The U.S. Government Engagement in Global Health: A Primer
What is Global Health?
Despite a growing emphasis on the importance of addressing global health by the international community and the U.S., there is currently no standard, agreed-upon definition for global health, and several different definitions exist. The Institute of Medicine has defined 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.” Global health programs take a “public health for the world” approach, focusing on the health of populations rather than the health of individuals.1
|Box 1. Definitions of Key Global Health Measures
Prevalence – the number of people with a particular condition at any given time (e.g., the number of people who are HIV positive).
Incidence – the number of new cases of a disease or condition in a population within a period of time (e.g., the number of people who became newly infected with HIV in a year).
Mortality – deaths; can reference overall mortality (i.e. from all causes) or deaths due to a particular disease or condition (e.g. deaths from HIV/AIDS) or deaths in a particular population (e.g. child deaths).
The field of global health has evolved out of the historical disciplines of “tropical medicine” and “international health,” but what sets global health apart from these prior eras is a recognition that the health of people around the world is highly interconnected, with domestic and foreign health inextricably linked.2,3 A key dimension of global health is an emphasis on addressing inequalities in health status between populations in rich and poor populations. Persons in low- and middle-income countries face lower life expectancies, higher burdens of disease, and are disproportionately affected by certain highly preventable causes of disease and mortality compared to persons in high-income countries. In low-income countries, preventable deaths from infectious diseases (such as respiratory infections, diarrheal diseases, HIV/AIDS, and malaria) are among the most common killers. In contrast, the most common causes of deaths in high-income countries are from chronic, non-communicable diseases (such as heart disease, stroke, cancer, and diabetes). It is important to note, though, that the burden of these chronic, non-communicable conditions has grown over time in low- and middle-income countries, and is expected to continue to grow in the future.
Current Global Health Challenges
There are many factors that contribute to these inequalities in health, and persons in low- and middle-income countries face many different kinds of health challenges. Some of the broader social conditions that lead to poor health, sometimes called “determinants of health,” for these populations include poverty; lack of education; lack of access to clean water, sanitation, and food; environmental conditions; and weak health systems. While many global health efforts seek to address and impact these larger determinants of health, more commonly they are directed toward more specific issues or causes of disease. Some of the most prominent issues and diseases targeted by global health efforts include:
HIV/AIDS – Human immunodeficiency virus (HIV) is the virus that causes acquired immunodeficiency syndrome (AIDS), the most advanced stage of HIV infection. People become infected with HIV primarily through sexual contact with an infected person, though it can also be transmitted through blood (e.g., by using a syringe that has been previously used by someone who is infected) or from a mother to a baby during pregnancy, delivery, or breastfeeding. HIV weakens the immune system, leaving those affected vulnerable to opportunistic infections and potentially death. Numerous prevention interventions exist to combat HIV, such as behavior change programs, condoms, blood supply safety, harm reduction efforts for injecting drug users, and male circumcision. HIV can be effectively treated with antiretroviral therapy, and recent research shows HIV positive persons being treated can also significantly reduce the risk of transmission to negative partners.4 While no cure exists, vaccines are currently being researched. Access to prevention and treatment programs, however, remains limited in many areas. Countries in sub-Saharan Africa (SSA) face the highest burden of disease from HIV, as it is estimated that approximately 70% of all people living with HIV are in SSA countries, and that 73% of all AIDS deaths occur in SSA.5
|Box 2. HIV/AIDS in 2015
Tuberculosis – Tuberculosis (TB) is an airborne infectious disease caused by bacteria that primarily affects the lungs. While active TB can be spread from person to person and is a major cause of illness and death around the world, TB can remain latent in otherwise healthy people, who exhibit no symptoms and cannot transmit the bacteria to others. In addition, it is a common and a serious threat to people with compromised immune systems, such as those living with HIV. Some complications from TB can be prevented by the Bacille Calmette-Guerin (BCG) vaccine, and other vaccines are currently being developed. TB control programs around the world commonly use a method called DOTS, or “directly observed treatment, short-course” to treat and prevent TB using a combination of drugs. As a result of inconsistent or partial treatment, incorrect prescribing, or interruptions in the drug supply, TB that is resistant to commonly used drugs has emerged as a major challenge for TB control efforts. Thirty countries, all of which are low- and middle-income, are considered “high-burden countries (HBCs),” accounting for approximately 87% of new TB cases each year.6
