Background on U.S. Global Tuberculosis (TB) Efforts

• The U.S. government has been involved in global TB activities for decades and began ramping up its efforts in the late 1990s when a global TB program was created. The U.S. had been the top donor to TB efforts.
• TB, an infectious disease caused by bacteria, causes more deaths than any other infectious agent worldwide, including 1.23 million people who died in 2024, and is among the 10 leading causes of death worldwide. TB is the leading cause of death among people with HIV.
• Recent decades have seen improvement, and U.S. government investments have contributed significantly to improving TB health outcomes, including an almost 25% decline in TB incidence between 2000 and 2023, and a significant drop in TB deaths.  
• Prior to its dissolution in 2025, USAID had served as the lead implementing agency for U.S. global TB efforts, focusing on 24 priority countries – with activities in 50 (including at least 20 of the 30 high burden countries) – to support prevention, detection, and treatment of TB, including drug-resistant TB. The Centers for Disease Control and Prevention (CDC) also had carried out global TB efforts, and the State Department’s Bureau of Global Health Security and Diplomacy (GHSD), which oversees PEPFAR, leads U.S. efforts to address TB-HIV co-infection.
• Prior to the start of the Trump administration, U.S. funding for global bilateral TB activities in FY 2024 was $406 million; funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) was $1.65 billion.                                                    

Current Status of U.S. Global TB Efforts

The following administration actions have had a significant impact on TB program operations:

• Stop-work order: The stop-work order initially froze all bilateral TB programming and services, halting existing work in the field. Because it halted payments, many implementers had to terminate staff and end some services.
• Limited waiver: Some TB activities were included in a limited waiver issued by the State Department on February 4, 2025, allowing “life-saving services” to continue, which are defined as “Essential screening, testing, and treatment for tuberculosis (TB) and drug resistant TB (DR-TB) including provision and monitoring of laboratory services, drug susceptibility testing, clinical visits, dispensing of essential medicines to avert near-term mortality and spread of infection.” HIV/TB activities were also allowed under PEPFAR’s limited waiver. Even with the waivers, services remained disrupted and implementers faced challenges in getting permission to resume programming and difficulties in getting paid.
• Dissolution of USAID: As the main government implementer of TB efforts, the dissolution of USAID and loss of most staff have significantly affected TB program implementation capacity and operations. Without USAID and most of its staff, TB efforts’ implementation capacity and operations have been affected. In addition, announcements of reductions at CDC could further affect global TB efforts.
• Canceled awards: In early 2025, it was reported that the administration canceled 86% of all USAID awards. KFF analysis found that of the 770 global health awards identified, 162 included TB activities, 79% of which were terminated.

• Legal actions: In response to two lawsuits filed against the administration’s actions, a federal judge issued a preliminary injunction ordering the government to pay for work completed by February 13, 2025, although not all payments have been made and the court did not stop the government from canceling awards. The government appealed the ruling and after several subsequent rulings in the case, the Supreme Court ultimately allowed the government to rescind (cancel) a portion of expiring global health funds before the end of the fiscal year. Further proceedings have been stayed, pending the outcome of a separate case.
• Reorganization: The administration notified Congress on March 28, 2025, of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department with global health activities, including for TB, to be integrated into its Bureau of Global Health Security and Diplomacy (GHSD) which oversees PEPFAR. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan, and with the dissolution of USAID, programs moved in July 2025.
• America First Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy, its roadmap for future U.S. government global health engagement. Per the strategy, the U.S. is negotiating bilateral, multi-year agreements with countries receiving U.S. global health assistance with an aim to transition the majority of countries to full self-reliance by the end of the agreement period. TB has been included in some of the agreements signed to date, although there is little information available on activities and funding.
• Policy restrictions: In January 2025, the Trump administration reinstated the expanded Mexico City Policy from Trump’s first term and further expanded it in January 2026 to apply to almost all non-military foreign assistance, many more entities, and additional areas of restrictions including activities related to diversity, equity and inclusion and “gender ideology” under a broader umbrella known as the “Promoting Human Flourishing in Foreign Assistance” (PHFFA) Policy.
• Funding: The Trump administration has requested significantly less funding for TB in its budget requests and canceled funding for numerous TB-related projects and awards. Despite this, Congress has continued to appropriate funding for bilateral global TB activities at close to prior year levels, including $390 million (at the State Department and CDC) in FY 2026. It also appropriated $1.25 billion for contributions to the Global Fund in FY 2026.

Impact on Global TB Services and Outcomes

• An internal USAID memo from 2025 estimated that the cessation of USAID’s TB control programs could increase global TB incidence by 28-32% and have a similar effect on new cases of multi-drug-resistant TB.
• According to WHO, the 30 highest TB-burden countries reported in 2025 that U.S. funding withdrawals were affecting services, including the loss of thousands of health workers, and disruptions of the drug supply chain and laboratory services.
• A rapid assessment survey of 108 WHO country offices in 2025 found that approximately 40% reported moderate or severe disruptions to TB services, including for medicines and health products, due to the U.S. foreign aid freeze and other shortages. A more recent 2025 WHO survey found that among 17 high-burden countries, 11 reported that cuts in external support undermined TB-related community engagement and TB screening efforts, 7 reported an impact on TB preventive treatment, and 3 reported an impact on TB treatment.
• In addition, several modeling studies have found that cuts in or termination of U.S. TB funding could result in significant increases in TB cases and deaths, and greater economic burden on households, in coming years.

What to Watch

• Implementation of the America First Global Health Strategy multi-year agreements with countries
• Status of U.S. funding appropriated by Congress for bilateral TB efforts and contributions to the Stop TB Partnership and the Global Fund
• Impact of the PHFFA Policy on U.S. funding and programs
• Impact of U.S. changes to global health programs on health outcomes

Background on PEPFAR

• The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), first authorized in 2003, is the largest commitment by any nation to address a single disease, working in more than 50 countries and the U.S. has been the top donor to HIV efforts, through PEPFAR and contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).
• PEPFAR is credited with having saved 26 million lives and enabling 7.8 million babies to be born without HIV infection. Studies have also found that PEPFAR funding is associated with several “spillover” effects including significant reductions in all-cause mortality, increases in childhood immunizations and in GDP growth, and retention of children in school.
• PEPFAR has been reauthorized by Congress four times, most recently in March 2024 for one year. Although that authorization expired on March 25, 2025, PEPFAR is a permanent part of U.S. law and, other than a set of eight time-bound provisions, continues as long as Congress appropriates funding.
• PEPFAR, per its authorizing statute, is to be overseen by a U.S. Global AIDS Coordinator, a Senate-confirmed position appointed by the President and holding the rank of ambassador, at the State Department’s Bureau of Global Health Security and Diplomacy (GHSD). GHSD is charged with coordinating its implementation through other government agencies (primarily USAID – before its dissolution – and CDC) and, historically, with implementing partners, civil society, and recipient countries.
• Prior to the start of the Trump administration, U.S. funding for PEPFAR in FY 2024 was $4.9 billion; funding for the Global Fund was $1.65 billion.

