Contents

• Introduction to U.S. Global Health Assistance
• U.S. Global Health Assistance Programs
• USAID Global Health Programs
• CDC Global Health Programs
• Global HIV/AIDS Programs
• Additional U.S. Global Health Assistance
• U.S. Global Health Priorities in the 107^th-110^th Congresses
• USAID Global Health Programs
• CDC Global Health Programs
• HIV/AIDS
• Avian and Pandemic Influenza
• Malaria
• Tuberculosis
• U.S. Global Health Priorities in the 111^th Congress
• FY2010 Foreign Operations Appropriations
• Key Provisions in FY2010 Foreign Operations Appropriations
• Administration Priorities
• Related Policy Issues
• How Should Global Health Assistance Be Defined?
• What Strategy Should Guide U.S. Global Health Assistance?
• What Is the Appropriate Balance of Funding for Global Health Programs?
• Balance Between Disease-Specific and Health Systems Efforts
• Balance Between Bilateral and Multilateral Health Assistance
• What Impact Would Foreign Aid Reform Initiatives Have on Global Health Assistance?
• Is U.S. Global Health Assistance Sufficiently Integrated and Coordinated?

Summary

U.S. funding for global health activities has grown significantly over the past decade, from $1.8 billion in FY2001 to $8.5 billion in FY2010. During this time period, Congress has significantly increased funding for responses against infectious disease outbreaks, including the 2009 influenza pandemic (H1N1), H5N1 avian influenza (avian flu), human immunodeficiency/acquired immunodeficiency syndrome (HIV/AIDS), tuberculosis (TB), and malaria. U.S. agencies and departments also supplement funds that Congress appropriates for these purposes with funds from their discretionary budgets.

Through FY2009 Supplemental Appropriations (P.L. 111-32), Congress appropriated $100 million to the U.S. Agency for International Development (USAID) for an additional contribution to the Multilateral Global Fund to Fight AIDS, Tuberculosis and Malaria and $50 million for international pandemic preparedness and response efforts. The Act also provided $200 million for domestic and global pandemic preparedness response programs conducted by the U.S. Centers for Disease Control and Prevention (CDC), though it did not specify how the funds should be apportioned.

President Barack Obama sent Congress a FY2010 budget request of $9.1 billion for global health initiatives. Of those funds, he proposed that $7.6 billion be funded through the Global Health and Child Survival Account (GHCS), which is funded through Foreign Operations Appropriations and supports USAID global health programs, global HIV/AIDS programs managed by the Office of the Global AIDS Coordinator (OGAC) at the Department of State and a U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund). The President asked that Congress support his new Global Health Initiative that would provide $63 billion over six years "to shape a new, comprehensive global health strategy" that would focus on "broader global health challenges, including child and maternal health, family planning, and neglected tropical diseases, with cost effective intervention." He also requested $1.5 billion in emergency funds to support U.S. domestic and international responses to the 2009 influenza pandemic and more than $319 million for CDC global health programs. Through the FY2010 Consolidated Appropriations Act (P.L. 111-117), Congress provided more than $8 billion for global health activities.

Foreign assistance reform, including global health aid, has emerged as a key issue in the 111^th Congress. This report discusses some of the policy questions Congress may face as it considers proposals to improve U.S. global health aid, including defining U.S. global health aid, identifying the scope of U.S. global health spending, determining oversight and leadership roles, and coordinating global health and development programs.

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U.S. Global Health Assistance: Background, Priorities, and Issues for the 111^th Congress

Introduction to U.S. Global Health Assistance

U.S. funding for global health activities has grown significantly over the past decade. Much of the growth in U.S. global health spending has been motivated by infectious disease outbreaks, including human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), severe acute respiratory syndrome (SARS), H5N1 avian influenza (avian flu), extremely drug-resistant tuberculosis (XDR-TB), and the 2009 influenza pandemic.¹

Estimates of U.S. global health assistance vary, due in part to fragmented funding streams and a lack of consensus on what should be considered U.S. global health assistance. Congress provides funds for U.S. global health assistance through a number of appropriations vehicles: Foreign Operations; Labor, Education, and Health; and Defense. The greatest proportion of these funds is provided for the President's Emergency Plan for AIDS Relief (PEPFAR), which supports global HIV/AIDS programs implemented by a number of agencies and departments, including the U.S. Agency for International Development (USAID), the Department of Health and Human Services (HHS) and its implementing agencies, the Department of Commerce, the Department of Defense (DOD), the Department of Labor (DOL), and the Peace Corps. PEPFAR funds are also used for U.S. contributions to the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund), a multilateral organization that supports global HIV/AIDS, TB, and malaria programs.² PEPFAR programs aside, the bulk of congressional appropriations for global health efforts are provided to USAID. Congress also provides funds to the Centers for Disease Control and Prevention (CDC) for global health activities.

In addition to funds Congress provides directly to U.S. agencies and departments for global health efforts, U.S. agencies and departments also use portions of their budgets for global health programs. For example, CDC regularly allots a part of its tuberculosis budget for international interventions, though Congress does not specify that the funds should be used for those purposes. Agencies and departments might also transfer funds among each other. At times, for instance, USAID transfers some funds to CDC for research and evaluation activities.

In addition to these funding sources, U.S. agencies implement programs that simultaneously address development and health challenges, such as those related to improving access to clean water, addressing the negative consequences of climate change and rapid urbanization, supporting the vulnerable in conflict or post-conflict environments, and responding to natural emergencies. A number of advocacy groups consider some of these activities as part of health assistance. This report defines global health assistance as those activities that Congress funds specifically to address global health challenges, unless otherwise indicated (such as global TB activities implemented by CDC).

U.S. Global Health Assistance Programs

Congress provides funds to USAID and CDC for U.S. global health assistance, and DOD for bilateral HIV programs. It also appropriates funds to the Office of the Global AIDS Coordinator (OGAC) at the Department of State for PEPFAR activities. The bulk of those funds are ultimately transferred to the Department of Commerce, DOD, DOL, HHS, the Peace Corps, and USAID for implementation of global HIV/AIDS activities.³

USAID Global Health Programs

Through Foreign Operations Appropriations, Congress specifies support for five key USAID global health programs:⁴

• child survival and maternal health, aimed at, among other things, reducing morbidity and mortality from key diseases such as polio, measles, and diarrhea, providing vaccines and immunizations, supporting safe delivery, and addressing malnutrition;
• vulnerable children, aimed at providing services to vulnerable children and orphans, particularly those affected by blindness and war (support for children made vulnerable by HIV/AIDS is provided through HIV/AIDS funds);
• HIV/AIDS, aimed at preventing and treating HIV/AIDS, particularly among vulnerable populations such as women, girls, and orphans, through voluntary counseling and testing, awareness campaigns, and antiretroviral medicines;
• other infectious diseases, aimed at addressing a number of diseases and resultant outbreaks, such as those related to pandemic and avian influenza, malaria, tuberculosis (TB), and neglected diseases; and
• family planning and reproductive health, aimed at increasing access to related services, such as reproductive health education to improve awareness about birth spacing, contraception, and sexually transmitted diseases.

CDC Global Health Programs

Through Labor/HHS Appropriations, Congress specifies support for five key CDC global health programs:⁵

• HIV/AIDS, aimed at improving capacity in laboratory services and health systems; strengthening in-country capacity to design and implement HIV/AIDS surveillance systems and surveys; and supporting host government capacity to monitor and evaluate the process, outcome, and impact of HIV prevention, care, and treatment programs;
• Malaria, aimed at designing technical and programmatic strategies, which include training, supervision, laboratory, communications, monitoring and evaluation, and surveillance systems; evaluating impact of long-lasting insecticide-treated nets (LLINs) and monitoring the spread of insecticide resistance; improving surveillance; and evaluating the performance of health workers;
• Global Disease Detection (GDD), aimed at strengthening and supporting public health surveillance, training, and laboratory methods; building in-country capacity; and enhancing rapid response capacity for emerging infectious diseases;
• Immunizations, aimed primarily at immunizing children younger than five years against polio and measles; and
• Other Global Health programs are aimed at building public health capacity among country leaders, particularly within Ministries of Health.

Although Congress does not appropriate funds to CDC specifically for global tuberculosis and pandemic influenza preparedness and response efforts, CDC allots a portion of its overall TB and pandemic preparedness funds for international assistance.

Global HIV/AIDS Programs

In addition to funds that Congress provides to USAID, CDC, and DOD for bilateral HIV/AIDS programs, it appropriates funds to the Department of State to manage PEPFAR funds. The bulk of these funds are subsequently transferred to the above mentioned agencies, as well as the Departments of Commerce and Labor and the Peace Corps. Congress also provides funds to the Departments of State and Health and Human Services for U.S. contributions to the Global Fund (Table B-4).

Additional U.S. Global Health Assistance

In addition to those areas specified by Congress as global health assistance, websites sponsored by implementing U.S. agencies and departments detail a more expansive view of global health aid (discussed more extensively in Appendix A). For example, USAID cites its work related to health system strengthening and environmental health. CDC collaborates closely with international organizations, such as the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) to respond to health emergencies, such as cholera outbreaks and pandemic influenza.

