The U.S. Government Engagement in Global Health: A Primer
Appendix A: Congressional Committees Jurisdiction Over U.S. Global Health Activities
| Departments/Agencies | House | Senate |
| Department of State (State)
United States Agency for International Development (USAID) Millennium Challenge Corporation (MCC) |
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Department of Health and Human Services (HHS)
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| Department of Defense (DoD) |
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| Department of Agriculture (USDA) |
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| Peace Corps |
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| Environmental Protection Agency (EPA) |
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| Department of Homeland Security (DHS) |
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| Department of Labor (DoL) |
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| Department of Commerce (Commerce) |
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| Office of the U.S. Trade Representative (USTR) |
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| + All Subcommittees listed are part of House and Senate Standing Appropriations Committees | ||
Appendix B: Timeline of Governing Statutes, Authorities, Policies, and Initiatives for U.S. Global Health
| Year | Agency | Title | Purpose |
| 1798 | HHS | Act for the Relief of Sick and Disabled Merchant Seamen | Created the Marine Hospital Service, a federal network of hospitals for the care of merchant seamen. Renamed the “Public Health and Marine-Hospital Service” in 1902 and the Public Health Service in 1912.1 |
| 1930 | USDA | Foreign Agricultural Service Act of 1930 (P.L. 71-304) | Created the Foreign Agricultural Service (FAS) which today is part of the USDA. Among its responsibilities is the provision of food aid and technical assistance.2 |
| 1944 | HHS | Public Health Service Act (Title 42, U.S. Code) | The Public Health Service Act of July 1, 1944 (42 U.S.C. 201) consolidated and revised all existing legislation relating to the Public Health Service, outlined the policy framework for Federal-state cooperation in public health; and established regulatory authorities that transferred with PHS to the Department of Health, Education and Welfare (HEW) and subsequently to the Department of Health and Human Services (HHS). The scope of the Act has been significantly broadened over time. The full act is captured under Title 42 of the US Code, “The Public Health and Welfare.”3 |
| 1954 | USDA USAID |
Public Law 83-480. The Agricultural Trade Development Assistance Act of 1954, renamed The Food for Peace Act in 1961 | Authorized concessional sales of U.S. agricultural commodities to developing countries and private entities by USDA (Title 1); direct donation of U.S. agricultural commodities for emergency relief and development (Title II) and government-to-government grants of agricultural commodities tied to policy reform (Title 3), both assigned to USAID in 1961 (also known as P.L. 480).4,5 |
| 1960 | HHS | International Health Research Act of 1960 (Public Law 86-610) | To advance the health sciences through cooperative international research and training. Established the National Institute for International Health and Medical Research, to provide for international cooperation in health research, research training, and research planning, and for other purposes. Section 307 as amended (incorporated into USC Title 42) authorized the Secretary of HHS to enter into international cooperative agreements for biomedical and health activities.6 |
| 1961 | USAID, State | Public Law 87-195. The Foreign Assistance Act of 1961 (FAA) | Reorganized U.S. foreign assistance programs including separating military and non-military aid and mandated the creation of an agency to administer economic assistance programs, which led to the establishment of USAID. Act created a policy framework for foreign assistance to developing nations and mandated the creation of an agency to promote long-term assistance for economic and social development.7,8 |
