United States - Global health

8 - US - bi/multi Health

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11 - Health Ranking abs US

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12 - Health ranking relative - US

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The US is the largest donor to global health, with funding concentrated on flagship interagency initiatives

In 2016 (the latest year for which multilateral and bilateral OECD data is available) the United States (US) was by far the world’s largest donor to global health, spending a total of US$10.3 billion on health official development assistance (ODA), according to data from the Organisation for Economic Co-operation and Development (OECD). This represented half (50%) of all health ODA provided by OECD DAC donor countries. Global health is a cornerstone of US development assistance: the US spent more of its development assistance on global health than any other donor, at 28% of its total ODA in 2016 (in second place was Canada, with 19% of total ODA spent on health).

Bilateral spending concentrates on priorities of flagship global health initiatives

The US spent a total of US$8.6 billion on bilateral health ODA in 2018, down 7% from a peak of US$9.2 billion in 2017. Bilateral spending on health accounts for 28% of all the US’ bilateral ODA spending.

Broadly, the US’ bilateral priorities within health are controlling the HIV/AIDS epidemic; fighting infectious diseases; and preventing child and maternal deaths. In line with these priorities, OECD DAC shows that the US’ bilateral health ODA in 2018 focused on STD control, including HIV/ AIDS (63%, or US$5.4 billion), reproductive health care (7%, US$640 million), family planning (7%, US$610 million), and malaria control (7%, US$569 million). Spending on infectious disease control — the second-highest funded health sub-sector in 2017 with US$706 million (a figure that had been relatively stable over the past five years) — dropped by 68% to a mere US$226 million in 2018.

For fiscal year (FY) 2020, Congress appropriated a total of US$9.1 billion for Global Health Programs (GHP), which comes from the State Department and United States Agency for International Development (USAID)¬¬ account. This is US$225 million more than FY2019 levels and US$2.8 billion more than the president’s FY2020 budget request (US$6.3 billion). This account represents the majority of US global health assistance. For the fourth year in a row, President Trump’s FY2021 budget request proposes a cut to global health assistance, this time by US$3.1 billion to US$6.0 billion. To date, however, Congress has largely rejected President Trump’s budget requests and global health spending has remained relatively stable.

The US is a key donor to Gavi and the Global Fund

The US is the Global Fund’s single largest donor, with contributions totaling US$17.5 billion from 2001 to 2019. This amounts to almost a third of all contributions received for that period (US$52.1 billion, according to Global Fund data), in line with US legislation that prevents it from providing more than one-third of the Global Fund’s total contributions.

For the 2020-2022 funding period, the US pledged US$4.7 billion, a US$400 million increase from its 2017-2019 contribution. For FY2020, appropriations totaled US$1.6 billion.

The US is the third-largest total donor to Gavi, the Vaccine Alliance (Gavi), after the United Kingdom and Norway. Between 2000 and 2018, the US’ total contributions to Gavi amount to US$2.2 billion, which represents 13% of all donations. The US pledged US$1.2 billion in direct contributions for 2021-2025, according to Gavi’s own data, an increase of US$100 million over its 2016-2020 pledge. According to The Kaiser Family Foundation (KFF), the US’ contribution to Gavi in FY2020 amounted to US$290 million, the same as in 2019.

The US is also the largest public donor to the Global Polio Eradication Initiative (GPEI). According to GPEI data, the US has contributed US$3.5 billion since 1985.

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

Caribbean: Haiti

Large interagency global-health initiatives underpin US global health assistance

The President’s Emergency Plan for AIDS Relief

The President’s Emergency Plan for AIDS Relief (PEPFAR), the umbrella program for all US HIV/AIDS activities channels about two-thirds of US funding for global health. PEPFAR covers bilateral funding for HIV/AIDS and tuberculosis (TB) programs, as well as US contributions to the Global Fund and UNAIDS.

PEPFAR is critical to the global HIV response. According to the KFF, funding from the US accounted for 73% of 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). The strategy dictates that PEPFAR continue to operate in 50 countries but focuses on epidemic control in just 13. 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 but are no longer in focus.

Between FY2004 and FY2019, the US provided almost US$90.0 billion through PEPFAR. In FY2020, PEPFAR disbursed US$7.2 billion (US$5.3 billion for bilateral HIV programming, US$1.6 billion for the Global Fund, and US$310 million for bilateral TB programming). The FY2021 President’s budget request proposes cutting PEPFAR funding to US$4.2 billion.

PEPFAR focus countries

Africa: Botswana, Côte d’Ivoire, Haiti, Kenya, Lesotho, Malawi, Namibia, Rwanda, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe

President’s Malaria Initiative

The US is also the largest funder of global initiatives to combat malaria. US malaria efforts, including bilateral programs, are achieved primarily through the President’s Malaria Initiative (PMI). PMI is an interagency initiative led by USAID that focuses on 24 countries in Africa and three programs in the Greater Mekong region in Asia. In FY2020, the US’ bilateral malaria funding amounted to US$770 million.

PMI focus countries

Africa: Angola, Benin, Burkina Faso, Cameroon, Cote d’Ivoire, 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

Maternal health is a priority, but support for sexual and reproductive health and rights remain contentious

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. USAID’s new report, ‘2019 Acting on the Call’, describes how USAID’s ‘Journey to Self-Reliance’ (USAID’s strategy to end the need for US foreign assistance; see ‘Policy priorities’ for more details) will be applied at the country level to prevent maternal and child deaths. This shift towards promoting self-reliance could result in a reorientation of funding or approaches in the sector.