U.S. Global Health Priorities in the 107^th-110^th Congresses

At the beginning of the George W. Bush Administration, Congress provided $1.4 billion to USAID for global health activities, primarily through the Child Survival and Health (CSH) Programs Fund in the FY2001 Foreign Operations Appropriations Act (P.L. 106-429).⁶ In addition, through the FY2001 Consolidated Appropriations Act (P.L. 106-554), Congress provided CDC $529.5 million to conduct domestic and global immunization activities. Included in this amount was $91.2 million for global polio eradication efforts. Prompted by President Clinton's request for support of his LIFE Initiative, Congress also provided funds to a number of U.S. agencies and departments to initiate global HIV/AIDS programs.⁷ Specifically, the FY2001 Consolidated Appropriations Act provided DOL $10 million and CDC $104.5 million for global HIV/AIDS activities; and the FY2001 Department of Defense Appropriations (P.L. 106-259), provided DOD $10 million for international HIV/AIDS programs.

USAID Global Health Programs

By the end of the George W. Bush Administration, in FY2008, Congress had nearly doubled its support for USAID's global health programs from FY2001 levels, having provided the agency almost $2.1 billion. The increase in support for USAID's global health activities reflected greater investments in countering infectious diseases, particularly pandemic and avian flu, malaria, and TB.⁸ Although appropriations language in each of the fiscal years during the Bush Administration specified that global health interventions would include water and sanitation programs that directly address the needs of mothers and children, support for water and sanitation efforts were funded through the Development Assistance (DA) account and has not been included in annual conference reports on USAID global health appropriations or in annual budget justification language related to global health assistance.

Until FY2008, Congress had primarily funded USAID's global health programs through the Child Survival and Health Account. In FY2008, Congress created a new account that combined appropriations for USAID global health activities funded through the CSH account with appropriations to OGAC for the Global HIV/AIDS Initiative and a U.S. contribution to the Global Fund. This new funding stream is now called the Global Health and Child Survival (GHCS) account.

CDC Global Health Programs

By the end of FY2008, Congress had expanded the list of global health efforts that it would fund through CDC and had increased support for CDC's global health programs by about 66% from FY2001 levels. In FY2001, Congress made available $224.1 million to CDC for global health efforts. By FY2008, that figure rose to $372.2 million for global health activities in seven key areas: HIV/AIDS, malaria, TB, global disease detection (GDD), immunizations, pandemic and avian influenza, and other global health programs (which includes training of foreign health practitioners).⁹ There were fluctuations, however, during this period: Congress boosted appropriations for the International Mother and Child HIV Prevention Initiative in FY2002-FY2004; increased support for GDD in FY2004-FY2008; and funded pandemic and avian influenza interventions at peak levels in FY2006.

HIV/AIDS

Funding for disease interventions has accounted for the greatest increases in U.S. global health spending in recent Congresses. For example, over the past 10 years, U.S. policymakers have shown high levels of interest in supporting and expanding U.S. efforts to fight global HIV/AIDS. From FY2001 through FY2003, Congress provided $2.4 billion for U.S. global HIV/AIDS efforts and $622.5 million for U.S. contributions to the Global Fund. These efforts have included the LIFE Initiative, launched under the Clinton Administration, and the International Mother and Child HIV Prevention Initiative, instituted under the Bush Administration, which were both subsequently incorporated into PEPFAR.

PEPFAR is the U.S. government-wide effort to fight global HIV/AIDS. The initiative was initiated in FY2004 after President George W. Bush proposed it in his 2003 State of the Union address and was authorized by the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L. 108-25). It is coordinated by the Office of the Global AIDS Coordinator at the Department of State and is implemented with USAID, DOD, HHS, DOL, Peace Corps, and the Department of Commerce. During the first five years of PEPFAR, Congress emphasized the rapid scale-up of HIV/AIDS programs globally, especially treatment with antiretroviral drugs. From FY2004 through FY2008, Congress provided more than $15 billion for U.S. efforts to combat global HIV/AIDS, including bilateral programs in over 100 countries, and more than $3 billion for U.S. contributions to the Global Fund.¹⁰

On July 30, 2008, the 110^th Congress enacted the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (Lantos-Hyde Act, P.L. 110-293), which authorized $48 billion for U.S. international HIV/AIDS, tuberculosis, and malaria programs from FY2009 through FY2013. The Act authorized a number of changes to U.S. international HIV/AIDS, tuberculosis, and malaria programs, including higher funding levels for programs targeted at the three diseases; the establishment of the U.S. Global Malaria Coordinator within USAID; and strategies to promote sustainability of health care systems in affected countries.

Avian and Pandemic Influenza

In FY2005, Congress began providing emergency supplemental funds for U.S. technical assistance efforts related to global pandemic influenza preparedness and response. Those funds have been used to train health workers in foreign countries to prepare for and respond to a pandemic that might occur from any influenza virus, including H5N1 avian flu and the newly emergent influenza virus, H1N1 "swine flu," which was characterized as a pandemic by WHO on June 11, 2009.¹¹ WHO reports that globally, an average of about 60% of those who have contracted H5N1 avian flu since 2003 have died and less than 1% of those who contracted H1N1 have died. It is important to note that many more people may have contracted H5N1 and H1N1; the number of cases reflects only those reported to WHO by health authorities.

Influenza A/H5N1 is one of many strains of avian influenza that can cause illness in poultry. Bird (or avian) flu outbreaks have occurred at various times around the world. Until 1997, there were no known human H5N1 cases. That year, 18 people in Hong Kong contracted the virus, of whom six died. To contain the virus, 1.5 million birds were killed. Since 2003, when the virus resurfaced and killed four people, scientists have closely monitored resurgent H5N1 outbreaks. The average H5N1 human fatality rate since the virus re-emerged in 2003 is about 60%, though the annual human fatality rate has fluctuated. The last human cases were reported to WHO on July 1, 2009, with a total of 436 people having contracted the virus, of whom 262 died.¹²

The State Department announced in October 2008 that the United States has pledged nearly $950 million to international avian and pandemic influenza efforts, accounting for 30.9% of overall international donor pledges of $3.07 billion since 2005.¹³ The funds have been used to support international efforts in more than 100 nations and jurisdictions. The assistance focused on three areas: preparedness and communication, surveillance and detection, and response and containment.¹⁴

Malaria

Over the past 10 years, Congress has increased funding for U.S. global malaria interventions. Similar to U.S. efforts to fight HIV/AIDS globally, U.S. malaria activities have increasingly focused on providing commodities that prevent and treat malaria in selected countries. From FY2001 through FY2005, Congress provided $414 million to fight malaria globally. During this time period, some Members of Congress and health experts maintained that U.S. bilateral malaria interventions—which were mostly implemented by USAID—yielded few tangible results, because a relatively small proportion of the funds were spent on commodities to treat malaria. Instead, they focused more on preventative measures like information campaigns and distributing insecticide treated bed nets, and less on other highly effective strategies like indoor residual spraying and malaria treatments.

In 2005, President Bush announced the President's Malaria Initiative (PMI), a coordinated U.S. government response to malaria in 15 sub-Saharan African countries.¹⁵ Launched in FY2006, PMI is led by USAID and implemented in conjunction with CDC. The initiative is part of a broader change in USAID's malaria policies, which since PMI's launching has focused on concentrating resources in fewer countries to increase program effectiveness; devoting greater resources to procure malaria commodities, such as drugs that treat or prevent malaria; and instituting indoor residual spraying. U.S. spending on malaria commodities has increased from 8% of the FY2004 USAID malaria budget to 46% of the FY2008 USAID malaria budget. From FY2006 through FY2009, Congress provided more than $1.5 million for U.S. malaria programs.

Tuberculosis

The World Health Organization (WHO) estimates that someone contracts TB every second and that about one-third of all people in the world carry TB; most of these cases, however, are latent. Some believe that congressional support for boosting funding for global TB programs rose in response to a 2007 incident when a man carrying XDR-TB entered the United States.¹⁶ Although some Members had already introduced legislation aimed at increasing support for global TB interventions and related research efforts, appropriations to global tuberculosis efforts changed little from FY2004 through FY2007, hovering between $90 million and $95 million. In FY2008, Congress made available $162.2 million to USAID for global TB efforts (some $67 million above FY2007 levels), $1.6 million to CDC, and directed the Office of the Global AIDS Coordinator to apply at least $150 million of its appropriation for the Global HIV/AIDS Initiative to TB/HIV co-infection programs.¹⁷ Unlike in the cases of the other three diseases (HIV/AIDS, malaria, and avian flu), Congress has not authorized the creation of a coordinating mechanism for overseeing U.S. support for international TB programs.

