The Trump Administration’s Foreign Aid Review: Proposed Reorganization of U.S. Global Health Programs

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, 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. Because the State Department is not an implementing agency, it has transferred most PEPFAR funding to USAID and CDC.
  • USAID, an independent agency established by Congress, had housed and managed most other U.S. bilateral global health programs, including TB, malaria, maternal and child health, and nutrition, receiving direct appropriations from Congress for these efforts. It 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 fund 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.

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:

• Funding freeze/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 let go of thousands of 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 of TB, malaria, maternal and child health, nutrition and infectious disease outbreak response Even with these waivers, services remain disrupted, and implementers have 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 have reduced program implementation capacity and operations. Announcements of reductions at CDC could further affect global health efforts.
• Cancelled awards: It was recently reported that the administration has canceled 86% of USAID awards. Of these, KFF analysis identified 770 global health awards, 80% of which 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 of the Mexico City Policy and withholding of UNFPA funding, and withdrawal from the World Health Organization.
• Proposed reorganization: The administration has also announced plans for restructuring or reducing global health efforts as follows:
  • On March 28, 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.
    • Requesting funding in the FY 2026 budget for remaining programs previously implemented by USAID.
    • 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. The State Department notes that these programs are already coordinated with GHSD, GHSD has expertise to manage them, and integration would result in synergies and allow GHSD to more effectively manage supply chains. The notification also indicates that the Department anticipates making investments to support integration.
  • On April 22, 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.” The reorganization would move GHSD from reporting to the Secretary of State to reporting to the Undersecretary for Economic Growth, Energy, and the Environment.
  • On April 16, a leaked FY 2026 HHS passback budget document proposed numerous changes to the HHS, including the elimination of CDC’s Center for Global Health, keeping only its global health security activities.

What to Watch

• Foreign aid review results: The administration could soon release results of foreign aid review, but it is unknown whether it will recommend any changes to global health programs, or how or if Congress will respond to its recommendations. Results of the international organization review are expected later this year.
• Reorganization: While the reorganization of U.S. global health programs is well underway, there are still many questions about what programs will be maintained and how they will be managed, implemented and monitored, particularly given the significant reductions in federal staff as well as of health care workers more broadly who have been affected by U.S. cuts.
• Leadership: Several leadership positions have yet to be announced, including the U.S. Global AIDS Coordinator (which requires Senate confirmation), the U.S. Malaria Coordinator, and others. Whether the administration will choose to nominate or appoint people to these positions is not yet known.
• Funding/President’s budget request: The administration has signaled that it may seek rescissions of FY 2025 funding amounts, which could further affect global health funding. In addition, the President’s FY 2026 budget request, expected soon, could further signal the administration’s plans.
• Congressional oversight: As budget and reorganization proposals and requests continue to circulate, members of Congress could choose to exert their own authority, including seeking further clarification and information about the potential impacts of proposed changes.