U.S. Global Health Assistance: Background
and Issues for the 113th Congress
Tiaji Salaam-Blyther
Specialist in Global Health
June 21, 2013
Congressional Research Service
7-5700
www.crs.gov
R43115
CRS Report for Congress
Pr
epared for Members and Committees of Congress
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Summary
Congress has supported the growth of U.S. global health programs since the George W. Bush
Administration. Combined global health funding from State-Foreign Operations, Labor-HHS and
Defense appropriations rose from $1.7 billion in FY2001 to $8.9 billion in FY2012. The FY2013
Consolidated Appropriations Act (P.L. 113-6) includes approximately $8.4 billion for global
health programs funded through State-Foreign Operations appropriations, up from $8.2 billion in
FY2012. (FY2013 funding levels will likely change, however, due to sequestration.) These funds
support global health programs implemented and managed by the U.S. Agency for International
Development (USAID), State Department and the Global Fund to Fight AIDS, Tuberculosis and
Malaria (Global Fund)—a multilateral organization aimed at fighting HIV/AIDS, TB, and malaria
worldwide. The act does not specify how much should be spent on global health programs
through other appropriations.
Concern about infectious diseases, especially HIV/AIDS, has driven much of the budgetary
increases. Excluding funding for the Global Fund, roughly 34% of the FY2001 U.S. global health
budget was aimed at programs that address HIV/AIDS. By 2012, about 57% of U.S. global health
spending was aimed at fighting HIV/AIDS worldwide, and the FY2014 budget request calls for
nearly 54% of global health spending to be aimed at the disease.
In the 112th Congress, concerns about the strength of the U.S. economy and federal spending
precipitated discussions about the role and efficacy of U.S. foreign aid, including global health
programs. Critics began to push for U.S. global health programs to demonstrate impact and
improve cost-efficiency. At the same time, supporters underscored the advances U.S. global
health programs had made, the millions of lives saved in part with U.S. resources, and the
promise of innovative health solutions. It is likely that this debate will continue in the 113th
Congress. Other issues the 113th Congress may face include
• deliberating funding levels for U.S. global health programs;
• examining U.S. leadership of U.S. global health programs;
• maintaining global HIV/AIDS commitments;
• deliberating the reauthorization of the President’s Emergency Plan for AIDS
Relief (PEPFAR) in FY2013; and
• determining the appropriate mix of multilateral and bilateral spending for global
HIV/AIDS, TB, and malaria programs.
These issues are summarized below.
Global Health Funding. Until FY2011, funding for global health had continuously increased.
Since then, funding has fluctuated. In FY2011, funding fell slightly and then grew by 0.4% in
FY2012. Sequestration requirements are prompting roughly 5% in budget cuts for global health
funding in FY2013. In that fiscal year, Congress appropriated nearly $8.5 billion for global health
activities funded through State-Foreign Operations, some 8% more than the Administration
requested. The FY2014 congressional budget justifications for Labor-HHS and Defense did not
specify funding levels for their global health programs. Global health funding will likely be an
important issue for the 113th Congress as it considers the FY2014 budget.
Congressional Research Service
U.S. Global Health Assistance: Background and Issues for the 113th Congress
GHI Leadership. President Barack Obama created the Global Health Initiative (GHI) to improve
the coordination and implementation of U.S. global health programs with the goal of deepening
the impact of U.S. global health investments. In the Quadrennial Diplomacy and Development
Review, the State Department announced plans to transfer the Office of the Global Health
Coordinator from the Department of State to USAID if key milestones were met. In July 2012,
the Administration announced that the GHI Office would close, but that the leadership structure
for the initiative would be maintained with USAID, the Centers for Disease Control and
Prevention (CDC), and the Office of the Global AIDS Coordinator (OGAC) at the State
Department collaboratively planning related efforts. At the same time the GHI leadership
announced the closing of the GHI Office, the State Department announced the establishment of
the Office of Global Health Diplomacy. Some global health observers questioned the rationale for
announcing these changes simultaneously.
Maintaining HIV/AIDS Commitments. The Lantos-Hyde Act of 2008 called for the
Administration to develop “Partnership Frameworks” with countries that would outline gradual
increases in country ownership of PEPFAR programs. As of May 7, 2013, 22 Partnership
Frameworks have been signed. Some HIV/AIDS advocates are concerned that these agreements
are being prematurely implemented and that countries will not be able to adequately maintain
related activities, particularly in the areas of HIV/AIDS treatment. Interruptions in treatment can
lead to drug resistance and death. Supporters, however, view these agreements as an important
step toward encouraging country ownership and assert that spending reductions are occurring
only in countries with a demonstrated capacity to replace the U.S. funds.
PEPFAR Reauthorization. The Lantos-Hyde Act (P.L. 110-293) authorizes appropriations to
fight global HIV/AIDS, tuberculosis (TB), and malaria through the Office of the Global AIDS
Coordinator (OGAC) and the President’s Malaria Initiative (PMI). This act expires at the end of
FY2013. If Congress does not reauthorize the legislation, related programs could continue to be
funded through annual appropriations, though some language demonstrating congressional intent
would expire.
Multilateral and Bilateral Funding. Since the creation of the Global Fund, some debates about
U.S. funding for global HIV/AIDS have pitted the Global Fund against PEPFAR. This framing is
somewhat inaccurate because U.S. contributions to the Global Fund are part of the PEPFAR
budget. Additionally, the Global Fund supports projects aimed at three diseases: HIV/AIDS, TB,
and malaria. At the same time, the United States is a key partner of the Global Fund and provides
support in a number of areas, including financing, board membership, and collaborative planning.
Discussions comparing spending on bilateral HIV/AIDS programs and the Global Fund
intensified following an announcement by the Obama Administration that it would seek $4 billion
for the Global Fund from FY2011 through FY2013. In FY2010, the Global Fund accounted for
14% of U.S. spending on global HIV/AIDS, TB, and malaria programs. In FY2012, 18% of U.S.
funding for the three diseases was directed to the Global Fund. The President requests that in
FY2014, 22% of U.S. spending on the three diseases be channeled through the Global Fund.
Although much of the discussions regarding the appropriate mix of multilateral and bilateral
funding focus on HIV/AIDS spending, the issue has broader implications for global health
programs. According to the World Health Organization (WHO), insufficient alignment of bilateral
and multilateral programs is wasteful and inefficient.
Congressional Research Service
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Contents
Introduction ...................................................................................................................................... 1
Appropriations for U.S. Global Health Programs ............................................................................ 3
State-Foreign Operations Appropriations .................................................................................. 5
Labor-HHS Appropriations ....................................................................................................... 5
Defense Appropriations ............................................................................................................. 5
Implementing Agencies and Departments ....................................................................................... 6
U.S. Agency for International Development ............................................................................. 6
Centers for Disease Control and Prevention .............................................................................. 6
Department of State ................................................................................................................... 7
Department of Defense .............................................................................................................. 8
U.S. Government Global Health Initiatives ..................................................................................... 8
President’s Emergency Plan for AIDS Relief (PEPFAR) .......................................................... 8
President’s Malaria Initiative (PMI) .......................................................................................... 9
Neglected Tropical Disease (NTD) Program ............................................................................. 9
The Global Health Initiative (GHI) ........................................................................................... 9
Coordinating GHI .............................................................................................................. 11
Funding GHI ..................................................................................................................... 11
Prioritizing Non-HIV/AIDS Programs Through GHI ....................................................... 13
FY2014 Funding ............................................................................................................................ 14
Global Health Spending by Other Stakeholders ............................................................................ 16
Issues for the 113th Congress ......................................................................................................... 17
Defining U.S. Global Health Assistance and GHI ................................................................... 18
Funding GHI ............................................................................................................................ 19
Maintaining HIV/AIDS Commitments ............................................................................. 20
Extending PEPFAR Authorization Legislation ....................................................................... 22
Balancing Bilateral and Multilateral Activities ....................................................................... 23
Conclusion ..................................................................................................................................... 24
Figures
Figure 1. U.S. Global Health Funding: FY2001-FY2014 Request .................................................. 1
Figure 2. U.S. Global Health Assistance: Appropriation Vehicles ................................................... 4
Figure 3. U.S. Global Health Assistance: Implementing Agencies and Initiatives .......................... 4
Figure 4. FY2012 Global Health Appropriations ............................................................................ 5
Figure 5. Timeline of U.S. Government Global Health Initiatives .................................................. 8
Figure 6. GHI Country Strategies: A Map ..................................................................................... 10
Figure 7. GHI Funding: FY2009-FY2014 ..................................................................................... 12
Figure 8. GHI Global Health Spending, by Program Area, FY2009-FY2012 ............................... 14
Figure 9. Official Development Assistance for Health, by Country, 2011 .................................... 16
Figure 10. Official Development Assistance for Health, FY2005-FY2011 ................................... 18
Congressional Research Service
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Figure 11. GHI Spending in Ethiopia, FY2009-FY2013 ............................................................... 21
Figure A-1. GHI Framework ......................................................................................................... 26
Tables
Table 1. U.S. Government Global Health Funding: FY2011-FY2014 Request ............................ 15
Table C-1. U.S. Global Health Spending, by Agency, FY2001-FY2014 ....................................... 28
Table C-2. State-Foreign Operations Appropriations, FY2001-2014 ............................................ 29
Table C-3. Labor, HHS Appropriations, FY2001-2014 ................................................................. 31
Table C-4. PEPFAR, FY2001-FY2014 .......................................................................................... 32
Appendixes
Appendix A. GHI Framework ....................................................................................................... 26
Appendix B. Non-Communicable Disease (NCD) Deaths Among People Under 60 Years,
by Country Income-Group .......................................................................................................... 27
Appendix C. U.S. Global Health Funding, FY2001-FY2014 ........................................................ 28
Contacts
Author Contact Information........................................................................................................... 33
Congressional Research Service
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Introduction
Congress has demonstrated interest in global health and has generally appropriated funds for
global health in excess of presidential requests, particularly since FY2000. U.S. government
funding for global health has grown from $1.7 billion in FY2001 to $8.9 billion in FY2012
(Figure 1). The Administration proposes spending more than $9 billion on global health
programs in FY2014.
Figure 1. U.S. Global Health Funding: FY2001-FY2014 Request
(current U.S. millions of dollars)
Source: Created by CRS from appropriations legislation and data received from the Office of Management and
Budget (OMB).
