The U.S. Government and Global Health

Table of Contents

Introduction

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While there is currently no standard, agreed-upon definition of global health, the National Academy of Medicine (formerly Institute of Medicine) defines global health as having “the goal of improving health for all people in all nations by promoting wellness and eliminating avoidable diseases, disabilities, and deaths.” A key dimension of global health is an emphasis on addressing inequities in health status between rich and poor countries and also for those who are most marginalized within countries, as well as a recognition that the health of people around the world is highly interconnected, with domestic and foreign health inextricably linked. 

The U.S. government has long been the largest donor to and implementer of global health programs in the world. These efforts have aimed to help improve the health of people in low- and middle-income countries while also contributing to broader U.S. global development goals, foreign policy priorities, and national security concerns, including helping safeguard the health of Americans. These efforts began decades ago and saw major expansion in the early part of the current century with the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR) and other programs. Since the beginning of the second Trump administration, however, the U.S. global health response has undergone significant change, disruption, and retraction, and the global health landscape has been altered in fundamental ways. This has included, as part of a major review of U.S. foreign aid, the dissolution of the U.S. Agency for International Development (USAID), the main implementing agency for U.S. global health programs, the elimination of numerous programs and projects, and the transition of remaining programs to the State Department.  As part of its review, the administration is seeking to assess whether U.S. foreign aid programs are aligned with U.S. national interests.

What Is the U.S. Role in Global Health?

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Historically, the U.S. role in global health is multifaceted and includes a broad range of activities. Its primary roles are as a supporter of bilateral (i.e., country-to-country) efforts, directly funding implementation of global health efforts in partner countries, and as a donor to multilateral health institutions (i.e., international organizations that pool support from multiple countries for one or more areas of global health). The U.S. also engages in global health diplomacy through its relationships with other governments, multilateral institutions, non-governmental organizations, and the private sector. Specifically, the U.S. government:

  • acts as a donor by providing financial and other health-related development assistance (e.g., commodities, like contraceptives or bed nets for protection from disease-carrying mosquitoes) to low- and middle-income countries;
  • operates programs and delivers health services;
  • provides technical assistance and other capacity-building support;
  • participates in major international health organizations and coordinates health efforts with other stakeholders through global health diplomacy;
  • conducts research;
  • supports international responses to disasters and other emergencies; and
  • partners with governments, non-governmental groups, and the private sector (Figure 1).

U.S. global health activities have targeted a variety of issues and used different intervention approaches such as:

  • Health services and systems strengthening: improving basic and essential health services, systems, and infrastructure;
  • Disease detection and response: supporting surveillance, prevention, and treatment of diseases, including both infectious (e.g., HIV, TB, malaria) and non-communicable diseases (e.g., cardiovascular disease, cancer);
  • Population and maternal/child health: promoting maternal health; reproductive health and family planning; child nutrition, immunization, and other child survival interventions;
  • Nutrition, water, and environmental health: providing non-emergency food aid and supporting dietary supplementation and food security; clean/safe water and sanitation; mitigation of environmental hazards; and
  • Research and development: investigating and developing new technologies, interventions, and strategies, including vaccines, medicines, and diagnostics.

What Are the Major Global Health Program Areas the U.S. Supports?

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While the U.S. government’s involvement in global health currently faces an uncertain future – with a more limited scope, the dissolution of USAID, and cancelation of numerous U.S.-supported global health projects, as the Trump administration seeks to reorganize foreign aid more broadly –  the U.S. has historically supported global health through a wide array of bilateral and multilateral global health programs in countries around the world including:

HIV/PEPFAR

While the U.S. first provided funding to address the emerging global HIV epidemic in 1986, U.S. funding and attention for these efforts has grown significantly in the last two decades, particularly following President George W. Bush’s 2003 announcement of the President’s Emergency Plan for AIDS Relief (PEPFAR), the coordinated U.S. government response to global HIV. Now the largest commitment by any nation devoted to a single disease, the launch of PEPFAR led to substantially increased U.S. support for HIV prevention, treatment, and care efforts, as well as U.S. contributions to multilateral entities, including the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the International AIDS Vaccine Initiative (IAVI).  PEPFAR, which is housed in the Department of State, has been credited with saving 26 million lives and contributing to broader health, educational, and economic gains.  Currently, PEPFAR faces significant change. While U.S. policymakers had been increasingly looking at when and how to transition PEPFAR services and financing to country governments, the current Trump administration has sought to narrow PEPFAR’s scope and significantly accelerate this timeline. See the “Status of PEPFAR” fact sheet for more information.