Current Status of PEPFAR

The following administration actions have had a significant impact on PEPFAR operations:

• Stop-work order: The stop-work order initially froze all PEPFAR programming and services, halting existing work in the field, including provision of antiretroviral therapy. Because it halted payments, many implementers had to terminate staff and end some services.
• Limited Waiver: PEPFAR received a limited waiver on February 1, 2025 (with additional information on February 6, 2025), allowing it to continue “life-saving HIV services”. However, the waiver only permitted certain activities: HIV treatment and care, prevention of mother-to-child transmission (PMTCT), pre-exposure prophylaxis (PrEP) for pregnant and breastfeeding women, and HIV testing. Other services, including PrEP for anyone else (including those already on PrEP) and HIV prevention more generally, as well as non-clinical programming for orphans and vulnerable children, were not permitted. Even with the waiver, implementers faced challenges in getting permission to resume HIV programming and difficulties getting paid.
• Dissolution of USAID: USAID was the main government implementing agency for PEPFAR, obligating 60% of its bilateral assistance in FY 2023. Without USAID and most of its staff, PEPFAR’s implementation capacity and operations have been affected. In addition, announcements of reductions at CDC, PEPFAR’s second largest implementing agency (obligating 37% in FY 2023), and questions about the stability of CDC’s funding, could further affect PEPFAR.
• Canceled awards: In early 2025, it was reported that the administration canceled 86% of all USAID awards. KFF analysis found that of the 770 global health awards identified, 379 included HIV activities, 71% of which were terminated, including several HIV treatment awards as well as most HIV prevention.
• Legal actions: In response to two lawsuits filed against the administration’s actions, a federal judge issued a preliminary injunction ordering the government to pay for work completed by February 13, 2025, although not all payments have been made and the court did not stop the government from canceling awards. The government appealed the ruling, and after several subsequent rulings in the case, the Supreme Court ultimately allowed the government to rescind (cancel) a portion of expiring global health funds before the end of the fiscal year. Further proceedings have been stayed, pending the outcome of a separate case.
• Reorganization: The administration notified Congress on March 28, 2025, of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department with global health activities to be integrated into GHSD. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan, and with the dissolution of USAID, programs moved in July 2025.
• America First Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy, its roadmap for future U.S. government global health engagement. Per the strategy, the U.S. is negotiating bilateral, multi-year agreements with countries receiving U.S. global health assistance with an aim to transition the majority of countries to full self-reliance by the end of the agreement period. HIV programs are an anchor of the strategy, and HIV has been included in most of the agreements signed to date, although there is little information available on activities and funding. A U.S. Global AIDS Coordinator has yet to be nominated.
• Long-acting injectable PrEP: On September 4, 2025, the administration announced that PEPFAR would partner with the Global Fund to support provision of long-acting injectable PrEP to up to 2 million people in high-burden countries by 2028.
• Policy restrictions: In January 2025, the Trump administration reinstated the expanded Mexico City Policy from Trump’s first term and further expanded it in January 2026 to apply to almost all non-military foreign assistance, many more entities, and additional areas of restrictions including activities related to diversity, equity and inclusion and “gender ideology” under a broader umbrella of the “Promoting Human Flourishing in Foreign Assistance” (PHFFA) Policy.
• Funding: The Trump administration has requested significantly less funding for PEPFAR in its budget requests and canceled funding for numerous HIV-related projects and awards. Despite this, Congress has continued to appropriate funding at or close to prior year levels for PEPFAR, including $4.8 billion in FY 2026. It also appropriated $1.25 billion for the Global Fund in FY 2026.

Impact on PEPFAR Services and Outcomes

Numerous reports have documented the impacts of these actions on services and outcomes:

• An analysis conducted shortly after the stop-work order was issued found that many PEPFAR implementing partners reported the cancellation of at least one category of activities; staff reductions; and risks to operations. 
• A rapid assessment survey of 108 WHO country offices, conducted in 2025, found that almost half reported moderate or severe disruptions to HIV services, including for medicines and health products, due to the U.S. foreign aid freeze and other shortages.
• A recent analysis in 14 countries found that the disruption in PEPFAR funding was associated with significant drops in access from early 2025 through early 2026 and that recovery remains limited, with ongoing reduced access to HIV services and commodities, including antiretroviral treatment, PrEP, HIV tests, and clinical monitoring tests.
• A tracking survey found that PrEP initiations declined by 13% and 66% in five high-burden countries between January-September 2024 and January-September 2025.
• A summary of available data as of December 2025 found that while some recovery had been reported in service uptake for HIV testing and treatment services, funding cuts and disruptions were continuing to have negative consequences for coverage of PrEP and other HIV prevention services, programs for adolescent girls and young women, and community-led HIV responses.
• In addition, several modeling studies have estimated that cuts in or termination of U.S. HIV funding could result in significant increases in new HIV infections and HIV-related deaths over the coming years.
• A recent analysis surveyed almost 170 PEPFAR-funded organizations in 46 countries, finding that more than 1,700 HIV service sites “closed entirely after terminated or delayed PEPFAR payments” since funding cuts in 2025 and that among organizations that lost funding almost none were able to find alternative funding support. It also found a range of HIV services, including those directed at key populations, HIV prevention such as PrEP and condom distribution, and PMTCT, were stopped, interrupted, or disrupted.
• A KFF analysis of the latest PEPFAR data provides a snapshot of PEPFAR results after the Trump administration’s changes: For some indicators, progress declined in FY 2025 Q4, including support for prevention services such as PrEP and the DREAMS program for adolescent girls and young women, both of which were significantly scaled back by the administration. There was also a drop in the number of people with HIV newly enrolled on antiretroviral therapy (ART), an important measure of access. There were areas where progress has been maintained or potentially improved, including the total number of people with HIV on ART, which was stable, and an increase in the number of people living with both HIV and TB who are receiving ART.

What to Watch

• Implementation of the America First Global Health Strategy multi-year agreements with countries
• Status of U.S. funding appropriated by Congress for PEPFAR and contributions to the Global Fund
• Impact of the PHFFA Policy on U.S. funding and programs
• Impact of U.S. changes to global health programs on health outcomes
• The future of transparent PEPFAR data monitoring and reporting

Background on U.S. Global Health Programs

• Historically, U.S. global health programs have been overseen and managed by three main federal departments and agencies: the State Department, USAID (now dissolved), and CDC.
  • The State Department is home to the Bureau of Global Health Security and Diplomacy (GHSD), which leads and oversees PEPFAR (which receives direct appropriations from Congress) as well as global health security and, more recently, other global health programs.
  • USAID, an independent agency established by Congress, had housed and managed most other U.S. bilateral global health programs (before its dissolution in 2025), including TB, malaria, maternal and child health, and nutrition, receiving direct appropriations from Congress for these efforts. Because the State Department had not historically served as an implementing agency, USAID also managed more than half of PEPFAR’s funding, through State Department transfers and direct appropriations from Congress.
  • CDC has global programs for HIV, TB, polio, and global health security, which receive direct Congressional appropriations and also manages and implements PEPFAR funding transferred by State and USAID.
• To carry out global health programs, federal agencies had funded other organizations, including non-profits, foreign governments, and international and multilateral health organizations, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and Gavi, the Vaccine Alliance.
• Prior to the start of the Trump administration, U.S. funding for global health, across multiple federal agencies and for bilateral and multilateral programs, including global health research, had totaled $12.0 billion in FY 2025.