U.S. Global Health Priorities in the 111^th Congress

The 111^th Congress continues to demonstrate support for addressing key global health issues. On December 16, 1009, the President signed the FY2010 Consolidated Appropriations Act (P.L. 111-117), making available nearly $10.0 billion for global health efforts (Table B-1). Of those funds, some $2.4 billion was provided to USAID, $430.2 million to CDC, and nearly $5.4 billion to the State Department for bilateral and multilateral global HIV/AIDS programs, including a $750.0 million contribution to the Global Fund. An additional $10.0 million was included in the FY2010 Department of Defense Appropriations (P.L. 111-118) for global HIV/AIDS interventions.

While the 107^th-110^th Congresses saw unprecedented increases in spending on global health efforts with the bulk of the increase aimed at combating specific diseases, the 111^th Congress began to emphasize coordination of all global health programs, support for health systems, and rapid response to new health challenges, such as deepening global hunger and the emergence of the FY2009 influenza pandemic.¹⁸ The 111^th Congress has also begun to emphasize the importance of gender-based issues, such as violence against women and access to prenatal care and reproductive health services, including family planning. Nonetheless, more than half of all funds Congress made available to USAID through GHCS in FY2010 were aimed at addressing infectious diseases, including HIV/AIDS.

FY2010 Foreign Operations Appropriations

The FY2010 Consolidated Appropriations Bill (P.L. 111-117) with the accompanying Conference Report (H.Rept. 111-366) includes funding increases for several bilateral and multilateral global health programs and emphasizes improving monitoring and evaluation. The Act made more than $8 billion available for global health programs, including about $5.4 billion for HIV/AIDS programs managed by OGAC, including a $750 million contribution to the Global Fund; an additional $300 million for a contribution to the Global Fund through NIH; some $2.4 billion for USAID; an estimated $328 million for CDC; and $10 million for HIV/AIDS programs conducted by DOD.

In FY2010, Congress increased appropriations for USAID global health programs funded through GHCS by about 11% from FY2009 levels. The bulk of that increase was comprised of a boost in funding for other infectious diseases. Support for diseases in that category rose by about 97% over FY2009 levels, with funding for malaria rising by 52%, TB by 39%, and neglected tropical diseases by more than 100%. Funding for pandemic and avian flu response fell, however, by more than 40%, including supplemental provisions. If supplemental funds are not considered, congressional appropriations for pandemic and avian flu response rose by nearly 40%. Appropriations remained at FY2009 levels for HIV/AIDS and vulnerable children programs.

Overall support for CDC global health programs rose by about 6%, excluding funding for pandemic and avian flu programs.¹⁹ Appropriations for most programs remained at FY2009 levels. Much of the increase was comprised of increases for immunizations (mostly for measles programs), Global Disease Detection Centers, and "other global health programs." The conference report specified that increased provisions were intended to support the establishment of at least one new regional GDD facility and increased capacity of at least one other center.

Appropriations for HIV/AIDS programs coordinated by the Department of State rose minimally, some 1%, and reached $5.4 billion including $750 million for a U.S. contribution to the Global Fund. An additional $300 million was made available for the Global Fund through the National Institutes of Health (NIH). The Act included funds to the State Department for contributions to several other multilateral entities that support global health programs, including $43.0 million for the Joint United Nations Program on HIV/AIDS (UNAIDS), $132.3 million for the United Nations Children's Fund (UNICEF), $55.0 million for the United Nations Population Fund (UNFPA), and $78.0 million for the Global Alliance for Vaccines and Immunization (GAVI).

Key Provisions in FY2010 Foreign Operations Appropriations

Issues of transparency and accountability are key themes for the 111^th Congress, particularly as they relate to global health. In light of these priorities, the conference report of the FY2010 Foreign Appropriations included several provisions related to reporting and oversight requirements, such as $400,000 for oversight of programs related to maternal health, child survival, family planning reproductive health, and infectious diseases.

The conference report also directed the Secretary of State to issue a report to the Appropriations Committees no later than 180 days after enactment that describes and examines ongoing U.S. global health programs in each country. The report should discuss the impact, outcomes, and effectiveness of the programs; detail complementary work conducted by private and public donors; recommend changes to such programs to improve results and enhance effectiveness; and indicate whether the programs are receiving adequate support. The conference report also requires OGAC to submit a report that specifies the effectiveness of HIV/AIDS prevention interventions; projects how the interventions will address key drivers of the epidemic; outlines how progress toward U.S. prevention strategy goals will be measured; details collaborative efforts between bilateral and multilateral HIV/AIDS programs; and describes how PEPFAR programs could be included within a U.S. global health strategy.

Administration Priorities

Global health has emerged as a key foreign policy goal early in the Obama Administration. When releasing his FY2010 budget request, President Obama indicated that the budget proposal "puts the United States on a path to double U.S. foreign assistance" and that the Administration would "increas[e] investments in global health programs."²⁰ The President requested that Congress approve his FY2010 budget request of $8.6 billion for the recently established Global Health and Child Survival Account.

On May 5, 2009, President Obama announced his new Global Health Initiative (GHI), a six-year, $63 billion from FY2009 to FY2014 to better coordinate the U.S. government's approach to global health programs.²¹ For example, the GHI looks to address reproductive health challenges through integrating family planning, maternal health services and HIV/AIDS screening and treatment.²² In announcing the initiative, the President stated,

In the 21^st century, disease flows freely across borders and oceans, and, in recent days, the 2009 H1N1 virus has reminded us of the urgent need for action. We cannot wall ourselves off from the world and hope for the best, nor ignore the public health challenges beyond our borders. An outbreak in Indonesia can reach Indiana within days, and public health crises abroad can cause widespread suffering, conflict, and economic contraction. We cannot simply confront individual preventable illnesses in isolation. The world is interconnected, and that demands an integrated approach to global health.

The GHI is a relatively new initiative whose full scope, objectives, and implementation strategy remain to be seen. The Administration has established a steering committee and working groups to plan the GHI strategy and recommend funding levels for U.S. global health programs beginning in FY2011,²³ though it has not yet clarified which U.S. agencies and departments participate in the steering committee and working groups nor which ones will be included in the GHI.

The GHI, as announced, does not appear to include an authoritative accounting and examination of all global health funding. According to one U.S. government budget source, the GHI-suggested six-year global health funding level of $63 billion does not include the global health budgets of all U.S. government agencies but is based on the current and projected global health budgets of the Department of State and USAID.²⁴

This ambiguity has led to some debate among health experts about whether the $63 billion proposal for GHI is sufficient. Some observers who assume the $63 billion is intended to support only global health programs implemented by the Department of State and USAID applaud the proposed spending level, citing increases to key programs, such as malaria, family planning, and reproductive health. Other health analysts who expect the $63 billion to support global health programs implemented by other agencies, such as CDC and DOD, maintain that the funding level is too low and would not enable implementing agencies to meet congressionally mandated goals and scale up global health programs to meet the United Nations Millennium Development Goals. One group, the Global Health Initiative Coalition, advocates the United States increase its global health funding to $95 billion for FY2009 through FY2014.²⁵

Related Policy Issues

Although there is strong support in Congress for global health assistance, there are growing concerns that insufficient coordination and integration of U.S. global health programs might limit the effectiveness and efficiency of these programs. With the exceptions of interagency efforts to address HIV/AIDS (PEPFAR), malaria (PMI) neglected tropical diseases (NTD Initiative) and avian flu (Avian Flu Task Force), the funding and implementation of U.S. global health initiatives are not always coordinated. As Congress continues to exercise oversight over global health programs, Members are taking action to identify the scope and breadth of global health programs and to understand how other development activities address and impact global health.

In the conference report of the FY2010 Consolidated Appropriations Act, for example, Congress directed the Administration to submit a report that includes an analysis of key global health challenges, a review of global health interventions that have been found to have the greatest impact, and an outline of those interventions that would most significantly reduce mortality and mortality with increased support. The section below details some issues Congress might consider as it debates the range of proposals health experts have advocated to improve U.S. global health assistance.

How Should Global Health Assistance Be Defined?

Some health experts urge the United States to develop a definition for global health and global health assistance (See Appendix A for more background on defining global health and U.S. global health assistance.) One supporter of this idea asserted that the absence of an established definition obscures important differences in philosophy, strategies, and priorities for action. Further, a lack of an established global health definition complicates efforts to develop a consensus on what related aid should achieve, the approaches that should be taken, the skills that are needed, and the ways that resources should be used.²⁶ Health experts have suggested a number of strategies for Congress to address this challenge, including

• drafting a bill that authorizes U.S. global health assistance. The legislation could define the scope of global health issues that U.S. global health assistance should address, identify which agencies or departments might be engaged in such an efforts, and clearly define the roles and actions that each implementing agency might take;
• amending or rewriting the Foreign Assistance Act to include the actions discussed above;
• in each relevant appropriations bill, defining global health and specifying the role that the implementing agency will play in addressing global health challenges; and
• directing the Administration to define global health and specify how each agency will address related challenges, especially in the context of the GHI.

What Strategy Should Guide U.S. Global Health Assistance?

