May 11, 2015
U.S. Global Health Assistance: The FY2016 Budget
Background
The President’s FY2016 budget request includes more than
$9 billion for global health assistance, including roughly $8
billion through State, Foreign Operations appropriation and
some $910 million through Department of Labor, Health
and Human Services (HHS), and Education appropriation.
This report excludes emergency funding for Ebola
responses. For information on Emergency Ebola
Appropriations, see CRS Report R43807, FY2015 Funding
to Counter Ebola and the Islamic State (IS).
State Foreign Operations
Appropriations
Through the State, Foreign Operations appropriation,
Congress provides funds to support the President’s
Emergency Plan for AIDS Relief (PEPFAR), the Global
Fund to Fight AIDS, Tuberculosis and Malaria, and global
health activities implemented by the U.S. Agency for
International Development (USAID). The FY2016 budget
request includes $5.4 billion in support of State-managed
HIV/AIDS programs and an additional $2.7 billion for
USAID-managed global health programs (Figure 1).
Figure 1. Foreign Operations Appropriations:
FY2014-FY2016
(current U.S. $ millions and percent)
Agency/Program
FY2014
FY2015
FY2016 FY2015-
Enacted Enacted Request FY2016
State HIV/AIDS
4,020.0
4,275.0
4,319.0
1%
Global Fund
1,650.0
1,350.0
1,107.0
-18%
-4%
5,670.0
5,625.0
5,426.0
USAID HIV/AIDS
State-GHP Total
330.0
330.0
330.0
0%
Tuberculosis
236.0
236.0
191.0
-19%
Malaria
665.0
669.5
674.0
1%
Maternal and Child Health
705.0
715.0
770.0
8%
Nutrition
115.0
115.0
101.0
-12%
-34%
Vulnerable Children
22.0
22.0
14.5
FP/RH
524.0
524.0
538.0
3%
NTDs
100.0
100.0
86.5
-14%
Global Health Security
72.5
72.5
50.0
-31%
USAID-GHP Total
2,769.5
2,784.0
2,755.0
-1%
FOREIGN OPS TOTAL
8,439.5
8,409.0
8,181.0
-3%
Source: Created by CRS from FY2016 State, Foreign Operations
Congressional Budget Justification and explanatory notes of the
FY2015 Consolidated Appropriations.
Notes: Excludes emergency appropriations for Ebola and global
health funds provided through other USAID accounts, such as the
International Disaster Assistance (IDA) account.
USAID groups its global health programs into three key
areas: saving mothers and children, creating an AIDS-Free
generation, and fighting other infectious diseases.
Significant progress has been made in each of these areas,
though challenges remain.
Maternal and Child Health
International efforts to improve healthcare during
pregnancy and childbirth has resulted in a 45% reduction in
maternal deaths from 1990, when 523,000 women died
from complications in pregnancy and childbirth.
Nonetheless, in 2013, almost 800 women died a day from
complications in pregnancy and childbirth, amounting to
289,000 deaths. Roughly one-third of these deaths occurred
in Nigeria and India. Human resource constraints continue
to complicate efforts to reduce maternal mortality. In many
developing countries, especially in sub-Saharan Africa,
pregnant women often deliver their babies without the
assistance of trained health practitioners who can help to
avert deaths caused by hemorrhage. The World Health
Organization (WHO) estimates that 27% of all maternal
deaths are caused by severe bleeding. Pre-existing
conditions like HIV/AIDS and malaria are also key
contributors to maternal mortality, accounting for roughly
28% of maternal deaths.
International efforts to improve child health have roughly
cut the number of child deaths in half from 12.7 million in
1990 to 6.3 million in 2013. WHO estimates that more than
half of the 1,700 child deaths a day that occurred in 2013
could have been avoided through low-cost interventions,
such as medicines to treat pneumonia, diarrhea, and
malaria, as well as tools that prevent the transmission of
malaria and HIV/AIDS from mother to child. Other factors,
like inadequate access to nutritious food, also impact child
health. WHO estimates that undernutrition contributes to
roughly 45% of all child deaths. The risk of a child dying is
at its highest within the first month of life, when 44% of all
child deaths occur. Children in sub-Saharan Africa are more
than 15 times more likely to die before reaching age five
than their counterparts in developed countries.
In FY2016, USAID requests an 8% increase in funding for
maternal and child health programs. The Administration
requests that $235 million of these funds be provided to
Gavi, the Vaccine Alliance to meet the Administration’s
four year $1 billion pledge to the multilateral effort, which
seeks to expand access to vaccines and introduce new ones.