Tuberculosis (TB)

Since the 1998 launch of USAID’s global TB control program, the U.S. response to global TB has expanded, particularly after 2003 when PEPFAR highlighted the U.S. government’s commitment to addressing TB. Prior to the current Trump administration, these efforts focused on diagnosis, treatment, and control of TB (including multi-drug-resistant and extensively drug-resistant TB, or MDR/XDR TB) as well as on research. The U.S. was also a donor to the Global Drug Facility of the Stop TB Partnership.  With the dissolution of USAID, remaining TB programming has been moved to the State Department and its scope has been reduced. See the “Status of U.S. Global Tuberculosis Efforts” fact sheet for more information.

Malaria/PMI

Engaged in malaria work since the 1950s, the U.S. supported expanded malaria efforts in low- and middle-income countries through the President’s Malaria Initiative (PMI), launched in 2005 and housed at and managed by USAID, as well as through research and other activities. PMI programs centered on expanding coverage of six key high-impact interventions to control or eliminate malaria, which included: diagnosis of malaria and treatment with artemisinin-based combination therapies (ACTs), entomological monitoring, intermittent preventive treatment in pregnancy (IPTp), indoor residual spraying (IRS) with insecticides, insecticide-treated mosquito nets (ITNs), and seasonal malaria chemoprevention (SMC). The U.S. has also supported the RBM Partnership to End Malaria.  Under the current administration, remaining PMI programming has been moved into the State Department. See the “Status of the President’s Malaria Initiative (PMI)” fact sheet for more information.

Maternal and Child Health (MCH)

Involved in efforts to improve MCH since the 1960s,  U.S. global MCH activities, which had been housed at and managed by USAID, aimed to bring to scale a range of high-impact interventions that mitigate maternal, newborn, and under-five deaths; prevent and address the indirect causes of such deaths (such as HIV, TB, and malaria); strengthen integration of maternal health services with family planning; improve equity of access to and use of services by vulnerable populations; and strengthen health systems. The U.S. has also been a donor to global organizations and initiatives addressing MCH, such as Gavi, the Vaccine Alliance, the United Nations Children’s Fund (UNICEF), and the Global Polio Eradication Initiative (GPEI).Under the current administration, remaining MCH programming has been moved into the State Department. See the “Status of U.S. Global Maternal and Child Health Efforts” fact sheet for more information.

Nutrition

For more than 40 years, the U.S. had been involved in nutrition efforts in low- and middle-income countries that aimed to prevent undernutrition through support for effective interventions, such as nutrition education, nutrition during pregnancy, exclusive breastfeeding, and micronutrient supplementation. Housed at and managed by USAID, U.S. global nutrition efforts were coordinated with the U.S. Feed the Future Initiative (FtF, launched in 2009), which aimed to address global hunger and food security. Currently, remaining nutrition programming has been moved to the State Department. See the “Status of U.S. Global Maternal and Child Health Efforts” fact sheet for more information.

Family Planning and Reproductive Health (FP/RH)

Engaged since the 1960s in international research on family planning and population issues as well as other FP/RH efforts (including the purchase and distribution of contraceptives in developing countries),  U.S. global FP/RH activities were designed to decrease the risk of unintended pregnancies and maternal and child mortality through effective interventions, including contraception, counseling, and post-abortion care. The U.S. also provided funding to global organizations addressing FP/RH, such as the United Nations Population Fund (UNFPA), though in some years, funding for UNFPA was withheld. The current administration has moved to end U.S. bilateral and multilateral support for family planning efforts. See the “Status of U.S. Family Planning and Reproductive Health Efforts” fact sheet for more information

Neglected Tropical Diseases (NTDs)

