United States - Global health

The US is the largest donor to global health  

In 2019, the US was by far the world’s largest donor to global health, spending a total of US$8.1 billion in official development assistance (ODA) to the sector, according to data from the Organisation for Economic Co-operation and Development (OECD). This represented 43% of all health ODA provided by OECD Development Assistance Committee (DAC) donor countries. In 2019, the US spent 24% of its development assistance on global health, more than any other donor.

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The US spent a total of US$5.9 billion on bilateral health ODA in 2019 (including earmarked contributions to multilateral organizations). This represented 81% of its ODA to health. The US’ bilateral health ODA in 2019 focused on sexually transmitted disease (STD) control, including HIV/AIDS (55%, or US$3.6 billion, 35% lower than 20182), malaria control (13% or US$869 million; +50%), reproductive health care (9% or US$560 million; -14%), and family planning (6% or US$418 million, -33%). Spending on infectious disease control — the second-highest funded health sub-sector in 2017 — plummeted by 74% over the course of two years to US$187 million in 2019. This steep decline represents the period of relative calm between three major health, namely the Ebola (2015), Zika (2016), and COVID-19 epi/pandemics (2020).

The other 19% of the US’ health ODA was channeled as core funding to multilaterals. The largest disbursement in 2019 went to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund; US$1.1 billion or 13% of its global health ODA). The US pledged US$4.7 billion to the Global Fund for 2020-2022. The US is its largest total donor. In 2019, the US also disbursed US$269 million (3% of global health ODA) 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 third-largest total donor to Gavi after the UK and Norway.  

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. In his first budget request for fiscal year (FY) 2022, President Joe Biden requested US$10.0 billion for global health programs (including US$850 million for global health security). This represents an increase of 9% over FY2021.  

US global health funding focuses on HIV/AIDS, infectious diseases, and maternal and child health; funding concentrated 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 73% of international assistance to HIV from donor governments in 2019. 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 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 FY2020, PEPFAR disbursed US$6.9 billion (including US$5.4 billion for bilateral HIV programming and US$1.6 billion for the Global Fund). PEPFAR funding in FY2021 was enacted at US$6.2 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 FY2021, US bilateral malaria funding amounted to US$770 billion. The Biden administration’s FY2022 budget proposes to maintain funding at this level.

 


PMI Focus Countries

Africa: Angola, Benin, Burkina Faso, Cameroon, Cote d’Ivoire, the Democratic Republic of the Congo, Ethiopia, Ghana, Guinea, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Tanzania, Uganda, Zambia, and Zimbabwe

Asia: Burma, Cambodia, Mekong Region, and Thailand


 

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. The administration under former President Donald Trump was criticized for its relatively minor role in the international response to COVID-19. Since taking office in January of 2021, however, Biden has reversed Trump’s pledged withdrawal from the World Health Organization (WHO) and announced that the US repay missed dues and increase funding. In March of 2021, Biden signed the American Rescue Plan into law, which included US$1.1 billion for the global COVID-19 response. US$3.9 billion was allocated to the Global Fund and US$4.0 billion to USAID. Biden also launched a National Security Council Directorate on Global Health Security and Biodefense (a function that Trump had eliminated prior to the outbreak of COVID-19). Under Biden, the US joined the COVAX initiative to provide vaccines globally with an initial pledge of US$2.0 billion in February of 2021 and a promised pledge of an additional US$2.0 billion.

Another significant focus of US health ODA is support for maternal, newborn, and child health (MNCH) through USAID, which now focuses on 25 countries (see box) and prioritizes five areas of intervention:

  1. Maternal health;
  2. Newborn health;
  3. Immunization
  4. Child health; and
  5. 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

Caribbean: Haiti


 

Despite the emphasis on MNCH, family planning is a contentious issue in the US, particularly under Republican administrations like that of Trump. In 2017, the Trump administration reinstated two policies restricting US funding for sexual and reproductive health and rights (SRHR) programming:  the Kemp Kasten Amendment and the Mexico City Policy (which it even expanded upon).The ‘Kemp-Kasten’ amendment withholds all US funding to the 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.  

Since assuming office, the Biden administration has repealed the Mexico City policy. Biden's State Department will provide US$56 million in core funding to the United Nations Population Fund (UNFPA) in its first year in office. President Biden’s FY2022 budget provides a 5% increase in family planning to US$640 million including an increase in core funding for UNFPA.

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.

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.
  • 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 related mainly to disease surveillance, health-systems capacity building through military and international training, and in US global health R&D efforts.

US 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.