| 1973 | USAID, State | Public Law 93-189. The New Directions Legislation of 1973 (in the Foreign Assistance Act of 1973) | Amended the FAA of 1961, directing USAID to focus its operational programs on five categories of assistance for meeting the basic needs of the poorest countries in the following areas: food and nutrition; population planning; health, education, and human resources development; selected development problems; selected countries and organizations.9 |
| 1984 | USAID,
State |
“Mexico City” Policy | President Reagan directive expanded prohibition on use of federal funds by foreign NGOs beyond existing requirements in the FAA of 1961, other law, and policies to also prohibit NGOs from using any funds, including non-federal funds, to “perform or actively promote abortion as a method of family planning” as a condition for receiving U.S. global family planning assistance. Rescinded in 1993 by President Clinton. Reinstated in 2001 by President Bush and extended to apply to “voluntary population planning” assistance provided by the Department of State. Rescinded by President Obama in 2009. Reinstated, and expanded to the vast majority of U.S. global health assistance, in 2017 by President Trump.10 |
| 1985 | USDA | The Food for Progress Act of 1985 (Public Law 99-198 (Title XI) | Authorized USDA to provide U.S. agricultural commodities to emerging democracies and developing countries committed to promoting free enterprise in agricultural development.11 |
| 1985 | DoD | Public Law 99-661 (Section 333) Humanitarian and Civic Assistance (HCA) program in the National Defense Authorization Act for Fiscal Year 1987, as amended in: Title 10 USC §401, §402 | Authorized U.S. military forces to carry out humanitarian and civic assistance activities in conjunction with other operations (such as joint exercises) if such activities support mutual U.S.-host country interests, build U.S. force operational readiness skills, and do not duplicate other USG assistance (401); permits the military to transport humanitarian supplies for NGOs without charge (“the Denton Amendment,” Section 402).12,13 |
| 1996 | Govt-wide; main roles for State, USAID, DoD, CDC, NIH | Presidential Decision Directive NSTC-7 on Emerging Infectious Diseases | White House established national policy to address emerging infectious disease threats through improved domestic and international surveillance, prevention, and response measures, as follow-up to National Science and Technology Council (NSTC) reports: “Infectious Disease – A Global Health Threat” (September 1995), “Meeting the Challenge — A Research Agenda for Health, Safety, and Food” (February 1996), and “Proceedings of the Conference on Human Health and Global Climate Change” (May 1996). Directive establishes standing NSTC Task Force on emerging infectious diseases.14 |
| 1999 | USAID, DoD, CDC | Leadership and Investment in Fighting an Epidemic (LIFE) Initiative | New program announced by President targeting funding for HIV to 14 hard hit countries in Africa and to India.15 |
| 1999 | DoD | Executive Order 13139 | Established the HIV and AIDS Research and Development Program within the Department of the Army.16 |
| 2000 | CDC | Public Law 106-113. Consolidated Appropriations Act of 2000, as described in House Report 106-419 | Congress first appropriated funding specifically for CDC’s international AIDS activities ($35 million), used to support the newly launched CDC Global AIDS Program (GAP).17 |
| 2000 | — | Appointment of Presidential Envoy for AIDS Cooperation | First U.S. envoy appointed to deal exclusively with a global health issue.18 |
| 2000 | USAID, CDC, NIH | Public Law 106-264. The Global AIDS and Tuberculosis Relief Act of 2000 | Authorized up to $600 million for U.S. global efforts on HIV and TB; Directed Secretary of the Treasury to enter into negotiations with the World Bank, other nations and interested parties to establish World Bank AIDS Trust Fund (what was to become the Global Fund to Fight AIDS, Tuberculosis and Malaria).19 |
