U.S. Global Health Assistance: FY2017-FY2020 Request

U.S. Global Health Assistance: FY2017-FY2020 Request

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Updated March 14, 2019
U.S. Global Health Assistance: FY2017-FY2019 Request
Background
policy, which restricts U.S. assistance to foreign NGOs
Congress has made global health a priority for several
engaged in voluntary abortion activities, even if such
years, including through support for global health
activities are conducted with non-U.S. funds. Whereas the
programs. From FY2001 through FY2008, appropriations
policy applied only to family planning and reproductive
for global health rose from less than $2 billion to almost $8
health programs under the George W. Bush Administration,
billion. The funding increases largely supported two U.S.
the Trump Administration reinstated the policy in January
programs aimed at fighting HIV/AIDS and malaria
2017, following its reversal during the Obama
worldwide: the President’s Emergency Plan for AIDS
Administration, and applied it to all global health programs
Relief (PEPFAR) and the President’s Malaria Initiative,
under a new policy called Protecting Life in Global Health
both launched during the George W. Bush Administration.
Assistance. In the 115th Congress, the House and Senate
During the Obama Administration, appropriations leveled
introduced legislation to permanently repeal the expanded
off and averaged roughly $9 billion annually.
policy. In the 116th Congress, S.Res. 20 promotes
permanently enacting the policy.
The FY2020 budget request would reduce overall funding
for global health by almost 30% from FY2019-enacted
Table 1. Global Health Appropriations:
levels and would include roughly $6.3 billion through State,
FY2017 Enacted-FY2020 Request
Foreign Operations (SFOPS) appropriations and some $0.4
(current U.S. $ millions)
billion through Department of Labor, Health and Human
Services (Labor-HHS) and Education appropriations (Table
1).
Global Health Appropriations
Foreign Operations. Through SFOPS appropriations,
Congress funds PEPFAR; the Global Fund to Fight AIDS,
Tuberculosis and Malaria (Global Fund); and global health
activities managed by the U.S. Agency for International
Development (USAID). The Administration proposes
reduced funding for all global health programs funded
through SFOPS appropriations from FY2019-enacted
levels, including a 35% reduction for USAID-managed
global health programs, a 23% cut for Department of State-

managed PEPFAR programs, and a 29% cut for U.S.
Sources: Congressional budget justifications and correspondence
contributions to the Global Fund.
with USAID and CDC legislative affairs offices.
Abbreviations: Department of State (State), U.S. Agency for
Labor-HHS. The FY2020 budget request includes a 6%
International Development (USAID), Global Fund to Fight AIDS,
reduction for global health programs implemented by the
Tuberculosis and Malaria (Global Fund), State-Foreign Operations
Centers for Disease Control and Prevention. The Labor-
(SFOPS) appropriations, Centers for Disease Control and Prevention
HHS budget request does not include a breakout of global
(CDC), National Institutes of Health (NIH), and Labor, Health and
health funding for the U.S. Centers for Disease Control and
Human Services, and Education (Labor-HHS) appropriations.
Prevention (CDC). The National Institutes of Health (NIH)
has not released budget projections for international
a. Includes amounts transferred to USAID for global health
HIV/AIDS research since FY2017.
activities from unobligated funds provided for the Ebola
outbreak.
Global Health Policy Debates
b. Funds for NIH international HIV/AIDS research are not typical y
Policy experts and Congress are discussing the significance
included in budget requests and are drawn from the overal
of three key actions by the Trump Administration: (1) to
budget of the Office of AIDS Research. Annual spending
reinstate and expand the Mexico City Policy, (2) to propose
amounts are reported in congressional budget justifications.
reducing the global health budget from previous fiscal
c. To maintain consistency across fiscal years, CRS did not
years, and (3) to prioritize PEPFAR engagement in specific
aggregate the total because funding levels for NIH international
countries.
HIV/AIDS research are not yet available.
Protecting Life in Global Health Assistance. Since the
Mexico City Policy was first established under the Reagan
U.S. Global Health Budget. The FY2020 budget request
Administration, Members on both sides of the issue have
included a proposal to cut global health funding by more
introduced legislation to permanently enact or repeal the
than $2 billion from FY2019-enacted levels. Some global
health experts warn that such reductions could imperil
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U.S. Global Health Assistance: FY2017-FY2019 Request
advances made in global health. Supporters of reduced
The Trump Administration appears to be continuing the 3.0
funding assert that current funding levels are unsustainable.
strategy and has proposed concentrating efforts in 13
countries (Botswana, Cote d'Ivoire, Haiti, Kenya, Lesotho,
The United States provides more official development
Malawi, Namibia, Rwanda, Swaziland, Tanzania, Uganda,
assistance (ODA) for health than any other country in the
Zambia, and Zimbabwe). In these countries, the
Development Assistance Committee (DAC)—a group of
Administration PEPFAR will work with other partners to
industrialized countries committed to international
ensure that 95% of HIV-positive people know their status,
development (Figure 1). The United States also apportions
95% of those who know their status are on ART, and that
more of its foreign aid to improving global health than other
95% of those on treatment maintain suppressed viral loads
major DAC donor country. In 2016, for example, health aid
for at least three years. These efforts, the Administration
($9.1 billion) accounted for 31% of U.S. ODA ($30.0
maintains, will lead to AIDS epidemic control.
billion). The second-largest foreign aid donor, Germany,
allocated 3% of its overall ODA ($24.4 billion) to health
The Trump Administration proposal to maintain treatment
aid ($641 million). The second-largest donor of health aid,
levels is a departure from the Bush and Obama
the United Kingdom, apportioned 13% of its development
Administrations, under which executive and legislative
assistance ($8.2 billion) for health aid ($1.1 billion).
priorities for PEPFAR included steadily increasing the
Figure 1. Global Development and Health Aid: 2016
number of people receiving ART through PEPFAR.
Figure 2. AIDS Deaths and ART Coverage: 2000-2017

