White House Releases FY21 Budget Request

The White House released its FY 2021 budget request to Congress on February 10, 2020, which includes significant cuts to global health programs compared to the FY 2020 enacted levels. In addition, in some cases, these cuts are steeper than those proposed by the Administration in last year’s request. The FY 2021 budget request includes funding for U.S. global health programs at the State Department, the U.S. Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH). Key highlights are as follows (see table for additional detail):

State Department & USAID:

  • Funding for global health programs through the Global Health Programs (GHP) account, which represents the bulk of global health assistance, totaled $5,998 million, a decrease of $3,095 million (34%) from the FY 2020 enacted level, and $346 million below the President’s FY 2020 request. Almost all program areas in the FY21 request declined compared to FY20 enacted levels.
  • Bilateral HIV funding through the President’s Emergency Plan for AIDS Relief (PEPFAR) is $3,180 million, $1,520 million below the FY20 enacted level, and $170 million below the FY20 Request ($3,350 million).
  • The request includes $658 million for the U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), a decrease of $902 million below the FY20 enacted level ($1,560 million) and $301 million below the FY20 Request ($958 million). The administration states that the U.S. will match $1 for every $3 contributed by other donors and that, when combined with already appropriated funding, this will keep the U.S. on track to meet its $3.3 billion pledge for the Global Fund’s sixth replenishment.
  • Funding for tuberculosis (TB) totals $275 million, $35 million below the FY20 enacted level ($310 million), and $14 million below the FY20 Request ($261 million).
  • Funding for malaria totals $709 million, $62 million below the FY20 enacted level ($770 million), and $35 million below the FY20 Request ($674 million).
  • The request includes $660 million for maternal and child health (MCH), a decrease of $191 million below the FY20 enacted level ($851 million), and $40 million below the FY20 Request ($620 million). This decrease is to bilateral MCH funding. Gavi, the Vaccine Alliance, which is included under MCH funding, is the only program area that did not decline compared to the FY20 enacted level; funding totals $290 million, matching the FY20 enacted level, and $40 million above the FY20 Request ($250 million).
  • Funding for nutrition totals $90 million, $60 million below the FY20 enacted level ($150 million), and $12 million below the FY20 Request ($79 million).
  • Bilateral family planning and reproductive health (FP/RH) funding totals $237 million, $287 million below the FY20 enacted level ($524 million), and the same level as requested in FY20 ($237 million). The FY21 Request proposed eliminating funding for the United Nations Population Fund (UNFPA). In FY20, Congress provided $32.5 million for the U.S. contribution to UNFPA. However, it is anticipated that the Trump Administration will invoke the Kemp-Kasten amendment to withhold this funding again (learn more about the Kemp Kasten amendment here).
  • The FY21 Request proposed eliminating funding for the vulnerable children program, which was funded at $25 million in FY20.
  • Funding for neglected tropical diseases (NTDs) totals $75 million, $28 million below the FY20 enacted level ($103 million), and matching the FY20 Request ($75 million).
  • Funding for global health security totals $90 million, a decrease of $10 million below the FY20 enacted level ($100 million) and matching the FY20 Request.
  • Funding to replenish the Emergency Reserve Fund, which is used to “quickly and effectively respond to emerging disease outbreaks,” totals $25 million; in FY20, Congress provided the authority to transfer $10 million in funding from other areas to the Emergency Reserve Fund if needed.
  • Funding for the World Health Organization (WHO) totaled $58 million, a $65 million decrease compared to the FY20 enacted level ($123 million) and flat compared to the FY20 Request.
  • Funding for the Pan American Health Organization (PAHO) totaled $16 million, a $50 million decrease compared to the FY20 enacted level ($66 million) and a $17 million decrease compared to the FY20 Request ($33 million).

Centers for Disease Control and Prevention (CDC): Funding for global health provided to the CDC totals $532 million, a decrease of $39 million compared to the FY20 enacted level ($571 million) and $75 million above the FY20 Request ($457 million). The entire increase in CDC funding is to support global health security activities; all other areas declined except global tuberculosis funding which remained flat. For example, funding for global HIV activities in the request declined by $59 million and funding for global immunization activities declined by $20 million.