Note: Includes global health funding through three appropriations vehicles: State-Foreign Operations; Labor,
HHS, and Education (Labor-HHS); and Defense. HIV/AIDS amounts include U.S. contributions to the Global
Fund to Fight AIDS, Tuberculosis and Malaria.
U.S. support for global health has been motivated in large part by concern about emergent and
reemerging infectious diseases. Following outbreaks of diseases like severe acute respiratory
syndrome (SARS), HIV/AIDS, and pandemic influenza, several presidents have highlighted the
threats they pose to economic development, stability, and security and launched a series of health
initiatives to address them. In 1996, for example, President Bill Clinton issued a presidential
decision directive that called infectious diseases a threat to domestic and international security
and called for U.S. global health efforts to be coordinated with those aimed at counterterrorism.1
1 The White House, Infectious Diseases, Presidential Decision Directive NSTC-7, June 12, 1996.
Congressional Research Service
1
U.S. Global Health Assistance: Background and Issues for the 113th Congress
President Clinton later requested $100 million for the Leadership and Investment in Fighting an
Epidemic (LIFE) Initiative in 1999 to expand U.S. global HIV/AIDS efforts.2 President George
W. Bush recognized the impact of infectious diseases on domestic and global security in his 2002
and 2006 national security strategy papers and created a number of initiatives aimed at them,
including the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2004, the President’s
Malaria Initiative (PMI) in 2005 and the Neglected Tropical Diseases (NTD) Program in 2006.3
President Barack Obama also recognized the risk of infectious diseases and made several
statements about how their spread across developing countries might impact U.S. security.4
Through the 2010 Quadrennial Diplomacy and Development Review (QDDR) and the 2010
National Security Strategy, the Obama Administration advocated for the coordination of health
programs in other areas, such as security, diplomacy and development. Rather than create an
initiative aimed at infectious diseases, President Obama sought to address them by affirming U.S.
commitment to global health and refining how U.S. global health programs function. In 2009,
President Obama announced the Global Health Initiative (GHI), a $63 billion, six-year strategy
aimed at improving the coordination and impact of U.S. global health initiatives (described fully
in the section entitled, “The Global Health Initiative (GHI)”).
Legislative and executive branch support for raising global health budgets have been largely
aligned, though some debates have emerged on more finite issues, such as the type of HIV/AIDS
interventions to support. Recurring debate has also centered on international family planning and
reproductive health programs.5 During the 112th Congress, concerns about slow economic
recovery began to erode support for maintaining higher global health spending levels. Some
Members questioned levels of non-security foreign aid and argued for the reduction or
elimination of development and health assistance. In total, foreign aid accounts for less than 1%
of the federal budget. Some Members contended cuts to these programs could yield important
savings, while others maintained such reductions would have little impact on the federal deficit,
could imperil the lives of vulnerable populations reliant on U.S. assistance, and might erode
progress achieved through increased investments. Examples of progress in global health aid
include the following:
• HIV/AIDS—The number of people receiving HIV/AIDS treatments through
PEPFAR has more than doubled from 1.7 million in 2008 to more than 5.1
million in 2012. Programs that prevent mother-to-child HIV transmission have
protected 230,000 infants against HIV in 2012.6 New HIV infections fell by 24%
from 2001 through 2011.7
• Tuberculosis (TB)—Between 1990 and 2011, TB mortality and prevalence rates
decreased by 34% and 35%, respectively, in 28 USAID priority countries.8
2 For more on the LIFE Initiative, see CRS Report RL33771, Trends in U.S. Global AIDS Spending: FY2000-FY2008.
3 For more on PMI and the NTD Program, see CRS Report R41644, U.S. Response to the Global Threat of Malaria:
Basic Facts and CRS Report R41607, Neglected Tropical Diseases: Background, Responses, and Issues for Congress.
4 See for example, White House, “Statement by the President on Global Health Initiative,” press release, May 5, 2009.
5 See CRS Report R41360, Abortion and Family Planning-Related Provisions in U.S. Foreign Assistance Law and
Policy and CRS Report RL33250, International Family Planning Programs: Issues for Congress.
6 PEPFAR, Working Together for an AIDS-Free Generation: World AIDS Day Results, March 14, 2013.
7 WHO, Millennium Development Goals, Fact Sheet, Number 290, November 2012.
8 Personal correspondence with USAID, March 29, 2013.
Congressional Research Service
2
U.S. Global Health Assistance: Background and Issues for the 113th Congress
• Malaria—From 2006 through 2011, more than 59 million insecticide-treated
nets (ITNs) and 11 million malaria treatments were procured with PMI support.
Malarial deaths declined by roughly 33% from 985,000 in 2000 to 655,000 in
2010. Children younger than five years account for the vast majority of malarial
deaths. In 12 of the original 15 PMI countries, child mortality rates have declined
in the range of 16% (Malawi) and 50% (Rwanda).9
• Maternal and Child Health—USAID and the Centers for Disease Control and
Prevention (CDC) have been key contributors to improved global coverage of
vaccines, from 73% in 2000 to 85% in 2010. The World Health Organization
(WHO) estimates that the U.S.-backed Global Alliance for Vaccines and
Immunization (GAVI) 10 supported the immunization of more than 325 million
children by the end of 2011, thereby preventing more than 5 million deaths from
vaccine-preventable diseases annually.11 Since 1990, deaths among children
under five have dropped by 42.5% from nearly 12 million annually to 6.9 million
in 2011; maternal deaths decreased by 47% from 1990 to 2010.12
• Family Planning and Reproductive Health—USAID considers child spacing
and access to voluntary contraception as important strategies for reducing child
and maternal mortality and averting abortions. Use of modern contraception in 27
countries reportedly increased from 10% in 1965 to 37% in 2011.13
Debates about U.S. global health funding levels will likely continue in the 113th Congress and
may intensify as Members seek to reduce overall spending.
Appropriations for U.S. Global Health Programs
Congress funds most global health assistance through three appropriations bills: State-Foreign
Operations and Related Programs (State-Foreign Operations); Labor, Health and Human Services,
and Education (Labor-HHS); and Department of Defense (Figure 2). These bills are used to fund
global health efforts implemented by USAID, CDC, and the Department of Defense (DOD),
including PEPFAR programs that are coordinated by the Department of State and implemented by
several U.S. agencies (Figure 3). Through PEPFAR, the United States contributes to multilateral
efforts to combat HIV/AIDS, TB, and malaria, including the Global Fund and the Joint United
Nations Program on HIV/AIDS (UNAIDS).
9 USAID, The President’s Malaria Initiative, Sixth Annual Report to Congress, April 2012, pp. 5 and 9.
10 GAVI Alliance is a public-private partnership focused on increasing access to immunization for children around the
world.
11 GAVI Alliance, GAVI Alliance Progress Report, 2011, p. 7.
12 WHO, Millennium Development Goals, Fact Sheet, Number 290, November 2012.
13 Ibid, p. 72 and USAID webpage on family planning.
Congressional Research Service
3
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Figure 2. U.S. Global Health Assistance: Appropriation Vehicles
Source: Created by CRS from appropriations legislation.
Figure 3. U.S. Global Health Assistance: Implementing Agencies and Initiatives
Source: Created by CRS from appropriations legislation.
Notes: Appropriations for HIV/AIDS programs implemented by CDC, State and USAID are part of PEPFAR.
Acronyms not previously described: Department of Commerce (DOC), Department of Labor (DOL),
Department of State (State), Food and Drug Administration (FDA), Health Resources and Services Administration
(HRSA), National Institutes of Health (NIH) Office of Global Health Affairs, Substance Abuse and Mental Health
Services Administration (SAMHSA).
Reports about U.S. spending on global health can vary because there is no single “global health”
appropriation. Some groups count funding for development issues that impact health, like water
and sanitation, towards U.S. global health spending. This report focuses on activities that receive
a specific amount for global health through State-Foreign Operations appropriations and Labor-
Congressional Research Service
4
U.S. Global Health Assistance: Background and Issues for the 113th Congress
HHS appropriations, and for global HIV/AIDS through Department of Defense appropriations.
Specific activities supported through these three appropriations vehicles are discussed below.
State-Foreign Operations Appropriations
The majority of U.S. global health programs are funded through the Global Health Programs
Account in the State-Foreign Operations appropriations (Figure 4). Most of the funds are used for
fighting HIV/AIDS, TB and malaria through bilateral programs and the Global Fund. A table
outlining global health funding through State-Foreign Operations is included in Appendix C.
Figure 4. FY2012 Global Health Appropriations
Source: Created by CRS from appropriations legislation and data received from OMB.
Labor-HHS Appropriations
Through Labor-HHS appropriations, Congress funds global health programs implemented by
CDC and provides resources to support international HIV/AIDS research conducted by the
National Institutes of Health (NIH). Congress appropriates specific amounts for various global
health programs implemented by CDC, though the appropriations language does not cover the
breadth of global health activities managed by CDC. At the same time, appropriations language
does not specify a particular amount for global HIV/AIDS research grants funded through NIH,
though the Administration typically includes these amounts in reports on PEPFAR funding. A
table outlining global health spending through Labor-HHS is included in Appendix C.
Defense Appropriations
Congress appropriates funds to DOD in support of its PEPFAR-related work through Defense
appropriations. On average, Congress provides between $8 million and $10 million annually for
these purposes. At the same time, DOD receives additional resources from the State Department
as an implementing partner of PEPFAR. A table outlining U.S. funding for global HIV/AIDS
programs, including those implemented by DOD, is included in Appendix C.
Congressional Research Service
5
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Implementing Agencies and Departments
This section briefly describes global health activities implemented or coordinated by each agency
or department with appropriations, as described above. This discussion is limited to those
agencies and departments for which Congress provides specific funding: USAID, State, CDC,
and DOD.
U.S. Agency for International Development14
USAID groups its global health activities into three areas: saving mothers and children, creating
an AIDS-Free generation, and fighting other infectious diseases. A summary of these efforts is
described below.
• Saving Mothers and Children. USAID seeks to save the lives of women and
children by reducing morbidity and mortality from common diseases and
undernutrition; supporting vulnerable children and orphans; increasing access to
family planning; and raising awareness about reproductive health. Under this
category, Congress designates a specific amount for the following health areas:
• maternal and child health,
• malaria,
• nutrition,
• family planning and reproductive health, and
• social services (vulnerable children).
• Creating an AIDS-Free Generation. USAID aims to combat HIV/AIDS by
supporting voluntary counseling and testing, awareness campaigns, and the
supply of antiretroviral medicines, among other activities.