Some critics contend that U.S. health assistance would be more effective if it were based on one single U.S. global health strategy. A number of global health experts have asserted that throughout the Bush Administration, Congress seemed to fund health initiatives in response to emerging health emergencies—such as outbreaks of diseases like XDR-TB or avian influenza—or to counter the ravages of particular diseases like HIV/AIDS or malaria. Supporters of developing a U.S. health assistance strategy suggest that Congress require the Administration to develop a strategy through which all U.S. global health assistance would be provided. The strategy, some propose, would be developed by a global health task force, who would be composed of a representative(s) from each agency or department and who would build the strategy on evidence-based approaches and measurable results. The strategy would also include specific goal(s)—that is, reduce mortality, improve health systems, and eradicate key diseases. Proponents maintain that the strategy could also clarify a number of other issues that remain unclear, including

• all sources of U.S. global health assistance provided by each agency and department;
• the goals and objectives of U.S. global health assistance that each of these agencies and departments follow;
• how U.S. agencies and departments identify and measure their global health goals and objectives; and
• the strengths and unique assets that each agency and department has in project implementation.

Proponents of a global health strategy assert that failure to align the goals of U.S. global health programs allows implementing U.S. agencies that sometimes have competing priorities to operate independently and provides little incentive to collaborate and integrate health activities. This argument has been made particularly when debating the advantages and drawbacks of disease-specific funding. Critics of the recent emphasis that the United States has placed on specific diseases argue that the goals and outcomes of programs (like PEPFAR and PMI) are not sufficiently developed and conducted in a manner that would complement ongoing U.S. global health efforts, do not account for how funding of other health programs might be affected, and threaten the overall function of country health systems. A U.S. global health strategy, supporters argue, could address these concerns.

Through the GHI, it appears the Administration is beginning to address this issue. Each GHI working group is reportedly charged with creating a so-called "concept paper" that describes the framework for U.S. activities in one of eight areas: integration and coordination; health systems strengthening; maternal and child health; family planning; nutrition; infectious diseases; metrics, monitoring and evaluation; and research.²⁷ The Administration has not yet explained how the concept papers will be used. Many stakeholders advocate that the papers be used to evaluate the efficiency and effectiveness of implementing U.S. global health programs across a broad array of departments and agencies, identify the strengths of each agency, and bring U.S. global health programs more in line with broader U.S. development policy priorities.

What Is the Appropriate Balance of Funding for Global Health Programs?

A number of health experts are calling for greater congressional support for programs that aim to address simultaneously infectious diseases and poorly functioning health systems. Examples include Health Systems 20/20 and the U.S. Pharmacopeia Drug Quality and Information (USP DQI) program.²⁸ Congress has also demonstrated support for bilateral global health programs (PEPFAR) and multilateral ones (Global Fund). Some maintain that a U.S. global health assistance strategy could be used to help the 111^th Congress identify the appropriate balance of support to give to global health interventions.

Balance Between Disease-Specific and Health Systems Efforts

The 111^th Congress has debated how best to apportion funds so as to fight key diseases while strengthening the health systems of recipient countries. Some advocates believe that Congress should invest the bulk of global health funds in disease-specific initiatives because they are able to garner greater political support by both U.S. and global leaders (due to their measurable outcomes) and their ability to be more easily expanded (since they are focused on one affliction). Disease-specific interventions can also be used, some argue, to bolster health systems, by building capacity and expertise in key areas. Other observers assert that investments in activities that target key diseases are better spent, because donors can divest gradually from the projects as countries learn to treat, prevent, and arrest the spread of the disease.

While many health experts applaud the advancements made by disease-focused efforts, such as PMI and PEPFAR, others would like to see a greater emphasis on strengthening health systems. In the past, critics of single disease initiatives focused on the failures of these efforts to sometimes take into account the interconnected nature of health care challenges and how, in resource-poor countries, such activities may create competition for limited human capacity (i.e., doctors, public health specialists, and skilled managers for health programs). While progress to better coordinate health efforts has been made, some experts assert that disease-specific initiatives would be less necessary if donors and recipient governments increased investments for building or improving healthcare infrastructure and expanded training opportunities. An emphasis on health systems, they suggest, would increase local capacity for addressing a range of ailments. Furthermore, should Congress not invest sufficiently in health systems, some health experts warn, progress made in disease-focused projects will not be sustainable, as the governments will not have the capacity to maintain the efforts.

Many health professionals contend that global health efforts should combine both approaches so that efforts aimed at specific diseases could occur simultaneously with efforts to build health capacity and infrastructure. Supporters suggest that the initial focus of global health aid could be on building capacity to respond to disease outbreaks, and over time, investments could increasingly be targeted at improving and developing the healthcare infrastructure. President Obama indicated his support for a better integrated approach to U.S. health assistance, though he did not indicate how this might be accomplished. He stated that, "I recognize that we will not be successful in our efforts to end deaths from AIDS, malaria, and tuberculosis unless we do more to improve health systems around the world, focus our efforts on child and maternal health, and ensure that best practices drive the funding for these programs."²⁹

Balance Between Bilateral and Multilateral Health Assistance

A single global health strategy, some experts assert, might also help Congress determine the appropriate balance of support for bilateral and multilateral global health efforts. The United States has provided substantial funding for bilateral health activities while also contributing to many international organizations that address global health, such as the Global Fund, WHO, UNICEF, and international medical research consortiums like the International AIDS Vaccine Initiative (IAVI), the GAVI Alliance, and the Medicines for Malaria Venture (MMV).³⁰ As overall provision for global health has increased, Congress has debated the appropriate apportionment of bilateral and multilateral funding for global health efforts.

Proponents of increased U.S. support for multilateral global health efforts argue that combining donor funding for health allows greater economies of scale, thereby leveraging funding for greater impact, and reduces the reporting burdens on countries that receive funding from multiple sources. Supporting multilateral funding mechanisms also allows donors like the United States to share the long-term responsibility of financing higher cost activities, such as providing treatment for HIV/AIDS-infected people.

Opponents of increasing funding for multilateral activities over bilateral activities assert that directing funding through bilateral programs promotes accountability, increases oversight, and ensures that programs reflect U.S. priorities and values. Further, skeptics of greater investments in multilateral programs note that bilateral resources are often used to bridge support for slow-moving multilateral ones.

What Impact Would Foreign Aid Reform Initiatives Have on Global Health Assistance?³¹

A number of Members have maintained that the 111^th Congress will take up foreign assistance reform. However, few of the reform proposals that are being debated and presented to Congress discuss comprehensively how their recommendations relate to U.S. global health programs. While a number of problems that critics cite in regard to current global health assistance programs, such as the disjointed policies, implementation, weak or uneven performance by some programs, and the absence of a comprehensive strategy are sometimes seen as common to most foreign aid sectors, various reform proposals could have unique implications for global health programs.³²

For example, rewriting the Foreign Assistance Act of 1961 in such a way that the resulting legislation is more concise and comprehensive would be particularly challenging in regard to health programs. Some observers believe that any rewrite of the Act should address the range of U.S. global health assistance efforts which operate under authorities outside of the Foreign Assistance Act.³³ CDC's global health programs, for example, are authorized through eight different Acts, including the Public Health Assistance Act. There are also a number of freestanding Acts that amend the Foreign Assistance Act and waive the requirement to authorize funds before making them available in appropriations.³⁴ The United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L. 108-25), for example, authorizes a number of U.S. global health assistance activities related to HIV/AIDS, TB, and malaria; and amends the Foreign Assistance, Public Health Assistance, and International Financial Institutions Acts. As such, any attempt to reform foreign assistance, should it include U.S. international health assistance, requires a comprehensive review of numerous authorizing Acts. ³⁵ The Millennium Challenge Corporation, for example, is funded through annual foreign operations appropriations bills, but is not authorized by the Foreign Assistance Act.

Not only might Congress need to consider the variety of authorities under which U.S. global health assistance operates, but also consider the related oversight challenges. A number of committees have oversight authority over various U.S. global health assistance, including committees on agriculture, appropriations, foreign affairs (House) and foreign relations (Senate), and education and labor (House) and health, education, labor and pensions (Senate). Any effort to reform U.S. global health assistance might require a cooperative effort of all committees that hold oversight authority.

Another popular reform proposal would create a cabinet-level international development agency with authority over all global health and development programs.³⁶ While some observers have cited the Office of the Global AIDS Coordinator to exemplify the benefits of establishing an independent high-level international development entity, others have concerns about the political implications of such a structure. Supporters maintain that a cabinet-level development agency might broaden the avenues of support through which the United States improves global health. Leadership outside of health bureaus might also raise the status of health interventions. Supporters of this idea assert that PEPFAR was so successful, in part, because the U.S. Global AIDS Coordinator was appointed as an Ambassador. Proponents contend that this elevated status helped to engender partnerships and commitments from foreign governments that other global health programs have yet to secure. On the other hand, should this new agency not carry the same political currency as the Department of State, programs implemented through a new development agency might not gain as much support domestically or globally.³⁷

While there is little question that PEPFAR has been one of the United States' most successful public diplomacy initiatives, some health experts have concerns about the political implications of a cabinet-level development agency. Some argue that further integrating global health programs into such an entity might lead to a level of politicization that health programs, in particular, have been largely protected from under the current structure. For example, CDC was able to respond immediately to the 2009 cholera outbreak in Zimbabwe, despite strained U.S. diplomatic relations with that country. Skeptics of foreign aid reform fear that a restructuring might result in diplomatic concerns outweighing global health concerns or the use of health assistance as a political tool.

