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The U.S. Government and Global Health

Overview

The U.S. Government has been engaged in international health activities for more than a century, and today is the largest funder and implementer of global health programs worldwide. The USG global health response – a key component of the USG’s international development portfolio, accounting for about 23% of the international affairs budget1 – is a multi-pronged, multi-billion dollar investment that targets a myriad of global health challenges, countries, and stakeholders. Efforts involve many different government departments and agencies, congressional committees, and funding streams. USG global health efforts aim to help improve the health of people in developing countries while also contributing to broader U.S. global development goals (like ending extreme poverty), foreign policy priorities (e.g., promoting democratic institutions, protecting U.S. diplomatic interests), and national security concerns (e.g., protecting Americans from external threats, promoting stability).2

Role

The USG’s role in global health is multifaceted. In addition to acting as a donor by providing financial and other health-related development assistance (e.g., commodities, like contraceptives) to low- and middle-income countries, the USG operates programs and delivers health services,  provides technical assistance and other capacity-building support, participates in major international health organizations through global health diplomacy and other efforts, conducts research, supports international responses to disasters and other emergencies, and partners with governments, non-governmental groups, and the private sector.  USG efforts include both bilateral programs (two-party, usually country-to-country) and multilateral engagement, and its activities address a range of global health challenges including: HIV, tuberculosis (TB), malaria, neglected tropical diseases (NTDs), family planning and reproductive health (FP/RH), maternal and child health (MCH, which includes environmental health and polio), nutrition, health systems strengthening (HSS), global health security, and increasingly, non-communicable diseases (NCDs).

Organization and Programs

The USG engagement in global health is largely carried out by executive branch departments and agencies (see Figure 1). Day-to-day activities are administered chiefly through the Department of State’s Office of the Global AIDS Coordinator (OGAC), the U.S. Agency for International Development (USAID), and Department of Health and Human Services (HHS) operating divisions, particularly the Centers for Disease Control and Prevention (CDC). Additionally, the HHS Office of Global Affairs leads the department’s engagement with bilateral and multilateral partners, while the Global Health Diplomacy (GHD) office within the Department of State provides diplomatic support (through U.S. Ambassadors and others) in implementing USG global health efforts.

The legislative branch of government also plays a role, as Congress introduces, considers, and passes global health-related legislation; oversees global health efforts; authorizes and appropriates funding; and confirms presidential appointees to key USG global health positions.3

Figure 1: Organization of USG Global Health Efforts

Figure 1: Organization of USG Global Health Efforts

Bilateral and Multilateral Efforts4

The USG supports a wide array of bilateral and multilateral global health efforts in countries around the world. Bilateral programs provide direct support to more than 60 low- and middle-income countries and typically operate in a particular set of countries with their own budgets, staff, strategies, objectives, and monitoring and evaluation practices; they often involve multiple USG agencies/departments.5 Additionally, USG support for multilateral global health efforts includes: contributions to international organizations (e.g., the Global Fund) and United Nations agencies (e.g., the World Health Organization (WHO)); serving as a member-nation of large multilateral health organizations (e.g., WHO); participating in multilateral governance (e.g., as a Board member); serving as signatory to international health standards, treaties, and agreements; providing technical assistance to international organizations; and providing additional staff capacity to international organizations (by detailing USG employees to these organizations for periods of time).