| 2002 | USAID, CDC | International Mother and Child HIV Prevention Initiative | Announced by President as new multi-year $500 million initiative, focused on 12 African and 2 Caribbean countries.20 |
| 2001 | DoL | Public Law 106-554. Department of Labor Appropriations Act, 2001 | Authorized the DoL’s Bureau of International Labor Affairs to award funds under and administer DoL’s Global HIV/AIDS Workplace Education program.21,22 |
| 2002 | USDA, USAID |
Public Law 107-171. The Farm Security and Rural Investment Act of 2002 | Reauthorized the Food for Peace Act through 2007 and provided the original authorization for McGovern–Dole International Food for Education and Child Nutrition Program through USDA’s Foreign Agricultural Service.23 |
| 2003 | State, USAID, DoD, Commerce, DoL, HHS, Peace Corps | Public Law 108-25. United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 | Required a comprehensive, integrated 5-year strategy for a coordinated USG response to global HIV/AIDS; established Office of the Global AIDS Coordinator in State; amended the Foreign Assistance Act of 1961 to define eligibility for HIV/AIDS assistance; mandated goals, benchmarks, and metrics for program evaluation; authorized up to $15 billion from FY 2004-8.24 |
| 2004 | FDA | Expedited Review of HIV Medications Under PEPFAR | New initiative announced for expedited review process for pharmaceutical products under PEPFAR, allowing any pharmaceutical industry sponsor worldwide to submit U.S. marketing applications for single entity, fixed dose combination (FDC), and co-packaged versions of previously approved antiretroviral therapies, even if a patent or market exclusivity in the U.S. remained in effect).25 |
| 2004 | State, Treasury, USTR, USAID, MCC |
Title V, Public Law 108-199. The Millennium Challenge Act of 2003 (in the Consolidated Appropriations Act, 2004) | Established the MCC as USG corporation responsible for administering funds from the Millennium Challenge Account; outlined by-laws for operations and structure. The MCC Board of Directors is composed of the Secretary of State, the Secretary of Treasury, the U.S. Trade Representative, the Administrator of USAID, the CEO of the MCC and four public members appointed by the President.26 |
| 2005 | USAID, CDC |
President’s Malaria Initiative (PMI). | Launch of new initiative committing $1.2 billion over five years to reduce malaria deaths by 50 percent in 15 African focus countries. Led by USAID, and implemented with CDC.27 |
| 2005 | USAID, CDC |
Public Law 109-13. The Emergency Supplemental Appropriations Act for Defense, the Global War on Terror, and Tsunami Relief | Provided $25 million to USAID for programs to control the global spread of avian flu, and stipulated that $15 million of it be transferred to CDC.28 |
| 2005 | State, USAID, MCC, DoD, CDC, EPA, USDA, Peace Corps | Senator Paul Simon Water for the Poor Act of 2005 (P.L. 109-121; WfP Act) | Built on existing U.S. international water and sanitation programs and requires the Secretary of State, in consultation with USAID and other U.S. Government agencies, to develop and implement a strategy “to provide affordable and equitable access to safe water and sanitation in developing countries”. Among its key objectives is to increase access to, and effective use of, safe drinking water and sanitation to improve human health. |
| 2006 | USAID | Public Law 109-234. Emergency Supplemental Appropriations Act for Defense, the Global War on Terror, and Hurricane Recovery | Provided $30 million to USAID for activities related to international surveillance, planning, preparedness, and response to avian influenza.29 |
| 2006 | DoD | DoD Directive 6485.02E. HIV/AIDS Prevention: Support to Foreign Militaries | Stated in 2006 and reissued in 2013, assigned responsibilities to the ASD/HA and ASD(SO/LIC) for policy development and guidance for DOD HIV/AIDS prevention support to foreign militaries consistent with Public Law 108-25 (PEPFAR); designated Navy as DoD Executive Agent for technical and logistical support of the global Defense HIV/AIDS Prevention Program (DHAPP); established Coordinating Board for DoD international HIV/AIDS activities with foreign militaries.30 |