Is U.S. Global Health Assistance Sufficiently Integrated and Coordinated?

A number of global health experts have asserted that improvements in coordination and integration of U.S. health assistance can be undertaken without launching into the comprehensive process of foreign assistance reform. Supporters of this idea maintain that Congress can create coordinating mechanisms—such as OGAC—that clarify oversight, funding, and implementation structures. Proponents maintain that since OGAC was launched, implementing agencies and departments have developed a clear sense of their roles and have improved their coordination, particularly at the planning phase. Other observers point out that the creation of OGAC has led to parallel structures (such as PMI) that are used to enhance coordination of U.S. global health efforts. Some health experts warn, however, that Congress might need to mandate such cooperation to ensure that the process is formalized and fully implemented. For example, in a joint memorandum, the leadership of PMI and PEPFAR directed headquarters and country staff to coordinate activities where possible, but they did not institute a formal process for collaboration between the programs. CDC coordinated an interagency forum to discuss U.S. global health policy through Project Horizon, yet the results of and impact of this effort have not been published.³⁸ In order for coordination efforts to be effective, some assert, that related efforts might also need to be strengthened. For example, the International Health Office at DOD, which is responsible for leading coordination efforts, does not appear to oversee the funding or coordination of key DOD programs that impact global health, such as DHAPP and GEIS.³⁹

Consensus is emerging that Congress might also need to consider how to improve intra-agency and interagency coordination and integration of U.S. global health programs in the field. The 111^th Congress has urged OGAC to expand efforts to address other health and development challenges through PEPFAR programs, such as health workforce shortages and access to treatment for tuberculosis, as well as access to education (see H.Rept. 111-187). Politically sensitive issues, however, like family planning and reproductive health, have been more complicated to integrate. According to a USAID official, although U.S. maternal and child health programs are mostly integrated with family planning and reproductive health initiatives, HIV/AIDS services are not and are provided in separate clinics.⁴⁰

The Lantos-Hyde Act enables organizations who receive PEPFAR funds to opt out of aspects of HIV prevention, treatment, or care programs that they find objectionable for moral or religious reasons.⁴¹ Supporters of these protections argue that faith-based and other non-governmental organizations (NGOs) that provide services to the poor and others in need may not accept U.S. funding to expand their programs without such assurances. They maintain that respecting these groups' views is essential on moral and practical grounds, as these organizations often have underlying religious ethics in their activities as well as long-standing relationships with the communities in which they work.

Critics of the conscience clause assert that when providers act to withhold information from HIV-positive mothers about contraception and family planning strategies, HIV prevention efforts are weakened. Some health experts propose that HIV/AIDS services be provided in existing health clinics to minimize the stigma some might face when attending an HIV/AIDS clinic; improve the likelihood that HIV-positive mothers might have access to services that could prevent them delivering HIV-positive children; and benefit from some of the considerable resources provided for HIV/AIDS services (including laboratory services, workforce, and supply systems).

Appendix A. Definitions of Global Health and Global Health Assistance

WHO defines health as, "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."⁴² That definition, however, is expansive and makes it difficult to identify when that "state" has been achieved. Scholars have noted that the use of the term "global health" has increased in the past 15 years but question whether a clear definition has emerged among public health experts. However, experts seem to agree that global health differs in several key ways from other terms that have been widely used in the last 60 years to refer to international approaches to health, such as tropical health and international health. In the past, terms such as tropical health and international health focused on disease challenges in developing countries, which may have been viewed as having little or limited impact on more developed countries. Today, the use of the term global health seems to suggest that health in rich and poor countries is closely connected. One study found that the term "global health" denotes mutual vulnerability.⁴³ For example, many countries recognize the universal threat that pandemic influenza and increasing disease resistance pose to available treatments. In addition, health challenges that once primarily affected industrialized countries, like chronic diseases (including heart disease, cancer and diabetes) and injuries caused by modern transportation, now disproportionately kill people in developing countries.

The Committee on the U.S. Commitment to Global Health at the Institute of Medicine (IOM), which is comprised of preeminent health experts, published a definition of global health in 2009 that seems to reflect how the concept of global health has evolved and how wide a range of factors it includes:

[T]he goal of improving health for all people in all nations by promoting wellness and eliminating avoidable disease, disability, and death. It can be attained by combining population-based health promotion and disease prevention measures with individual-level clinical care. The U.S. global health enterprise involves many sectors (both governmental and nongovernmental) and disciplines (within and beyond the health sciences), and is characterized by intersectoral, interdisciplinary, and international collaboration.⁴⁴

Similarly, there is not yet a universal definition of "health assistance," though many definitions seem to acknowledge the range of factors that impact health and can be used to improve it. While few advocacy groups, NGOs, and think tanks formally define "global health assistance," their attention to certain issues suggests that some areas of consensus do exist in practice. For example, many of these organizations address HIV/AIDS, malaria, tuberculosis, neglected tropical diseases, maternal and child health, reproductive health and family planning, and hunger and malnutrition as part of their global health programs. A growing number of these groups highlight other global health issues, such as chronic disease, the impact of climate change and urbanization on health, the importance of international medical research on a range of diseases that impact both poor and rich countries, and equal access to medicine and health technology. While many groups are increasingly advocating for coordinated support of related development sectors (such as education, infrastructure development, road construction, agriculture, and women's rights), most deem assistance in these areas to be complementary to rather than inclusive of global health assistance. However, it appears the water and sanitation sector is increasingly considered by some groups to be part of global health, due to its links to many diseases including diarrhea and cholera.

In a 2009 report that examined the range of actors that contributed to U.S. health assistance, the Kaiser Family Foundation, defined U.S. global health assistance as:

U.S. policy (legislation, regulations, executive orders, guidance, and other relevant policy statements), activities, initiatives, programs, and funding used to address health problems that transcend national boundaries with the goal of improving health by reducing avoidable disease, disabilities, and deaths. Such activities operate primarily across the following broad and interrelated domains: health services and systems, disease detection and response, reproductive health and family planning, maternal and child health, nutrition, water, environmental health, and research and development.⁴⁵

U.S. Global Health Assistance, as Specified by the Administration

In addition to those areas specified by Congress as global health assistance, Websites of implementing U.S. agencies and departments detail a more expansive view of global health aid. For example, USAID cites its work related to health system strengthening and environmental health. CDC's global health work includes collaborations with international organizations like WHO and UNICEF to respond to health emergencies, such as cholera outbreaks and pandemic influenza response.

U.S. Agency for International Development

Although Congress funds USAID's global health activities through five elements (discussed in "USAID Global Health Programs"), according to USAID's website, its global health interventions include additional elements:

• Nutrition, aimed at decreasing morbidity and mortality caused by poor nutrition through a package of services, which include micronutrient supplementation and food fortification (particularly among vulnerable populations such as pregnant and lactating mothers, children younger than five years, orphans, and people living with HIV/AIDS).
• Environmental health, aimed at addressing environmental issues that affect health, such as access to clean water, indoor air quality, and sanitation.⁴⁶
• Health systems, aimed at ensuring developing countries health systems are equitable, efficient and effective in responding to the health needs of the population.

Funding for family planning and reproductive health was shifted from the DA account to the CSH account in FY2002. Appropriations language in each fiscal year from FY2001 through FY2008 specified that USAID's global health activities would support six key health programs: (1) child survival and maternal health; (2) immunization and oral rehydration; (3) other health, nutrition, water and sanitation, which directly address the needs of mothers and children, and related education programs; (4) assistance for children displaced or orphaned by causes other than AIDS; (5) prevention, treatment, control of, and research on HIV/AIDS, tuberculosis, polio, malaria, and other infectious diseases, and assistance to communities severely affected by HIV/AIDS, including children infected or affected by AIDS; and (6) family planning and reproductive health.

U.S. Department of Agriculture

Before the 2006 outbreaks of avian influenza across Asia and Europe, there was little discussion about USDA's role in improving global health (with the exception of food aid).⁴⁷ Since then, some health experts have begun to identify U.S. efforts to contain, control, and respond to zoonotic infections (infections that can be transmitted between animals and humans), such as H5N1 avian flu and H1N1, as components of U.S. global health assistance.