Having historically worked on addressing NTDs through research and surveillance, attention to and funding for U.S. global NTD efforts increased markedly in 2006 with the launch of the USAID NTD Program and the subsequent announcement of expanded efforts across the U.S. government in 2008. These efforts had focused on five NTDs (soil-transmitted helminths,  lymphatic filariasis or elephantiasis, onchocerciasis or river blindness, schistosomiasis or snail fever, and trachoma) that are responsible for the overwhelming majority of the NTD burden but can be controlled and even eliminated with low-cost and effective interventions, such as an integrated control approach targeting multiple NTDs simultaneously through mass drug administration (MDA). The future of NTD efforts is uncertain amid the current Trump administration’s foreign aid freeze and dissolution of USAID.

Global Health Security (GHS)

While the U.S. has supported global health security work for more than two decades, its involvement has expanded over time, with attention to these efforts growing significantly due to the COVID-19 pandemic. These efforts aimed to reduce the threat of emerging and re-emerging diseases by supporting preparedness, detection, and response capabilities worldwide. The U.S. had also played a key role in the development and 2014 launch of the “Global Health Security Agenda (GHSA).” Through this international partnership that now involves more than 70 countries and international organizations, the U.S. worked to help countries make measurable improvements in their GHS capabilities. The U.S. had also been a donor to the new Pandemic Fund, which seeks to provide sustained financing to help countries build their capacity to prevent, prepare for, and respond to epidemics and pandemics.  While the first U.S. global health security strategy had been developed by the first Trump administration, the current Trump administration has withdrawn this strategy, eliminated several global health security positions and some offices, and withdrawn from U.S. engagement in key international efforts. See the “Status of Global Health Security/Pandemic Preparedness” fact sheet for more information.

How Much Funding Does the U.S. Provide for Global Health?

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In FY 2025, U.S. funding appropriated by Congress for global health totaled $12.4 billion. While this funding has been appropriated to federal agencies, the current administration has withheld much of it from programming and sought to formally rescind (cancel) more than $1 billion in funding for global health, including some PEPFAR funding (Congress voted to amend the rescission package, reducing that amount to $500 million, and exempting PEPFAR and some other global health programs from cuts).  As such, funding amounts presented here for the current fiscal year may not reflect actual obligations or outlays of U.S. support. There is ongoing litigation federal court regarding these actions.

As Figure 2shows, U.S. appropriations for global health have grown significantly since the early 2000s, in large part due to funding for initiatives such as PEPFAR and PMI, but with spikes in some years due to emergency or supplemental funding for disease outbreaks such as Ebola, Zika, and COVID-19. Funding reached its highest level to date in FY 2021, largely due to the U.S. global response to the COVID-19 pandemic.

Although a large majority of the American public overestimates the share of the federal budget that is spent on foreign aid (with nearly half believing that the share is greater than 20%), U.S. foreign aid actually accounts for 1% or less of the federal budget, with U.S. funding for global health—which is part of the foreign affairs budget—accounting for an even smaller share.

U.S. Global Health Funding (in billions), FY 2006 - FY 2025

U.S. Global Health Funding by Program Area

Looking across funding for the major global health program areas since FY 2006, most U.S. global health funding over time has been directed to HIV programs, accounting for approximately 50% of U.S. global health funding in most years (Figure 3). The Global Fund accounted for the next largest share over the period, followed by MCH and malaria. More recently, the U.S. has emphasized global health security more, with funding for these efforts increasing considerably during the COVID-19 pandemic and afterward. Consistent with this trend, most funding was provided to HIV efforts ($5.4 billion or 44%), followed by the Global Fund ($1.7 billion or 13%) and maternal and child health and global health security (both $1.3 billion or 10%) in FY 2025 (Figure 4).

Distribution of U.S. Global Health Funding, by Program Area, FY 2006 - FY 2025
U.S. Global Health Funding (in millions), by Program Area , FY 2025

Bilateral vs. Multilateral Aid

Most U.S. global health funding is provided bilaterally – that is, funding provided by the U.S. directly to or on behalf of a recipient country or region. In FY 2025, about 80% of the U.S. global health budget was provided through bilateral programs. The remainder (about 20%) is provided multilaterally through U.S. contributions to international institutions and organizations (see “What Multilateral Health Organizations Are Supported by the U.S.?”).