Current Status of U.S. Global Health Programs

The following administration actions have or are likely to have a significant impact on the structure and operations of U.S global health programs:

• Stop-work order: The stop-work order, as part of the foreign aid review, initially froze all bilateral global health programming and services, halting existing work in the field (it was not applied to the Global Fund or Gavi). Because it halted payments, many implementers had to terminate staff and end some services.
• Limited waivers: Certain bilateral global health programs received waivers to allow “life-saving services” to continue, including a limited set of PEPFAR services and TB, malaria, maternal and child health, nutrition and infectious disease outbreak response services. Even with these waivers, services remained disrupted, and implementers faced challenges in getting permission to resume programming and difficulties in getting paid.
• Dissolution of USAID: Because USAID was the main implementing agency for global health efforts, its dissolution and loss of most of its staff reduced program implementation capacity and operations. Announcements of reductions at CDC could further affect global health efforts.
• Cancelled awards: In early 2025, it was reported that the administration canceled 86% of USAID awards. KFF analysis found that of the 770 global health awards identified, 80% were listed as terminated, totaling $12.7 billion in unobligated funding.
• Other executive orders and actions: In addition to the foreign aid review, several other orders and actions have or will likely affect global health, including: a review of international organization participation, the reinstatement and further expansion of the Mexico City Policy (now under a broader umbrella called the Promoting Human Flourishing in Foreign Assistance (PHFFA) Policy) and withholding of UNFPA funding, and withdrawal from the World Health Organization.
• Legal actions: In response to two lawsuits filed against the administration’s actions, a federal judge issued a preliminary injunction ordering the government to pay for work completed by February 13, 2025, although not all payments have been made and the court did not stop the government from canceling awards. The government appealed the ruling, and after several subsequent rulings in the case, the Supreme Court ultimately allowed the government to rescind (cancel) a portion of expiring global health funds before the end of the fiscal year. Further proceedings have been stayed, pending the outcome of a separate case.
• Reorganization: The administration moved to restructure and/or reduce global health efforts as follows:
  • On March 28, 2025, Secretary of State Rubio announced that the State Department and USAID had notified Congress of their intent to “restructure certain Department bureaus and offices that would implement programs and functions realigned from USAID” as follows:
    • Proposing legislation to abolish USAID as an independent agency.
    • Separating almost all USAID personnel from federal service within the current fiscal year.
    • Identifying USAID programs that “continue to advance the Administration’s foreign policy objectives,” including a subset of global health activities to be transferred to GHSD. These include programs that help reduce health disparities, deliver lifesaving vaccines, promote maternal and child health, and control malaria, TB, and other diseases.
  • On April 22, 2025, Secretary Rubio announced a reorganization of the State Department to “empower the Department from the ground up, from the bureaus to the embassies”, including removing redundant offices and non-statutory programs that are “misaligned with America’s core national interests.” On May 29, 2025, the State Department notified Congress with further details, including that GHSD would be reorganized to include three major divisions: Health Programs (with the Office of Health Programs and the Office of Program Transition and Supply Chain), Health Policy and Diplomacy (with the Office of Health Diplomacy and the Office of Program Planning and Evaluation), and Global Health Security (with the Office of Outbreak Detection and Response). With the dissolution of USAID in July 2025, U.S. global health programs were moved to the State Department.
• America First Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy, its roadmap for future U.S. government global health engagement, with 3 broad pillars – making America safer, stronger, and more prosperous – and focusing on HIV, TB, malaria, polio, and global health security. Per the strategy, the U.S. is negotiating bilateral, multi-year agreements with countries receiving U.S. global health assistance. The agreements include co-investment by countries and aim to transition the majority of countries to full self-reliance by the end of the agreement period. The U.S. will provide 100% of current levels of funding for health commodities and frontline healthcare workers for HIV, TB, malaria, and polio through FY 2026 and reduced funding thereafter (and rapidly reduce funding for activities other than health commodities and frontline health personnel). Global health security activities focus on surveillance, data sharing and laboratory capacity, to enable early detection and rapid containment of outbreaks originating outside the U.S. A KFF analysis of the MOUs finds that the administration plans to reduce funding to countries by billions over the next five years, relative to the prior five-year period.
• Funding: While the Trump administration has requested significantly less funding for global health in its budget requests, Congress has continued to appropriate funding at close to prior year levels, including $11.3 billion in FY 2026.

What to Watch

• Implementation of the America First Global Health Strategy bilateral, multi-year agreements with selected countries (see KFF tracker)
• Status of U.S. funding appropriated by Congress for global health programs
• Impact of the new policies on U.S. funding and programs, including the PHFFA Policy
• Impact of U.S. changes to global health programs on health outcomes

Background on the U.S. and the Global Fund

• The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) is an independent public-private, multilateral financing entity created in 2002. It raises and pools resources from multiple donors to address HIV, TB, and malaria and in turn, invests up to $5 billion per year in more than 100 low- and middle-income countries.
• The Global Fund reports that it has helped to save 70 million lives and reduce the combined death rate of its three focus diseases by 63% since 2002. With its support, in 2024, 25.6 million people were on antiretroviral therapy, 7.4 million were treated for TB, and 162 million mosquito nets were distributed.
• The U.S. government was instrumental in the creation of the Global Fund and is its largest donor, accounting for 33% of its funding. It also plays a significant role in governance and oversight of the Global Fund, holding one of twenty Board seats and currently sitting on two Board committees.
• Only LMICs whose most recent Gross National Income (GNI) per capita is below a certain threshold and meet disease burden criteria are eligible for Global Fund assistance. Countries are required to co-finance by investing in health systems and HIV, TB, and malaria national responses. To date, 11 countries have graduated from Global Fund support.

• The Global Fund has been considered the “multilateral component” of PEPFAR, as well as U.S. bilateral efforts focused on malaria and TB, complementing and extending the reach of U.S. programs to many more countries. It also works differently than U.S. bilateral health programs; unlike the U.S., it has no in-country presence and does not implement programs, instead providing financial assistance based on technical evaluations of country-led proposals. It also plays an important market shaping role through pooled procurement, driving down prices of health products, accelerating innovation and adoption of new products, and promoting quality standards, among other strategies.
• U.S. participation in the Global Fund is authorized in the legislation that created PEPFAR, as a permanent part of U.S. law. Other parts of the authorization are time-bound, including several related to the Global Fund such as a requirement that U.S. contributions to the Global Fund cannot exceed 33% of all contributions, used to limit U.S. funding and leverage support from other donors. Because PEPFAR’s current authorization expired on March 25, 2025, this requirement is not in place unless Congress includes it in appropriations or other legislative language.
• The Global Fund replenishes funding every three years, with periodic “pledging conferences” (the latest was held in November 2025). Its current replenishment (its eighth) generated $12.68 billion in pledges for the 2026-2028 period, including a pledge of $4.6 billion from the U.S.

• Prior to the start of the Trump administration, U.S. funding for the Global Fund in FY 2024 was $1.65 billion.