|Box 3. Tuberculosis in 2015
Malaria – Malaria is a parasitic disease that is spread to people through the bite of a particular mosquito species, known as Anopheles, which thrive in warm tropical and sub-tropical climates. Symptoms of malaria include fever, vomiting, and diarrhea, and in severe cases it leads to death. Malaria control efforts involve a combination of prevention and treatment strategies and tools. Prevention strategies include use of insecticide-treated bed nets and indoor residual spraying for mosquito control, and the use of drugs to prevent infection. A malaria vaccine is not yet available, although clinical trials are underway. Drugs for treating malaria include: chloroquine, primaquine, and artemisinin-based combination therapy (ACT). Drug resistance is an important issue in malaria, as the parasite has developed resistance to common anti-malarial drugs in some areas. While access to malaria prevention and treatment services in affected areas has grown over time, gaps remain. Sub-Saharan Africa is the hardest hit region in the world.7,8
|Box 4. Malaria in 2015
Neglected Tropical Diseases – Neglected tropical diseases (NTDs) are a group of parasitic, bacterial, and viral infections that primarily affect the most impoverished and vulnerable populations in the world. They are called NTDs because until recently they had received only scant attention in global health efforts. More than one billion people, almost all of whom live in low- and middle-income countries, are infected with one or more NTDs, and another 2 billion people are at risk.9 Seven NTDs, including worm infections such as roundworm and hookworm, schistosomiasis (a parasitic infection transmitted by fresh water snails), and trachoma (a bacterial infection that can cause blindness), are currently receiving more attention because highly cost-effective treatment and prevention tools are currently available to address them.10
Family Planning and Reproductive Health – Family planning is the ability of a person or family to plan for and attain the desired number of children as well as the desired spacing and timing of births. Reproductive health is the state of complete physical, mental, and social well-being in all matters relating to the reproductive processes, functions, and system at all stages of life.11 Access to family planning and reproductive health (FP/RH) services is critical to the health of women and children worldwide because these services are effective in decreasing the risk of unintended pregnancies, maternal and child mortality, and other complications.12,13 FP/RH education and services support birth spacing, contraception, counseling, post-abortion care, screening/testing for HIV and other sexually transmitted infections (STIs), repair of obstetric fistula, antenatal and postnatal care, and human papillomavirus (HPV) vaccines to prevent cervical cancer and genital warts. Novel FP/RH tools, such as microbicides (compounds that can be inserted into the vagina or rectum to protect against STIs), are also being pursued. Approximately 12% of women developing countries have an unmet need for family planning.14
|Box 5. FP/RH in 2015
Maternal and Child Health – Maternal and child health (MCH) programs address the health needs of mothers before and during pregnancy and childbirth, as well as the health of newborns and young children. Ninety-nine percent of maternal deaths and deaths in children under 5 occur in the developing world.15,16 According to WHO, most maternal deaths are preventable through “quality family planning services, skilled care during pregnancy, childbirth and the first month after delivery, or post-abortion care services and where permissible, safe abortion services.” Addressing health care for newborns and young children focuses on care during pregnancy, safe delivery, neonatal care, and breastfeeding, as well as prevention and treatment of diseases and conditions such as pneumonia, diarrhea, malaria, HIV/AIDS, and malnutrition. There are many low-cost prevention and treatment measures – such as immunization, antibiotics, insecticide treated bed nets, zinc supplements, and oral rehydration therapy – that can reduce infant and child mortality and improve their health.
|Box 6. MCH in 2015
Polio – Poliomyelitis, or polio, is a crippling, and sometimes fatal viral disease. Polio is transmitted through the fecal-oral route, and enters the body through the mouth when people eat food or drink water contaminated with excreta. The virus is easily spread in areas with poor hygiene and mainly affects children under five years of age. Polio cannot be cured, but is preventable through vaccination. A global effort to completely eradicate the disease began in 1988 and since then the numbers of polio cases have dropped over 99% worldwide. The eradication effort continues today but as of 2016 three developing countries – Nigeria, Pakistan, and Afghanistan – have not been able to interrupt polio transmission and remain endemic for the disease, and outbreaks of the disease continue to occur in other low-income countries.17 Polio could surge again if eradication is not completed and control measures are scaled back.