Although zoonotic infections affect human health, there is no consensus on whether related interventions should be counted towards U.S. global health assistance. Congress has provided funds to USDA in support of avian influenza interventions and pandemic influenza preparedness efforts since FY2005. The Avian Influenza Action Group—the coordinating mechanism for U.S. global avian and pandemic preparedness efforts—reports that USDA has spent about $37 million on such efforts.⁴⁸ There is no consensus on whether the funds are to be counted as part of U.S. assistance for global health or international animal health. USDA highlights its role in improving animal and plant health globally, but does not frame the discussion in the context of global health.⁴⁹

U.S. Department of Commerce

The Department of Commerce reports that two agencies are engaged in global health related efforts: the International Trade Administration (ITA) and the National Oceanic and Atmospheric Administration (NOAA).⁵⁰ The ITA, through the Manufacturing and Services (MAS) Unit and the Office of Health and Consumer Goods (OHCG), works with the U.S. Food and Drug Administration (FDA) and other U.S. agencies to raise the issue of "current Good Manufacturing Practices" (cGMPs) in bilateral discussions. As the pharmaceutical industry becomes increasingly globalized, ITA works with its foreign counterparts to identify solutions for the presence of counterfeit medicines in the global supply chain. Additionally, OHCG partners with the FDA and other U.S. agencies to engage foreign regulators in bilateral discussions on "Quality by design" (Qbd), which supporters believe will minimize the need for regulatory oversight.

Within NOAA, the National Environmental Satellite, Data, and Information Service (NESDIS) scientists conduct research to develop satellite-derived products that are useful for U.S. and international health organizations. The applications from the NOAA satellite data include drought and famine early warning, malaria monitoring, wild land fire detection, and smoke monitoring. Although these activities are not purported to improve global health either on the Department of Commerce's Website or in annual budget justifications, the Department of Commerce considers NOAA's work as a global health effort. The State Department's Office of the Global AIDS Coordinator also asserts that Commerce contributes to its efforts to engage the private sector in U.S. global HIV/AIDS activities and assists with "data management and analysis, survey support, estimating infections averted, and supporting mapping of country-level activities."⁵¹ In public documents that analyze U.S. global health assistance, these efforts are not usually included.

U.S. Department of Defense

The Department of Defense reports two programs related to global health: the Department of Defense HIV/AIDS Prevention Program (DHAPP) and the Global Emerging Infections Surveillance and Response System (GEIS). As part of PEPFAR, DHAPP works primarily with African militaries to prevent HIV infections through education about the disease. Working in partnership with CDC and international health organizations, GEIS brings together DOD's overseas laboratories and the resources of the U.S. military health system to better address the threat of emerging infectious diseases for the purpose of force health protection.

The U.S. military is engaged worldwide through partnerships with other U.S. government agencies, non-governmental organizations (NGOs), and foreign governments to provide care in response to humanitarian disasters and during conflicts, including activities in Iraq and Afghanistan (through Central Command), Central and South America and the Caribbean (through Southern Command), and Africa (through Africa Command). According to DOD sources, the reported goal of these activities is "to promote stability and security for people in areas with little governmental capability, to assist foreign governments with disaster response, and to transition communities and nations away from threatening circumstances to those with more promise for the future." DOD personnel sometimes highlight health activities carried out as part of Stability, Security, Transition, and Reconstruction Operations (SSTRO) and Humanitarian Assistance and Disaster Relief (HADR) programs, though Congress does not appropriate funds to these activities as part of U.S. global health assistance. Other DOD programs related to global health include

• the U.S. Military HIV Research Program (MHRP), which conducts clinical trials overseas and carries out community-based PEPFAR programs in several African countries;
• health-related programs and projects carried out through DOD's Overseas Humanitarian, Disaster and Civic Aid (OHDACA) account and other accounts;
• DOD's international research related to infectious diseases such as malaria;
• the Air Force's International Health Specialist program;
• some medical, dental, and veterinary civilian assistance programs (MEDCAPs, DENTCAPs, and VETCAPs respectively); and
• the International Health office under the Assistant Secretary of Defense for Health Affairs.

U.S. Department of Health and Human Services

Congress provides annual appropriations to CDC for "global health activities" through Labor, Health and Human Services, and Education appropriations. The largest proportion of funds for CDC's global health programs are provided through five main budget lines: Global HIV/AIDS, Global Malaria, Global Disease Detection, Global Immunization, and Other Global Health. In practice, CDC does not treat its domestic and global programs separately. Instead, it uses the same experts to address domestic and global health issues. As such, CDC engages in a wider range of activities globally than what is captured in these five areas. CDC often leverages its own resources in response to global requests for technical assistance in a number of areas that also have domestic components, such as outbreak response (including pandemic/avian influenza preparedness and prevention, as well as TB); the prevention and control of injuries and chronic diseases; emergency assistance and disaster response; environmental health; reproductive health; and safe water, hygiene, and sanitation.

In addition to these appropriations, Congress funds research efforts of the National Institutes of Health (NIH) in support of its research efforts that aim to improve global health. Each institute at NIH supports international research in some capacity, though it is not clear how much is spent on global efforts specifically. In particular, Congress annually appropriates funds to the Office of AIDS Research (OAR) as an implementing partner of PEPFAR. The NIH Fogarty International Center facilitates global health research conducted by U.S. and international investigators; builds partnerships between health research institutions in the United States and abroad, and trains scientists to address global health needs.⁵²

Millennium Challenge Corporation

The Millennium Challenge Corporation (MCC) supports global health activities by including health infrastructure and health system capacity building projects in many of its compact and threshold agreements with developing countries. These activities include, for example, programs that improve water and sanitation facilities, increase standards for diagnostic and treatment protocols, construct and equip laboratory facilities, renovate health centers, and strengthen management of health system resources. MCC emphasizes the impact that a lack of clean water has on the health of developing countries' populations, especially the poor. In some areas, projects funded by MCC also support U.S. global HIV/AIDS activities by improving countries' health system infrastructure and practices and by carrying out HIV/AIDS awareness efforts.⁵³ MCC's selection process also promotes and encourages attention to global health issues by considering public health expenditure and immunization rates among its indicators of eligibility.⁵⁴

U.S. Department of State

At the U.S. Department of State, a number of activities may be related to global health and are conducted by the Office of the Director of Foreign Assistance (F Bureau); the Offices of the Global AIDS Coordinator (OGAC or S/GAC) and Global Women's Issues (S/GWI), which report directly to the Secretary of State; and five bureaus or offices within the purview of the Under Secretary for Democracy and Global Affairs (G).⁵⁵

The F Bureau develops the U.S. foreign assistance budget and oversees these resources, including U.S. health assistance provided by USAID, the Peace Corps, and the Department of State. OGAC coordinates and oversees U.S. foreign assistance resources to fight global HIV/AIDS. ⁵⁶ S/GWI coordinates Department of State foreign policy efforts that relate to women's issues, including the political, economic, and social advancement of women around the world. In this capacity, the office is tasked with raising awareness about discrimination and violence against women, supporting U.S. efforts to extend access to education and healthcare to women and girls, and increasing women's political participation.⁵⁷

Within the G Bureau, the Oceans, Environment, and Science (OES) Bureau promotes U.S. foreign policy around environmental and scientific issues such as "infectious diseases, biodiversity, climate change, access to water and energy, ocean and polar affairs, science and technology cooperation, management of toxic chemicals, environmental components of trade agreements, and the exploration of space."⁵⁸ It represents the United States during major international negotiations in these areas and supports the efforts of 50 Environment, Science and Technology, and Health (ESTH) Foreign Service officers stationed in U.S. embassies around the world.⁵⁹ The Bureau of Population, Refugees, and Migration (PRM) supports multilateral institutions and non-governmental organizations that provide healthcare services to refugees; formulates U.S. foreign policy on population and migration; and administers U.S. refugee assistance and admissions programs.⁶⁰ The Bureau of Educational and Cultural Affairs conducts activities in partnership with private sectors and NGOs to address health globally.⁶¹

Two other G offices may contribute to global health efforts: the Office of the Science and Technology Adviser to the Secretary (G/STAS) and the Office to Monitor and Combat Trafficking in Persons (G/TIP). G/STAS provides scientific and technological expertise—including those related to global health and food security issues—to the Secretary of State, other senior Department officials, and U.S. embassies. It also leads U.S. efforts to cooperate with foreign countries through science diplomacy and promotes the growth of science and technology capacity in developing countries.⁶² G/TIP asserts that TIP directly relates to public health and the spread of disease, as trafficking victims may be exposed to infectious diseases, experience physical violence and unsafe working conditions, and suffer from poor nutrition.⁶³ The office supports efforts to identify and protect trafficking victims while working for stronger international efforts to prevent TIP and prosecute traffickers.

Peace Corps

The Peace Corps estimates that 23% of its volunteers work on health-related projects.⁶⁴ Peace Corps' work in global health is different from that of other agencies, in large part because the work is volunteer-driven. The scope of these projects includes hygiene and sanitation; water systems development and enhancement; food security; maternal and child health; communicable diseases; chronic illnesses; and healthy lifestyles. Volunteers and their counterparts address these health issues in a variety of ways, including formal classroom instruction from kindergarten to university level; materials development; training for health care providers; and informal health sessions using murals, theater, radio, television, and puppet shows. The Peace Corps reports that in FY2008, there were over 1,700 health and HIV/AIDS volunteers providing assistance through 52 projects worldwide. Global health activities conducted by Peace Corps volunteers are not usually counted towards U.S. global health assistance, except those related to PEPFAR.