Which U.S. Agencies Are Involved in Carrying Out Efforts in These Program Areas?

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Historically, the U.S. government’s engagement in global health has been carried out and overseen by multiple executive branch departments and agencies and the legislative branch, including several congressional committees (Figure 5). The current administration has made significant changes to this infrastructure. See the “Proposed Reorganization of U.S. Global Health Programs” fact sheet for more information.

Executive Branch

In general, U.S. global health engagement has developed within two main structures of the Executive Branch of government: the foreign assistance structure, which is predominantly global development-oriented and has close links to foreign policy; and the public health structure, which has its roots in disease prevention, control, and surveillance efforts.

Most funding for and oversight of U.S. global health resides within the foreign assistance structure, including:

  • Department of State (State): Established in 1789, the Department of State is the Cabinet-level foreign affairs agency of the United States. It advances U.S. objectives and interests worldwide through its primary role in developing and implementing the President’s foreign policy. Prior to the current Trump administration, it also provided policy direction to USAID, the lead federal agency for development assistance. The Trump administration has dissolved USAID and moved remaining global health activities into the Department of State. The Department of State’s Bureau for Global Health Security and Diplomacy (GHSD) coordinates the Department’s work on global health security, including HIV, and houses PEPFAR.
  • U.S. Agency for International Development (USAID): Established in 1961, USAID was an independent U.S. federal government agency that received overall foreign policy guidance from the Secretary of State. Its role was to support long-term and broad-based economic growth in countries and advance U.S. foreign policy objectives by supporting activities through each of its programmatic functional bureaus (e.g., Bureau for Global Health) and regional bureaus. Most USAID global health programs had been coordinated through the Bureau for Global Health, including HIV and other infectious diseases, MCH, nutrition, FP/RH, NTDs, and global health security. USAID has now been dissolved by the current administration.  
  • Millennium Challenge Corporation (MCC): Established in 2004, MCC administers the Millennium Challenge Account (MCA), a U.S. government initiative providing development assistance to eligible countries to promote economic growth and reduce poverty in low- and middle-income countries. Although MCC supports several health-related programs, health is not the main focus or purpose of its work; its design is intended to link MCC contributions for development assistance (to reduce poverty through support for economic growth) to greater responsibility by low- and middle-income countries for successfully attaining certain governance and development benchmarks. The current Trump administration had sought to close down the agency but ultimately did not do so.

Agencies within the public health structure operate global health programs directly or in conjunction with foreign assistance agencies. They are represented most prominently by several agencies within the Department of Health and Human Services (HHS), including:

  • Office of Global Affairs (OGA): OGA’s primary function is global health diplomacy – particularly coordinating and maintaining engagement across HHS and the U.S. government with foreign governments and ministries of health, multilateral organizations, civil society groups, and the private sector – exchanging best practices and sharing technical knowledge to advance U.S. global health priorities and research.
  • Centers for Disease Control and Prevention (CDC): With a long history of working on international health issues, prior to the current Trump administration, CDC focused on disease control and prevention and health promotion through operations, development assistance, basic and field research, technical assistance, training/exchanges, and capacity building. The current administration has eliminated many of the staff working on these issues and sought to eliminate the CDC’s global health center.
  • National Institutes of Health (NIH): One of the world’s leading research entities on global health, NIH conducts biomedical and behavioral science research on diseases and disorders to enhance diagnosis, prevention, and treatment and provides technical assistance and training. Prior to the current Trump administration, all 27 of the agency’s institutes and centers engaged in global health activities, but these activities are already being curtailed or eliminated.
  • Food & Drug Administration (FDA): The FDA screens pharmaceutical and biological products for safety and efficacy and helps oversee the safety of the U.S. food supply.
  • Health Resources and Services Administration (HRSA): HRSA builds human and organizational capacity and promotes health systems strengthening to deliver care in PEPFAR countries.