• Fighting Other Infectious Diseases. USAID works to address a number of
infectious diseases and resultant outbreaks. Congress appropriates a specific
amount for: TB, pandemic influenza and other emerging threats, and NTDs.
Centers for Disease Control and Prevention15
Through Labor-HHS appropriations, Congress specifies support for the following CDC global
health activities:
• HIV/AIDS. CDC works with Ministries of Health (MOHs) and global partners to
increase access to integrated HIV/AIDS care and treatment services; strengthen
and expand high-quality laboratory services; conduct research; and support
resource-constrained countries develop sustainable public health systems.
14 For background on USAID’s global health programs, see CRS Report RS22913, USAID Global Health Programs:
FY2001-FY2012 Request; and http://www.usaid.gov/what-we-do/global-health.
15 For background on CDC’s global health programs, see CRS Report R40239, Centers for Disease Control and
Prevention Global Health Programs: FY2001-FY2012 Request; and http://www.cdc.gov/globalhealth/index.html.
Congressional Research Service
6
U.S. Global Health Assistance: Background and Issues for the 113th Congress
• Parasitic Diseases and Malaria. CDC aims to reduce death and illness
associated with parasitic diseases, including malaria, by capacity building and
enhancing surveillance, monitoring and evaluation, vector control, case
management, and diagnostic testing. CDC also identifies best practices for
parasitic disease programs and conducts epidemiological and laboratory research
for the development of new tools and strategies.
• Global Disease Detection (GDD) and Emergency Response. Through GDD,
CDC builds capacity to monitor, detect, and assess disease threats and responds
to requests from other U.S. agencies, United Nations agencies, and non-
governmental organizations for support in humanitarian assistance activities.
• Global Immunization. CDC works to advance several global immunization
initiatives aimed at preventable diseases, including polio, measles, rubella, and
meningitis; accelerate the introduction of new vaccines; and strengthen
immunization systems in priority countries through technical assistance,
monitoring and evaluation, social mobilization and vaccine management.
• Global Public Health Capacity Development. CDC help MOHs develop Field
Epidemiology Training Programs (FETPs) that strengthen health systems by
enhancing laboratory management, applied research, communications, program
evaluation, program management, and disease detection and response.
Department of State
Through OGAC, the State Department leads PEPFAR and oversees all U.S. spending on global
HIV/AIDS, including those appropriated to other agencies and multilateral groups like the Global
Fund and UNAIDS. In July 2012, the Administration announced an expansion of the State
Department’s engagement in global health with the launch of the Office of Global Health
Diplomacy (OGHD).16 The office seeks to “guide diplomatic efforts to advance the United States’
global health mission” and provide “diplomatic support in implementing the Global Health
Initiative’s principles and goals.”17 The Global AIDS Coordinator also leads OGHD. The key
objectives of the OGHD are to
• provide ambassadors with expertise, support and tools to help them effectively
work with country officials on global health issues;
• elevate the role of ambassadors in their efforts to pursue diplomatic strategies and
partnerships within countries to advance health;
• support ambassadors to build political will among partner countries to improve
health and strengthen health systems;
• strengthen the sustainability of health programs by helping partner countries meet
the health care needs of their own people and achieve country ownership; and
• foster shared responsibility and coordination among donor nations, multilateral
institutions, civil society, the private sector, faith-based organizations,
foundations, and community members.
16 GHI, “Global Health Initiative Next Steps - A Joint Message,” press release, July 3, 2012.
17 Department of State, “Strengthening Global Health by Elevating Diplomacy,” blog post, December 14, 2012.
Congressional Research Service
7
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Following the announcement of the OGHD, some observers questioned whether the
Administration was quietly abandoning GHI. For more on this issue, see section on
“Coordinating GHI.”
Department of Defense
DOD carries out a wide range of health activities abroad, including infectious disease research,
health assistance following natural disasters and other emergencies, and training of foreign health
workers and officials.18 The only global health activity for which Congress provides a specific
appropriation, however, is DOD’s HIV/AIDS Prevention Program (DHAAP). Congress has never
appropriated more than $10 million to DOD for its global HIV/AIDS work, though it receives
transfers from the Department of State as an implementing agency of PEPFAR. These funds are
used to support research, care, treatment and prevention programs.19 Table C-4 in Appendix C
outlines annual funding for DHAAP.
U.S. Government Global Health Initiatives
As previously discussed, Presidents Clinton and Bush created global health initiatives to address
infectious diseases (Figure 5). During the Bush Administration, consensus emerged that these
initiatives, particularly PEPFAR, needed to be better integrated with other public health activities
to improve efficiency and sustainability. President Obama maintained support for the Bush Era
health initiatives but attempted to address these concerns with the launch of the GHI. The section
below describes these global health initiatives.
Figure 5. Timeline of U.S. Government Global Health Initiatives
Source: Created by CRS.
President’s Emergency Plan for AIDS Relief (PEPFAR)20
In January 2003, President Bush announced PEPFAR, a government-wide initiative to combat
global HIV/AIDS. PEPFAR supports a wide range of HIV/AIDS prevention, treatment, and care
activities and is the largest commitment by any nation to combat a single disease. Later that year,
Congress enacted the Leadership Act (P.L. 108-25), which authorized $15 billion to be spent from
FY2004-FY2008 on bilateral and multilateral HIV/AIDS, TB and malaria programs and
authorized the creation of OGAC to oversee all U.S. spending on global HIV/AIDS. OGAC
distributes the majority of the funds it receives from Congress for global HIV/AIDS programs to
18 For more information on these efforts, see CRS Report RL34639, The Department of Defense Role in Foreign
Assistance: Background, Major Issues, and Options for Congress; and Kaiser Family Foundation, The U.S. Department
of Defense and Global Health, September 2012.
19 For more on DOD’s HIV/AIDS research, see http://www.hivresearch.org/research.php and for DHAAP, see
http://www.med.navy.mil/sites/nhrc/dhapp/Pages/default.aspx.
20 For more information on PEPFAR, see CRS Report R42776, The President’s Emergency Plan for AIDS Relief
(PEPFAR): Funding Issues After a Decade of Implementation, FY2004-FY2013.
Congressional Research Service
8
U.S. Global Health Assistance: Background and Issues for the 113th Congress
multilateral groups like the Global Fund, as well as federal agencies and departments. In 2008,
Congress enacted the Lantos-Hyde Act (P.L. 110-293), which authorized the appropriation of $48
billion for global HIV/AIDS, TB, and malaria efforts from FY2009-FY2013.
President’s Malaria Initiative (PMI)21
In June 2005, President Bush announced PMI to expand and coordinate U.S. global malaria
efforts. PMI was originally established as a five-year, $1.2 billion effort to halve the number of
malaria-related deaths in 15 sub-Saharan African countries through the expansion of four
prevention and treatment techniques: indoor residual spraying (IRS), insecticide-treated nets
(ITNs), artemisinin-based combination therapies (ACTs), and intermittent preventative treatment
for pregnant women (IPTp). 22 The Obama Administration expanded the goals of PMI to halving
the burden of malaria among 70% of at-risk populations in Africa by 2014 and added the
Democratic Republic of Congo, Guinea, Nigeria, and Zimbabwe as partner countries.
The Lantos-Hyde Act authorized the establishment of the U.S. Malaria Coordinator at USAID.
The Malaria Coordinator oversees implementation efforts of USAID and CDC and is advised by
an Interagency Advisory Group that includes representatives from USAID, HHS, State, DOD, the
National Security Council (NSC), and the Office of Management and Budget (OMB).
Neglected Tropical Disease (NTD) Program23
The NTD Program started in 2006, following FY2006 appropriations language that directed
USAID to make available at least $15 million for fighting seven NTDs.24 It is managed by
USAID and jointly implemented by USAID and CDC. When the program was launched, the
Bush Administration sought to support the provision of 160 million NTD treatments for 40
million people in 15 countries. In 2008, President Bush reaffirmed his commitment to tackling
NTDs and proposed spending $350 million from FY2008 through FY2013 on expanding the
program to 30 countries. In 2009, the Obama Administration amended the targets of the NTD
program and called for the United States to support halving the prevalence of NTDs among 70%
of the affected population in target countries.
The Global Health Initiative (GHI)
In May 2009, President Obama announced GHI to expand the impact of U.S. government health
programs. GHI aims to improve the coordination and integration of U.S. bilateral global health
programs, which were described above, and emphasizes the application of results-based funding.
Other important goals of GHI include the following:
21 For more information on PMI, see CRS Report R41644, U.S. Response to the Global Threat of Malaria: Basic Facts,
and CRS Report R41802, The Global Challenge of HIV/AIDS, Tuberculosis, and Malaria.
22 The original 15 PMI countries were Angola, Benin, Ethiopia, Ghana, Kenya, Liberia, Madagascar, Malawi, Mali,
Mozambique, Rwanda, Senegal, Tanzania, Uganda and Zambia.
23 For more information on the NTD Program, see CRS Report R42931, Progress in Combating Neglected Tropical
Diseases (NTDs): U.S. and Global Efforts from FY2006 to FY2013.
24 Section 593, P.L. 109-102, FY2006 Foreign Operations Appropriations. The seven NTDs specified in the legislation
are: three soil-transmitted helminthes, schistosomiasis, lymphatic filiariasis, trachoma, and onchocerciasis.
Congressional Research Service
9
U.S. Global Health Assistance: Background and Issues for the 113th Congress
• increasing the impact of U.S. global health investments;
• advancing country ownership of health aid;
• strengthening health systems;
• investing in women and girls; and
• enhancing program monitoring and evaluation and research and innovation.25
GHI encompasses global health activities implemented by USAID and carried out through
PEPFAR and PMI. The initiative aims to advance sustainable improvements in global health in
three areas: protecting communities from infectious diseases, saving the lives of mothers and
children and creating an AIDS-free generation. In each of these areas, the Administration has set
goals and measurable indicators. For a description of these, see Figure A-1 in Appendix A.
Through GHI, the U.S. government is developing “country strategies” that outline U.S. support
for national health plans. The purpose of the strategies is to align the goals of GHI and partner
countries, coordinate U.S. global health efforts, and enhance the efficiency and sustainability of
these efforts. The strategies are developed in the U.S. missions by representatives of each
implementing agency and have reportedly been completed for approximately 40 countries.26 As of
June 18, 2013, GHI has published 35 of these (Figure 6).