U.S. Global Health Assistance, as Specified by the OECD

According to the Organization for Economic Cooperation and Development (OECD), in 2007, the United States provided some $1.1 billion on health assistance and $4.5 billion on population and reproductive health programs, which includes support for HIV/AIDS control.⁶⁵ Included in the $1.1 billion, is U.S. support for "basic health" and "general health." Basic health includes health care, health infrastructure, nutrition, infectious disease control, health education and health personnel development. General health includes aid for developing health sector policy, planning and programs, medical education, training and research, and medical (non-basic) health services.⁶⁶

U.S. global health spending levels, as reported by implementing agencies, seem to closely mirror those reported to the OECD by USAID. Using the same accounting structure as OECD, total USAID and CDC health assistance (excluding HIV/AIDS, family planning and reproductive health, and a U.S. contribution to the Global Fund), as reported by the agencies, reached $1.2 billion in FY2007. Total funding for population and reproductive health programs (including all bilateral HIV/AIDS assistance) reached $4.1 billion. The list of agencies and departments that OECD reports were involved in U.S. global health assistance activities in 2007 was more extensive than those included in this report, however.⁶⁷

Appendix B. U.S. Global Health Spending: FY2001-FY2010

Acknowledgments

Craig Moscetti, Intern, contributed to the January 29, 2010, update to this report.