Major Program Areas
  • HIV (PEPFAR): While the USG first provided funding to address the emerging global HIV epidemic in 1986, funding and attention has increased significantly in the last decade, particularly following the 2003 announcement of the President’s Emergency Plan for AIDS Relief (PEPFAR) by President Bush. PEPFAR’s launch led to a major increase in USG support for HIV prevention, treatment, and care efforts, as well as contributions to the Global Fund to Fight AIDS, TB and Malaria (the Global Fund), the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the International AIDS Vaccine Initiative (IAVI). Today, the Department of State’s U.S. Global AIDS Coordinator oversees this USG-wide effort, which is implemented by USAID, CDC, and other agencies.6
  • Tuberculosis (TB): USAID began its global TB control program in 1998, and since that time, the USG response has grown, particularly expanding after 2003 when the USG’s commitment to addressing TB was highlighted as part of PEPFAR. Today, led by USAID and implemented alongside other agencies, USG TB efforts focus on diagnosis, treatment, and control of TB (including multi-drug resistant and extensively drug-resistant TB (MDR/XDR TB)) and on research. The USG is also a donor to the Global Drug Facility of the Stop TB Partnership, a global network of public and private entities working to eliminate TB.7
  • Malaria (PMI): Engaged in malaria work since the 1950s, the USG supports malaria efforts through the President’s Malaria Initiative (PMI, launched in 2005) as well as other activities, including research. PMI programs, overseen by USAID’s U.S. Global Malaria Coordinator and implemented by USAID and CDC, center on expanding coverage of four key high-impact interventions: artemisinin-based combination therapy (ACT), intermittent preventive treatment in pregnancy (IPTp), indoor residual spraying (IRS) with insecticides, and insecticide-treated mosquito nets (ITNs).
  • Neglected Tropical Diseases (NTDs): Having historically engaged in NTD efforts through research and surveillance, the USG expanded its response by launching the USAID NTD Program in 2006, which aimed to reduce the prevalence of seven NTDs through integrated treatment programs using mass drug administration (MDA), and the U.S. NTD Initiative in 2008, which aimed to intensify efforts and increase funding for activities across the USG. Efforts are led by USAID and involve CDC, NIH, and other agencies.
  • Family Planning/Reproductive Health (FP/RH): The USG has been engaged in international research on FP and population issues as well as other FP/RH efforts, including the purchase and distribution of contraceptives in developing countries, since the 1960s. Today, led by USAID and involving several agencies, USG FP/RH activities are designed to decrease the risk of unintended pregnancies and maternal and child mortality and to support effective interventions, including contraception, counseling, and post-abortion care. The USG is also a donor to the United Nations Population Fund (UNFPA).
  • Maternal and Child Health (MCH): The USG has been involved in efforts to improve MCH since the 1960s. Today, led by USAID and involving several agencies, USG MCH activities aim to: improve equity of access to and use of services by vulnerable populations; bring to scale a range of high impact interventions that mitigate maternal, newborn, and under-five deaths; prevent and address the indirect causes of such deaths (such as HIV, TB, and malaria); strengthen integration of maternal health services with FP; and strengthen health systems. Additionally, some water, sanitation, and hygiene (WASH) activities are part of the environmental health efforts within the USAID MCH program. The USG is also a donor to global organizations addressing MCH, like Gavi, the Vaccine Alliance (Gavi); the United Nations Children’s Fund (UNICEF); and the Global Polio Eradication Initiative (GPEI).
  • Nutrition: For more than 40 years, USAID has been involved in nutrition efforts, aiming to prevent undernutrition through interventions such as nutrition education, nutrition during pregnancy, exclusive breastfeeding, and micronutrient supplementation.8 USAID’s nutrition efforts are coordinated with the USG’s Feed the Future Initiative (FtF, launched in 2009), which aims to address global hunger and food security and is led by USAID and the U.S. Department of Agriculture.
Geographic Landscape

USG global health efforts are carried out in more than 60 countries (mostly in Africa but also in Asia, Latin America and the Caribbean, the Middle East, and Europe and Eurasia) through bilateral support to countries or through regional programs.9 Additional countries are reached indirectly through USG contributions to multilateral organizations. The USG typically operates multiple global health programs in most of the countries. While more support is generally directed to countries facing a higher burden of disease, other factors influencing where USG health assistance is directed include: the presence of willing and able partner governments; a history of positive relations and goodwill with host countries; strategic and national security priorities; funding; and personnel availability.10

Key Legislation and Strategies

USG global health efforts are guided by key legislation, strategies, and policy and guidance documents – both those that are global health-specific as well as those that are broader (e.g., the U.S. National Security Strategy11 and the Presidential Policy Directive on U.S. Global Development Policy (PPD 6),12 which both briefly mention global health’s contributions to these broader USG strategies). Those that address global health in more depth include:

  • The Public Health Service Act of 1944 and The Foreign Assistance Act of 1961. These early acts established the main agencies (e.g., USAID) that carry out global health activities and specify where and how funds should be directed. Together, they govern much of U.S. global health policy today.
  • PEPFAR authorizing legislation. Collectively, the original 2003 legislation and the subsequent reauthorizations in 2008 and 2013, established the USG’s largest global health effort and shaped its evolution over the years.13
  • United States Government Global Health Initiative (GHI) Strategy (2011). The GHI strategy laid out a more comprehensive strategy and approach to U.S. global health programs.14 The strategy aims to build upon and consolidate the successes of existing U.S. global health programs and initiatives (such as U.S. global HIV/AIDS efforts) and establishes cross-cutting principles (e.g., encourage country ownership and invest in country-led plans)15 and approaches for these efforts. It also aims to improve coordination and cooperation among U.S. agencies.
  • Agency-specific global health strategies. Several agencies have developed their own global health strategies including USAID (USAID’s Global Health Strategic Framework), HHS (HHS Global Strategy), and CDC (CDC Global Health Strategy).16

U.S. Global Health Budget17

The USG is the largest donor to global health in the world, and its investment in global health has grown significantly over time, particularly in the last decade (see Figure 2).18 However, since FY 2010, U.S. funding for global health has remained relatively flat. The FY 2017 President’s budget request proposes $10.3 billion in specified funding for global health.19

Figure 2: U.S. Global Health Funding, FY 2006-FY 2017 Request

Figure 2: U.S. Global Health Funding, FY 2006-FY 2017 Request

  • While funding is channeled through multiple agencies and programs, most funding for global health is provided by Congress to the Department of State (largely because most PEPFAR funding is channeled through the department), followed by USAID, HHS, and DoD.20
  • The majority of U.S. government funding for global health (more than 80%) is captured under the Global Health Programs (GHP) account, with an additional $1-2 billion per year for global health activities provided through other accounts.
  • HIV/AIDS has received the most U.S. global health funding of any program since FY 2001 and accounted for more than half of total global health funding in FY 2016.
  • Most funding (80% in FY 2016) is provided bilaterally with the remainder provided to multilateral organizations, such as the Global Fund and Gavi.21 Most USG global health funding designated for specific country and regional efforts is allocated to Africa, followed by Asia, Latin America and the Caribbean, the Middle East, and Europe and Eurasia.22

Looking Ahead

Looking ahead, there are several key issues and opportunities facing policymakers regarding USG engagement in global health.  These include questions about: future funding for global health programs in the context of ongoing budget constraints; how best to balance priorities across the global health portfolio, and between bilateral and multilateral efforts; how to strengthen interagency coordination and leadership; how to manage the transition to country ownership and changing role of U.S. global health assistance; and what role the U.S. should play in the development landscape, as global efforts focus on making progress toward the aims outlined in the Sustainable Development Goals (SDGs) for achievement by 2030.

