The US is the largest donor to global health
The United States (US) is by far the world’s largest donor to global health, spending a total of US$10.0 billion on health official development assistance (ODA) in 2016 (the latest year in which full data is available), according to data from the Organisation for Economic Co-operation and Development (OECD). This represents half (50%) of all health ODA provided by OECD Development Assistance Committee (DAC) donor countries.
Global health is a cornerstone of US development assistance: the US spends more of its development assistance on global health than any other donor. In 2016, 28% of total ODA was allocated to global health programs. Broadly, priorities within health include HIV/AIDS; infectious diseases; and preventing maternal and child deaths.
For fiscal year (FY) 2019, Congress appropriated a total of US$11.0 billion for global health. This is US$147 million more than FY2018 levels and US$2.1 billion more than the president’s FY2019 budget request (US$6.7 billion). This account represents the majority of US global health assistance. The President’s FY2020 budget request proposes a cut of approximately US$2.5 billion to global health assistance to US$6.3 billion, which would be the lowest funding level since FY2007. To date, however, Congress has rejected President Trump’s budget requests and global health spending has remained largely stable.
The US has several large interagency global health initiatives which underpin US global health assistance. The President’s Emergency Plan for AIDS Relief (PEPFAR), the umbrella program for all US HIV/AIDS activities, is the linchpin of US global health activities: About two-thirds of US funding for global health is channeled through the initiative. PEPFAR covers bilateral funding for HIV/AIDS, as well as US contributions to the Global Fund and the Joint United Nations Programme on HIV/AIDS (UNAIDS).
PEPFAR is also particularly important to the global HIV response. According to the Kaiser Family Foundation (KFF), the US accounted for 73% of all international assistance to HIV from donor governments in 2018. In 2017, the Secretary of State introduced the PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020). Under this strategy, PEPFAR continues to operate in 50 countries but has a particular focus on achieving epidemic control in just 13 (see box). The new strategy has been controversial: critics have raised concerns about what this means for the other countries, especially high-burden countries such as Nigeria, which need the most assistance.
Between FY2004 and FY2019, the US provided more than US$90 billion through PEPFAR. In FY2019, the US provided US$6.8 billion (US$5.4 billion for bilateral HIV programming and US$1.4 billion for the Global Fund), a slight increase compared to FY2018. The president’s FY2020 budget request proposed US$4.9 billion in total funding for PEPFAR, a cut of US$1.9 billion (-27%) compared to the FY2019 level.
Tuberculosis funding is counted as part of PEPFAR. In FY2019, US funding for bilateral TB efforts was US$306 million.
PEPFAR focus countries:
Botswana, Côte d’Ivoire, Haiti, Kenya, Lesotho, Malawi, Namibia, Rwanda, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe
The US is also the largest funder of global anti-malaria efforts. According to KFF data, bilateral malaria funding amounted to US$984 million in FY2019. US malaria efforts, including bilateral programs, are achieved primarily through the President’s Malaria Initiative (PMI). PMI is an interagency initiative led by the United States Agency for International Development (USAID) that focuses on 24 countries in Africa and three programs in the Greater Mekong region in Asia. Overall, the US provides bilateral malaria support to more than 30 countries through the PMI and other activities. The president’s FY2020 budget proposed US$871 million for malaria funding, a cut of US$113 million (-12%) compared to the FY19 level.
PMI focus countries:
Angola, Benin, Burkina Faso, Burma, Cambodia, Cameroon, Cote d’Ivoire, 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, Zimbabwe
In recent years, the US has increasingly focused on the Global Health Security (GHS) agenda, an interagency initiative by the US’ Centers for Disease Control and Prevention (CDC) and USAID to drive progress on preventing, detecting, and responding to infectious disease threats. Spending in global health security totaled US$504 million in 2019. In May 2019, the White House released the US Global Health Security Strategy, which established a three-pronged approach to global security: 1) strengthening partner country global health security capacities, 2) increased international support for global health security, and 3) a homeland prepared for and resilient against global health security threats.
Another significant focus of USAID’s work is support for maternal and child health, which now focuses on 25 countries (see box) and prioritizes five areas of intervention: maternal health, newborn health, immunization, child health and water, and sanitation and hygiene. USAID’s new report, ‘2019 Acting on the Call’, describes how USAID’s ‘Journey to Self-Reliance’ (in other words, using foreign assistance towards the goal of ending its need to exist; see Key Question 2: What are the US’ strategic priorities for development?’ for more details) will be applied at the country level to prevent maternal and child deaths. This shift towards promoting self-reliance raises the possibility of reorienting funding and approaches in the sector. US support for maternal, newborn and child health (MNCH) has increased over time (for more information on nutrition, see ‘Sector: Nutrition’). In FY2019, funding for MNCH totaled $1.4 billion, comprised of US$1.2 million for MNCH and US$145 million for nutrition.