Fogarty International Center (FIC): Funding for the Fogarty International Center (FIC) at the National Institutes of Health (NIH) totaled $74 million, $7 million below the FY 2020 enacted level ($81 million) and $7 million above the FY20 Request ($67 million).

Resources:
The table (.xls) below compares global health funding in the FY 2021 request to the FY 2020 enacted funding amounts as outlined in the  “Consolidated Appropriations Act, 2020” (P.L. 116-94; KFF summary here) and the FY 2020 request (KFF summary here). Note that total funding for global health is not currently available as some funding provided through USAID, Health and Human Services (HHS), and the Department of Defense (DoD) is not yet available.
Table: KFF Analysis of FY21 Budget Request for Global Health
Department / Agency / Area FY20
Requesti
(millions)
FY20
Enacted
(millions)
FY21
Requesti
(millions)
Difference
(millions)
FY21 Request
– FY20 Request
FY21 Request
– FY20
Enacted
 SFOPs – Global Health
HIV/AIDS $3,350.0 $4,700.0 $3,180.3 $-169.7
 (-5%)
$-1,519.7
 (-32%)
State Department $3,350.0 $4,370.0 $3,180.3 $-169.7
(-5%)
$-1,189.7
(-27%)
USAID $0.0 $330.0 $0.0 $0
(NA)
$-330.0
(-100%)
of which Microbicides $0.0 $45.0 $0.0 $0
(NA)
$-45.0
(-100%)
Global Fund $958.4 $1,560.0 $657.6 $-300.8
 (-31%)
$-902.4
 (-58%)
Tuberculosisii $262.0  –   –  –
Global Health Programs (GHP) account $261.0 $310.0 $275.0 $14
(5%)
$-35
(-11%)
Economic Support Fund (ESF) account $1.0 Not available Not available  –  –
Malaria $674.0 $770.0 $708.5 $34.5
 (5%)
$-61.5
 (-8%)
Maternal & Child Health (MCH)iii iv  –   –  –
GHP accountv $619.6 $851.0 $659.6 $40
(6%)
$-191.4
(-22%)
of which Gavi $250.0 $290.0 $290.0 $40
(16%)
$0
(0%)
of which Poliov $16.0 $61.0 Not available  –  –
UNICEFvi Not available $139.0 Not available  –  –
ESF account $75.5 Not available Not available  –  –
of which Poliov $7.0 v Not available  –  –
Nutritionvii $89.7  –  –  –
GHP account $78.5 $150.0 $90.0 $11.5
(15%)
$-60
(-40%)
ESF account $11.2 Not available Not available  –  –
Family Planning & Reproductive Health (FP/RH) $259.0 $607.5  –  –  –
Bilateral FPRH $259.0 $575.0  –  –  –
GHP account $237.0 $524.0 $237.0 $0
(0%)
$-287
(-55%)
ESF account $22.0 $51.1 Not available  –  –
UNFPA $0.0 $32.5 $0.0 $0
(NA)
$-32.5
(-100%)
Vulnerable Children $0.0 $25.0 $0.0 $0
(NA)
$-25.0
(-100%)
Neglected Tropical Diseases (NTDs) $75.0 $102.5 $75.0 $0
 (0%)
$-27.5
 (-27%)
Global Health Security $90.0 $100.0 $90.0 $0
 (0%)
$-10
 (-10%)
GHP account $90.0 $100.0 $90.0 $0
(0%)
$-10
(-10%)
Emergency Reserve Fund $0.0 viii $25.0 $25.0
(NA)
 –
Other (Non-GHP account) $90.8 $188.4 $74.2 $-16.6
(-18%)
$-114.2
(-61%)
World Health Organization (WHO)ix $57.9 $122.7 $57.9 $0
(0%)
$-64.7
(-53%)
Pan American Health Organization (PAHO)ix $32.9 $65.8 $16.3 $-16.6
(-50%)
$-49.5
(-75%)
SFOPs Total (GHP account only) $6,343.5 $9,092.5 $5,998.0 $-345.5
(-5%)
$-3,094.5
(-34%)
Health & Human Services (HHS)
Centers for Disease Control & Prevention (CDC) – Total Global Health $457.0 $570.8 $532.2 $75.2
 (16%)
$-38.6
 (-7%)
Global HIV/AIDS $69.5 $128.4 $69.5 $0
(0%)
$-58.9
(-46%)
Global Tuberculosisx $7.2 $7.2 $7.2 $0
(0%)
$0
(0%)
Global Immunization $206.0 $226.0 $206.0 $0
(0%)
$-20
(-9%)
Polio Not available $176.0 $165.0  – $-11
(-6%)