|Box 7. Polio in 2015
Nutrition – Poor nutrition comes in various forms and is typically characterized by inadequate or excess intake of protein, energy, and micronutrients such as vitamins. Undernutrition, a lack of the nutrients needed by the body for appropriate growth and development, can result from an inadequate food supply or from insufficient intake of certain types of food (e.g., protein and micronutrients), and is especially prevalent in populations in low- and middle-income countries. Undernutrition increases the risk of certain diseases and can lead to premature death, especially in infants and children. Nutrition interventions include breastfeeding promotion, infant and young child feeding programs, micronutrient supplementation (e.g., vitamin A), food fortification, and improving food security.18 Almost all of the approximately 795 million undernourished people in the world live in developing countries.19
|Box 8. Nutrition, 2014-2015
|Box 9. Water and Sanitation, 2015
Emerging Challenges in Global Health – A number of other issues are receiving increasing attention within global health. Non-communicable diseases (NCDs), particularly cardiovascular disease, cancer, chronic lung disease, and diabetes, which have historically been seen as primarily health problems of the developed world, are now seen as increasingly important contributors to the burden of disease of developing countries that should receive greater attention from global health efforts. Similarly, mental health conditions, such as depression, are increasingly being seen as an important health issues for developing countries.21,22,23 Finally, recent infectious disease threats, like Zika, Ebola24,25 and antimicrobial resistance, have contributed to global health security gaining traction as an emerging issue in global health.
|Box 10. Impacts of the 2014-2015 Ebola Outbreak
What Has Been the International Response to Global Health Challenges?
There is a long history of international efforts to tackle health issues. In the mid-1800s, for example, a group of countries began to negotiate international agreements on how to combat cross-border outbreaks of infectious diseases such as cholera and yellow fever.26 After World War II, international efforts expanded with the establishment of the United Nations and its health-focused agencies such as the WHO and the United Nations Children’s Fund (UNICEF), and with new challenges, new agencies have formed, such as the Joint United Nations Programme on HIV/AIDS (UNAIDS). Joint efforts on global health efforts have grown significantly since the early 2000s, as new international goals and targets for addressing health challenges have been established, new global health funding vehicles and initiatives created, and the amount of donor funding directed at global health increased.27
Key Stakeholders in Global Health
There are a diverse set of stakeholders involved in efforts to improve global health. These include multilateral and international organizations, donor and partner governments, the private sector, research organizations, civil society, academia, and individuals.28 Donor governments channel support for global health programs either bilaterally (i.e. giving their support directly to another country), or multilaterally (i.e. giving their support to a multilateral organization, which channels the funds to support global health programs in recipient countries). The private sector, civil society, academic and research organizations are other important partners in global health programs. Developing country governments, local organizations, and individuals are also key stakeholders in determining how global health programs are funded and implemented. With these numerous stakeholders and multiple initiatives in the field of global health, coordination between donors remains a key challenge in the international response.
Key Global Health Milestones
Since 2000, a number of treaties, commitments, partnerships, and other multilateral agreements addressing health have been supported by the international community, some of which have turned out to be important and durable milestones, while others have been less so. Figure 1 highlights some of the more important developments in international cooperation on global health.
Donor government funding, including both the bilateral funding given directly to other countries (which may be given to a country government or provided to NGOs and other organizations to carry out work in recipient countries) and the multilateral funding given indirectly through contributions to multilateral organizations, accounts for most external health aid channeled to the developing world. As such, this donor support constitutes a major component of the global health response.
Donor government funding for global health has risen significantly since 2002, the first year data are available, growing from $4.4 billion to a peak of $22.8 billion in 2013 (see Figure 2). However, funding declined for the first time in 2014 to $21.5 billion.