Current Status of U.S. Support for the Global Fund

• Stop-work order: The foreign aid review’s stop-work order initially froze all U.S. bilateral programming but was not applied to the Global Fund or other multilateral institutions. The administration subsequently announced that it canceled 86% of all USAID awards. Since the Global Fund relies on PEPFAR and other U.S. implementers, as well as U.S. government staff and expertise, to assist countries in delivering services, the disruption of that work affected some Global Fund efforts as well.
• International organizations review: A second executive order, calling for a 180-day review of U.S. participation in all international intergovernmental organizations, was initiated. Per the order, the purpose of the review was to determine which are “contrary to the interests of the United States and whether such organizations, conventions, or treaties can be reformed”. The Global Fund was not on the list of 66 international organizations from which the U.S. withdrew, per a January 7, 2026, presidential memorandum.
• America First Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy, its roadmap for future U.S. government global health engagement. Per the strategy, the U.S. is negotiating bilateral, multi-year agreements with countries receiving U.S. global health assistance with an aim to transition the majority of countries to full self-reliance by the end of the agreement period. The U.S. government reports that it is coordinating with the Global Fund as it develops these agreements.
• Long-acting injectable PrEP: On September 4, 2025, the administration announced that PEPFAR would partner with the Global Fund to support provision of long-acting injectable pre-exposure prophylaxis (PrEP) to up to 2 million people in high-burden countries by 2028.
• Policy restrictions: In January 2025, the Trump administration reinstated the expanded Mexico City Policy from Trump’s first term and further expanded it in January 2026 to apply to almost all non-military foreign assistance, many more entities including multilateral organizations, and additional areas of restrictions including activities related to diversity, equity and inclusion and “gender ideology” under a broader umbrella known as the “Promoting Human Flourishing in Foreign Assistance” (PHFFA) Policy.
• Funding: The Trump administration has requested significantly less funding for the Global Fund in its budget requests, and has not provided to the Global Fund all of the funding pledged by the U.S. to, and appropriated for, the seventh replenishment period (which included 2025). Despite this, Congress has continued to appropriate funding in support of U.S. pledges, including $1.25 billion in FY 2026. In addition, Congress included language in the FY 2026 spending bill stating that there remained “sufficient unobligated balances” from prior acts “to fulfill the United States pledge for the seventh replenishment.”

What to Watch

• Implementation of the America First Global Health Strategy multi-year agreements with countries
• Status of U.S. funding appropriated by Congress for the Global Fund
• Impact of the PHFFA Policy on U.S. funding and programs, including support for multilateral organizations
• Impact of U.S. changes to global health programs on health outcomes

Background on U.S. Global Maternal and Child Health (MCH) Efforts

• The U.S. government has been involved in supporting global maternal and child health (MCH) efforts for more than 50 years, as a top donor and provider of technical assistance and other support, helping to contribute to worldwide success in reducing maternal and child mortality.
• Still, in 2024, 4.9 million children under the age of 5 (more than 13,000 every day) died, with the highest rates of under-5 mortality in sub-Saharan Africa. About 260,000 women (or nearly one every two minutes) died during and following pregnancy and childbirth in 2023 – 92% of them in low- and middle-income countries. The majority of these deaths are preventable with proper interventions and access to care.
• Recent decades have seen major gains in preventing maternal and child mortality. Both the number and the rate of children dying before age 5 have fallen by more than 60% since 1990, and almost 100 countries have cut under-five mortality rates by at least two-thirds in that time. From 2000 to 2023, the annual number of maternal deaths worldwide fell by 40%. The U.S. government has contributed significantly to these gains, reporting that it helped to save the lives of more than 9.3 million children and 340,000 women over the past decade alone.
• Prior to its dissolution in 2025, USAID had served as the lead U.S. implementing agency for MCH activities, reaching more than 40 countries, including 25 “high priority” countries, primarily in Africa and southern Asia. The CDC also supported global MCH activities, primarily through immunization and technical assistance to build in-country capacity.
• Prior to the start of the Trump administration, U.S. funding provided to bilateral MCH activities in FY 2024 was $865.7 million; funding for Gavi was $300 million and for UNICEF was $142 million.

Current Status of U.S. MCH Programs

The following administration actions have had a significant impact on MCH program operations:

• Stop-work order: The stop-work order initially froze all MCH programming and services, halting USAID’s MCH programming, including pre- and post-natal health services and lifesaving maternal health care. Because the order halted payments, many implementers had to terminate staff and end some services.
• Limited waiver: Maternal and child health activities were included in a limited waiver issued by the State Department on February 4, 2025, allowing “life-saving services” to continue, defined as essential services related to the prevention, diagnosis and treatment of severe illnesses and conditions which–if not addressed–lead to mortality in women, newborns, and children under five. Listed in the waiver were antenatal care and post-partum services, essential newborn care, essential immunizations and treatment of acute child illness. Even with the waiver, services remained disrupted and implementers faced challenges in getting permission to resume programming and difficulties in getting paid.

• Dissolution of USAID: As the main government implementer of MCH efforts, the dissolution of USAID and loss of most staff significantly affected MCH implementation capacity and operations. In addition, announcements of reductions at CDC could further affect global MCH efforts.
• Canceled awards: In early 2025, it was reported that the administration canceled 86% of all USAID awards. KFF analysis found that of the 770 global health awards identified, 266 included MCH activities, 86% of which were terminated.
• Legal actions: In response to two lawsuits filed against the administration’s actions, a federal judge issued a preliminary injunction ordering the government to pay for work completed by February 13, 2025, although not all payments have been made and the court did not stop the government from canceling awards. The government appealed the ruling and after several subsequent rulings in the case, the Supreme Court ultimately allowed the government to rescind (cancel) a portion of expiring global health funds before the end of the fiscal year. Further proceedings have been stayed, pending the outcome of a separate case.
• Reorganization: The administration notified Congress on March 28, 2025, of its intent to permanently dissolve USAID and move any remaining USAID operations to the State Department, with global health activities, including for MCH, to be integrated into its Bureau of Global Health Security and Diplomacy (GHSD) which oversees PEPFAR. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan, and with the dissolution of USAID, programs moved in July 2025.
• America First Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy, its roadmap for future U.S. government global health engagement. Per the strategy, the U.S. is negotiating bilateral, multi-year agreements with countries receiving U.S. global health assistance with an aim to transition the majority of countries to full self-reliance by the end of the agreement period. MCH has been included in several of the agreements signed to date, although there is little information available on activities and funding.
• Policy restrictions: In January 2025,the Trump administration reinstated the expanded Mexico City Policy from Trump’s first term and further expanded it in January 2026 to apply to almost all non-military foreign assistance, many more entities, and additional areas of restrictions including activities related to diversity, equity and inclusion and “gender ideology” under a broader umbrella known as the “Promoting Human Flourishing in Foreign Assistance” (PHFFA) Policy.
• Funding: The Trump administration has requested significantly less funding for MCH in its budget requests and canceled or suspended funding for numerous MCH-related projects and awards. This includes suspending funding for Gavi (unless it meets certain conditions) and rescinding funding for UNICEF. Despite this, Congress has continued to appropriate level funding for these programs including $845 million for bilateral MCH activities (at the State Department and CDC), $300 million for Gavi, and funding for UNICEF “consistent with prior year levels” in FY 2026.