| 2008 | USAID | Neglected Tropical Diseases (NTD) Initiative | Launch of new President’s initiative to provide $350 million over five years to provide integrated treatment in Africa, Asia, and Latin America, targeting seven major NTDs.31 |
| 2008 | USDA, USAID | Public Law 110-246. The Food, Conservation, and Energy Act of 2008 (The Farm Bill) | Comprehensive reauthorization of all U.S. food and farm policies, including Food for Education, Food for Progress, and Food for Peace programs; re-titled Title I from “Trade and Development Assistance” to “Economic Assistance and Food Security.”32 |
| 2008 | State, USAID, DoD, Commerce, DoL, HHS, Peace Corps | Public Law 110-293. Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 | Re-authorized PEPFAR, including an increased funding authorization of up to $48 billion over five years (FY2009-2013); extended the geographic and programmatic scope of HIV/AIDS, malaria, and tuberculosis control and prevention strategies; proposed use of framework agreements with recipient countries; removed some spending requirements on prevention efforts; endorsed health systems strengthening; and established a Global Malaria Coordinator in USAID.33 |
| 2013 | State, USAID, DoD, Commerce, DoL, HHS, Peace Corps | Public Law 113-56. PEPFAR Stewardship and Oversight Act of 2013 |
Extended a number of existing authorities of PEPFAR and strengthened the oversight of the program through updated reporting requirements, among other things.34 |
| 2016 | State, USAID, USDA, Commerce, Treasury, Trade | Public Law 114-195. Global Food Security Act of 2016 |
Reaffirmed the U.S. commitment to ending global hunger, poverty, and malnutrition.35 |
| 2016 | State, DoD, DoJ, Agriculture, HHS, Homeland Security, OMB, USAID, EPA, CDC, Office of Science and Technology Policy | Executive Order. Advancing the Global Health Security Agenda to Achieve a World Safe and Secure from Infectious Disease Threats | Advanced the Global Health Security Agenda (GHSA), a multi-country partnership that aims to accelerate progress in building country capacity to prevent, detect, and respond to infectious diseases. Establishes the U.S. commitment to achieving the targets of the GHSA.36 |
| 2017 | State, USAID, HHS, and others to be determined | Mexico City Policy | President Trump reinstated and expanded Mexico City Policy, first instated by President Reagan in 1984, repealed by President Clinton in 1993, reinstated by President Bush in 2001, and rescinded by President Obama in 2009 (see 1984 entry above),.37 |
| 2018 | State, USAID, DoD, Commerce, DoL, HHS, Peace Corps | Public Law 115-305. PEPFAR Extension Act of 2018 |
Extended a number of existing authorities of PEPFAR through FY 2023 and FY2024, depending on the provision.38 |
Appendix C: Major U.S. Global Health and Related Initiatives by Country, FY 2017
| Country/Region | HIV/AIDS | Tuberculosis | Malaria | Neglected Tropical Diseases | Maternal and Child Health | Family Planning and Reproductive Health | Nutrition | Water Supply and Sanitation | Global Health Security | Other Public Health Threats |
| Africa | 27 | 11 | 25 | 17 | 20 | 21 | 13 | 16 | 12 | 0 |
| Angola | X | – | X | – | – | X | – | – | – | – |
| Benin | – | – | X | X | X | X | – | – | – | – |
| Botswana | X | – | – | – | – | – | – | – | – | – |
| Burkina Faso | – | – | X | X | – | – | – | – | – | – |
| Burundi | X | – | X | – | X | X | – | – | – | – |
| Cameroon | X | – | X | X | – | – | – | – | – | – |
| Côte d’Ivoire | X | – | X | X | – | – | – | – | X | – |
| Democratic Republic of Congo | X | X | X | X | X | X | X | X | – | – |
| Djibouti | X | – | – | – | – | – | – | – | – | – |
| Egypt | – | – | – | – | – | X | – | – | – | – |
| Eswatini | X | – | – | – | – | – | – | – | – | – |
| Ethiopia | X | X | X | X | X | X | X | X | X | – |