In addition to the foreign assistance and public health service agencies, other departments and agencies involved in global health have included the Department of Defense (DoD), the Department of Agriculture (USDA), the Peace Corps, the Environmental Protection Agency (EPA), the Department of Homeland Security (DHS), the Department of Labor (DoL), the Department of Commerce (Commerce), the Office of the U.S. Trade Representative (USTR), and the National Security Council (NSC). The NSC, which sits within the White House, plays a significant role across the U.S. government, as it is responsible for coordinating and reviewing the U.S. strategy and activities related to global health security, including its international response. However, the administration has eliminated many of the staff working on these issues, and is no longer operating the White House Office of Pandemic Preparedness and Response (OPPR), which had been responsible for domestic policy coordination related to health security.

Legislative Branch

The U.S. Congress introduces, considers, and passes global health-related legislation; oversees global health efforts, specifying how funds for these programs are to be (and not to be) spent; authorizes and appropriates funding; and confirms presidential appointees to key U.S. global health positions. Major committees of the House of Representatives (House) and Senate with jurisdiction over global health efforts include: the House Committee on Foreign Affairs, Senate Committee on Foreign Relations, House Committee on Energy and Commerce, Senate Committee on Health, Education, Labor, and Pensions, and the Senate and House Appropriations Committees.

The U.S. global health response has been defined by numerous governing statutes, authorities, and policy decisions. For instance, the legislation that created PEPFAR in 2003 and its subsequent reauthorizations in 2008, 2013, 2018, and 2024 are key statutes of U.S. global health policy, as they govern its bilateral HIV response, bilateral assistance for TB and malaria, and participation in the Global Fund. Other statutory requirements that shape the implementation and scope of U.S. global health activities are those governing U.S. global FP/RH efforts, such as those directing how U.S. funds may not be spent. For instance, the Helms Amendment (1973) prohibits the use of foreign assistance to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion. The Kemp-Kasten Amendment (1985) prohibits funding any organization or program, as determined by the President, that supports or participates in the management of a program of coercive abortion or involuntary sterilization (it has been invoked at times to restrict funding to UNFPA).

While Congress has authority over many aspects of global health, the current administration has taken several actions without its direct consent (such as eliminating USAID and withholding Congressionally-directed appropriations), and has questioned the extent of Congressional authority in these areas. It is unclear if Congress will act on these issues and some of these questions are being litigated in federal court.

Where Do U.S. Bilateral Global Health Programs Operate?

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Prior to the current Trump administration, the U.S. provided bilateral support for U.S. global health programs in almost 80 countries, with additional countries reached through U.S. regional global health programs and U.S. contributions to multilateral organizations. Multiple factors determined where the U.S. channeled its global health support. While more U.S. support was generally directed to countries facing a higher burden of disease, it was also influenced by factors such as the presence of willing and able partner governments, a history of positive relations and goodwill with host countries, strategic and national security priorities, and funding and personnel availability. The majority of countries receiving U.S. bilateral support for global health (“partner countries”) were located in sub-Saharan Africa (35 countries), followed by the Western Hemisphere (14 countries), East Asia and Oceania (11 countries), South and Central Asia (9 countries), Europe and Eurasia (4 countries), and Middle East and North Africa (4 countries) (Figure 5). Most U.S. bilateral support for global health programs was provided in sub-Saharan Africa (84%) (Figure 6). Furthermore, the top 10 country recipients of U.S. global health funding, representing 59% of U.S. bilateral support for global health, were all in this region (Figure 7).

Countries Where the U.S. Operates Global Health Programs, by Region, FY 2023
U.S. Global Health Funding, by Region, FY 2023
Top 10 Recipient Countries of U.S. Global Health Funding, FY 2023

The U.S. typically operated more than one health program (HIV, TB, malaria, etc.) in each partner country. While in most countries, the U.S. operated programs in four or fewer global health areas, this number was generally higher in countries in sub-Saharan Africa (five or more).

What Multilateral Health Organizations Are Supported by the U.S.?