Impact on MCH Services and Outcomes

• An internal USAID memo from 2025 reported that the cessation of USAID programming for MCH would affect services for 16.8 million pregnant women annually, eliminate postnatal care for 11.3 million newborns within the first two days of life, and prevent 14.8 million children under 5 from receiving treatment for pneumonia and diarrhea.
• A rapid assessment survey of 108 WHO country offices in 2025 found that almost half reported moderate or severe disruptions to MCH services, including for medicines and health products, due to the U.S. foreign aid freeze and other shortages. WHO also said that funding cuts have “led to facility closures and loss of health workers, while also disrupting supply chains for lifesaving supplies and medicines such as treatments for haemorrhage, pre-eclampsia and malaria – all leading causes of maternal deaths.”
• In addition, several modeling studies have found that cuts in or termination of U.S. MCH funding could result in significant increases in maternal and child deaths and, as a result, the maternal mortality ratio, under 5 mortality rate, and stillbirth rate in coming years.

What to Watch

• Implementation of the America First Global Health Strategy multi-year agreements with countries
• Status of U.S. funding appropriated by Congress for bilateral MCH efforts and contributions to Gavi and UNICEF
• Impact of the PHFFA Policy on U.S. funding and programs
• Impact of U.S. changes to global health programs on health outcomes

Background on the U.S. and CEPI

• The Coalition for Epidemic Preparedness Innovations (CEPI) aims to accelerate the development of vaccines and other technologies to prepare for and respond to epidemic and pandemic threats. Pooling and leveraging contributions from more than 30 governments, philanthropic foundations, and private sector partners, CEPI invests to drive research and development into vaccine and therapeutic candidates against high-threat pathogens. It also works to strengthen global laboratory and vaccine manufacturer networks and regulatory environments and to research and support vaccine safety. A core focus is its “100 Days Mission”, an effort to reduce the time it takes to develop vaccines and other countermeasures during outbreaks with pandemic potential.
• Since its founding in 2017, CEPI contributed to the first licensed vaccine for Chikungunya; is supporting the development of vaccines for Lassa fever, MERS, Nipah virus and Rift Valley fever, all of them currently in clinical trials; and aided in the development of seven COVID-19 vaccines that were licensed for use.
• The U.S. government made its first financial contribution to CEPI in 2020 and has thus far invested $217 million in the organization. It has also collaborated in other ways with the CEPI including through partnerships with U.S. International Development Finance Corporation (DFC), the Department of Defense, and the U.S. Biomedical Advanced Research and Development Agency (BARDA). The U.S. FDA had also been a member of CEPI’s Joint Coordination Group, and USAID, which had managed the relationship with CEPI, before its dissolution in 2025, had held the U.S. government seat on the CEPI Investors Council.
• CEPI reports that it has contributed significantly to the U.S. economy through its funding of U.S.-based vaccine developers and that this funding far exceeds the amount of funding it has received from the U.S. government.
• CEPI replenishes funding every five years. For the last replenishment round, held in 2022, the U.S. pledged $150 million over five years, which has been exceeded. The next replenishment round, known as CEPI 3.0, covers the 2027-2031 period. Additionally, CEPI has launched a Ebola R&D funding appeal (specifically medical countermeasures to the Bundibugyo strain of Ebolavirus), to which the U.S. has pledged $50 million. The U.S. accounts for approximately 6% of total contributions received by CEPI to date.
• Prior to the start of the Trump administration, U.S. funding provided to CEPI in FY 2024 was $100 million.

Current Status of U.S. Support for CEPI

• Stop-work order: The foreign aid review’s stop-work order initially froze all U.S. bilateral programming but was not applied to CEPI or other multilateral institutions. The administration subsequently announced that it canceled 86% of all USAID awards. KFF analysis found that of 770 global health awards identified, 80% were listed as terminated, including the CEPI contract. CEPI reported that it has not received a termination notice, but it has not received any regular funding from the Trump administration.
• International organizations review: A second executive order, calling for a 180-day review of U.S. participation in all international intergovernmental organizations, was initiated. Per the order, the purpose of the review was to determine which are “contrary to the interests of the United States and whether such organizations, conventions, or treaties can be reformed”. CEPI was not on the list of 66 international organizations from which the U.S. withdrew, per a January 7, 2026, presidential memorandum.
• Reorganization: The administration notified Congress on March 28, 2025, of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department, including global health activities, which would be integrated into its Bureau of Global Health Security and Diplomacy (GHSD). On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan. With the dissolution of USAID, programs moved in July 2025.
• America First Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy, its roadmap for future U.S. government global health engagement. Per the strategy, the U.S. is negotiating bilateral, multi-year agreements with countries receiving U.S. global health assistance with an aim to transition the majority of countries to full self-reliance by the end of the agreement period. Global health security figures prominently in the new strategy, although CEPI, and other international organizations that focus on pandemic preparedness and response, are not mentioned.
• Funding: The Trump administration has not included funding for CEPI in its budget requests and has provided no regular funding to the organization. Despite this, the Congress has continued to appropriate funding for CEPI, stating that funding should be consistent with prior year amounts.

What to Watch

• Implementation of the America First Global Health Strategy
• Status of U.S. regular funding appropriated by Congress for CEPI but, as yet, not provided by the Trump administration
• Further results of the administration’s international organizations review
• U.S. international engagement in pandemic preparedness and response

Background on U.S. Global Family Planning & Reproductive Health (FP/RH) Efforts

• The U.S. government had supported FP/RH efforts for 60 years and was the largest donor to the sector. It also was one of the largest purchasers and distributors of contraceptives internationally.
• Still, each year, about 260,000 women die from complications during pregnancy and childbirth, almost all in low- and middle-income countries. Almost one-third of these deaths could be prevented with greater access to contraception. Worldwide, an estimated 259 million women have an unmet need for modern contraception.
• Recent decades have seen major gains in access to family planning and reproductive health services. The U.S. government contributed significantly to this progress, reporting that in the countries it supported, modern contraceptive prevalence increased from less than 10% in 1965 to 34% in 2023 and family size fell from more than 6 to 3.9. It also estimated that it would reach up to 24 million women and couples with contraceptive services and supplies, helping to prevent 14,000 maternal deaths and 8.1 million unintended pregnancies, in 2023.
• Prior to its dissolution in 2025, USAID had served as the lead U.S. implementing agency for FP/RH activities, working in 41 countries, with focused efforts in 29 high-need countries and the Francophone West African region. The CDC also supported some global FP/RH activities primarily through research, surveillance and technical assistance.
• The U.S. role in global FP/RH has often been contested, influenced by differing views and political debates primarily related to abortion. As a result, U.S. foreign assistance funding is governed by several legislative and policy requirements, including the Mexico City Policy (which has been implemented and rescinded along Presidential party lines and was significantly expanded by both Trump administrations), the Helms Amendment, and the Kemp-Kasten Amendment.
• Prior to the start of the Trump administration, U.S. funding provided to bilateral FP activities in FY 2024 was $575 million; funding for UNFPA was $30.5 million.