HIV/AIDS
In 2012, roughly 2.3 million people worldwide contracted
HIV, some 33% less than new infections in 2001. Some
70% of new HIV cases occurred in sub-Saharan Africa.
While the number of new cases is declining, the number of
people living with HIV is rising. In 2012, more than 35
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U.S. Global Health Assistance: The FY2016 Budget
million people were living with HIV globally. Expanded
access to anti-retroviral treatments (ART) has decreased the
number of people dying from AIDS-related causes. In 2012,
1.6 million people died from HIV/AIDS, down from the
peak of 2.3 million in 2005.
Figure 2. AIDS Deaths Worldwide: 1995-2012
(millions)
Despite the threat that infectious diseases pose to the world,
the FY2016 budget request cuts funding for all USAID
infectious disease programs, except malaria.
Labor, HHS Appropriations
The FY2016 budget includes an 8% increase for global
health programs implemented by the Centers for Disease
Control and Prevention (CDC) and a 2% boost for
international HIV/AIDS research conducted by the National
Institutes of Health (NIH, Figure 3). Budgetary increases
were aimed at two key priorities for CDC: eradicating polio
and accelerating efforts to improve pandemic preparedness.
Figure 3. Labor-HHS Appropriations: FY2014-FY2016
(current U.S. $ millions and percent)
Source: Source: Adapted by CRS from the Joint United Nations
Program on AIDS (UNAIDS), 2013 Global Report, 2013.
The United States has contributed substantially to
improving global access to ART through PEPFAR and its
support for the Global Fund to Fight AIDS, Tuberculosis
and Malaria. In 2012, WHO estimated that 9.7 million
people in low- and middle-income countries were receiving
ART. At the end of FY2012, PEPFAR was supporting the
provision of ART to more than 5.1 million people, thereby
supporting treatment for more than half of all HIV-positive
people in low- and middle-income countries. By the end of
September 30, 2014, PEPFAR was supporting the provision
of ART to 7.7 million people. For FY2016, the
Administration requests no change for PEPFAR funding
through USAID, but proposes a reduction in support to the
Global Fund.
Other Infectious Diseases
In recent years, a succession of new and reemerging
infectious diseases have caused outbreaks and pandemics
that have affected thousands of people worldwide: Severe
Acute Respiratory Syndrome (SARS, 2003), Avian
Influenza H5N1 (2005), Pandemic Influenza H1N1 (2009),
Middle East Respiratory Syndrome coronavirus (MERSCoV, 2013), and the ongoing Ebola outbreak in West
Africa. The incapacity of Guinea, Liberia, and Sierra Leone
to contain and end the ongoing Ebola epidemic has revealed
the threat that weak health systems pose to the world. The
United States plays a leading role in the Global Health
Security Agenda, a multilateral effort to improve the
capacity of countries worldwide to detect, prevent, and
respond to diseases with pandemic potential.
At the same time that the world faces threats from new
diseases, long-standing diseases like tuberculosis (TB)
continue to pose a threat to global health security. Among
infectious diseases, TB is the second most common cause
of death worldwide. Multi-drug resistant (MDR)-TB is of
growing concern, as it is more expensive and difficult to
treat. Less than half of all MDR-TB patients survive. WHO
asserts that global funding for addressing MDR-TB is
insufficient and weaknesses in health systems complicate
efforts to treat the disease and prevent its further spread.
Source: Created by CRS from FY2016 State, Foreign Operations
Congressional Budget Justification.
Notes: Excludes appropriations for Ebola.
Eradicating Polio
Expanded access to vaccines has contributed significantly
to global declines in child deaths. According to the CDC,
80% of the world is now polio-free and polio cases have
declined by more than 99% from 1998 levels. The disease
is endemic in only three countries: Afghanistan, Nigeria,
and Pakistan. Polio activities are part of broader efforts to
expand access to vaccine-preventable illnesses, such as
measles. Global vaccine efforts have reduced measles
deaths by 75% from 2000 levels.
Pandemic Preparedness and Global Health
Security
The largest budgetary increase in the global health request
is for improving disease detection, surveillance, and control
capacity worldwide. Based on recent trends, CDC
anticipates the international community will seek its
expertise in responding to at least 100 disease outbreaks in
2016. CDC reports it responded to 268 global disease
outbreaks in 2013 and provided assistance to over 145
humanitarian missions in 35 countries, including response
to the Syrian Refugee crisis and Typhoon Haiyan in the
Philippines. Additional funds are also sought to deepen
U.S. engagement in the Global Health Security Agenda. For
more information on the Global Health Security Agenda,
see CRS In Focus IF10022, The Global Health Security
Agenda and International Health Regulations.