Figure 6. GHI Country Strategies: A Map
Source: GHI website, http://www.ghi.gov/country/index.htm, accessed on June 18, 2013.
Notes: The country strategies have been published for Armenia, Bangladesh, Benin, Bolivia, Burundi, Cambodia,
Democratic Republic of Congo, Dominican Republic, Ethiopia, Georgia, Ghana, Guatemala, Honduras, Indonesia,
Kenya, Lesotho, Liberia, Malawi, Mali, Mozambique, Namibia, Nepal, Nigeria, Philippines, Rwanda, Senegal, Sierra
Leone, South Africa, Swaziland, Tanzania, Uganda, Ukraine, Vietnam, Zambia, and Zimbabwe.
25 For more information on these goals, see GHI, United States Government Global Health Initiative Strategy, 2011.
26 Personal communication with OGAC, April 1, 2013.
Congressional Research Service
10
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Coordinating GHI
From 2011 to mid-2012, GHI was coordinated by an executive director at the Department of State
who reported to the Secretary of State and the GHI Operations Committee. The committee, which
oversees and manages GHI, is chaired by the USAID Administrator, the Global AIDS
Coordinator, and the Director of CDC. The Administration considered transferring leadership of
GHI from the State Department to USAID by late FY2012 on the condition that USAID met a set
of benchmarks related to management capacity, as outlined in the Quadrennial Diplomacy and
Development Review (QDDR).27
In July 2012, the co-coordinators of GHI—Ambassador Goosby (State/OGAC), Lois Quam
(State/GHI), Administrator Rajiv Shah (USAID) and Director Thomas Frieden (CDC)—
announced a collective recommendation to end the QDDR benchmark process, close the GHI
office, and establish an Office of Global Health Diplomacy (GHD) at the Department of State to
guide diplomatic efforts for advancing the U.S. global health mission.28 The press release
underscored, however, that GHI would continue to be the central focus and guiding strategy of
U.S. global health programs.
Several observers debated the implications of the statement, particularly whether the
Administration was quietly abandoning GHI. Some interpreted the announcement as a signal that
the Administration was using the new GHD office to indirectly resolve arguments in Washington
about who should ultimately lead U.S. global health efforts.29 The Administration maintains,
however, that the GHD office is not taking over the coordinating function that the GHI office
played.30 Further, the Administration maintains a website for GHI and continues to cite it as the
guiding mechanism for U.S. global health work.
Funding GHI
When launching GHI, President Obama proposed spending $63 billion on global health from
FY2009 through FY2014. The President announced that $51 billion of those funds would be
aimed at HIV/AIDS and TB programs and the rest on global health programs implemented by
USAID. From FY2009-FY2012, GHI funding reached $34.3 billion. The FY2013 Consolidated
Appropriations act provided an additional $5.7 billion for State-managed HIV/AIDS programs,
including $1.65 billion for the Global Fund. The act also included nearly $2.8 billion for global
health programs implemented by USAID, though it did not specify for which programs. Figure 7
estimates the additional funds needed to meet the GHI funding goals. This figure will likely
change, however, as FY2013 funding levels for global health spending under sequestration has
not yet been released.
27 For a list of the benchmarks, see Appendix 2 in State Department, Quadrennial Diplomacy and Development Review,
2010, pp. 217-219.
28 GHI, “Global Health Initiative Next Steps - A Joint Message,” press release, July 3, 2012. For more information on
this office, see the “Department of State” section.
29 Amanda Glassman, “The Office of Global Health Diplomacy: A Christmas Miracle or Lump of Coal?” December
17, 2012.
30 Personal communication with OGAC, April 1, 2013.
Congressional Research Service
11
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Figure 7. GHI Funding: FY2009-FY2014
(current U.S. millions and percentage of GHI budget goal)
Source: Created by CRS from appropriations legislation and data received from OMB.
Notes: *FY2013 HIV/AIDS, TB, and malaria total was calculated by adding the $4.1 billion for State-HIV/AIDS
and $1.65 for the Global Fund, as specified in the FY2013 Consolidated Appropriations act with FY2012
estimates for related programs. These include $350 million for USAID HIV/AIDS programs, $650 million for
USAID malaria programs, $236 million for USAID TB programs, $117.8 million for CDC HIV/AIDS programs,
$9.4 million for CDC malaria programs, and 8.0 million for DOD HIV/AIDS programs. The $388.9 million
FY2013 request is used for NIH international HIV/AIDS research, as the Administration’s request is general y
met and Congress does not provide an amount for this program. Instead, NIH draws the funds from the budget
for the Office of HIV/AIDS Research. Due to sequestration, however, these figures will likely change.
HIV/AIDS, TB and Malaria Programs. From FY2009-FY2012, the United States spent $34.3
billion on global HIV/AIDS, TB and malaria programs. The FY2013 Consolidated
Appropriations act appropriated $5.7 billion for State-managed HIV/AIDS programs, including
$1.65 billion for the Global Fund. Assuming that other HIV/AIDS, TB and malaria-related efforts
are funded at FY2012 levels in FY2013 and that the President’s FY2014 budget for the diseases is
met, funding for fighting these three diseases would be roughly $7 billion—or—about 15% less
than sought by the Administration, though this amount may change following sequestration.
Non-HIV/AIDS, TB and Malaria Programs. From FY2009-FY2012, the United States spent
nearly $5.2 billion on non-HIV/AIDS, TB and malaria programs. The FY2013 Consolidated
Appropriations act appropriated almost $2.8 billion for global health programs implemented by
USAID. Assuming that USAID’s HIV/AIDS, TB and malaria programs would be funded at
FY2012 levels for FY2013 and that the President’s FY2014 budget for other health programs is
met, funding for programs not associated with these three diseases would be about $5.2 billion—
or some 32%—less than sought by the Administration, though this amount may change following
sequestration.
Congressional Research Service
12
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Prioritizing Non-HIV/AIDS Programs Through GHI
One goal of GHI is to improve the health of women and children, particularly through
investments in maternal and child health, family planning and reproductive health and nutrition.
The President also seeks to increase support for fighting other infectious diseases like NTDs.
Congress has supported these ideas and increased funding in these areas. From FY2009 through
FY2012, funding for maternal and child health grew by 22% and rose by 15% for family planning
and reproductive health. During the same time period funding for nutrition grew by 73% and
more than doubled for NTDs.
Nutrition. The Obama Administration has taken several steps to emphasize the importance of
improving nutrition worldwide. In September 2010, former Secretary of State Hillary Clinton
launched the 1,000 Days Campaign, a global effort to promote targeted action and investment in
improving the nutritional status of pregnant women and children within their first two years of
life.31 In addition, USAID Administrator Rajiv Shah serves as the U.S. representative to the
United Nations Scaling Up Nutrition (SUN) Movement, which aims to improve nutrition
worldwide.32 A group of Nobel Laureate economic experts ranked efforts to address
undernutrition as the most cost-effective investment in foreign aid. The economists concluded
that each dollar spent on reducing chronic undernutrition could yield a $30 benefit.33
The Administration addresses nutrition through a variety of programs. For example, nutrition is a
link between the Global Health Initiative and the Feed the Future (FtF) Initiative. Focus countries
for FtF are largely aligned around GHI countries with the highest burden of undernutrition.
USAID also uses resources through accounts like the Development Assistance account and
McGovern-Dole International Food for Education to improve nutrition worldwide, though
funding levels for nutrition activities within these accounts are not set by Congress. USAID is
reportedly working on a strategic framework that would improve means for tracking nutrition
funding and outcomes across all programs, especially global health, food security and food aid.
Other Infectious Diseases. President Obama has advocated increasing funding for programs to
combat other infectious diseases. Congressional support for this idea preceded the GHI. From
FY2000-FY2012 funding grew for TB by 45% and malaria by 70%. From FY2006-FY2012,
funding rose by 256% for NTDs. Despite these increases, TB and NTD programs continued to
account for less than 3% and 2% of the GHI budget respectively due to the large portion of the
budget aimed at the HIV/AIDS and the Global Fund (Figure 8).
31 Hillary Clinton, “1,000 Days: Change a Life, Change the Future,” remarks, New York City, September 21, 2010.
32 For more information on the SUN Movement, see http://scalingupnutrition.org/.
33 John Hoddinott et al., Copenhagen Consensus 2012 Challenge Paper, March 30, 2012, p. 4. A related report on
nutrition concluded that the cost-benefit ratios ranged between $23.8 and $138.6. Ibid, p. 37. Nutrition advocates
commonly use this statistic to assert that each dollar invested could yield up to a $139 return.
Congressional Research Service
13
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Figure 8. GHI Global Health Spending, by Program Area, FY2009-FY2012
(in millions of current U.S. dol ars and percentages)
Source: Created by CRS from appropriations legislation and data received from OMB.
Abbreviations: Maternal and Child Health (MCH), Vulnerable Children (VC), Tuberculosis (TB), Family
Planning and Reproductive Health (FP/RH), Neglected Tropical Diseases (NTDs).
Non-Communicable Diseases. The majority of U.S. global health resources are aimed at fighting
infectious diseases. Nonetheless, non-communicable diseases (NCDs) are a growing problem in
middle-income and developing countries. More than 36 million people died from NCDs
worldwide in 2008, primarily from cardiovascular diseases (CVDs), which accounted for 48% of
NCD deaths. Some 21% of NCD deaths were attributable to cancers, while 12% were associated
with chronic respiratory diseases and 3% with diabetes.34 A combination of factors contribute to
the rising prevalence of NCDs in low- and middle-income countries, including increasing use of
tobacco and illicit drugs, declining levels of physical activity, and changing diets. Limited
capacity in low- and middle-income countries to address NCDs, which are mostly preventable,
have resulted in higher mortality rates from NCDs than among more affluent countries. In 2008,
for example, more than 80% of all NCD deaths occurred among people younger than 60 years in
low- and middle-income countries (Appendix B).
FY2014 Funding
The Administration has requested $9.1 billion to fund global health programs in FY2014, roughly
2% more than FY2012 levels (Table 1). Notable increases include a 57% boost for the Global
34 WHO, Noncommunicable Diseases Country Profiles 2011, 2011, p.5.
Congressional Research Service
14
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Fund and 13% jump in funding for CDC’s global health programs. State-managed bilateral
HIV/AIDS programs were the only efforts for which the Administration requested a reduction
from FY2012 levels (-10.5%). When compared against the FY2013 Consolidated Appropriations
Act, the FY2014 budget request for State-managed global HIV/AIDS efforts was 1.2% lower and
the request for the Global Fund was the same.