Current Status of U.S. FP/RH Programs

The following administration actions have had a significant impact on FP/RH program operations:

• Stop-work order: The stop-work order initially froze all FP/RH programming and services, halting USAID’s FP/RH programming including procurement and delivery of contraceptive commodities. Because the order halted payments, many implementers had to terminate staff and end some services.
• Limited waiver: While the State Department issued a waiver of the stop-work order allowing certain “life-saving services” to continue, family planning services were specifically prohibited from continuation, including in the blanket humanitarian waiver issued on January 28, 2025, and the limited global health waiver issued on February 4, 2025.
• Dissolution of USAID: As the main government implementer of FP/RH efforts, the dissolution of USAID and loss of most staff significantly affected FP/RH implementation capacity and operations. In addition, announcements of reductions at CDC could further affect global FP/RH efforts.
• Canceled awards: In early 2025, it was reported that the administration has canceled 86% of all USAID awards. KFF analysis found that of the 770 global health awards identified, 233 included FP/RH activities, 85% of which were terminated.
• Legal actions: In response to two lawsuits filed against the administration’s actions, a federal judge issued a preliminary injunction ordering the government to pay for work completed by February 13, 2025, although not all payments have been made and the court did not stop the government from canceling awards. The government appealed the ruling and after several subsequent rulings in the case, the Supreme Court ultimately allowed the government to rescind (cancel) a portion of expiring global health funds before the end of the fiscal year. Further proceedings have been stayed, pending the outcome of a separate case.
• Reorganization: The administration notified Congress on March 28, 2025, of its intent to permanently dissolve USAID and move any remaining USAID operations to the State Department, with global health activities to be integrated into its Bureau of Global Health Security and Diplomacy (GHSD) which oversees PEPFAR. FP/RH programs were not continued.
• America First Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy, its roadmap for future U.S. government global health engagement. Per the strategy, the U.S. is negotiating bilateral, multi-year agreements with countries receiving U.S. global health assistance with an aim to transition the majority of countries to full self-reliance by the end of the agreement period. FP/RH activities are not included in these agreements.
• Policy restrictions: In January 2025, the Trump administration reinstated the expanded Mexico City Policy from Trump’s first term and further expanded it in January 2026 to apply to almost all non-military foreign assistance, many more entities, and additional areas of restrictions including activities related to diversity, equity and inclusion and “gender ideology” under a broader umbrella known as the “Promoting Human Flourishing in Foreign Assistance” (PHFFA) Policy. The administration also withdrew from membership in and support of UNFPA on January 7, 2026.
• Funding: The Trump administration has requested no funding for FP in its budget requests and stopped supporting this work in 2025, including rescinding FP funding and withholding funding from UNFPA. Despite this, Congress has continued to appropriate level funding for these programs including $575 million for bilateral FP activities and $32.5 million for UNFPA in FY 2026.

Impact on FP/RH Services and Outcomes

• A rapid assessment survey of 108 WHO country offices in 2025 found that more than four in ten reported moderate or severe disruptions to FP and contraception services, with 38% reporting such disruptions for commodities specifically, due to the U.S. foreign aid freeze and other shortages.
• Reports have indicated that millions of dollars in shipments of already purchased contraceptive commodities intended for low- income countries expired while the administration assessed whether to incinerate the supplies or transfer them to another distributor.
• It is estimated that the loss of U.S. funding in 2025 resulted in a global contraceptive procurement funding gap of approximately $250 million.
• In addition, several modeling studies have found that cuts in or termination of U.S. FP funding could result in significant increases in unintended pregnancies, unsafe abortions, and maternal deaths.

What to Watch

• Implementation of the America First Global Health Strategy multi-year agreements with countries and whether countries will choose to continue any FP activities previously supported by the U.S. government.
• Status of U.S. funding appropriated by Congress for bilateral FP efforts and contributions to UNFPA
• Impact of the PHFFA Policy on U.S. funding and programs
• Impact of U.S. changes to global health programs on health outcomes

Background on U.S. Global Health Security Efforts

• The U.S. has supported global health security (GHS) and pandemic preparedness efforts for decades through funding and technical support provided to low- and middle-income countries (as well as support for multilateral efforts). This had included the development of formal GHS partnerships with other countries, starting with 17 in 2014 and rising to more than 50 in 2024.
• GHS efforts are designed to help countries and regions build capacities needed to prevent avoidable outbreaks, detect infectious disease threats early, and reduce the impacts of epidemics and pandemics through rapid and effective responses.
• Specific activities include: improving surveillance and laboratory systems, reducing the risks of animal to human disease exposures, training epidemiologists, and fostering better biosafety and biosecurity practices.
• U.S. investments in GHS have led to measurable increases in capacity, including improvement in 9 of 15 technical areas between 2018 and 2023 in GHS partnership countries and reductions in average outbreak response times.
• Prior to 2025, multiple U.S. agencies, coordinated by the National Security Council (NSC), were involved in these efforts including USAID (now dissolved), the Centers for Disease Control and Prevention (CDC), the Department of Defense (DoD), the State Department, HHS, and USDA. The first U.S. GHS Strategy was released in 2019 by the first Trump administration and an updated strategy was released by the Biden administration in 2024.
• Prior to the start of the Trump administration, U.S. funding provided to bilateral GHS activities in FY 2024 was $1.25 billion; $100 million was provided to the Coalition for Epidemic Preparedness Innovations (CEPI) and $250 million to the Pandemic Fund.

Current Status of U.S. Global Health Security Programs

The following administration actions have had a significant impact on U.S. GHS programs:

• Stop-work order: The stop-work order initially froze all USAID-based GHS programming and services. As a result, many GHS implementing partners let staff go and some USAID-supported GHS activities in progress were interrupted, such as funding for transport of samples and phone plans for contact tracers.
• Limited waiver: Some GHS activities were included in a limited waiver issued by the State Department on February 4 allowing “life-saving services” to continue, including: rapid emergency response to immediate infectious disease outbreaks, focused on pathogens with pandemic potential and those that pose a national security risk to U.S. citizens (e.g., mpox and H5N1), including detection, prevention, and containment and supply of medical countermeasures. Even with the waiver, services remained disrupted and implementers faced challenges in getting permission to resume programming and difficulties in getting paid.
• Dissolution of USAID: Before its dissolution, USAID had about 50 staff supporting international outbreak response efforts, a number which dropped to six in the early weeks of the Trump administration. As a result, many GHS partners lost points of contact and technical support, in addition to the loss of funding. Announcements of reductions at the CDC could further affect GHS capacity.
• Reorganization: The administration notified Congress on March 28, 2025, of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department with global health activities (including for GHS) to be integrated into its Bureau of Global Health Security and Diplomacy (GHSD). On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan, and with the dissolution of USAID, programs moved in July 2025.
• America First Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy, its roadmap for future U.S. government global health engagement (the Trump administration withdrew the 2024 Global Health Security Strategy and has not released an updated strategy). Per the America First strategy, the U.S. is negotiating bilateral, multi-year agreements with countries receiving U.S. global health assistance with an aim to transition the majority of countries to full self-reliance by the end of the agreement period. Global health security figures prominently in the new strategy and is part of all of the agreements signed to date. Goals include enabling detection of outbreaks with epidemic potential within seven days and containing outbreaks originating outside the U.S. rapidly at their source, prioritizing mobilization within 72 hours of detection.
• Withdrawal from WHO: In January 2025, President Trump announced that the U.S. would withdraw from the World Health Organization (WHO) and halted its funding (the formal withdrawal was completed in January 2026). The administration also said that the U.S. would not be bound by the recently revised International Health Regulations or the new pandemic agreement being negotiated by WHO, two international instruments that outline roles and responsibilities for countries to prepare for and respond to outbreaks.
• Funding: The Trump administration has requested significantly less funding for GHS in its budget requests and canceled or suspended funding for GHS-related projects and awards, including for contributions to CEPI and the Pandemic Fund. Despite this, Congress has continued to appropriate funding for bilateral GHS efforts at close to prior year levels, including $1.1 billion in FY 2026, and called for funding consistent with prior amounts for contributions to CEPI and the Pandemic Fund.