Footnotes

1.	For more information on U.S. efforts to address each of these diseases globally, see CRS Report RL34569, PEPFAR Reauthorization: Key Policy Debates and Changes to U.S. International HIV/AIDS, Tuberculosis, and Malaria Programs and Funding, by [author name scrubbed]; CRS Report RL32072, Severe Acute Respiratory Syndrome (SARS): The International Response, by [author name scrubbed] and [author name scrubbed]; CRS Report RL33219, U.S. and International Responses to the Global Spread of Avian Flu: Issues for Congress, by [author name scrubbed]; CRS Report RL34246, Tuberculosis: International Efforts and Issues for Congress, by [author name scrubbed]; and CRS Report R40588, The 2009 Influenza Pandemic: U.S. Responses to Global Human Cases , by [author name scrubbed].
2.	For background information on the Global Fund, see CRS Report RL33396, The Global Fund to Fight AIDS, Tuberculosis, and Malaria: Progress Report and Issues for Congress, by [author name scrubbed].
3.	For more information on how U.S. funds are used for global HIV/AIDS efforts, see CRS Report RL34569, PEPFAR Reauthorization: Key Policy Debates and Changes to U.S. International HIV/AIDS, Tuberculosis, and Malaria Programs and Funding, by [author name scrubbed].
4.	For more information on USAID global health programs, see CRS Report RS22913, Global Health: USAID Programs and Appropriations from FY2001 through FY2010, by [author name scrubbed].
5.	For more information on CDC global health programs, see CRS Report R40239, Centers for Disease Control and Prevention Global Health Programs: FY2001-FY2010, by [author name scrubbed].
6.	For comparative purposes, this estimate excludes contributions to UNICEF and the Global Fund, which Congress began to fund through appropriations to the Department of State for U.S. contributions to international organizations and programs in FY2004 and FY2008, respectively.
7.	For more information on the LIFE Initiative and early U.S. HIV/AIDS efforts, see CRS Report RL33771, Trends in U.S. Global AIDS Spending: FY2000-FY2008, by [author name scrubbed].
8.	For more information on congressional support for USAID global health activities see CRS Report RS22913, Global Health: USAID Programs and Appropriations from FY2001 through FY2010, by [author name scrubbed].
9.	For more information on CDC's global health programs, see CRS Report R40239, Centers for Disease Control and Prevention Global Health Programs: FY2001-FY2010, by [author name scrubbed].
10.	These programs and funding were authorized by Congress through the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L. 108-25).
11.	For more information on the 2009 influenza pandemic, see CRS Report R40588, The 2009 Influenza Pandemic: U.S. Responses to Global Human Cases , by [author name scrubbed], and CRS Report R40554, The 2009 Influenza Pandemic: An Overview, by [author name scrubbed] and [author name scrubbed].
12.	For up to date information on human cases of H5N1 avian flu, see WHO, Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO, http://www.who.int/csr/disease/avian_influenza/country/en/.
13.	Correspondence with Jeffrey Lutz, Avian Influenza Task Force, U.S. Department of State, April 28, 2009 and U.S. Department of State press release, "U.S. International Avian and Pandemic Influenza Assistance Approaches $950 Million," October 25, 2008 at http://2001-2009.state.gov/r/pa/prs/ps/2008/oct/111241.htm.
14.	In addition to these funds, other U.S. agencies and departments conduct pandemic and avian influenza activities, which in many cases serve both domestic and international objectives (i.e., quarantine, rapid-testing, etc.). For example, DOD-Global Emerging Infections System (GEIS) and the National Institutes of Health (NIH) conduct avian influenza research activities.
15.	For more information, see CRS Report R40494, The President's Malaria Initiative and Other U.S. Global Efforts to Combat Malaria: Background, Issues for Congress, and Resources, by [author name scrubbed].
16.	Two months after Andrew Speaker entered the United States carrying XDR-TB, Congress held a special hearing on U.S. efforts to contain and combat TB domestically and globally. See, U.S. Congress, Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, Cracks in the system: An examination of one tuberculosis patient's international public health threat, 110th Cong., 1st sess., June 6, 2007, S.Hrg.110-359.
17.	For more information on U.S. funding for global TB programs, see CRS Report RL34246, Tuberculosis: International Efforts and Issues for Congress, by [author name scrubbed].
18.	See CRS Report R40127, The Impact of Food Insecurity and Hunger on Global Health: Issues for Congress, by [author name scrubbed] and [author name scrubbed], and CRS Report R40588, The 2009 Influenza Pandemic: U.S. Responses to Global Human Cases , by [author name scrubbed].
19.	Congress does not specify how much CDC should spend on global TB and pandemic flu efforts. CDC allocates a portion of its TB and pandemic flu provisions to international efforts. CDC has not yet reported how much it anticipates spending on such efforts in FY2010. For more information on this, see CRS Report R40239, Centers for Disease Control and Prevention Global Health Programs: FY2001-FY2010, by [author name scrubbed].
20.	Office of Management and Budget, A New Era of Responsibility: Renewing America's Promise, FY2010 Budget, February 26, 2009, p. 32, http://www.whitehouse.gov/omb/assets/fy2010_new_era/A_New_Era_of_Responsibility2.pdf.
21.	The White House, "Statement by the President on Global Health Initiative," press release, May 5, 2009, http://www.whitehouse.gov/the_press_office/Statement-by-the-President-on-Global-Health-Initiative/.
22.	Hillary Rodham Clinton, U.S. Department of State Secretary, "Remarks on the 15th Anniversary of the International Conference on Population and Development," January 9, 2010, http://www.state.gov/secretary/rm/2010/01/135001.htm
23.	The White House, Office of the Press Secretary, "Statement by the President on Global Health Initiative," press release, May 5, 2009, http://www.whitehouse.gov/the_press_office/Statement-by-the-President-on-Global-Health-Initiative/.
24.	CRS conversation with USAID official, October 9, 2009.
25.	The Global Health Initiative Coalition, The Future of Global Health: Ingredients for a Bold and Effective U.S. Initiative, October 2009, http://www.theglobalhealthinitiative.org/documents/report.pdf
26.	Jeffrey P. Koplan et al., "Towards a Common Definition of Global Health," The Lancet, vol. 373, no. 9679 (June 6, 2009), pp. 1993-1995, http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673609603329.pdf?id=aeaa5a245ca1fddb:-440ae75e:121c09b750a:6b821244482965683.
27.	CRS interviews with CDC and USAID officials, October 6 and 8, 2009.
28.	"Health Systems 20/20 is a five-year (2006-2011) cooperative agreement funded by USAID to offer USAID- supported countries help in solving problems in health governance, finance, operations, and capacity building." For more information on Health Systems 20/20, see http://www.healthsystems2020.org/. "The USP DQI Program is supported by USAID and focuses on the healthcare needs of people in developing countries. USP DQI advances strategies to improve drug quality and the appropriate use of drugs through provision of: continuing education for healthcare professionals; access to current, evidence-based drug information; technical leadership for regional and international cooperation." For more information on USP DQI, see http://www.usp.org/worldwide/.
29.	The White House, "Statement by the President on Global Health Initiative," press release, May 5, 2009, http://www.whitehouse.gov/the_press_office/Statement-by-the-President-on-Global-Health-Initiative/.
30.	For more information on these organizations, see CRS Report RL33396, The Global Fund to Fight AIDS, Tuberculosis, and Malaria: Progress Report and Issues for Congress, by [author name scrubbed]; WHO – http://www.who.int/en/; UNICEF – http://www.unicef.org/; IAVI – http://www.iavi.org/; the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunization) – http://www.gavialliance.org/; and MMV – http://www.mmv.org/.
31.	This section was co-authored with Marian Lawson, Analyst in Foreign Assistance.
32.	For more information about foreign aid reform, see CRS Report R40102, Foreign Aid Reform: Studies and Recommendations, by [author name scrubbed] and [author name scrubbed], and CRS Report RL34243, Foreign Aid Reform: Issues for Congress and Policy Options, by [author name scrubbed] and [author name scrubbed]. Partners in Health, et al., Global Health Recommendations for a New Administration and Congress.
33.	CRS Report R40089, Foreign Assistance Act of 1961: Authorizations and Corresponding Appropriations, by [author name scrubbed].
34.	CRS Report R40557, Foreign Operations Appropriations: General Provisions, by [author name scrubbed], [author name scrubbed], and [author name scrubbed].
35.	For a listing of many U.S. statutes, authorities, and policies governing U.S. global health policy, see Jen Kates, Julie Fischer, and Eric Lief, The U.S. Government's Global Health Policy Architecture: Structure, Programs, and Funding, April 2009, Kaiser Family Foundation, p. 27, http://www.kff.org/globalhealth/7881.cfm.
36.	See U.S. Representative Betty McCollum, "Rep. McCollum Proposes Cabinet-level Department for International Development and Humanitarian Relief," press release, January 24, 2008, http://interaction.org/files.cgi/6516_Rep_McCollum_Proposes_Cabinet-level_Department.pdf.; Institute of Medicine, The U.S. Commitment to Global Health: Recommendations for the New Administration, National Academy of Sciences, December 2008, http://www.nap.edu/catalog./12506.html; George J. Schieber et al., "Financing Global Health: Mission Unaccomplished," Health Affairs, vol. 26, no. 4 (July/August 2007); Nancy Birdsall, editor, The White House and the World: A Global Development Agenda for the Next U.S. President, Center for Global Development, August 2008, http://www.cgdev.org/content/publications/detail/16560; and Modernizing Foreign Assistance Network, New Way, New Day: U.S. Foreign Assistance for the 21st Century, Policy Proposal, June 1, 2008, http://modernizingforeignassistance.net/documents/newdaynewway.pdf.
37.	Gerald F. Hyman, A Cabinet-Level Development Agency: Right Problem, Wrong Solution, CSIS, April 2009.
38.	For more information on Project Horizon, see CDC, "The Spirit of Engagement," CDC Global Health e-Brief, First Quarter 2008, http://www.cdc.gov/washington/EGlobalHealthEditions/E-brief_first_quarter_2008.pdf; and Project Horizon Progress Report, Summer 2006, http://www.osif.us/images/Project_Horizon_Progress_Report.pdf.
39.	DOD, International Health office, OASD-HA, Force Health Protection and Readiness branch, "About International Health," http://fhp.osd.mil/intlhealth/about.jsp.
40.	Discussions with Barbara Bennett, Congressional Liaison Officer, USAID, April 23, 2009.
41.	These protections originally appeared in the so-called "conscience clause" in the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L. 108-25). It states that organizations can not be required to either endorse or use a multisectoral or comprehensive approach to HIV prevention or endorse, use, or participate in any prevention method or treatment program to which the organization has a religious or moral objection as a condition of receiving U.S. HIV/AIDS assistance.
42.	WHO, What is the WHO definition of Health?, Webpage on frequently asked questions, http://www.who.int/suggestions/faq/en/index.html.
43.	Supinda Bunyavanich and Ruth B. Walkup, "US Public Health Leaders Shift Toward a New Paradigm of Global Health," American Journal of Public Health, vol. 91, no. 10 (October 2001), p. 1556–1558.
44.	Institute of Medicine, The U.S. Commitment to Global Health: Recommendations for the Public and Private Sectors, 2009, http://www.nap.edu/catalog/12642.html;
45.	For more on definitions of global health, see Kaiser Family Foundation, The U.S. Government's Global Health Policy Architecture: Structure, Programs and Funding, 2009, http://www.kff.org/globalhealth/7881.cfm; and Jeffrey P. Koplan et al., "Towards a Common Definition of Global Health," The Lancet, vol. 373, no. 9679 (June 6, 2009), pp. 1993-1995, http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673609603329.pdf?id=aeaa5a245ca1fddb:-440ae75e:121c09b750a:6b821244482965683.
46.	Information about USAID's global health programs was summarized from http://www.usaid.gov/our_work/global_health/#. Also see CRS Report RS22913, Global Health: USAID Programs and Appropriations from FY2001 through FY2010, by [author name scrubbed].
47.	For more information about U.S. responses to avian influenza worldwide, see CRS Report RL33219, U.S. and International Responses to the Global Spread of Avian Flu: Issues for Congress, by [author name scrubbed].
48.	Correspondence with Jeffrey Lutz, Avian Influenza Action Group, U.S. Department of State, April 28, 2009.
49.	For more information on USDA's global efforts, see http://www.aphis.usda.gov/international_safeguarding/index.shtml and http://www.fas.usda.gov/.
50.	The description of global health-related activities by the Department of Commerce was summarized by CRS from e-mail correspondence with Matt Stout, Office of Legislative and Intergovernmental Affairs, February 18-20, 2009.
51.	For more information on Commerce's contribution to OGAC, see http://www.pepfar.gov/agencies/c19398.htm.
52.	For more information on NIH's Fogarty International Center, see http://www.fic.nih.gov/programs/index.htm.
53.	This section based on MCC fact sheets, "MCC Recognizes World AIDS Day," "MCC Infrastructure Programs in African Countries," "MCC's Commitment to Water and Sanitation," and "MCC Recognizes World Health Day."
54.	MCC webpage on selection indicators, http://www.mcc.gov/selection/indicators/index.php.
55.	S/GAC indicates that the Global AIDS Coordinator reports directly to the Secretary of State. The Office of Global Women's Issues was announced in early 2009 by Secretary of State Hillary Clinton. It used to be located under the Office of the Under Secretary for Democracy and Global Affairs as the Office of the Senior Coordinator for International Women's Issues (G/IWI). The Avian Influenza Action group is under the Office of the Under Secretary for Democracy and Global Affairs but, according to a recent CRS conversation with a senior State Department official, has reportedly been relocated within the International Health Biodefense Office that is part of the Bureau of Oceans, Environment, and Science. For more information on the Office of the Under Secretary for Democracy and Global Affairs, see http://www.state.gov/g/.
56.	F Bureau reports on global HIV/AIDS spending within the Department of State and USAID budgets but does not coordinate these efforts. OGAC reports on all U.S. government spending on global HIV/AIDS and coordinates and oversees these efforts.
57.	State Department, "Office of International Women's Issues," http://www.state.gov/g/wi/. For more information on VAW, see CRS Report RL34438, International Violence Against Women: U.S. Response and Policy Issues, coordinated by [author name scrubbed].
58.	State Department, "Bureau of Oceans and International Environmental and Scientific Affairs," http://www.state.gov/g/oes/.
59.	Ibid.
60.	State Department, "PRM: What We Do," http://www.state.gov/g/prm/c25756.htm; and State Department, "PRM: How We Work," http://www.state.gov/g/prm/c25757.htm. For more information, see CRS Report RL31689, U.S. International Refugee Assistance: Issues for Congress, by [author name scrubbed].
61.	State Department, Bureau of Educational and Cultural Affairs, "Support Women's Health," http://exchanges.state.gov/index/womens_health.html.
62.	State Department, "STAS Mission and Objectives," http://www.state.gov/g/stas/c6063.htm. For more information, see CRS Report RL34503, Science, Technology, and American Diplomacy: Background and Issues for Congress, by [author name scrubbed].
63.	In its 2003 report, the G/TIP Office stated, "Trafficking brutalizes men, women, and children, exposing them to rape, torture, and to HIV/AIDS and other sexually transmitted and infectious diseases, violence, dangerous working conditions, poor nutrition, and drug and alcohol addiction. Increasing numbers of adults and children trafficked into prostitution as well as street children are contracting HIV/AIDS. Trafficked children are less likely to participate in immunization programs, defeating government efforts to eradicate early childhood diseases. Severe psychological trauma from separation, coercion, sexual abuse, and depression often leads to a life of crime, drug and alcohol addiction, and sexual violence." Department of State, Victims of Trafficking and Violence Protection Act of 2000: Trafficking in Persons Report , 2003, p.11, http://www.state.gov/g/tip/rls/tiprpt/2003/index.htm. For more information on G/TIP, see http://www.state.gov/g/tip/index.htm.
64.	Information about Peace Corps' global health-related activities were summarized by CRS from e-mail correspondence with Suzie Carroll, Acting Director of Congressional Relations, Peace Corps, February 19, 2009.
65.	OECD tracks official development assistance by calendar year, while figures used throughout this report are based on fiscal years. See http://stats.oecd.org/WBOS/Index.aspx?DatasetCode=CSP2008.
66.	OECD, Classification by Sector or Destination , Annex 5: Reporting on the Purpose of Aid, http://www.oecd.org/dataoecd/40/23/34384375.doc.
67.	Agencies and departments that reported in 2007 providing health assistance to USAID for OECD reporting, included the Army, the Trade Development Agency, USAID, and the Departments of Agriculture, Defense, Health and Human Services, Labor, State, and Interior.