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In addition to its bilateral programs, the U.S. has a long history of engagement with multilateral health organizations and international institutions, beginning with its role in the development of the first such organizations, including the Pan-American Health Organization (PAHO) in the early 1900s and the World Health Organization (WHO) a few decades later. This involvement continued with, for example, the Global Fund (which the U.S. helped to launch in 2001), Gavi (launched in 2000), the GHSA (which the U.S. played a key role in developing and launching in 2014), and the Pandemic Fund (launched in 2022). Prior to the current Trump administration – which is carrying out a review of its engagement in international organization to determine the future of U.S. multilateral participation and support – U.S. support for multilateral global health efforts has taken various forms, including:

  • Funding. The U.S. has often been the largest or one of the largest donors to multilateral health efforts, funding core (generally used to support essential functions and operations) and voluntary (used for specific projects or initiatives the U.S. seeks to support) contributions. About a fifth (19%) of U.S. global health funding supported U.S. contributions to multilateral health organizations (Figure 8). However, some global health support to multilateral organizations has already been reduced or eliminated by the current Trump administration, such as funding and engagement in the World Health Organization, UNFPA, and the Pandemic Fund.
  • Governance. The U.S. has been active in the governance structures that oversee multilateral global health organizations and initiatives, including holding permanent or rotating seats on many of their boards.
  • Technical assistance. The U.S. has offered technical assistance in support of grants to partner countries, providing additional staff capacity to international organizations (by detailing U.S. government employees to these organizations for periods of time).
  • Standard setting. The U.S. has engaged in standard-setting, weighing in on global plans, treaties, and agreements to respond to a range of health issues as they are developed and considered for approval by the larger body.
U.S. Multilateral Global Health Funding (in millions), FY 2025

The U.S. has engaged with a number of multilateral global health organizations, including health-focused specialty agencies of the United Nations (U.N.) and international financing mechanisms for global health. Key among these are eight to which Congress specifically directs funding (though the U.S. also reaches other multilateral health institutions without direct Congressional appropriations but rather through general support), of which the U.S. has been the top contributor to five (the Global Fund, PAHO, UNAIDS, UNICEF, and WHO):

U.N. Agencies

  • World Health Organization (WHO): WHO, created in 1948, is the directing and coordinating authority for health within the U.N. system. WHO provides international leadership on global health matters, shaping the health research agenda, setting norms and standards, providing technical support to countries, and monitoring and assessing health trends. The U.S. has been involved in WHO since its creation, providing financial and technical support as well as participating in its governance structure. However, President Trump announced on the first day of his second term that the U.S. would withdraw as a member of WHO and halt funding to the organization.
  • Pan American Health Organization (PAHO): PAHO is the oldest international health agency, founded originally as the International Sanitary Bureau in 1902. The U.S. joined PAHO as a member state in 1925. PAHO, the specialized international health agency for the Americas, “works with countries throughout the region to improve and protect people’s health” and serves as the WHO Regional Office for the Americas and as the health organization of the inter-American System.
  • Joint United Nations Programme on HIV/AIDS (UNAIDS): UNAIDS, created in 1996 as the successor organization to the WHO Global Programme on AIDS (GPA), is the leading global organization for addressing HIV/AIDS. Coordinating efforts across the U.N. system, it is made up of 11 U.N. co-sponsors and guided by a Programme Coordinating Board (PCB), which is a subset of its co-sponsors and government representatives. The U.S. currently serves on the PCB.
  • United Nations Children’s Fund (UNICEF): UNICEF, created in 1946, aims to improve the lives of children, particularly the most disadvantaged children and adolescents, and is one of the largest purchasers of vaccines worldwide. The U.S. was a founding member that same year.
  • United Nations Population Fund (UNFPA): UNFPA, created in 1969, is the largest purchaser and distributor of contraceptives worldwide. While the U.S. helped to found UNFPA and was a leading supporter for many years, its support has fluctuated significantly and sometimes been withheld entirely over the years, due to ongoing U.S. political debates about abortion. The Trump administration has announced that it is withholding funding from UNFPA.