| Ghana | X | – | X | X | X | X | X | X | X | – |
| Guinea | – | – | X | X | X | X | – | – | X | – |
| Guinea-Bissau | – | – | – | – | – | – | – | – | X | |
| Kenya | X | X | X | – | X | X | X | X | X | – |
| Lesotho | X | – | – | – | – | – | – | – | – | – |
| Liberia | X | – | X | – | X | X | – | X | X | – |
| Madagascar | – | – | X | – | X | X | – | X | – | – |
| Malawi | X | X | X | – | X | X | X | X | – | – |
| Mali | X | – | X | X | X | X | X | X | – | – |
| Mozambique | X | X | X | X | X | X | X | X | – | – |
| Namibia | X | – | – | – | – | – | – | – | – | – |
| Niger | – | – | X | X | – | – | – | – | – | – |
| Nigeria | X | X | X | X | X | X | X | X | – | – |
| Rwanda | X | – | X | – | X | X | X | X | – | – |
| Senegal | X | – | X | X | X | X | X | X | – | – |
| Sierra Leone | X | – | X | X | – | – | – | – | X | – |
| South Africa | X | X | – | – | – | – | – | – | X | – |
| South Sudan | X | – | – | – | X | – | – | X | – | – |
| Tanzania | X | X | X | X | X | X | X | X | X | – |
| Togo | – | – | – | X | – | – | – | – | – | – |
| Uganda | X | X | X | X | X | X | X | X | X | – |
| Zambia | X | X | X | – | X | X | X | X | – | – |
| Zimbabwe | X | X | X | – | X | X | – | – | X | – |
| East Asia and Pacific | 5 | 4 | 2 | 5 | 5 | 3 | 2 | 2 | 5 | 0 |
| Burma | X | X | X | – | X | – | – | – | – | – |
| Cambodia | X | X | X | X | X | X | X | – | – | – |
| Indonesia | X | X | – | X | X | – | – | X | X | – |
| Laos | – | – | – | X | – | – | X | – | – | – |
| Malaysia | – | – | – | – | – | – | – | – | X | – |
| Mongolia | – | – | – | – | – | – | – | – | X | – |
| Papua New Guinea | X | – | – | – | – | – | – | – | – | – |
| Philippines | – | X | – | X | X | X | – | X | – | – |
| Thailand | – | – | – | – | – | – | – | – | X | – |
| Timor-Leste | – | – | – | – | X | X | – | – | – | – |
| Vietnam | X | – | – | X | – | – | – | – | X | – |
| Europe and Eurasia | 1 | 1 | 0 | 0 | 1 | 0 | 0 | 0 | 4 | 0 |
| Azerbaijan | – | – | – | – | – | – | – | – | X | – |
| Georgia | – | – | – | – | – | – | – | – | X | – |
| Turkey | – | – | – | – | – | – | – | – | X | – |
| Ukraine | X | X | – | – | X | – | – | – | X | – |
| Near East | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 4 | 2 | 1 |
| Jordan | – | – | – | – | X | X | – | X | X | X |
| Lebanon | – | – | – | – | – | – | – | X | – | – |
| West Bank and Gaza | – | – | – | – | – | – | – | X | – | – |
| Yemen | – | – | – | – | – | – | – | X | X | – |
| South and Central Asia | 3 | 6 | 0 | 2 | 6 | 5 | 4 | 4 | 3 | 1 |
| Afghanistan | X | X | – | – | X | X | X | X | – | X |
| Bangladesh | – | X | – | X | X | X | X | – | X | – |
| India | X | X | – | – | X | X | – | X | X | – |
| Kyrgyzstan | – | X | – | – | – | – | – | – | – | – |
| Nepal | X | – | – | X | X | X | X | X | – | – |
| Pakistan | – | – | – | – | X | X | – | – | X | – |
| Tajikistan | – | X | – | – | X | – | X | X | – | – |
| Uzbekistan | – | X | – | – | – | – | – | – | – | – |
| Western Hemisphere | 3 | 0 | 0 | 7 | 2 | 2 | 2 | 3 | 3 | 0 |
| Brazil | X | – | – | X | – | – | – | – | – | – |
| Colombia | – | – | – | X | – | – | – | – | X | – |
| Chile | – | – | – | – | – | – | – | – | X | – |
| Ecuador | – | – | – | X | – | – | – | – | – | – |
| Dominican Republic | X | – | – | – | – | – | – | X | – | – |
| Guatemala | – | – | – | X | X | X | X | X | – | – |
| Haiti | X | – | – | X | X | X | X | X | – | – |
| Mexico | – | – | – | X | – | – | – | – | – | – |
| Peru | – | – | – | – | – | – | – | – | X | – |
| Venezuela | – | – | – | X | – | – | – | – | – | – |
| Total | 39 | 22 | 27 | 31 | 35 | 32 | 21 | 29 | 29 | 2 |
| Source: KFF analysis of data from the State Department, Foreign Assistance Dashboard [website], available at: http://www.foreignassistance.gov; accessed June 2018. USAID, Countries Supported by USAID’s NTD Program, available at: https://www.neglecteddiseases.gov/where-we-work accessed June 2018. USAID, Countries Supported by USAID’s Global Health Security Agenda Program, available at: https://www.usaid.gov/what-we-do/global-health/health-systems/countries accessed June 2018. | ||||||||||