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
Despite the emphasis on MNCH, funding for family planning (FP) is currently highly controversial within US foreign assistance policy. Funding levels to the area have thus far remained stable. While the president’s FY2019 budget request slashed funding in half for FP and reproductive health (RH), Congress rejected these cuts and ultimately provided US$608 million, which includes US$575 million for bilateral programs and $33 million for UNFPA. The president’s FY2020 budget again requests a 57% cut in funding for FP (from US$608 million in FY2019 to US$259 million in the FY2020). Congress is likely to again reject this proposed cut.
Additionally, for the third year in a row, the State Department invoked the ‘Kemp-Kasten’ amendment, which withholds all funding for the United Nations Population Fund (UNFPA). Funding for UNFPA in FY2019 was expected to total US$33 million. As per US law, any funding withheld from UNFPA under the policy will now be made available to other family planning, maternal health, and reproductive health activities.
In 2017, the Trump administration reinstated and expanded the ‘Global Gag Rule’. The rule, also known as the Mexico City policy, blocks US global health funding for both non-US non-government organizations (NGOs) directly involved in abortions or abortion rights advocacy or those who fund or support other groups which provide or discuss abortion. As a result, FP organizations such as International Planned Parenthood Federation and Marie Stopes International have lost significant US funding by refusing to comply, and numerous reports have noted the policy’s adverse effects on other NGOs that provide HIV/AIDS services. In 2019, the rule was expanded to prohibit covered organizations from funding groups that provide abortions services or information, even if those groups received no US assistance. The full effect of the expanded rule has not yet been ascertained.
The US provides most of its funding for global health bilaterally
Most of US ODA funding for health is delivered through bilateral programs. According to OECD data, US$9.0 billion of the US’ health ODA in 2017 was provided bilaterally, up from US$8.3 billion in 2016. This spending pattern mirrors the PEPFAR and PMI approach to HIV/AIDS, TB, and malaria programming. In line with the priorities outlined above, according to OECD data, bilateral health ODA in 2017 focused on STD control, including HIV/ AIDS (64%, or US$5.8 billion), followed by infectious disease control (8%, or US$691 million), reproductive health care (8%, US$678 million), malaria control (6%, US$530 million), and family planning (5%, US$476 million).
In 2016 (the latest year for which full data is available), the US channeled 17% or US$1.7 billion of its health ODA multilaterally. In absolute terms, this makes the US the largest donor to global-health multilateral organizations. However, the share of its ODA allocated to multilateral health programs is far below the DAC average for 2016 (56%), mainly due to the US’ immense bilateral global health investments.
The Global Fund was a key recipient of US multilateral health ODA in 2016, receiving 66% of the US’ multilateral health funding. The US is the Global Fund’s single largest donor, with contributions totaling US$15.0 billion from 2001 to 2019. This amounts to almost a third of all contributions received for that period (US$49 billion, according to Global Fund data), in line with US legislation that prevents the US from providing more than one-third of the Global Fund’s total contributions. For the 2017-2019 funding period, the US pledged US$4.3 billion. In the president’s FY2020 Request, the administration proposed pledging US$3.3 billion for the Global Fund’s October 2019 replenishment. It also proposed matching US$1 for every US$3 contributed by other donors (compared to the existing commitment of US$1 for every US$2).
The US is the third-largest donor to Gavi, the Vaccine Alliance (Gavi), after the United Kingdom and Norway. Total contributions to Gavi amount to US$1.9 billion from 2000 to 2018. The US pledged US$1.1 billion in direct contributions for 2016 to 2020, according to Gavi’s own data. According to KFF, the US’ contribution to Gavi in FY2018 amounted to US$290 million. The US is also the largest public donor to the Global Polio Eradication Initiative (GPEI). According to GPEI data, the US has contributed US$3.3 billion since 1985.
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 executive branch (see Key Question 3: ‘Who are the main actors in the US's development cooperation?’). Several governmental departments and agencies participate in the decision-making and implementation of the US’ global health programs.
USAID is the primary development agency for the US. It is the main implementer of PEPFAR programs and is responsible for other global health-related programs such as MNCH, nutrition, family planning and reproductive health, other infectious diseases, nutrition, and water and sanitation. USAID leads on PMI through the US Global Malaria Coordinator, appointed by the president, and implements it jointly with the Centre for Disease Control (CDC).
The 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) works mostly domestically but does have a global function through the Office of Global Affairs (OGA). HHS has two primary executing agencies:
- CDC is largest government agency working in disease control and prevention and health promotion. The CDC implements some PEPFAR and PMI programs.
- National Institutes of Health (NIH) conducts basic research on diseases and disorders. It is a PEPFAR implementing agency and leads on 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 and plays a critical role in disease surveillance, in health-systems capacity building through military and international training, and in US global health R&D efforts (see ‘Deep Dive: Global Health R&D’ for more information)
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.
Civil society sources
- Congressional Research Service, State, Foreign Operations and Related Programs: FY2019 Budget and Appropriations (2019)
- Kaiser Family Foundation (KFF), Factsheet: the US President's Emergency Plan for AIDS Relief (PEPFAR; 2019)
- Kaiser Family Foundation (KFF), Factsheet: US Global Health Budget Global Health Security (2019)