Other Global Vaccines/Measles Not available $50.0 $41.0  – $-9
(-18%)
Parasitic Diseases $24.5 $26.0 $24.5 $0
(0%)
$-1.5
(-6%)
Global Public Health Protectionxi $149.8 $183.2 $225.0 $75.2
(50%)
$41.8
(23%)
Global Disease Detection and Emergency Response Not available $173.4 Not available  –  –
of which Global Health Security (GHS) $99.8 $125.0 $175.0 $75.2
(75%)
$50
(40%)
Global Public Health Capacity Development Not available $9.8 Not available  –  –
National Institutes of Health (NIH) – Total Global Health $760.1 Not available Not available  –  –
HIV/AIDS $511.1 Not available Not available  –  –
Malaria $182.0 Not available Not available  –  –
Fogarty International Center (FIC) $67.0 $80.8 $73.5 $6.5
(10%)
$-7.2
(-9%)
Notes:
i – In the FY20 and FY21 Request, the administration proposed to consolidate the Development Assistance (DA), Economic Support Fund (ESF), the Assistance for Europe, Eurasia, and Central Asia (AEECA), and the Democracy Fund (DF) accounts in to one new account — the Economic Support and Development Fund (ESDF). ESF funding for the FY20 Request reflects the amounts requested by the administration for ESDF.
ii – Some tuberculosis funding is provided under the ESF account, which is not earmarked by Congress in the annual appropriations bills and determined at the agency level (e.g. in FY18, TB funding under the ESF account totaled $4 million).
iii – Some MCH funding is provided under the ESF account, which is not earmarked by Congress in the annual appropriations bills and determined at the agency level (e.g. in FY18, MCH funding under the ESF account totaled $15.5 million).
iv – It is not possible to calculate total MCH funding in the FY20 and FY21 request because UNICEF, which has historically received funding through the International Organizations and Programs (IO&P) account, was not specified in the FY20 and FY21 request.
v – The minority summary of the FY20 conference agreement states that part of the increase in MCH funding is “due to a shift of $7.5 million for polio prevention programs from the Economic Support Fund account to the Global Health Programs account.”
vi – UNICEF funding in the FY20 Conference Agreement includes an earmark of $5 million for programs addressing female genital mutilation.
vii – Some nutrition funding is provided under the ESF account, which is not earmarked by Congress in the annual appropriations bills and determined at the agency level. (e.g. in FY17, nutrition funding under the ESF account totaled $21 million).
viii – The explanatory statement accompanying the FY20 Conference Agreement states that the “agreement includes authority to reprogram $10,000,000 of Global Health Program funds to the Emergency Reserve Fund if necessary to replenish amounts used during fiscal year 2020 to respond to emerging health threats.”
ix – The FY20 enacted WHO and PAHO amounts are estimates.
x – In FY20, the administration proposed to formally transfer $7.2 million from the “HIV/AIDS, Viral Hepatitis, STI and TB Prevention” account to “Global Tuberculosis” activities under “Global Health Programs” at CDC. The FY20 conference agreement formalizes this transfer.
xi – In the CDC FY20 congressional justification, this funding line is titled “Global Disease Detection and Other Programs”.

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