Table 1. U.S. Government Global Health Funding: FY2011-FY2014 Request
(current U.S. $ millions)
FY2012
FY2013
Estimate
CR-
FY2011
FY2012
FY2013
FY2013
FY2014
-FY2014
FY2014
Enacted
Estimate
Request
CRa
Request
Request
Request
State Global HIV/AIDS
4,585.8
4,492.9
3,700.0
4,070.5
4,020.0
-10.5%
-1.2%
State Global Fund
748.5
1,300.0
1,650.0
1,650.0
1,650.0
57.1%
0.0%
USAID Global Health
2,498.0
2,625.0
2,504.0
2,641.1
2,645.0
0.8%
0.1%
State-Foreign
7,832.3
8,417.9
7,854.0
8,361.6
8,315.0
1.8%
-0.6%
Operations
CDC Global Health
340.1
347.6
362.9
n/sb 393.0 13.1%
n/sa
NIH Global AIDS
399.1 1.7% 1.8%
Research
375.7 392.4
388.9 392.0
HHS Global Fundc 297.3
0.0
0.0
0.0
0.0
0.0%
n/sa
Labor-HHS
1,013.1
740.0
751.8
n/sb
792.1
7.0%
n/sa
DOD Global HIVA/IDSd 10.0 8.0 0.0 n/sa n/s n/s n/sa
Total
8,855.4
9,165.9
8,605.8
n/sa
9,107.1
2.1%
n/sa
Source: Compiled by CRS from congressional budget justifications, appropriations legislation, and personal
communication with OMB.
Notes: Includes global health funding provided through State-Foreign Operations, Labor-HHS, and Defense
appropriations.
a. The FY2013 Consolidated Appropriations act did not specify (n/s) an amount for these programs barring
efforts to sum U.S. global health funding (n/a). The amounts listed in this column will likely change due to
sequestration.
b. The FY2014 congressional budget justification did not provide a budget amount for FY2013.
c. FY2011 was the last fiscal year in which Congress appropriated funds for a U.S. contribution to the Global
Fund through Labor-HHS. This category is not applicable (n/a) for al other fiscal years.
d. The Administration does not typical y request funds for DOD global HIV/AIDS programs. Efforts to
compare FY2012 funding against FY2013 budgetary requests are not applicable (n/a).
The Administration maintains the proposed budget reductions for some global health activities,
particularly HIV/AIDS, reflect increased efficiencies brought about by better integration between
programs, greater use of community health workers and nurses, and lower treatment costs.
Scaling back funding for bilateral HIV/AIDS programs in some countries, such as South Africa,
Kenya, Ethiopia, and also represent efforts to encourage program ownership among countries
with growing capacity to manage national HIV/AIDS programs through higher domestic
Congressional Research Service
15
U.S. Global Health Assistance: Background and Issues for the 113th Congress
investments, greater availability of resources from other donors, and reductions in HIV
prevalence.35 Despite global HIV/AIDS budget cuts, the Administration projects fulfilling related
GHI targets, particularly the target that calls for supporting the provision of HIV/AIDS treatments
for 6 million HIV-positive people worldwide by the end of 2013.36
Global Health Spending by Other Stakeholders
The United States provides more official development assistance (ODA) for health than any other
country in the Development Assistance Committee (DAC).37 In 2011, U.S. spending on global
health accounted for more than half of all health aid provided by DAC members (Figure 9). At
the same time, the United States apportions more of its foreign aid to improving global health
than most other donor countries. As illustrated in Figure 9, Canada is the only other donor that
apportions 28% of its ODA to health aid.
Figure 9. Official Development Assistance for Health, by Country, 2011
(current U.S. millions and percent of total)
Source: Created by CRS from the Organization for Economic Cooperation and Development (OECD) website
on statistics at http://www.oecd.org/statistics/, accessed on February 5, 2012.
Notes: Data in this figure reflects reported spending by DAC members. The data does not include funding from
other sources, including European Union institutions, the World Bank or private donors like the Gates
Foundation. Health aid levels in this figure include the OECD aid categories of health and population.
35 Eric Goosby, President’s Budget Request Reflects Strong Commitment on Global AIDS, Department of State,
February 13, 2012.
36 State Department, Executive Budget Summary, Function 150 and Other International programs, FY2013, pp. 74-80.
37 DAC is an organization of 24 countries that focus on development. DAC members are part of the OECD, a group of
34 countries committed to international development.
Congressional Research Service
16
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Due to varying data col ection practices, as described in the section on “Defining U.S. Global Health Assistance
and GHI,” total amounts reported by OECD on global health aid may differ from national estimates. The
Administration reports, for example, that the United States spent $8.85 billion on global health aid in FY2011,
while the OECD reports the United States spent $8.33 billion in 2011.
In 2011, ODA for health by other DAC countries include Greece ($3 million), Portugal ($17 million), Finland
($20 million), New Zealand ($20 million), Luxembourg ($41 million), Switzerland ($67 million), Austria ($74
million), Italy ($91 million), Ireland ($96 million), Denmark ($142 million), Netherlands ($154 million), Korea
($162 million), France ($179 million), Sweden ($182 million), Norway ($183 million), Spain ($200 mil ion),
Belgium ($211 million).
The global health funding system is becoming increasingly complicated as a variety of new actors
become involved. The private sector and private foundations are playing a growing role in
addressing global health. In 2011, for example, spending on global health by the Bill & Melinda
Gates Foundation was higher than all DAC countries except the United States. Specifically, the
OECD reported that in 2011, the Gates Foundation spent some $2.4 billion on global health,
roughly $553 million more than Britain, the second largest DAC donor.38
GHI Strategy documents released by the Obama Administration and legislation introduced by the
112th Congress appear to welcome broader engagement in global health, particularly public-
private partnerships. There is some debate, however, among global health analysts about how the
burgeoning number of players might impact global health effectiveness in general and U.S.
influence in this realm in particular. 39 The growth of actors in the global health sector raises
several questions:
• How might U.S. influence be affected by the growing number of global health
actors, particularly in the area of country ownership?
• How might the United States effectively engage with non-state actors to avoid
duplication of resources and improve the sustainability of its investments?
• How might the United States maintain its accountability and transparency
standards while reducing reporting burdens?
Issues for the 113th Congress
The U.S. role in global health has been both applauded and criticized. Supporters have celebrated
the attention the United States has brought to global health, as well as advancements U.S.
programs have helped to make in improving global health. In real terms, donor countries have
increased ODA for health since the launch of U.S. global health initiatives like PEPFAR, PMI,
and the NTD Program (Figure 10). At the same time, some critics have disapproved of the
establishment of U.S. health programs that parallel, rather than operate within, national health
services, particularly for global HIV/AIDS programs. Critics contended the U.S programs
38 OECD online database at http://stats.oecd.org/.
39 See for example, Nicole A. Szlezák et al., “The Global Health System: Actors, Norms, and Expectations in
Transition,” PLoS Medicine, vol. 7, no. 1 (January 5, 2010), p. e1000183; Robert Black et al., “Accelerating the Health
Impact of the Gates Foundation,” The Lancet, vol. 373, no. 9675 (May 9, 2009), pp. 1584-1585; Kirstin Matthews and
Vivian Ho, “The Grand Impact of the Gates Foundation,” European Molecular Biology Organization, vol. 9, no. 5
(2008), pp. 409-412; David Stuckler, Sanjay Basu, and Martin McKee, “Global Health Philanthropy and Institutional
Relationships: How Should Conflicts of Interest Be Addressed?,” PLoS Medicine, vol. 8, no. 4 (April 12, 2011),
p. e1001020.
Congressional Research Service
17
U.S. Global Health Assistance: Background and Issues for the 113th Congress
unnecessarily duplicated national health efforts of host countries and hampered country
ownership of health programs. This section discusses these issues as well as some other pressing
global health policy issues facing the 113th Congress.
Figure 10. Official Development Assistance for Health, FY2005-FY2011
(current U.S. $ millions and annual percent change)
Source: Created by CRS from the Organization for Economic Cooperation and Development (OECD) website
on statistics at http://www.oecd.org/statistics/, accessed on February 5, 2012.
Notes: Data in this figure reflects spending by DAC members and does not include funding from other sources,
including European Union institutions, the World Bank or private donors like the Gates Foundation.
Health aid levels include the OECD aid categories of health and population.
Defining U.S. Global Health Assistance and GHI
When President Obama announced the Global Health Initiative, some expressed hope that
questions about what programs should be counted towards U.S. global health spending would be
resolved. Some believe these questions remain and that some confusion persists about what
activities are included under GHI. For example, official documents on GHI spending only cover
global health activities funded through PEPFAR and the Global Health Programs account in
State-Foreign Operations, even though other agencies and departments outside of State, USAID
and CDC play a role in GHI. The Department of Defense, for instance, expends a significant
amount of resources on global health,40 yet GHI documents do not outline the relationship
40 The Department of Defense supports a wide array of activities that improve global health, especially responses to
natural disasters and conflicts. The department also maintains laboratories in several countries that conduct research on
(continued...)
Congressional Research Service
18
U.S. Global Health Assistance: Background and Issues for the 113th Congress
between DOD and the other implementing agencies nor do they explain how agencies like DOD
will further the goals of GHI.
Questions also remain about the coordination of global health programs between Washington and
the field and whether several long-standing issues with U.S. global health assistance have been
addressed, including
• a lack of consensus on what programs to count towards U.S. global health
spending;
• an unclear role for each implementing agency in improving global health,
particularly through GHI; and
• ambiguous leadership of U.S. global health efforts.
By any calculation, funding for global health has grown considerably since FY2000, particularly
through FY2008. Congress has used appropriations and authorizing legislation to direct how
those budgetary increases are to be applied and to detail the roles and responsibilities for key
global health positions. The Leadership Act, for example, authorized the creation of the Global
AIDS Coordinator while the Lantos-Hyde Act authorized the establishment of the Malaria
Coordinator. The legislation spelled out the roles of the coordinators, the oversight authority of
the positions and the priority areas to be addressed in carrying out related programs.
Congress has not separately authorized GHI. Legislation authorizing the establishment of a
Global Health Coordinator could clarify some of the questions regarding GHI, as discussed
above. Congress has also not yet considered legislation to authorize the Global Health Diplomacy
Office. Authorizing legislation might also be considered as an option for clarifying the role of the
GHD office, as well as resolving some of the questions listed in previous sections about the
oversight authorities of the office.
