A Reporter's Guide to U.S. Global Health Policy
U.S. Global Health Policymaking
The U.S. government has been engaged in international health activities for more than a century, beginning with efforts in the late 1800s to promote growing international trade and travel while protecting borders from external diseases. The U.S. government’s commitment to global health has grown and evolved considerably over time, most markedly in the last decade, and global health has become a stated U.S. policy priority.
The U.S. role is multi-faceted, and includes acting as donor to low- and middle-income countries through bilateral aid; engaging in global health diplomacy; providing technical assistance and expertise; operating programs; participating in international health organizations; leading world research and development efforts; and partnering with other government and non-governmental organizations and donating to multilateral institutions.
The scope of U.S. global health engagement is broad, and includes basic and essential health care services and infrastructure development; disease detection and response; population and maternal/child health; nutrition support through non-emergency food aid and dietary supplementation; clean water/sanitation promotion; and mitigation of environmental hazards.
This part of the guide outlines the U.S. government entities involved in global health efforts and explains their roles. It then looks at the major initiatives and programs the U.S. has undertaken to improve health around the world. Finally, this section looks at global health spending levels and how the U.S. finances its work.
Organization and Architecture
U.S. engagement in global health has developed within two main structures of the government: the foreign assistance structure, which is predominantly global development-oriented and has close links to foreign policy, and the public health structure, which has its roots in disease control and surveillance efforts. There are multiple agencies, departments, and Congressional committees that together comprise the U.S. government’s global health “architecture.”
The following federal agencies comprise the U.S.’s global health architecture:
- The State Department leads the executive branch in all matters related to foreign policy, including relationships with foreign governments and international organizations through U.S. embassies, consulates, and diplomatic missions. It negotiates international agreements and treaties and manages foreign aid to low- and middle-income countries. The Department’s role in global health has increased significantly in recent years as the resources provided by the U.S. have expanded. This includes the hundreds of U.S. missions and embassies abroad that help coordinate U.S. government global health programs in the field and support operations and interactions with host country governments. Key State Department offices involved in global health are:
- Established in 1961, the U.S. Agency for International Development (USAID) historically has served as the government’s lead agency in providing economic development and humanitarian assistance to people around the world. While USAID is technically an independent agency of the federal government, it works under the aegis and policy direction of the Secretary of State, and the State Department has statutory authority over the USAID budgeting process. USAID – which operates in more than 100 countries around the world through more than 80 field missions – is organized into several programmatic bureaus, including global health, as well as regional bureaus. USAID serves as the lead agency for the President’s Malaria Initiative (PMI) – an interagency initiative that is implemented with the CDC – as well as the Neglected Tropical Diseases Program and Feed the Future. The agency has set forth a Global Health Strategic Framework that outlines the direction for fiscal years 2012 – 2016 and incorporates the principles of the U.S. Global Health Initiative (GHI).
- The Millennium Challenge Corporation (MCC), a U.S. corporation that functions as an independent government agency, was established in 2004 to reduce “global poverty through the promotion of sustainable economic growth.” Although health is not the main focus of its work, its activities include projects aimed at health generally and HIV specifically. The MCC is responsible for the stewardship of the Millennium Challenge Account (MCA), which receives funds appropriated by Congress every year. The MCC provides country funds through competitive, multi-year “compacts” based on their demonstrated commitment in three areas: good governance; economic freedom; and investment in people, particularly women and children.
- The Department of Health and Human Services (HHS) serves as the U.S. government’s principal agency in all areas of health, supporting activities that range from basic research to financing health care. HHS has an Office of Global Affairs (OGA), which represents the department with international organizations and multilateral institutions and reviews all documents related to international health. In 2011, HHS announced a Global Health Strategy which emphasizes broader health diplomacy using the principles of evidence-based knowledge, leveraging partnerships, responding to local needs, capacity building, sustainability, emphasizing prevention, and improving health equity. Within HHS, the following major operating divisions are involved in global health:
- The Centers for Disease Control and Prevention (CDC) is responsible for activities related to health promotion, prevention, and preparedness for health threats in the U.S., but also engages in international health efforts. Through the Center for Global Health, the CDC provides development aid and technical assistance, conducts research, and operates disease surveillance programs. It also works with other federal agencies on global health.
- The National Institutes of Health (NIH) conducts and sponsors biomedical and behavioral science research. The National Institute of Allergy and Infectious Diseases (NIAID) carries out key research on diseases at the center of global health efforts (including HIV/AIDS, tuberculosis and malaria). NIH also operates the Fogarty International Center, which works to build partnerships between health research institutions in the U.S. and abroad and train research scientists, and is a PEPFAR implementing agency.
- The Food and Drug Administration (FDA) regulates the safety and efficacy of drugs, biological products, and medical devices. FDA also acts as a PEPFAR implementing agency, and is charged with expediting the review of pharmaceuticals for purchase by the office of the U.S. Global AIDS Coordinator.