Source: Created by CRS from the Organization for Economic
Cooperation and Development (OECD) website on statistics at
http://stats.oecd.org/, accessed on July 9, 2018.
Abbreviations: United States of America (USA), Development
Assistance Committee (DAC), and United Kingdom (UK).
Those funds have contributed to significant improvements
in global health. Between 1990 and 2015, for example, the
global maternal mortality ratio fell by 44% and preventable
child deaths declined by 58% between 1990 and 2017.

Expanded access to vaccines has contributed significantly
Source: Created by CRS from the Joint United Nations Program on
to global declines in child deaths. For instance, since 2017,
AIDS (UNAIDS) database, at http://aidsinfo.unaids.org.
global vaccine efforts have reduced measles deaths by 80%
Outlook
from 2000 levels, and wild polio virus is circulating in only
The United States government spends more on global
two countries.
health programs than any other country in the world.
Funding and policy decisions that it makes may reverberate
PEPFAR Engagement. Annual AIDS death rates have
across the international community. Some experts are
been steadily declining, and the rate at which this has
concerned that the progress made in global health to date
occurred has accelerated since PEPFAR was launched
may be undermined should the United States reduce global
(Figure 2). AIDS deaths declined from a peak of 1.9
health funding or decrease global engagement. Others
million in 2003 to 0.9 million in 2017. Declines in AIDS
maintain that U.S. global health programs could be
deaths have been attributed in large part to expanded access
improved by streamlining programs, improving efficiency,
to antiretroviral treatment (ART) provided through
and aligning funding with U.S. priorities.
PEPFAR programs and U.S. contributions to the Global
Fund. Before PEPFAR was launched in 2003, roughly 4%
Broader related policy concerns include addressing the
of people in low- and middle-income countries were on
health effects of climate change (e.g., drought-related
ART. By 2017, ART coverage had reached an estimated
malnutrition and the spread of infectious diseases through
59% in those areas.
national disasters) and bolstering pandemic preparedness
worldwide. For more on these and other global health
Toward the end of the Obama Administration, the State
issues, see CRS Report R43115, U.S. Global Health
Department announced PEPFAR 3.0—a plan to “more
Appropriations: FY2001-FY2019.
directly support HIV services and populations where the
highest impact gains towards an AIDS-free generation will
Edward Gracia, CRS Research Assistant, contributed to this
be felt.” When this strategy was announced, HIV/AIDS
In Focus.
advocates bemoaned the shift and questioned whether
partner countries and local civil society were sufficiently
Tiaji Salaam-Blyther, Specialist in Global Health
prepared for the divestment. Supporters argued that HIV
IF10131
spending levels were unsustainable and the funds needed to
be spent where impact could be maximized.
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U.S. Global Health Assistance: FY2017-FY2019 Request

Disclaimer
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