Funding given by donor governments to recipient countries, otherwise known as Official Development Assistance (ODA), has increased each year since 2002, the first year data are available. The share of this funding that was provided by donor governments for health activities increased by large amounts during the early part of the past decade. These increases were largely spurred on by the creation of several new funding initiatives and mechanisms such as the Global Fund and PEPFAR. However, this share has remained essentially flat in more recent years and declined in 2014. This flattening and recent decline has raised concerns about the ability of countries to meet global health goals and targets, such as those of the Sustainable Development Goals (SDGs).”31,32
The U.S. has been the largest donor to health in each year over the entire period between 2002 and 2014, and has dedicated the greatest share of its ODA to health.33 The donor mix has shifted over this time, in part due to the entrance of new donors, particularly the Global Fund, which became the second largest donor to health after the U.S. in 2006 (and remains so today). The U.S. and the Global Fund combined accounted for nearly half of total donor funding for health in 2014 (see Figure 3).
What Is The Role And Scope Of U.S. Government Support For Global Health?
The U.S. government supports global health programs for a number of reasons, including as a humanitarian effort meant to address serious inequalities in health between developed and developing countries, and as a way to support U.S. national security and foreign policy goals. The current U.S. National Security Strategy states that the U.S. will “work with partners through the Global Health Security Agenda in pursuit of a world that is safer and more secure from infectious disease.”34 Global health programs are believed to contribute to national security because they support economic development, the spread of democracy, and increased stability. These programs can also protect the health and economic security of U.S. citizens more directly by reducing the impacts of international health threats such as outbreaks of infectious disease.35
Components of the U.S. engagement on global health include policies (such as legislation, regulations, executive orders, guidance, and other relevant issuances that address global health) and a broad range of initiatives and programs that are meant to improve health in developing countries. The U.S. role is multifaceted (Figure 4), and includes such activities as:
- Acting as a donor by providing financial and other health-related development assistance (e.g., commodities) to low- and middle-income countries, through both bilateral and multilateral channels;
- Engaging in global health diplomacy through international negotiations and agreements;
- Providing technical assistance, other capacity-building support to countries and organizations;
- Operating (i.e. implementing) programs and delivering health services in other countries;
- Participating in governance of and membership in major international health organizations such as the WHO and the Global Fund;
- Engaging in global health research and development efforts;
- Partnering with governments, non-governmental groups, and the private sector; and
- Supporting international responses to disasters and other emergencies to save lives and livelihoods.
U.S activities are targeted at a broad range of issues, and use different intervention approaches such as:
- Health services and systems: Improving basic and essential health services, systems, and infrastructure;
- Disease detection and response: Supporting surveillance, prevention, and treatment of diseases including both infectious and non-communicable diseases;
- 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, 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.
Which Agencies and Programs of the U.S. Government Are Involved in Global Health?
The U.S. government’s engagement in global health is overseen and carried out by multiple agencies, departments, and several Congressional committees (see Figure 5). In general, the U.S. global health engagement has developed within two main structures of the 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 at the Department of State (State), the U.S. Agency for International Development (USAID), and the Millennium Challenge Corporation (MCC). The public health structure, represented most prominently by several agencies within the Department of Health and Human Services (HHS), also plays an important global health role. Additional departments and agencies are also involved in global health, including the Department of Defense (DoD), 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 National Security Council (NSC), and the Office of the U.S. Trade Representative (USTR).
A schematic of the U.S. government’s global health organization can be seen in Figure 5 below.
Foreign Assistance Agencies
The U.S. global health engagement is primarily based in foreign assistance agencies, which receive the bulk of government funding appropriated by Congress to operate the majority of global health programs and activities.
Department of State (State): Established in 1789, the State Department is the Cabinet-level foreign affairs agency of the United States. The Department advances U.S. objectives and interests in the world through its primary role in developing and implementing the President’s foreign policy. The State Department also provides policy direction to USAID, the lead federal agency for development assistance. Most of the State Department’s global health policy development and coordination activity is overseen by the Under Secretary for Civilian Security, Democracy, and Human Rights, the Under Secretary for Economic Growth, Energy, and the Environment, and the Office of the U.S. Global AIDS Coordinator (OGAC). Through OGAC (created in 2003), the U.S. Global AIDS Coordinator oversees the implementation of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), exercising oversight authority over all funding and activities for global AIDS carried out by multiple departments and agencies. The State Department also contributes to the development of the U.S. government’s Global Water Strategy, which addresses clean water, sanitation, and hygiene (WASH) efforts in developing countries, as charged by the Senator Paul Simon Water for the Poor Act of 2005 and Water for the World Act of 2014. Further, in 2012 the Department created an Office of Global Health Diplomacy (GHD), which has been given the responsibility to “guide diplomatic efforts to advance the United States’ global health mission” and goals.36 More information on PEPFAR and U.S. WASH efforts can be found in the “What Are The Major U.S. Global Health Program Areas And Efforts?” section below.
