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$9.5 billion on health official development assistance (ODA) in 2015, according to data from the Organisation for Economic Co-operation and development (OECD). This represents half (50%) of all health ODA provided by OECD donor countries that year.
The US spends more of its development assistance on global health than any other donor. In 2015 (the latest year for which full sectoral data is available), 27% of total ODA was allocated to global health programs. While US government funding on global health sharply increased during the Bush and Obama administrations (see details below), it is unclear how funding will develop under the current administration. Due to the ongoing appropriations process, global health ODA levels have remained largely stable to date, with some decreases to certain sectors such as family planning, and a stronger political focus on the Global Health Security Agenda.
While the president’s fiscal year (FY) 2018 budget request (May 2017) slashed global health funding by approximately US$2.5 billion (27%), Congress rejected these cuts in its FY2018 budget bill passed on March 21, 2018. The omnibus bill provides US$8.7 billion for Global Health Programs (State Department and USAID; GHP) account, US$35 million less than FY2017 levels and US$2.2 billion more than the president’s FY2018 request. This account represents the majority of US global health assistance. Notably, the congressional FY2018 budget preserves funding levels to bilateral HIV/AIDS programs (US$4.7 billion); the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund; US$1.4 billion); malaria (US$755 million); and neglected tropical diseases (US$100 million), among others. Polio funding (US$59 million) from two different accounts also stood at FY2017 levels.
In addition, funding to global health efforts of the Centers for Disease Control and Prevention (CDC) increased in the FY2018 omnibus bill, from US$435 billion to US$489 million, for HIV/AIDS, immunization, parasitic diseases, and protection. Support to the global health programming of the National Institutes of Health (NIH) is still unknown, as it is determined at agency level.
The US has several large interagency global-health initiatives under President George W. Bush, which underpin US global health assistance. The President’s Emergency Plan for AIDS Relief (PEPFAR), set up in 2003, is the umbrella program for all US HIV/AIDS activities. 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 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. In 2017, the Secretary of State introduced the PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020). Under this strategy, PEPFAR would continue to operate in 50 countries, but focus on epidemic control in 13 countries.
The President’s Malaria Initiative (PMI) was launched in 2005. PMI is an interagency initiative led by the USAID, focusing on 19 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. However, the President’s FY2019 budget looks to cut malaria funding from US$755 million in FY2017 to US$674 million in FY2019 (US$81 million, 11%). Interestingly, this is US$250 million more than the president’s FY2018 budget request.
ODA to health relies on bilateral programs: According to OECD data, US$8.2 billion of the US’ health ODA in 2016 was provided bilaterally, up from US$7.6 billion in 2015 (80% of 2015’s total health ODA). This spending pattern mirrors the PEPFAR and PMI approach to HIV/AIDS, TB, and malaria programming. According to government data, 80% (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 2016 focused on STD control, including HIV/ AIDS (59%, or US$4.9 billion), followed by infectious disease control (8%, or US$629 million), malaria control (8%, US$625 million), reproductive health care (7%, US$570 million), and family planning (6%, US$488 million).
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 support for maternal, newborn and child health (MNCH) has increased over time as well, 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; for FY2018, MNCH funding totals US$1.1 billion, including US$990 million for MNCH and US$125 million for nutrition. As a comparison, MNCH funding was US$730 million in 2006. USAID has 24 priority countries for MNCH (see box), primarily located in Africa and South and Central Asia.
While the president’s FY2018 budget request eliminated reproductive health and family planning (FP) funding, Congress rejected these cuts, providing US$608 million, of which US$575 million are for bilateral programs, which matches FY2017 levels. In addition, Congress allocated US$32.5 million to UNFPA, meeting FY2017 levels and rejecting the elimination of this funding in the president’s FY2018 request. The FY2018 omnibus bill also does not codify the ‘Mexico City Policy’ (also known as the ‘Global Gag Rule’) into law, though it maintains some of the policy’s conditions. The policy, which the Trump administration reinstated in 2017 and which expands on the previous Mexico City rule, blocks federal funding for non-government organizations (NGOs) that provide abortion information, counselling, or referrals, or that advocate for such services.
Other health areas which received increases in the FY2018 omnibus bill, in contrast to the president’s FY2018 request are: Tuberculosis programming (US$261 million, up US$21 million) and global health security (US$173 million, a 138% increase from the FY2017 level). This is aligned with the current US government’s emphasis on global health security.
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’ global health cooperation. These include:
State Department: According to KFF, in FY2017 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 HIV/AIDS-related activities. 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.
USAID: In FY2017, USAID managed US$3.2 billion in global health funding. 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 CDC. Irene Koek is Acting US Global Malaria Coordinator, and the Senior Deputy Assistant Administrator. USAID is a 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.
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. Most of HSS’s global health engagement is executed through four agencies: CDC, NIH, the Food and Drug Administration (FDA), and Health Resources and Services Administration (HRSA). The two primary ones are:
CDC: CDC is an operating division of HHS and is the largest government agency working in disease control and prevention and health promotion, with US$128 million to HIV efforts and US$296 million contributed in FY2017 to other 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’ malaria research and development (R&D) activities. In FY2017, NIH received US$493 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$5 million for malaria in FY2017 and US$272 million for the Global Health Security Agenda. It conducts a wide range of US global health activities, including HIV and other infectious diseases, 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 (see ‘Deep Dive: Global Health R&D’ for more information).
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, (2017).