Non-U.N. Financing Mechanisms

  • Gavi, the Vaccine Alliance (Gavi): Gavi, created in 2000, is a public-private partnership that aims to increase access to immunization in poor countries. The U.S. has been involved in Gavi since its creation through contributions, participation in Gavi’s governance, and technical assistance. The U.S. is the second largest donor to Gavi’s core programs and the top donor to Gavi’s COVAX Advance Market Commitment (COVAX AMC), a financial mechanism within COVAX that supports low- and middle-income countries through procurement and distribution of COVID-19 vaccines.
  • Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund): The Global Fund, created in 2001, is an independent multilateral financing entity that supports HIV, TB, and malaria programs in low- and middle-income countries. The U.S. was involved in creating the Global Fund and maintains a permanent seat on its Board. U.S. contributions and those of other donors are pooled and then provided by the Global Fund to country-driven projects based on technical merit and need.
  • TB Global Drug Facility: The Global Drug Facility, created in 2001, is a financing mechanism of the Stop TB Partnership; it provides grants to countries for TB drugs.

U.S. support for multilateral institutions overall has fluctuated over time, reflecting, in part, changing U.S. leadership views on the relative value of bilateralism versus multilateralism. As a result, U.S. engagement in and contributions to specific multilateral health organizations and institutions may change over time. For example, the U.S. under the first Trump administration did not participate in the partnership to create  COVAX (an international partnership led by the Coalition for Epidemic Preparedness Innovations [CEPI], Gavi, and WHO) to facilitate greater global access to the COVID-19 vaccine, although Congress did provide $4 billion in emergency funding to Gavi in support of COVID-19 vaccine access. Under the Biden administration, the U.S. joined the COVAX partnership.

Multilateral initiatives complement U.S. bilateral global health efforts, helping make progress toward U.S. goals in various program areas. In some cases, U.S. multilateral global health support allows the U.S. to reach a larger number of countries; it also may help to leverage additional funding and provide opportunities for improved coordination and technical consultations. Additionally, U.S. policies related to funding can greatly influence other financial support for multilaterals. For instance, since U.S. law has required that the U.S. contribution to the Global Fund cannot exceed 33% of total contributions from all donors, the U.S. contribution has leveraged other donor contributions; in effect, this requirement encouraged increased support from other donors and prevented the U.S. from becoming the predominant donor to the Global Fund.

How Does the U.S. Compare to Other Donors of International Health Assistance?

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The U.S. has been the largest donor to global health, providing over 40% of all international health assistance among major donor governments (Figure 9).

U.S. was the Largest Donor Government of International Health Assistance in 2023

In addition, the U.S. has historically devoted more of its foreign assistance to health than any other donor government, contributing over a quarter of its foreign assistance to global health in 2023 (Figure 10). The U.S. has also been the largest government donor to several specific global health areas, including HIV and family planning. Currently, however, the Trump administration is withholding global health funds in several areas and actual spending levels are still unknown.

Donor Governments with the Largest Share of Development Assistance Directed to International Health in 2023

Future Outlook

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While the U.S. has been engaged in international health activities for over a century and has historically been the largest funder and implementer of global health programs worldwide, it is currently undergoing a fundamental shift, with a significantly reduced footprint and role.  Given the prominence of the U.S. in global health, these actions have and will influence the larger global health ecosystem and the health of those in low and middle income countries. Among the key issues to watch are:

  • The future direction of U.S. leadership in and degree of commitment to global health as the Trump administration reorganizes foreign assistance more broadly and seeks to permanently alter the U.S. role.
  • The status of U.S. funding for global health, particularly given the interplay between Congress and the administration on whether and how that funding gets spent and ongoing litigation in this area.
  • The ability of global health implementers to continue to deliver services to those who need them, given their loss of funding and future uncertainty.
  • The future role of multilateral institutions in global health, as the U.S. bilateral role is reduced, but also its support for multilateral health efforts remains unclear.
  • Whether other donors (governments, foundations, the private sector) will help to fill some of the gaps left by the U.S.
  • Whether the nations that have been recipients of U.S. global health support will increase their own financing and delivery of health services to their populations.

Resources

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Citation

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Oum, S., Moss, K., & Kates, J., The U.S. Government and Global Health. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/health-policy-101-the-u-s-government-and-global-health/ (date accessed).