Tiaji Salaam-Blyther, tsalaam@crs.loc.gov, 7-7677
www.crs.gov | 7-5700
IF10131Updated March 14, 2019
U.S. Global Health Assistance: FY2017-FY2019 Request
Background
Congress has made global health a priority for several
years, including through support for global health
programs. From FY2001 through FY2008, appropriations
for global health rose from less than $2 billion to almost $8
billion. The funding increases largely supported two U.S.
programs aimed at fighting HIV/AIDS and malaria
worldwide: the President’s Emergency Plan for AIDS
Relief (PEPFAR) and the President’s Malaria Initiative,
both launched during the George W. Bush Administration.
During the Obama Administration, appropriations leveled
off and averaged roughly $9 billion annually.
policy, which restricts U.S. assistance to foreign NGOs
engaged in voluntary abortion activities, even if such
activities are conducted with non-U.S. funds. Whereas the
policy applied only to family planning and reproductive
health programs under the George W. Bush Administration,
the Trump Administration reinstated the policy in January
2017, following its reversal during the Obama
Administration, and applied it to all global health programs
under a new policy called Protecting Life in Global Health
Assistance. In the 115th Congress, the House and Senate
introduced legislation to permanently repeal the expanded
policy. In the 116th Congress, S.Res. 20 promotes
permanently enacting the policy.
The FY2020 budget request would reduce overall funding
for global health by almost 30% from FY2019-enacted
levels and would include roughly $6.3 billion through State,
Foreign Operations (SFOPS) appropriations and some $0.4
billion through Department of Labor, Health and Human
Services (Labor-HHS) and Education appropriations (Table
1).
Table 1. Global Health Appropriations:
FY2017 Enacted-FY2020 Request
(current U.S. $ millions)
Global Health Appropriations
Foreign Operations. Through SFOPS appropriations,
Congress funds PEPFAR; the Global Fund to Fight AIDS,
Tuberculosis and Malaria (Global Fund); and global health
activities managed by the U.S. Agency for International
Development (USAID). The Administration proposes
reduced funding for all global health programs funded
through SFOPS appropriations from FY2019-enacted
levels, including a 35% reduction for USAID-managed
global health programs, a 23% cut for Department of Statemanaged PEPFAR programs, and a 29% cut for U.S.
contributions to the Global Fund.
Labor-HHS. The FY2020 budget request includes a 6%
reduction for global health programs implemented by the
Centers for Disease Control and Prevention. The LaborHHS budget request does not include a breakout of global
health funding for the U.S. Centers for Disease Control and
Prevention (CDC). The National Institutes of Health (NIH)
has not released budget projections for international
HIV/AIDS research since FY2017.
Global Health Policy Debates
Sources: Congressional budget justifications and correspondence
with USAID and CDC legislative affairs offices.
Abbreviations: Department of State (State), U.S. Agency for
International Development (USAID), Global Fund to Fight AIDS,
Tuberculosis and Malaria (Global Fund), State-Foreign Operations
(SFOPS) appropriations, Centers for Disease Control and Prevention
(CDC), National Institutes of Health (NIH), and Labor, Health and
Human Services, and Education (Labor-HHS) appropriations.
a.
b.
Policy experts and Congress are discussing the significance
of three key actions by the Trump Administration: (1) to
reinstate and expand the Mexico City Policy, (2) to propose
reducing the global health budget from previous fiscal
years, and (3) to prioritize PEPFAR engagement in specific
countries.
Protecting Life in Global Health Assistance. Since the
Mexico City Policy was first established under the Reagan
Administration, Members on both sides of the issue have
introduced legislation to permanently enact or repeal the
c.
Includes amounts transferred to USAID for global health
activities from unobligated funds provided for the Ebola
outbreak.
Funds for NIH international HIV/AIDS research are not typically
included in budget requests and are drawn from the overall
budget of the Office of AIDS Research. Annual spending
amounts are reported in congressional budget justifications.
To maintain consistency across fiscal years, CRS did not
aggregate the total because funding levels for NIH international
HIV/AIDS research are not yet available.
U.S. Global Health Budget. The FY2020 budget request
included a proposal to cut global health funding by more
than $2 billion from FY2019-enacted levels. Some global
health experts warn that such reductions could imperil
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U.S. Global Health Assistance: FY2017-FY2019 Request
advances made in global health. Supporters of reduced
funding assert that current funding levels are unsustainable.