Impact on GHS Services and Outcomes

• The combination of administration actions described above has reduced capacity and may challenge communication and coordination across U.S. agencies and with partners, contributing to slower responses to emerging health threats, greater impacts, and increased risk of importation of diseases into the U.S.
• Experts estimate that there is a 50% chance of another pandemic emerging in the next 25 years, with the risk greatest in the least prepared countries. 
• The health impacts of poorly controlled outbreaks can be severe. An internal USAID memo from 2025 estimated that the risk of losing USAID GHS programs alone could result in more than 28,000 new cases of dangerous infectious diseases, such as Ebola and Marburg, every year.
• Emerging diseases can result in major economic and social costs, even with small-scale outbreaks.
  • The SARS 2003 outbreak led to an estimated $30 billion in economic losses (over $3 million per case) from reduced commerce, travel and trade.
  • The 2014-2015 West Africa Ebola epidemic led to an estimated $53 billion in economic losses. A single Ebola patient in New York cost the city’s $4.3 million in response measures.
  • Measles outbreaks in the U.S., often initiated through importation from other countries, can lead to significant costs; a recent study from Washington state found that a 71-case measles outbreak led to societal costs of $3.4 million, or almost $50,000 per case.
• Pandemics have even more massive economic costs, as experienced with COVID-19, which cost the U.S. alone an estimated at $16 trillion – a number four times the lost economic output from the 2008 financial crisis.
• News broke in mid-May of the ongoing Ebola outbreak in the Democratic Republic of the Congo, and given all of the changes made by the U.S. to its foreign assistance and global health response, U.S. support is taking shape under very different circumstances and through different organizational mechanisms than in the past, but a recent KFF analysis found that the speed of the U.S. government’s response to the current outbreak is on par with the prior two outbreaks, and initial U.S. funding amounts are already surpassing the prior two outbreaks.

What to Watch

• Implementation of the America First Global Health Strategy multi-year agreements with countries
• Status of U.S. funding appropriated by Congress for bilateral GHS efforts and contributions to CEPI and the Pandemic Fund
• U.S. international engagement in pandemic preparedness and response

Background on PMI

• The U.S. government has been involved in global malaria activities since the 1950s and has been the largest donor to the sector. In 2005, the President’s Malaria Initiative (PMI) was launched to scale up funding and activities to address malaria in the hardest hit African countries, helping to contribute to global success in driving down malaria cases and deaths.
• Still, in 2024, there were 282 million cases of malaria, a life-threatening disease spread to humans by mosquitoes, and 610,000 malaria deaths (the majority of which were among children under age five), a slight increase over the prior year.
• Recent decades have seen major gains in reducing the impact of malaria, and PMI is credited with having helped to save 11.7 million lives and prevent 2.1 billion malaria cases. Indeed, as of 2024, in countries where PMI worked, global efforts supported a 29% decrease in malaria case rates and 48% decline in deaths. In addition, U.S. malaria assistance has been found to bolster the national economies in countries and communities most heavily affected by the disease with an analysis finding that every dollar of U.S. malaria assistance increased GDP in recipient countries nearly six-fold. The introduction of two malaria vaccines in 2021 and 2023 has increased optimism in the potential to further strengthen global malaria control.
• Prior to the dissolution of USAID in 2025, PMI had operated as an interagency initiative led by USAID and implemented in partnership with CDC, focused in 30 countries that account for most of the world’s malaria cases and deaths. It had been overseen by a U.S. Global Malaria Coordinator, a position created by Congress in 2008 to be appointed by the President and based at USAID.
• While the Trump administration has requested significantly less funding for PMI in its budget requests, prior to the start of the Trump administration U.S. funding provided to PMI and other bilateral global malaria efforts in FY 2024 was about $805 million; funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) was $1.65 billion.

Current Status of PMI/Malaria Activities

The following administration actions have had a significant impact on PMI operations:

• Stop-work order: The stop-work order initially froze all PMI programming and services, halting existing PMI activities, including bed net provision, residual spraying and delivery of antimalarial medicines. Because the order halted payments, many implementers had to terminate staff and end some services.
• Limited waiver: Malaria programs received a limited waiver on February 4, 2025, allowing “life-saving services” to continue, including those that “must resume within 30 days to ensure malaria diagnosis and treatment, as well as prevention through distribution of nets and indoor residual spraying targeting highest burden areas…and lifesaving malaria medicines for pregnant women and children”. Even with the waiver, services remained disrupted and implementers faced challenges in getting permission to resume programming and difficulties in getting paid.
• Dissolution of USAID: USAID was the main government implementing agency for malaria efforts, obligating almost all bilateral malaria assistance in FY 2023 (96%). Without USAID and most of its staff, PMI’s implementation capacity and operations have been affected. In addition, announcements of reductions at CDC could further affect global malaria efforts.
• Canceled awards: In early 2025, it was reported that the administration canceled 86% of all USAID awards. KFF analysis found that of the 770 global health awards identified, 157 included malaria activities, 80% of which were terminated.
• Legal actions: In response to two lawsuits filed against the administration’s actions, a federal judge issued a preliminary injunction ordering the government to pay for work completed by February 13, 2025, although not all payments have been made and the court did not stop the government from canceling awards. The government appealed the ruling and after several subsequent rulings in the case, the Supreme Court ultimately allowed the government to rescind (cancel) a portion of expiring global health funds before the end of the fiscal year. Further proceedings have been stayed, pending the outcome of a separate case.
• Reorganization: The administration notified Congress on March 28, 2025, of its intent to permanently dissolve USAID and move any remaining USAID operations to the State Department, with global health activities, including for malaria, to be integrated into its Bureau of Global Health Security and Diplomacy (GHSD) which oversees PEPFAR. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan, and with the dissolution of USAID, programs moved in July 2025.
• America First Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy, its roadmap for future U.S. government global health engagement. Per the strategy, the U.S. is negotiating bilateral, multi-year agreements with countries receiving U.S. global health assistance with an aim to transition the majority of countries to full self-reliance by the end of the agreement period. Malaria has been included in most of the agreements signed to date, although there is little information available on activities and funding. A U.S. Malaria Coordinator has yet to be appointed.
• Policy restrictions: In January 2025, the Trump administration reinstated the expanded Mexico City Policy from Trump’s first term and further expanded it in January 2026 to apply to almost all non-military foreign assistance, many more entities, and additional areas of restrictions including activities related to diversity, equity and inclusion and “gender ideology” under a broader umbrella known as the “Promoting Human Flourishing in Foreign Assistance” (PHFFA) Policy.
• Funding: The Trump administration has requested significantly less funding for PMI and other malaria efforts in its budget requests and canceled funding for numerous malaria-related projects and awards. Despite this, Congress has continued to appropriate level funding for PMI and other bilateral global malaria efforts, including about $805 million in FY 2026. It also appropriated $1.25 billion for the Global Fund in FY 2026.