Funding GHI
Debates about U.S. global health spending levels are complex and, some argue, distinct from
general debates over foreign aid levels because many U.S. global health programs offer
immediate life-saving interventions. Several global health advocates argue that U.S. support for
global health is critical for scaling up the use of new—and potentially very successful—tools to
prevent and treat diseases, including HIV/AIDS and malaria. A number of observers contend that
a decline or leveling off of global health spending could threaten U.S. efforts to develop multi-
year agreements with governments that call for recipient countries to increasingly assume
responsibility over the programs. At the same time, some Members have questioned the impact of
U.S. global health investments, criticized corrupt practices by various governments receiving
global health assistance, and called for greater commitment to health by recipient countries.41
(...continued)
tropical diseases. These facilities include the Global Emerging Infections System, the Walter Reed Army Institute of
Research, Naval Medical Research Centers, and regional commands, including U.S. Africa Command. For more
information on these activities, see U.S. Army Medical Research and Materiel Command, USAMRMC Product
Portfolio, June 2007.
41 Shannon Kowalski, The Human Cost of Misplaced Priorities, Open Society Foundation, Blog, April 5, 2010.
Congressional Research Service
19
U.S. Global Health Assistance: Background and Issues for the 113th Congress
The Administration is reportedly taking steps to address concerns about aid effectiveness and
corruption. In 2011, USAID Administrator Rajiv Shah created a suspension and debarment task
force to monitor, investigate and respond to suspicious activity.42 In the same year, USAID
released a new evaluation policy that seeks to increase independent evaluation of ongoing
projects with results being released within three months of completing the evaluation.43 In
February 2012, President Obama signed an executive order establishing the President’s Global
Development Council, to be administered by USAID. According to the White House, the council
will inform and provide advice to the President and other U.S. officials on U.S. global
development policies and practices and solicit input on current and emerging issues in the field.44
Maintaining HIV/AIDS Commitments
On World AIDS Day in December 2011, President Obama announced that the United States was
committed to supporting treatments for 6 million HIV-positive people by the end of 2013.45 This
announcement followed the May 2011 release of findings, which indicated that early initiation of
HIV treatment in discordant couples46 reduced HIV transmission by 96%. The NIH-funded
research found that HIV transmission rates declined precipitously following consistent and proper
use of HIV medication due to dramatic reductions in viral loads.47 The finding was hailed by
many as a “game-changer” and led several HIV/AIDS experts to argue that HIV/AIDS could be
eliminated as a public health problem.48 The announcement also led to calls for maintaining U.S.
support of HIV treatment around the world.
The United States spends more than any other country on fighting HIV/AIDS worldwide,
accounting for 59% of all donor government spending in 2011.49 Additionally, the United States
remains a key donor for multilateral programs, like the Global Fund, accounting for roughly 1/3
of all country donors. Most developing countries are heavily reliant on donors to fund their
national HIV/AIDS plans.50 In Kenya, for example, donors provided more than 80% of the
resources needed to support its $709 million HIV/AIDS budget in 2011.51
The Lantos-Hyde Act called for the creation of partnership frameworks that would outline plans
for increasing country ownership and funding of national HIV/AIDS plans.52 The U.S.-South
Africa Partnership Framework Implementation Plan, for example, envisions reducing PEPFAR
42 U.S. Congress, Senate Committee on Foreign Relations, Statement by Dr. Rajiv Shah, USAID Administrator, Hearing
on International Development Policy Priorities in the FY 2012 Budget, 112th Cong., 1st sess., April 13, 2011.
43 Ibid. Also see, USAID, Evaluation Policy, January 19, 2011.
44 The White House, “Fact Sheet: The President’s Global Development Council,” press release, February 9, 2012.
45 The White House, “Remarks by the President on World AIDS Day,” press release, December 1, 2011.
46 HIV-serodiscordant couples have one partner who is HIV-positive and another who is HIV-negative.
47 NIH, National Institute of Allergy and Infectious Diseases, “Treating HIV-infected people with antiretrovirals
protects partners from infection: Findings result from NIH-funded international study,” press release, May 12, 2011.
48 “HIV Treatment as Prevention: Breakthrough of the Year, 2011,” Science Magazine, Special Issues 2011.
49 Jennifer Kates et al., Financing the Response to AIDS in Low-and Middle-Income Countries: International
Assistance from Donor Governments in 2011, Kaiser Family Foundation, July 2012, p. 2.
50 Michel Sidibé, Executive Director of UNAIDS, “Partners in Treatment,” Remarks at United Nations Industrial
Development Organization (UNIDO) Industrial Development Board (IDB) 38th Session, November 24, 2010.
51 UNAIDS, Together We Will End AIDS, 2012, p. 109.
52 P.L. 110-293, Section 301. Also see the PEPFAR website on Partnership Frameworks.
Congressional Research Service
20
U.S. Global Health Assistance: Background and Issues for the 113th Congress
aid from the FY2012 level of roughly $484 million to $250 million by FY2017.53 Similarly, the
government of Nigeria, commits to funding half of its national HIV/AIDS program by the end of
the framework’s five-year implementation.54
Most global health experts agree that country ownership of global health programs is important.
Some observers are concerned, however, that the United States is hastily drafting partnership
frameworks with countries that are not prepared to assume control over national HIV/AIDS
programs.55 The FY2013 budget request, for example, called for a 57% reduction in global health
spending for Ethiopia from FY2012 levels. The biggest cut would come from PEPFAR programs,
which the Administration proposes decreasing by roughly 80% from $254 million in FY2012 to
$54 million in FY2013 (Figure 11).
Figure 11. GHI Spending in Ethiopia, FY2009-FY2013
(millions of U.S. current dollars)
400
350
300
250
200
150
100
50
-
FY2009 Actual
FY2010 Actual
FY2011 Actual FY2012 Estimate FY2013 Request
HIV/AIDS
334
324
289
254
54
TB
5
10
10
13
10
Malaria
20
31
41
43
39
MCH
18
18
21
27
22
FP/RH
21
25
28
30
29
Nutrition
0
4
7
7
7
Total GHI
397
411
396
375
161
Source: Created by CRS from http://www.foreignassistance.gov.
Notes: FY2009-FY2011 actual, FY2012 estimate, FY2013 request. Congress had not yet specified funds for
nutrition programs in FY2009.
There is some uncertainty about what impact spending cuts may have on national HIV/AIDS
plans.56 In January 2013, for example, global health experts expressed alarm about proposals to
53 Department of State, Partnership Framework Implementation Plan in Support of South Africa’s National HIV, STI &
TB Response, 2012/13 - 2016/2017, August 2012, p. 33, http://www.pepfar.gov/documents/organization/196651.pdf.
54 Ambassador Eric Goosby advocated the application of the Partnership Framework in his statement for U.S.
Congress, House Committee on Foreign Affairs, PEPFAR: From Emergency to Sustainability and Advances Against
HIV/AIDS, 111th Cong., September 29, 2010.
55 Deirdre Shesgreen, “What Should Country Ownership Really Mean as PEPFAR Moves into Next Phase?” Center for
Global Health Policy, May 20, 2010.
56 Amanda Glassman, “Ethiopia’s AIDS Spending Cliff,” Center for Global Development, September 11, 2012.
Congressional Research Service
21
U.S. Global Health Assistance: Background and Issues for the 113th Congress
drastically reduce PEPFAR funds in Ethiopia. An Ethiopian official reportedly indicated,
however, that the government had been expecting the budget cuts and that it will reduce funding
for “softer programmatic activities;” employ innovative strategies; and mobilize internal
resources to replace the lost funds.57
Opponents to sharp budget cuts point to reports and press accounts from South Africa of stock
outs, staff shortages, and poor service at several district and national health centers due to poor
management of resources.58 HIV/AIDS advocates are concerned that by shifting HIV/AIDS
service to local health centers, patients may not be able to access their medicines in a timely
fashion (raising the risk of drug resistance) or may avoid the centers altogether due to the poor
conditions.59
Reductions of U.S. global HIV/AIDS budgets are distressing for those concerned about taking
advantage of recent scientific developments and about maintaining funding for HIV/AIDS
treatment programs. This issue is sensitive, since people without medicine will inevitably die. The
Administration maintains that reductions in operating costs and increased efficiencies will enable
the United States to reach its treatment goals while reducing spending.60 There is some concern
that abrupt reductions in global HIV/AIDS funding will imperil the gains made over the last
decade from unprecedented spending levels. Other observers question whether the United States
should vow to continuously increase the number of patients receiving treatment considering HIV-
positive people need to be treated for a lifetime.61
Extending PEPFAR Authorization Legislation
Funds to carry out PEPFAR have been authorized under two successive authorization acts: the
Leadership Act of 2003 (P.L. 108-25) and the Lantos-Hyde Act of 2008 (P.L. 110-293). The acts
authorized the appropriation of $15 billion and $48 billion, respectively, for fighting HIV/AIDS,
TB, and malaria. Authorization for funds to carry out PEPFAR is set to expire at the end of
FY2013. The U.S. Congress has become more divided over issues related to foreign aid in
general since Lantos-Hyde was enacted. It is uncertain whether these issues will be sufficiently
resolved as to enable reauthorization in the 113th Congress. If Congress does not enact a second
reauthorization, PEPFAR activities could continue to be funded through annual appropriations,
but Congress might consider whether its priorities could be sufficiently delineated through
appropriations alone.
57 United Nations Office for the Coordination of Humanitarian Affairs, “Ethiopia: Concerns Over HIV/AIDS Funding
Cuts,” IRIN News, January 9, 2013.
58 Doctors Without Borders, Emergency Intervention at Mthatha Depot: The Hidden Cost of Inaction, January 2013.
59 Mishack Mahlangu, “HIV Patients Stranded As PEPFAR Funds Dry Up,” Health Systems Trust, January 29, 2013;
Doctors Without Borders et al., Emergency Intervention at Mthatha Depot, January 2013.
60 Eric Goosby, “President’s Budget Request Reflects Strong Commitment on Global AIDS,” blog.aids.gov, February
13, 2012.
61 Mead Over, Prevention Failure: The Ballooning Entitlement Burden of U.S. Global AIDS Treatment Spending and
What to Do About It, Working Paper 144, April 2008; and Neil Patel, Emergency to Efficiency, Harvard Political
Review Online, December 5, 2010.