The United States provides more official development
assistance (ODA) for health than any other country in the
Development Assistance Committee (DAC)—a group of
industrialized countries committed to international
development (Figure 1). The United States also apportions
more of its foreign aid to improving global health than other
major DAC donor country. In 2016, for example, health aid
($9.1 billion) accounted for 31% of U.S. ODA ($30.0
billion). The second-largest foreign aid donor, Germany,
allocated 3% of its overall ODA ($24.4 billion) to health
aid ($641 million). The second-largest donor of health aid,
the United Kingdom, apportioned 13% of its development
assistance ($8.2 billion) for health aid ($1.1 billion).
Figure 1. Global Development and Health Aid: 2016
The Trump Administration appears to be continuing the 3.0
strategy and has proposed concentrating efforts in 13
countries (Botswana, Cote d'Ivoire, Haiti, Kenya, Lesotho,
Malawi, Namibia, Rwanda, Swaziland, Tanzania, Uganda,
Zambia, and Zimbabwe). In these countries, the
Administration PEPFAR will work with other partners to
ensure that 95% of HIV-positive people know their status,
95% of those who know their status are on ART, and that
95% of those on treatment maintain suppressed viral loads
for at least three years. These efforts, the Administration
maintains, will lead to AIDS epidemic control.
The Trump Administration proposal to maintain treatment
levels is a departure from the Bush and Obama
Administrations, under which executive and legislative
priorities for PEPFAR included steadily increasing the
number of people receiving ART through PEPFAR.
Figure 2. AIDS Deaths and ART Coverage: 2000-2017
Source: Created by CRS from the Organization for Economic
Cooperation and Development (OECD) website on statistics at
http://stats.oecd.org/, accessed on July 9, 2018.
Abbreviations: United States of America (USA), Development
Assistance Committee (DAC), and United Kingdom (UK).
Those funds have contributed to significant improvements
in global health. Between 1990 and 2015, for example, the
global maternal mortality ratio fell by 44% and preventable
child deaths declined by 58% between 1990 and 2017.
Expanded access to vaccines has contributed significantly
to global declines in child deaths. For instance, since 2017,
global vaccine efforts have reduced measles deaths by 80%
from 2000 levels, and wild polio virus is circulating in only
two countries.
PEPFAR Engagement. Annual AIDS death rates have
been steadily declining, and the rate at which this has
occurred has accelerated since PEPFAR was launched
(Figure 2). AIDS deaths declined from a peak of 1.9
million in 2003 to 0.9 million in 2017. Declines in AIDS
deaths have been attributed in large part to expanded access
to antiretroviral treatment (ART) provided through
PEPFAR programs and U.S. contributions to the Global
Fund. Before PEPFAR was launched in 2003, roughly 4%
of people in low- and middle-income countries were on
ART. By 2017, ART coverage had reached an estimated
59% in those areas.
Toward the end of the Obama Administration, the State
Department announced PEPFAR 3.0—a plan to “more
directly support HIV services and populations where the
highest impact gains towards an AIDS-free generation will
be felt.” When this strategy was announced, HIV/AIDS
advocates bemoaned the shift and questioned whether
partner countries and local civil society were sufficiently
prepared for the divestment. Supporters argued that HIV
spending levels were unsustainable and the funds needed to
be spent where impact could be maximized.
Source: Created by CRS from the Joint United Nations Program on
AIDS (UNAIDS) database, at http://aidsinfo.unaids.org.
Outlook
The United States government spends more on global
health programs than any other country in the world.
Funding and policy decisions that it makes may reverberate
across the international community. Some experts are
concerned that the progress made in global health to date
may be undermined should the United States reduce global
health funding or decrease global engagement. Others
maintain that U.S. global health programs could be
improved by streamlining programs, improving efficiency,
and aligning funding with U.S. priorities.
Broader related policy concerns include addressing the
health effects of climate change (e.g., drought-related
malnutrition and the spread of infectious diseases through
national disasters) and bolstering pandemic preparedness
worldwide. For more on these and other global health
issues, see CRS Report R43115, U.S. Global Health
Appropriations: FY2001-FY2019.
Edward Gracia, CRS Research Assistant, contributed to this
In Focus.
Tiaji Salaam-Blyther, Specialist in Global Health
https://crsreports.congress.gov
IF10131
U.S. Global Health Assistance: FY2017-FY2019 Request
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