Endnotes
  1. KFF analysis of the FY 2016 Omnibus bill (P.L. 114-113); see KFF, The U.S. Global Health Budget: Analysis of Appropriations for Fiscal Year 2016, Jan. 2016. This percentage is the share of global health funding provided through the International Affairs account (Function 150), Base (Enduring) funding only.

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  2. U.S. Global Health Programs interagency website, “About,” http://www.ghi.gov/about/index.html; White House, Office of the Press Secretary, “Statement by the President on Global Health Initiative,” May 5, 2009; White House, National Security Strategy, 2010; White House, National Security Strategy, 2015.

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  3. For more information, see KFF, The U.S. Congress and Global Health: A Primer, Jan. 2016.

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  4. KFF global health policy fact sheets, http://kff.org/topic/global-health-policy/?post_type=fact-sheet.

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  5. KFF analysis of FY 2015 country level data in the U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov, accessed June 2016.

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  6. Other agencies and departments involved include the National Security Council (NSC), National Institutes of Health (NIH), Health Resources and Services Administration (HRSA), U.S. Food and Drug Administration (FDA), Peace Corps, and Departments of Labor, Commerce, and Defense (DoD).

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  7. Stop TB Partnership website, www.stoptb.org/.

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  8. USAID, “Improving nutrition for women and young children,” webpage, http://www.usaid.gov/what-we-do/global-health/nutrition.

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  9. KFF analysis of FY 2015 country level data in the U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov, accessed June 2016.

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  10. KFF, The U.S. Global Health Initiative: A Country Analysis, 2011.

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  11. The 2015 National Security Strategy mentions global health as part of U.S. efforts to increase global health security and invest in Africa’s future, and it places severe global infectious disease outbreaks among the top strategic risks to U.S. national security interests. White House, National Security Strategy, 2015.

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  12. The PPD highlights global health as a “key element” of the new development strategy. White House, PPD-6, 2010.

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  13. U.S. Congress: United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003 (P.L. 108-25), Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (P.L. 110-293), and PEPFAR Stewardship and Oversight Act of 2013 (P.L. 113-56).

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  14. USG, USG Global Health Initiative Strategy Document, 2011.

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  15. The other six principles are: focus on women, girls and gender equality; build sustainability through the strengthening of health systems; strengthen and leverage key multilateral organizations, global health partnerships, and private sector engagement; increase impact through strategic coordination and integration; improve metrics, monitoring, and evaluation; and promote research and innovation to identify what works.

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  16. At the time they were developed, all of these strategies - USAID, USAID Global Health Framework, 2012; HHS, Global Health Strategy, 2011; CDC, CDC Global Health Strategy, 2012-2015, 2012 - were rooted at the highest strategic level in the then-current National Security Strategy (2010). The HHS strategy has since been “renewed”, in 2016, as The Global Strategy of the U.S. Department of Health and Human Services.

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  17. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications and Operating Plans, Congressional Appropriations Bills , Press Releases, and Conference Reports; and U.S. Foreign Assistance Dashboard  website, ForeignAssistance.gov.

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  18. Institute for Health Metrics and Evaluation, Financing Global Health 2015, 2016; PolicyCures, G-FINDER Report 2015, 2015; KFF, Donor Funding For Health in Low-& Middle-Income Countries, 2002-2013, 2015.

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  19. Represents total known funding provided through the State Department, USAID, CDC, NIH, and DoD. FY13 includes the effects of sequestration. FY16 and FY17 are preliminary estimates. Some global health funding is determined at the agency level and is not yet known for FY16 and FY17; for comparison purposes these amounts are assumed to remain at prior year levels. The FY17 total does not include a proposed transfer of $129 million from emergency Ebola funding provided by Congress in FY15 to malaria. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications and Operating Plans, Congressional Appropriations Bills, Press Releases, and Conference Reports; and U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov.

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  20. Based on specified funding for global health programs in the President’s budget request, ForeignAssistance.gov, and Congressional appropriations bills. There is additional funding for global health activities that is determined at the agency level and is not specified by the Administration or in Congressional appropriations, and is therefore not included in the totals presented.

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  21. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications and Operating Plans, Congressional Appropriations Bills , Press Releases, and Conference Reports; and U.S. Foreign Assistance Dashboard  website, ForeignAssistance.gov.

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  22. KFF analysis of FY 2015 country level data in the U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov, accessed June 2016.

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