A variety of other government departments and offices have involvement in global health, including:
- The National Security Council, which coordinates national security and foreign policy within the Executive Office of the President, including a focus on security issues related to global health.
- The Office of Management and Budget, which prepares the President’s budget requests to Congress.
- The White House Office of National AIDS Policy, which coordinates the government’s effort to address HIV/AIDS within the U.S. and works with international bodies.
- The Department of Defense, which supports humanitarian aid, assistance with other military health systems, disease surveillance and research.
- The Department of Agriculture, which provides food assistance to low-income countries, and is an implementer of Feed the Future (FtF).
- The Peace Corps, which provides volunteers to communities in developing nations that assist with health services and food security.
More than 15 Congressional committees have jurisdiction and oversight over global health programs. Much of the more detailed policy deliberations in Congress occur at the committee level, including both authorizing committees (which authorize government programs and provide legislative oversight of executive agencies) and appropriating committees (which consider specific funding levels for programs). Key committees include:
- The House Committee on Foreign Affairs is responsible for oversight and legislation relating to all foreign assistance, including programs operated by the State Department, the MCC and USAID. Key subcommittees include: Africa, Global Health and Human Rights (which has jurisdiction over global health issues generally, including specific responsibility for the region of Africa); and Oversight and Investigations (which includes jurisdiction over the issues relating the United Nations).
- The Senate Committee on Foreign Relations is responsible for oversight and legislation relating to all foreign assistance, including programs operated by the State Department, the MCC and USAID. Key subcommittees include: International Development and Foreign Assistance, Economic Affairs and International Environmental Protection, and International Operations and Organizations, Human Rights, Democracy and Global Women’s Issues.
- The House Energy and Commerce Committeehas jurisdiction over a number of areas of health care, including biomedical research, public health, and the regulation of drugs. Key subcommittees include: Health and Oversight and Investigations.
- The Senate Committee on Health, Education, Labor and Pensions (HELP) has jurisdiction over a number of areas of health care, including biomedical research, public health, and the regulation of drugs.
- The House Committee on Appropriations has jurisdiction over the appropriation of funds for government agencies and programs. Key subcommittees include: Labor, Health and Human Services, Education, and Related Agencies (with responsibility for NIH and CDC); and State, Foreign Operations, and Related Programs (with responsibility for the State Department and USAID).
- The Senate Committee on Appropriations has jurisdiction over the appropriation of funds for government agencies and programs. Key subcommittees include: Labor, Health and Human Services, Education, and Related Agencies (with responsibility for NIH and CDC); and State, Foreign Operations, and Related Programs (with responsibility for the State Department and USAID).
A detailed Kaiser Family Foundation report on the architecture of U.S. global health policy is available here.
Health Initiatives and Programs
The U.S. government carries out global health activities in more than 100 countries throughout the world that are either hardest hit by health problems (e.g., countries in sub-Saharan Africa heavily impacted by HIV), have the poorest economies (e.g., Haiti), and/or represent larger U.S. strategic interests (e.g., Afghanistan, Pakistan, China).
Historically, there has been no organizing mechanism across the many government structures, programs, and funding streams engaged in global health. Further, much of the effort has been built around disease-specific activities rather than broader, comprehensive approaches. To address, in part, these characteristics of the U.S. response, the Obama Administration announced the U.S. Global Health Initiative (GHI) in May 2009. The GHI was proposed as an effort to develop a comprehensive U.S. government strategy for global health.
The GHI acts as an “umbrella” over most, but not all, U.S. global health programs throughout the world. The GHI brings together several different existing funding streams for global health. These include funding for: HIV/AIDS, TB and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) under the President’s Emergency Plan for AIDS Relief (PEPFAR); malaria, including the President’s Malaria Initiative (PMI); NTDs; MNCH; FP/RH; nutrition; and health systems strengthening.
Major initiatives and programs, most of which fall under the GHI umbrella, are described below. Additionally, click here for a detailed table showing the geographic and programmatic scope of U.S. global health efforts.
HIV/AIDS: The U.S. government first became involved in efforts to address the global HIV/AIDS epidemic in the mid-1980s. Existing U.S. HIV/AIDS efforts were consolidated and further bolstered by PEPFAR, announced in 2003 by President Bush and authorized through the United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003 (P.L. 108-25). PEPFAR is the largest commitment by any nation to combat a single disease in history and includes all bilateral HIV/AIDS activities and funding as well as contributions to the Global Fund and UNAIDS.
The original legislation created the Office of the Global AIDS Coordinator (OGAC) at the State Department, headed by an appointee with the rank of Ambassador. PEPFAR is overseen by the State Department and carried out by several agencies, primarily USAID and CDC. PEPFAR was reauthorized in 2008 through the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2009 (P.L. 110-293 or “Lantos-Hyde”). PEPFAR’s HIV activities operate in about 60 countries around the world and include prevention efforts and support for the provision of treatment and care.
