billion to USAID. Biden also launched a National Security Council Directorate on Global Health Security and Biodefense (a function that Trump eliminated prior to the COVID-19 outbreak). Under Biden, the US joined the COVID-19 Vaccines Global Access (COVAX) initiative to provide vaccines globally with an initial pledge of US$2.0 billion in February 2021 and a promised pledge of an additional US$2.0 billion.
In July 2021, the Biden Administration released a US ‘COVID-19 Global Response and Recovery Framework,’ setting forth the following five objectives to end the pandemic, mitigate its negative impacts, and strengthen future pandemic preparedness:
- Accelerate the equitable distribution of COVID-19 vaccinations;
- Strengthen health systems in order to reduce the severe effects of COVID-19 and to better prepare for future threats;
- Address the acute needs that COVID-19 has caused, including reducing household economic shocks and building resilience;
- Provide economic and other support to critical systems that COVID-19 has put under stress; and
- Bolster international health security architecture for a better response to pandemic threats.
The US effort will be a whole-of-government response and will include partnerships with both international organizations, other governments, private and non-profit sectors, and frontline communities.
In September 2021, the US announced a joint COVID-19 vaccination plan with the EU. The ‘US-EU Agenda for Beating the Global Pandemic: Vaccinating the World, Saving Lives Now, and Building Back Better Health Security’ outlined the following five pillars of joint US-EU commitments: 1) vaccine sharing; 2) vaccine readiness; 3) bolstering global vaccine supply and therapeutics; 4) proposal to achieve global health security; and 5) a partners' roadmap for regional vaccine production.
At the 2021 United Nations General Assembly (UNGA) in September 2021, the US committed to participate in the establishment of a new Financial Intermediary Fund (FIF) hosted by the World Bank with the global goal of raising US$10.0 billion per year. The International Monetary Fund (IMF) will oversee the FIF by the end of 2021, and the fund will support global pandemic surveillance and cooperation to expedite the development of new vaccines. It will also coordinate investments in regional manufacturing capacity in low-income countries and lower-middle-income countries (LMICs) for vaccines and treatments. Also at 2021 UNGA, President Biden convened the first ‘Global COVID-19 Summit,’ at which he pledged an additional 500 million vaccine doses, bringing the US commitment to approximately 1.1 billion.
As a follow-on in May 2022, the US co-hosted the second ‘Global COVID-19 Summit’ alongside Belize, Germany, Indonesia, and Senegal. At the summit, Vice President Kamala Harris called on Congress to provide US$22.5 billion in supplemental funding to address COVID-19, which includes US$5 billion in global response efforts. In terms of pledges at the summit, the US committed an additional US$200 million to the FIF in 2022, bringing the total to US$450 million. Additional non-financial commitments included sharing vaccine research and development tools, increasing testing on generics, expanding ‘test and treat’ strategies for low- and middle-income countries, and expanding dose donations through COVAX.
As of June 23, 2022, Congress has passed six emergency supplemental funding bills to address COVID-19, with US$19 billion going to global response efforts. Of this, US$10.5 billion (55%) has been appropriated to or managed by USAID, with the remainder going to the US Department of State or the Centers for Disease Control and Prevention (CDC).
Another significant focus of US health ODA is support for maternal, newborn, and child health (MNCH). The FY2023 budget request puts US$880 million toward MNCH, much of which is allocated through USAID, and focuses on 25 countries (see box) and five areas of intervention:
- Maternal health;
- Newborn health;
- Child health; and
- Water, sanitation and hygiene (WASH).
USAID’s MNCH focus countries
Africa: the Democratic Republic of the Congo, 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
Despite the US’ policy emphasis on MNCH, family planning is a contentious issue in the US, particularly under Republican administrations. Since assuming office, the Biden Administration repealed two policies reinstituted under the Trump Administration that restrict US funding for sexual and reproductive health and rights (SRHR) programming: the Kemp Kasten Amendment and the Mexico City Policy. The Kemp-Kasten Amendment withholds all US funding to the United Nations Population Fund (UNFPA). The Mexico City Policy, also known as the ‘global gag rule’, blocks US global health funding for both non-US non-government organizations (NGOs) directly involved in abortion services or abortion rights advocacy and for those who fund or support other groups which provide or discuss abortion. Despite the Biden Administration’s repeal, the overturning of ‘Roe v. Wade,’ the landmark 1973 decision by the US Supreme Court which ruled that the US Constitution conferred the right to an abortion, on June 20, 2022, impacts the effectiveness of the removal of the Mexico City Policy, as it could hurt local-level efforts to expand sexual and reproductive health rights (SRHR), limit funding, and increase stigma around SRHR and related care.
Biden's State Department provided US$31 million in core funding to the United Nations Population Fund (UNFPA) in FY2021, with US$33 million appropriated in the budget for FY2022. President Biden’s FY2023 budget provides a 8% increase in the overall family planning budget to US$653 million.
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 government departments and agencies participate in the decision-making and implementation of the US’ global health programs. These include:
USAID is the main implementer of PEPFAR programs and is responsible for programs in MNCH, nutrition, family planning and reproductive health, other infectious diseases, nutrition, and water and sanitation. USAID also 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 US State Department provides some policy direction for USAID. Most of the State Department’s global health work is overseen by the Office of the US Global AIDS Coordinator (OGAC), which coordinates all US HIV/AIDS-related activities.
The Department for Health and Human Services (HHS) mainly works domestically but does have a global function through the Office of Global Affairs (OGA). Two of HHS’ primary executing agencies are:
- CDC: the largest government agency working in disease control and prevention and health promotion. The CDC implements some PEPFAR and PMI programs; and
- National Institutes of Health (NIH): conducts basic research on diseases and disorders. It is a PEPFAR implementing agency and leads the US’ malaria research and development (R&D) activities (see sector: ‘Global Health R&D’).
Department of Defense (DOD) conducts a wide range of US global health activities related mainly to disease surveillance, health-systems capacity building through military and international training, and US global health R&D efforts.
Congress controls global health funding levels through multiple appropriations bills, which fund several departments and agencies. Over 15 congressional committees oversee US global health engagement. In addition, around ten caucuses (informal congressional groups) focus specifically on issues related to global health.