Congressional Research Service
22
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Balancing Bilateral and Multilateral Activities
The appropriate balance between bilateral and multilateral assistance is a frequent point of
contention among U.S. policymakers. This debate has intensified in recent years as the Obama
Administration has taken several steps to heighten support for multilateral organizations,
particularly the Global Fund. The United States is a leading contributor to several other
multilateral health organizations, including UNAIDS, WHO, the International AIDS Vaccine
Initiative (IAVI), and the GAVI Alliance, among others. Nonetheless, discussions about the
appropriate mix of multilateral and bilateral funding have primarily focused on U.S. support for
the Global Fund.
Proponents of strong bilateral funding argue that direct U.S. global health spending carries a
number of advantages, including the ability to
• strategically direct where and how aid is used,
• more easily monitor and evaluate use of aid and program impact, and
• more rapidly adjust how funds are spent.
On the other hand, some observers maintain U.S. participation in multilateral responses to global
health offers distinct advantages, including the ability to
• pool and leverage limited resources, which can capitalize on efficiencies,
• coordinate assistance with a range of donors, and
• provide aid that better aligns with the priorities of the recipient countries.
The debate about the appropriate funding levels for bilateral and multilateral funding can distract
from another important issue: alignment of bilateral and multilateral programs. According to a
report by WHO, 20% to 40% of health spending is wasted through inefficiency.62 The report
identified several areas in which donors could eliminate waste, namely through aligning financial,
reporting, and monitoring practices. By harmonizing the auditing, monitoring, and evaluation of
bilateral and multilateral programs, WHO asserted, health staff could use some of the time spent
on compiling reports to addressing other health issues.
Supporters of donor harmonization call on the Obama Administration to sign the International
Health Partnership Compact, an international agreement drafted by the International Health
Partnership (IHP+) that calls for the international community to work together to improve the
efficiency of health aid.63 The compact specifically calls on
• international organizations and bilateral donors to use national health plans as
the basis for funding and planning health aid, ensure efforts to address particular
diseases are funded and implemented as part of a broader effort to improve health
systems, and be accountable for health aid by annually evaluating, monitoring,
and reporting on results;
62 WHO, Health Systems Financing: The Path to Universal Coverage, World Health Report, 2010, p. vi.
63 See the IHP+ website at http://www.internationalhealthpartnership.net/en/.
Congressional Research Service
23
U.S. Global Health Assistance: Background and Issues for the 113th Congress
• governments to use national health plans to guide development of health
systems, work with all stakeholders (including civil society and international
organizations) and ensure that budgets reflect common vision for the health
sector, tackle misappropriation of funds, strengthen health and financial
management systems, and be accountable to the citizenry and funders through
reports on results; and
• other donors to use their resources to advance coordinated multilateral
approaches to strengthening health systems, continue to invest in learning and
evaluation mechanisms to identify best practices, and be accountable and hold
organizations receiving support accountable for measuring impact and directing
funding to proven successes.
As of May 2013, 58 countries, multilateral organizations, and other donors have signed the
International Health Partnership Compact.64 While the Obama Administration has indicated
support for the agreement,65 the United States has not signed it.
Conclusion
Global health has been a central issue in congressional debates over foreign assistance programs
and funding levels. Some expect that global health will be an area of ongoing congressional
interest, both as a way to potentially reduce overall spending and to improve the effectiveness of
aid. In determining funding levels for global health programs, Congress may consider
• ways that the United States can encourage country ownership of global health
programs;
• the appropriate balance of funding between bilateral and multilateral programs;
• the role that the United States plays in global health, particularly in relation to
other donors; and
• the extent to which the United States can invest in new global health areas.
The rising global prevalence of non-communicable diseases can threaten U.S. efforts to transfer
ownership of U.S. global health programs to recipient countries. Many middle-income countries
like South Africa face dual epidemics of diseases associated with growing prosperity (diabetes)
and persistent poverty (vaccine preventable deaths). In the absence of higher spending levels,
bolstering health systems will likely gain greater importance in U.S. global health programs. Such
efforts could help countries formulate sustainable plans to address these mostly preventable
diseases while addressing infectious diseases that have threatened poor countries for decades.
Along with debating issues related to U.S. global health assistance, Congress may also consider
its own role in U.S. global health aid. Congress has exercised growing involvement in shaping
global health programs by authorizing the creation of key global health positions, enacting
legislation that included spending directives and described congressional priorities. Global health
analysts have debated whether Congress’s elevated role has helped or hindered the efficacy of
64 See http://www.internationalhealthpartnership.net/.
65 See USAID, The United States Government Global Health Initiative Strategy, March 1, 2011, p. 8.
Congressional Research Service
24
U.S. Global Health Assistance: Background and Issues for the 113th Congress
global health programs. For example, some argue that congressional spending directives have
limited the ability of country teams to tailor programs to in-country needs. Others argue that
congressional mandates and recommendations have protected critical areas in need of support and
facilitated the implementation of a cohesive global health strategy across agencies.
Congressional Research Service
25
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Appendix A. GHI Framework
Figure A-1. GHI Framework
Source: Reproduced by CRS from GHI website, http://www.ghi.gov/about/goals/index.htm, accessed on January
9, 2013.
Abbreviations and Acronyms: anti-retroviral treatments (ARVs), health system strengthening (HSS),
maternal (mat.), mil ion (M), modern contraceptive prevalence rate (MCPR), monitoring and evaluation (ME),
mortality (mort.), neglected tropical diseases (NTDs), proportion (prop.), tuberculosis (TB).
Congressional Research Service
26
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Appendix B. Non-Communicable Disease (NCD)
Deaths Among People Under 60 Years, by Country
Income-Group
Figure B-1. Global NCD Mortality Among People Under 60 Years
Source: WHO, Noncommunicable Diseases Country Profiles 2011, 2011, p. 5.
Congressional Research Service
27
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Appendix C. U.S. Global Health Funding,
FY2001-FY2014
Table C-1. U.S. Global Health Spending, by Agency, FY2001-FY2014
(current U.S. $ millions)
FY2001
FY2002
FY2003
FY2004
FY2005
FY2006
FY2007
Agency/Department
Actual
Actual
Actual
Actual
Actual
Actual
Actual
State
HIV/AIDS
0.0 0.0 0.0
488.1
1,373.9 1,777.1
2.869.0
USAID
Global
Health
1,115.1 1,297.5 1,572.0 1,451.4 1,314.6
1,456.9 1,653.9
Global
Fund
100.0 50.0 248.4 397.6 248.0
445.5 625.0
State-Foreign
Operations 1,215.1 1,347.5 1,820.4 2,337.1 2,936.5
3,679.5 5,147.9
CDC
Global
Health
224.1 315.5 344.0 427.9 302.1
311.7 307.6
NIH
Global
AIDS
Research 160.1 218.2 278.5 317.2 369.5
373.0 361.7
Global
Fund
0 125.0 99.0 149.0 99.2
99.0 99.0
DOL
HIV/AIDS
10.0 10.0 9.9 2.0 0.0
0.0 0.0
Labor-HHS
Appropriations 390.8 665.3 728.0 903.9 772.7
783.7 768.3
DOD
HIV/AIDS
10.0 14.0 7.0 4.3 7.5
5.2 0.0
Total
Global
Health
1,715.9 2,076.8 2,803.8 3,642.9 3,964.7
4,715.9 6,163.7
FY2008
FY2009
FY2010
FY2011
FY2012
FY2013
FY2014
Agency/Department
Actual
Actual
Actual
Actual
Estimate
Consolidateda
Request
State
HIV/AIDS
4,116.4 4,559.0 4,609.0 4,585.8 4,242.9
4,070.5 4,020.0
USAID
Global
Health
1,834.2 2,030.0 2,518.6 2,498.0 2,625.0
2,641.1 2,645.0
Global
Fund
545.5 700.0 750.0 748.5 1,300.0
1,650.0 1,650.0
State-Foreign
Operations 6,496.1 7,289.0 7,877.6 7,832.3 8,417.9
8,361.6 8,315.0
CDC
Global
Health
302.3 319.1 334.8 330.2 347.6
not
specifieda 393.0
NIH
Global
AIDS
Research 411.7 451.7 485.6 375.7 392.4
392.0 399.1
Global
Fund
294.8 300.0 300.0 297.3
0.0
0.0
0.0
DOL
HIV/AIDS
0.0 0.0 0.0 0.0 0.0
0.0 0.0
Labor-HHS
Appropriations 1,008.8 1,060.5 1,132.3 1,013.1 740.0 not specifieda
792.1
DOD
HIV/AIDS
8.0 8.0 8.0 10.0 8.0
not
specifieda 0.0
Total
Global
Health
7,512.9 8,457.5 9,017.9 8,855.4 9,165.9 not specifieda
9,107.1
Source: Appropriations legislation, congressional budget justifications, and personal communication with OMB.
Notes: This table does not include funding for the UN Children’s Fund (UNICEF), which was appropriated to the Child
Survival and Health account prior to FY2004.
Figures in FY2001-2008 include funds appropriated to multiple accounts within State-Foreign Operations. Figures in FY2009-
FY2013 only include appropriations to the Global Health Programs Account.
a. The FY2013 Consolidated Act did not specify an amount.