Tuberculosis (TB): U.S. global TB efforts, primarily carried out by USAID in about 40 countries, are focused on the diagnosis, treatment, and control of TB and multi-drug and extensively drug resistant (MDR/XDR) TB.
Malaria: PMI, first launched in 2005 by President Bush, is an interagency initiative led by USAID, and implemented in partnership with the CDC. U.S. malaria programs operate in more than 20 countries, including 17 PMI focus countries, and work to expand coverage of high-impact interventions such as insecticide-treated mosquito nets (ITNs), indoor residual spraying (IRS) with insecticides, intermittent preventive treatment in pregnancy (IPTp), and artemisinin-based combination therapy (ACT).
Neglected Tropical Diseases (NTDs): USAID’s NTD Program seeks to control seven neglected tropical diseases through integrated mass drug administration in 20 countries in Africa, Asia, and Latin America.
Family Planning and Reproductive Health (FP/RH): USAID’s FP/RH activities are designed to decrease the risk of unintended pregnancies and maternal and child mortality and support interventions including contraception, counseling, post-abortion care, and screening/testing for HIV and other sexually transmitted infections (STIs). The U.S. operates FP/RH programs in nearly 50 countries.
Maternal and Child Health (MNCH): MNCH interventions aim to reduce maternal and child mortality through increasing access to skilled care at birth, preventing and treating newborn infections/childhood diseases, and preventing malnutrition. The U.S. operates MNCH programs in nearly 60 countries.
Nutrition: Nutrition efforts aim to prevent undernutrition through interventions such as nutrition education, nutrition during pregnancy, exclusive breastfeeding and micronutrient supplementation; they are to be coordinated between the GHI and the Feed the Future (FtF) Initiative (see next paragraph for more information). The U.S. operates nutrition programs in 26 countries. Nutrition and food security efforts are generally considered non-emergency food aid as opposed to emergency food aid given in response to war or natural disasters.
Other Health-Related Activities:
Feed the Future (FtF): Introduced in 2009 following the G8 Summit in L’Aquila, Italy, FtF is the U.S. government’s initiative to improve food security. The initiative is led by USAID and USDA, and like the GHI, FtF plans to invest in country ownership, improve coordination, leverage multilateral institutions, and ensure long-term accountability, while addressing the underlying causes of hunger.
Water, Sanitation, and Hygiene: USAID’s water, sanitation, and hygiene (WASH) activities aim to build capacity, strengthen water and sanitation utilities, mobilize domestic resources, improve household and community-level hygiene and sanitation, and work with disaster relief efforts to implement water and sanitation activities. One major U.S. effort to address WASH issues is the Senator Paul Simon Water for the Poor Act of 2005 (P.L. 109-121; the WfP Act), which builds on existing U.S. international water and sanitation programs. The initiative identifies priority water countries and provides assistance through capacity building activities, institutional strengthening, and policy/regulatory reform; diplomatic engagement; direct investment; investments in science and technology; and through partnerships.
The U.S. is a significant provider of health assistance to low- and middle-income countries. From 2002-2010, the U.S. government was the single largest bilateral donor to health ($6.4 billion) and it accounted for over a third of all health development assistance (34.6%). Further information on donor funding for global health is available here.
Funding for global health programs now considered part of the GHI has risen more than five-fold in the last decade, from $1.7 billion in FY 2001 to $8.8 billion in FY 2012. U.S. government funding for GHI activities in FY 2012 represented less than 1% of the total federal budget. The FY 2013 budget request for the GHI is $8.5 billion, a decrease of about $300 million from FY 2012 and would represent the lowest level funding since the GHI’s initial $8.4 billion in FY 2009. If approved by Congress, the FY 2013 budget request would bring cumulative GHI funding (FY 2009-FY2013) to over $43 billion, or 69% of the proposed six-year total of $63 billion.
Increases in global health funding have been driven, in large part, by growth in HIV/AIDS spending through PEPFAR. In FY 2012, bilateral HIV funding alone was almost 60% of the budget and additional funding is provided to HIV through contributions to the Global Fund.
This graphic illustrates the development of U.S. global health funding over the last 13 years by sector.
Most of the funding for global health is in the form of direct country assistance, known as bilateral aid. During FY 2009 through FY 2012, 17% of GHI’s budget was for multilateral aid, which is given to institutions like the Global Fund.
Funding for U.S. global health programs is entirely discretionary, determined annually by Congress during the appropriations process. Since there are multiple U.S. government departments and agencies that receive appropriations for GHI programs including USAID, Department of State, NIH, CDC, and DoD, funding is subject to multiple appropriations bills and Congressional appropriations subcommittees.The Basics of Global Health Current Issues in U.S. Global Health Policy