Impact on PMI Services and Outcomes

• An internal USAID memo from 2025 estimated that an additional 12.5-17.9 million malaria cases and an additional 71,000-166,000 deaths could occur annually if PMI was halted permanently.
• A rapid assessment survey of 108 WHO country offices in 2025 found that of the 64 malaria-endemic countries surveyed, more than half reported moderate or severe disruptions to malaria services, including for medicines and health products, due to the U.S. foreign aid freeze and other shortages.
• In early April 2025, almost 30% of planned insecticide treated net (ITN) distribution campaigns were off-track or at risk of being delayed due to funding shortages, and such risks continue today. Several countries also face stock-out risks for key commodities including for rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT). Reductions in funding also threaten investments in new and improved malaria prevention, diagnostic, and treatment interventions. Such disruptions pose significant risks, particularly during peak malaria seasons across Africa where seasonal malaria campaigns are needed to protect millions of people. In a court filing challenging the funding freeze, for example, a major U.S. implementer reported that it had to delay the start of anti-malarial campaigns in Africa last year.
• A modeling project estimated that a full year U.S. funding cuts could result in an additional 2.4 million malaria cases among adults and an additional 7.2 million malaria cases among children.

What to Watch

• Implementation of the America First Global Health Strategy multi-year agreements with countries
• Status of U.S. funding appropriated by Congress for bilateral malaria efforts and contributions to the Global Fund
• Impact of the PHFFA Policy on U.S. funding and programs
• Impact of U.S. changes to global health programs on health outcomes

Background on the U.S. and Gavi

• Gavi, the Vaccine Alliance (Gavi), is an independent public-private, multilateral financing entity created in 2000. It raises and pools resources from multiple donors and in turn, disburses approximately $1.7 billion per year to support procurement and distribution of vaccines in low- and middle-income countries (LMICs).
• Gavi supports vaccines against 20 infectious diseases, and hosts the global emergency vaccine stockpiles against Ebola, yellow fever, meningitis, and cholera. By playing a market shaping role through pooled procurement, demand forecasting, support for regional manufacturing capacity, and other strategies, Gavi helps to drive down prices for vaccines in LMICs.
• Gavi reports that it has helped to immunize more than 1.2 billion children in 78 LMICs, preventing more than 20 million deaths, and generating economic benefits estimated at more than $280 billion, since 2000.
• The U.S. government was one of the original donors to Gavi and had been its third largest contributor in recent years, providing 13% of its funding since its inception. Gavi also had a donor liquidity partnership with the U.S. International Development Finance Corporation (DFC) allowing Gavi to quickly access up to $1 billion from a “Rapid Financing Facility” to support routine immunization and pandemic response, backed by forthcoming donor pledges. Additionally, the U.S. was the largest donor to COVAX, the international effort housed at Gavi that supported the development, procurement, and delivery of COVID-19 vaccines to LMICs (COVAX ended in 2023).
• Only LMICs whose most recent Gross National Income (GNI) per capita is below a certain threshold are eligible for Gavi assistance (56 countries in 2026). Countries are required to co-finance a portion of their vaccines on a sliding scale. To date, 19 countries have graduated from Gavi assistance.

• Gavi had been the primary mechanism by which the U.S. government supported the procurement of vaccines for LMICs. The USAID bilateral maternal and child health program had complemented Gavi by supporting in-country capacity building and immunization campaigns and, prior to its dissolution in 2025, USAID had managed the U.S. partnership with Gavi.
• Every five years, Gavi replenishes funding through “pledging conferences”. For the 2026-2030 period, Gavi secured more than $9 billion towards a target budget of $11.9 billion, which it estimates would save at least 8 million lives by 2030.
• Prior to the start of the Trump administration, U.S. funding provided to Gavi in FY 2024 was $300 million.

Current Status of U.S. Support for Gavi:

• Stop-work order: The foreign aid review’s stop-work order initially froze all U.S. bilateral programming but was not applied to Gavi or other multilateral institutions. The administration subsequently announced that it canceled 86% of all USAID awards. KFF analysis finds that of 770 global health awards identified, 80% are listed as terminated, including the main Gavi contract as well as the COVAX contract. Gavi reports that it has not received a termination notice for its main contract, although it did receive one for COVAX (all U.S. funding was already disbursed to COVAX in 2021).
• International organizations review: A second executive order, calling for a 180-day review of U.S. participation in all international intergovernmental organizations, was initiated. Per the order, the purpose of the review was to determine which are “contrary to the interests of the United States and whether such organizations, conventions, or treaties can be reformed”. Gavi was not on the list of 66 international organizations from which the U.S. withdrew, per a January 7, 2026, presidential memorandum.
• Reorganization: The administration notified Congress on March 28, 2025, of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department, including global health activities which would be integrated into its Bureau of Global Health Security and Diplomacy (GHSD). Delivery of lifesaving vaccines is listed among the USAID activities to be continued at GHSD, although currently the relationship with Gavi is being managed through the Office of Global Affairs at the Department of Health and Human Services. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan, and with the dissolution of USAID, programs moved in July 2025.
• America First Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy, its roadmap for future U.S. government global health engagement. Per the strategy, the U.S. is negotiating bilateral, multi-year agreements with countries receiving U.S. global health assistance with an aim to transition the majority of countries to full self-reliance by the end of the agreement period. While the strategy and country agreements include the importance of polio and malaria vaccination and metrics for measuring their delivery, Gavi is not mentioned, and the U.S. has not announced how it will procure these vaccines.
• Funding: The Trump administration has not included funding for Gavi in its budget requests, including its FY27 budget request that stated that any future funding for Gavi is “contingent on the organization making necessary reforms and meeting certain benchmarks on vaccine safety.” While Congress appropriated $300 million for U.S. contributions to Gavi in FY 2025 and FY 2026, the current administration has not provided funding to Gavi after citing concerns about vaccine safety, despite Gavi following globally-recognized scientific standards and evidence. Gavi has committed to working toward accelerating its transition to different vaccines, in partnership with its Board and countries, and based on manufacturers ability to expand production capacity, among other factors. On July 29, 2026, the administration announced it would “immediately release” $600 million in Congressionally-appropriated FY25 and FY26 funding to Gavi.
• U.S. representation on the Gavi Board: The U.S. historically played a role in Gavi’s governance, including as a Board and committee member, but with the suspension of U.S. funding by the Trump administration, the U.S. is no longer eligible to be part of the Board. In its recent announcement that it would resume funding, the administration stated that the U.S. “expects to resume its place on the Gavi Board.”   
• Potential impact on health outcomes: The loss of U.S. support for Gavi would affect procurement of vaccines for LMICs, with particular impact on children. Gavi estimates that loss of funding could result in 75 million children not receiving routine vaccinations over the next five years, leading to more than 1.2 million children dying as a result. Reductions in vaccine stockpiles could also impact outbreak control.

What to Watch

• Implementation of the America First Global Health Strategy
• Status of U.S. funding appropriated by Congress for Gavi and the U.S. role in Gavi governance
• Further results of the administration’s international organizations review
• Impact of U.S. changes to global health programs on health outcomes