Congressional Research Service
28
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Table C-2. State-Foreign Operations Appropriations, FY2001-2014
(current U.S. $ millions)
FY2001
FY2002
FY2003
FY2004
FY2005
FY2006
FY2007
Agency/Program
Actuala
Actuala
Actuala
Actuala
Actuala
Actuala
Actuala
HIV/AIDS
305.0 395.0 587.7 513.5 347.2
346.5 325.0
Tuberculosis
50.0 60.0 64.2 74.7 79.4
81.8 80.8
Malaria
55.0 65.0 64,6 79.6 79.4
98.9 248.0
USAID Global Fund
100.0
50.0
248.4
397.6
248.0
247.5
247.5
Maternal/Child
Health
295.3 315.0 411.9 328.1 347.5
369.6 392.6
Nutrition c
n/a n/a n/a n/a n/a
n/a n/a
Vulnerable
Children
14.9 25.0 26.8 27.8 24.5
12.6 6.5
Family
Planning/Reproductive
Health 376.2 402.5 391.0 398.1 396.8
393.5 396.5
Neglected Tropical Diseasesd
n/a n/a n/a n/a n/a
14.8 14.9
Pandemic
Flu/Other
18.7 35.0 25.8 29.6 39.8
139.2 189.6
USAID
Total
1,215.1 1,347.5 1,820.4 1,849.0 1,562.6
1,704.4 1,901.4
State Department HIV/AIDSe
n/a n/a n/a
488.1
1,373.9 1,777.1
2,869.0
State Department Global Fundf
n/a n/a n/a n/a n/a
198.0
377.5
State Department Total
0.0
0.0
0.0
488.1
1,373.9
1,975.1 3,246.5
State-Foreign
Operations
Total 1,215.1 1,347.5 1,820.4 2,337.1 2,936.5
3,679.5 5,147.9
FY2008
FY2009
FY2010
FY2011
FY2012
FY2013
FY2014
Agency/Program
Actuala
Actualb
Actualb
Actualb
Estimateb
Consolidated
Request
HIV/AIDS
347.2 350.0 350.0 349.3 350.0
330.0
Tuberculosis
148.0 162.5 225.0 224.6 236.0
191.0
Malaria
347.2 382.5 585.0 618.8 650.0
670.0
USAID Global Fund
0.0
100.0
0.0
0.0
0.0
0.0
Maternal/Child
Health
449.0 440.1 474.0 548.9 605.6
680.0
not specifiedg
Nutrition c
n/a 54.9 75.0 89.8 95.0
95.0
Vulnerable
Children
14.9 15.0 15.0 15.0 17.5
13.0
Family
Planning/Reproductive
Health 398.0 455.0 528.6 527.0 523.9
534.0
Neglected Tropical Diseasesd
14.9 25.0 65.0 76.8 89.0
85.0
Pandemic
Flu/Other
115.0 145.0 201.0 47.9
58.0
47.0
USAID Total
1,834.2 2,130.0 2,518.6 2,498.0 2,625.0
2,641.1 2,645.0
State Department HIV/AIDSe
4,116.4 4,559.0 4,609.0 4,585.8 4,492.9
4,070.5 4,020.0
State Department Global Fundf
545.5 600.0 750.0 748.5 1,300.0
1,650.0 1,650.0
State Department Total
4,661.9 5,159.0 5,359.0 5,334.3 5,792.9
5,720.5 5,670.0
State-Foreign Operations Total
6,496.1 7,289.0 7,877.6 7,832.3 8,417.9
8,361.6 8,315.0
Source: Appropriations legislation, congressional budget justifications, and personal communication with OMB.
Congressional Research Service
29
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Notes: This table does not include funding for the UN Children’s Fund (UNICEF), which was appropriated to the Child Survival and
Health account prior to FY2004.
a. Figures in FY2001-2008 include funds appropriated to multiple accounts within State-Foreign Operations.
b. Figures in FY2009-FY2013 only include appropriations to the Global Health Programs Account.
c. After the announcement of GHI in 2009, Congress began to appropriate funds for nutrition programs. Until then, nutrition funds
were included in appropriations for maternal and child health programs.
d. USAID received its first appropriation for neglected tropical diseases per language in the FY2006 State Foreign Operations
appropriations that directed USAID to make available at least $15 million for fighting seven NTDs.
e. The Department of State received its first appropriation for managing PEPFAR funds through FY2004 State Foreign Operations
appropriations.
f.
Congress provided funds to the State Department for a contribution to the Global Fund for the first time in FY2006 through the
FY2006 State Foreign Operations appropriations.
g. The FY2013 Consolidated Act did not specify an amount.
Congressional Research Service
30
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Table C-3. Labor, HHS Appropriations, FY2001-2014
(in millions of current dollars)
FY2001 FY2002 FY2003 FY2004
FY2005
FY2006
FY2007
HHS Program
Actual
Actual
Actual
Actual
Actual
Actual
Actual
HIV/AIDS
104.5 168.7 182.6 266.9 123.8
122.6 121.0
Immunizations
106.6 133.8 148.8 137.8 144.4
144.3 142.4
Polio 91.2
107.4
106.4
96.8
101.2
101.1
99.8
Other
Global/Measles
15.4 26.4 42.4 41.0 43.2
43.2 42.6
Parasitic
Disease/Malaria
n/a n/a n/a n/a n/a
n/a n/a
Malaria
13.0
13.0 12.6 9.2
9.1
9.0 8.9
Global Disease Detection
0.0
0.0
0.0
11.6
21.4
32.4
32.0
FE(L)TP/SMDP
n/a n/a n/a 2.4 3.4
3.4 3.3
CDC
Total
224.1 315.5 344.0 427.9 302.1
311.7 307.6
NIH Global AIDS Research
160.1
218.2
278.5
317.2
369.5
373.0
361.7
HHS Global Fund
0.0
125.0
99.0
149.0
99.2
99.0
99.0
DOL
10.0 10.0 9.9 9.9 2.0
0.0 0.0
Labor, HHS, Education Total
394.2
668.7
731.4
904.0
772.8
783.7
768.3
FY2008 FY2009 FY2010 FY2011
FY2012
FY2013
FY2014
HHS Program
Actual
Actual
Actual
Actual
Estimate Consolidated Request
Global AIDS Program (GAP)
118.9
118.9
119.0
118.7
117.1
131.9
Immunizations
139.8 143.3 153.7 150.9 160.3
183.0
Polio
98.0 101.5 101.8 101.6 111.3
131.0
Other
Global/Measles
41.8 41.8 51.9 49.3 49.0
52.0
Parasitic Disease/Malariaa
n/a n/a 19.8 19.9 19.4
22.2
Malaria
8.7 9.4 9.4 9.4 9.4
10.7
not specified b
Global Disease Detection
31.4
33.7
44.2
41.9
41.6
45.6
FE(L)TP/SMDP
3.5 13.8 8.5 9.3 9.2
10.3
CDC
Total
302.3 319.1 345.2 340.7 347.6
393.0
NIH Global AIDS Research
411.7
451.7
485.6
375.7
392.4
399.1
HHS Global Fund
294.8
300.0
300.0
297.3
0.0
0.0
DOL
0.0 0.0 0.0 0.0 0.0
0.0
Labor, HHS, Education Total
1,008.8
1,070.8
1130.8
1,013.7
740.0 not specified b
792.1
Source: Appropriations legislation, congressional budget justifications, and personal communication with OMB.
Acronyms: not applicable (n/a), not specified (n/s), Field Epidemiology Laboratory Training Program (FELTP)/Sustainable Management
Development Program (SMDP).
a. The FY2012 Congressional Budget Justification proposed creating a new funding category, Parasitic Diseases/Malaria,
that combined funding for programs aimed at addressing parasitic diseases (like neglected tropical diseases) with those
aimed at combating malaria. Since FY2010, CDC operating plans have reported spending in this fashion.
b. The FY2013 Consolidated Act did not specify an amount.
Congressional Research Service
31
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Table C-4. PEPFAR, FY2001-FY2014
(current U.S. $ millions)
FY2001
FY2002
FY2003
FY2004
FY2005
FY2006
FY2007
Agency/Department
Actual
Actual
Actual
Actual
Actual
Actual
Actual
State HIV/AIDSa 0.0
0.0
0.0
488.1
1,373.9
1,975.1
3,246.5
State Global Fundb
0.0 0.0 0.0 0.0 0.0
198.0
377.5
USAID Global HIV/AIDS
405.0
445.0
836.1
911.1
595.2
594.0
572.5
USAID Global Fund
100.0
50.0
248.4
397.6
248.0
247.5
247.5
State-Foreign Operations
405.0
445.0
836.1
1,399.2
1,969.1
2,569.1
3,819.0
CDC Global HIV/AIDS
104.5
168.7
182.6
266.9
123.8
122.6
121.0
NIH Global AIDS Research
160.1
218.2
278.5
317.2
369.5
373.0
361.7
HHS Global Fund
0.0
125.0
99.0
149.0
99.2
99.0
99.0
DOL Global HIV/AIDS
10.0
10.0
9.9
9.9
2.0
0.0
0.0
Labor-HHS Appropriations
274.6
521.9
570.0
743.3
594.5
594.6
581.7
DOD Global HIV/AIDS
10.0
14.0
7.0
4.3
7.5
5.2
0.0
Total PEPFAR
689.6
980.9
1,413.1
2,146.5
2,571.1
3,168.9
4,400.7
Total Global Fund
100.0
175.0
347.4
546.6
347.2
544.5
724.0
Agency/Department
FY2008
FY2009
FY2010
FY2011
FY2012
FY2013
FY2014
Actual
Actual
Actual
Actual
Estimate Consolidated Request
State HIV/AIDSa 4,661.9
5,159.0
5,359.0
5,334.3
5,542.9
4,070.5
4,020.0
State Global Fundb 545.5
600.0
750.0
748.5
1,300.0 1,650.0
1,650.0
USAID Global HIV/AIDS
347.2
450.0
350.0
349.3
350.0
not specifiedc 330.0
USAID Global Fund
0.0
100.0
0.0
0.0
0.0
0.0
0.0
State-Foreign Operations
5,009.1
5,609.0
5,709.0
5,683.6
5,892.9
not specifiedc
6,000.0
CDC Global HIV/AIDS
118.9
118.9
119.0
118.7
117.1
not specifiedc 131.9
NIH Global AIDS Research
411.7
451.7
485.6
375.7
364.7
392.0
399.1
HHS Global Fund
294.8
300.0
300.0
297.3
0.0
0.0
0.0
DOL Global HIV/AIDS
0.0
0.0
0.0
0.0
0.0
0.0
0.0
Labor-HHS Appropriations
825.4
870.6
904.6
791.7
481.6
531.0
not specifiedc
DOD Global HIV/AIDS
8.0
8.0
10.0
10.0
8.0
0.0
Total PEPFAR
5,842.5
6,487.6
6,623.6
6,485.3
6,382.5 not specifiedc
6,531.0
Total Global Fund
840.3
1,000.0
1,050.0
1,045.8
1,300.0
1,650.0
1,650.0
Source: Appropriations legislation, congressional budget justifications, and personal communication with OMB.
Notes: Rows that are indented and italicized are included within totals of the preceding rows.
a. The Department of State received its first appropriation for managing PEPFAR funds through FY2004 State Foreign
Operations appropriations.
b. Congress provided funds to the State Department for a contribution to the Global Fund for the first time in FY2006
through the FY2006 State Foreign Operations appropriations.
c. The FY2013 Consolidated Appropriations Act did not specify an amount.
Congressional Research Service
32
U.S. Global Health Assistance: Background and Issues for the 113th Congress
Author Contact Information
Tiaji Salaam-Blyther
Specialist in Global Health
tsalaam@crs.loc.gov, 7-7677
Congressional Research Service
33