Despite the emphasis on MNCH, family planning (FP) is currently a battleground within US foreign assistance policy. Congress provided FP and reproductive health (RH) with US$608 million in FY2020, despite the president’s budget requesting US$259 million. Congress also allocated US$33 million to the United Nations Population Fund (UNFPA), meeting FY2019 levels and rejecting the elimination of this funding in the president’s FY2020 request. Additionally, for the fourth year in a row, the State Department invoked the ‘Kemp-Kasten’ amendment, which withholds all funding for the UNFPA. 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. The president’s FY2021 budget once again requests a 61% cut in funding for FP (from US$608 million in FY2020 to US$237 million in the FY2021).

In 2017, the Trump administration reinstated and expanded the Mexico City Policy. Also known as the ‘Global Gag Rule’, the policy blocks US global health funding for both non-US non-government organizations (NGOs) directly involved in abortion services or abortion rights advocacy or for those who fund or support other groups which provide or discuss abortion. According to the Kaiser Family Foundation, the policy potentially applied to US$7.4 billion in reallocated health spending in FY2019. In September of 2020, the Trump administration proposed  a further expansion of the policy, which already applied to global health grants and cooperative agreements, to encompass contracts as well. The proposal came just a month after findings from the US State Department that the Mexico City Policy had had far-reaching consequences  for global health efforts (even those with no link to abortion services), specifically harming efforts to treat tuberculosis and HIV/AIDS and efforts to deliver nutritional assistance, particularly in Sub-Saharan Africa.

As part of an ongoing push to conservatize US development work related to women’s sexual and reproductive health and rights (SRHR) and LGBTQ  + rights, the US State Department's Commission on Unalienable Rights issued a September 2020 report  excluding previously recognized rights, including reproductive rights. USAID also issued a new draft gender policy which adopted outdated terms such as "fertility awareness" and "early sexual debut" in place of evidence-based approaches to sexual and reproductive services and education. Experts have pointed out that the use of terminology such as "unalienable rights" and "basic and legal rights" in place of "human rights" narrows the scope of legal protections that the policy will offer, meaning that women, girls, and LGBTQ+ individuals risk further curtailment of health resources. The draft also uses a binary gender definition, eliminating any references to the LGBTQ+ population and failing to address intersectionality, a philosophy which recognizes that some people face multiple forms of discrimination.


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

The US is a strong supporter of global health security but has yet to fully join the international COVID-19 response

The US is a robust supporter of global health security. In response to COVID-10, funding for global health security is expected to reach as much as US$535 million in 2020, up from a level of US$100 million in 2019.  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.

In April 2020, President Trump froze all US funding to the World Health Organization (WHO), stating that his administration would undertake a review of the organization's handling of COVID-19, especially as it relates to China. Notably, the US also refrained from participating in the European Commission’s global pledging event for the COVID-response on May 4, 2020. Given the US’ importance as a top global health donor, the risks associated with this de-funding cannot be understated. Although the Trump administration gave notice to withdraw from WHO in July 2020, the withdrawal would not be effective until a year later, in July of 2021. The incoming Biden administration has already announced it will reverse the withdrawal and remain a WHO member.

In March 2020, Congress passed three supplemental appropriations bills to address the COVID-19 response. The first and third supplementals contained funding for US foreign assistance. On March 6, 2020, Congress approved US$1.3 billion in emergency funding for the State Department and USAID to address the COVID-19 threat, despite the fact the Trump Administration’s emergency request included no international funding. The largest share of this funding (33%, or US$435) was allocated to Global Health Programs. It will be administered by USAID. No less than US$200 million will be used by the Emergency Reserve Fund, which can be quickly accessed to respond to emerging disease threats. The third supplemental provided US$1.1 billion in international funding. Some of the funding was for diplomatic expenses, including evacuations of US personnel and citizens, and increased expenses associated with COVID-19. The bill also provided US$258 million for international disaster response and US$350 million for vulnerable refugee populations.

Since that time, an ongoing battle  in US congress over domestic and international relief packages to address the effects of the COVID-19 crisis has fallen sharply along partisan lines. The updated HEROES Act (Health and Economic Recovery Omnibus Emergency Solutions Act) passed in early October 2020 by the Democrat-controlled House, provided US$2.20 trillion  in assistance , and US$9.0 billion for the international COVID-19 response.

A mid-November bill released by the Senate Appropriations Committee provided  US$55.2 billion in development assistance spending for FY2021, holding funding levels steady from the previous year and rejecting the major cuts requested by President Trump. There was not provision for any emergency international COVID-19 funding that advocates had hoped for. A final bill, which must reconcile the differences between the House and Senate packages, may ultimately include funding for global COVID-19 assistance but the outcome is unclear. The Senate bill also left out the US$805 million allocated in the House bill for family planning, opting instead to allocate a US$461 million package.

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 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 CDC.

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.

  • 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.

Department of Defense (DOD): conducts a wide range of US global health activities and plays a critical role in disease surveillance, health-systems capacity building through military and international training, and in US global health R&D efforts (see sector: '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.