U.S. Agency for International Development (USAID): Established in 1961, USAID is an independent U.S. federal government agency that receives overall foreign policy guidance from the Secretary of State. USAID’s role is to support long-term and equitable economic growth in countries and advance U.S. foreign policy objectives by supporting activities in each of its programmatic functional bureaus (e.g., Bureau of Global Health) as well as regional bureaus. Most USAID global health programs are coordinated through the Bureau of Global Health, including HIV/AIDS and other infectious diseases, maternal and child health, family planning and reproductive health, nutrition, and environmental health. Other bureaus and offices within USAID that address global health issues include the Bureau for Economic Growth, Education, and Environment, which implements clean water and sanitation projects, and the Bureau for Democracy, Conflict, and Humanitarian Assistance, which administers the largest U.S. international food assistance program, the Food for Peace Program (Public Law 480 Title II). USAID serves as the lead agency for the President’s Malaria Initiative (PMI), which is implemented with the Centers for Disease Control and Prevention (CDC), and also serves as one of the main PEPFAR implementing agencies. More information on PMI, PEPFAR, and USAID programs can be found in the “What Are The Major U.S. Global Health Program Areas And Efforts?” section below.
Millennium Challenge Corporation (MCC): Established in 2004, MCC administers the Millennium Challenge Account (MCA), a U.S. government initiative which provides development assistance to eligible countries in order to promote economic growth and reduce poverty in low- and middle-income countries. MCC supports a number of health-related programs, but health is not the main focus or purpose of its work. The MCA is designed to link contributions for development assistance to greater responsibility by developing nations. The MCC is a government corporation with a Board of Directors that includes the Secretary of State (Chair), the Secretary of Treasury, the U.S. Trade Representative, the Administrator of USAID, the CEO of the MCC, and four public members appointed by the U.S. President with the advice and consent of the U.S. Senate.
Public Health Service Agencies
Public health service agencies operate global health programs directly, or in conjunction with foreign assistance agencies.
Department of Health and Human Services (HHS): Established as a Cabinet-level department in 1953, HHS is the U.S. government’s principal agency for protecting the health of all Americans and providing essential human services. The Office of Global Affairs (OGA), housed within the office of the secretary and led by the Assistant Secretary for Global Affairs, provides policy guidance to and coordinates with other Federal departments and agencies, international organizations, and the private sector on international and refugee health issues, and manages the health attaché program. While HHS directly operates some in-country programs, much of its global health efforts are provided through technical assistance to foreign assistance agencies through four HHS operating divisions:
- Centers for Disease Control and Prevention (CDC): With a long history working on international health issues, the CDC focuses on disease control and prevention and health promotion through operations, development assistance, basic and field research, technical assistance, training/exchanges, and capacity building. A strategic framework adopted in 2007 explicitly includes global health promotion among CDC’s overarching goals, and in 2010, the agency created a new Center for Global Health (CGH) to lead the agency’s global health effort, across its many different centers and offices, and with partner countries. CGH consists of four divisions: the Division of Global HIV/AIDS, which works with Minsters of Health (MoH) to combat HIV/AIDS through PEPFAR; the Division of Parasitic Diseases and Malaria, which works with USAID to implement PMI; the Division of Global Health Protection, which houses the Field Epidemiology Training Program (FETP) and the Sustainable Management Development Program; and the Global Immunization Division, which provides support to MoHs to control vaccine-preventable diseases worldwide. Additionally, the CDC Office of Infectious Diseases (OID) includes three national centers and also works to coordinate global health activities.37
- 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. All 27 of the agency’s institutes and centers engage in global health activities. In particular, the National Institute of Allergy and Infectious Diseases (NIAID) carries out a significant amount of global health research on infectious diseases, including HIV, as well as on immunologic and allergic diseases and conditions. NIH also operates the Fogarty International Center which works to build partnerships between health research institutions in the U.S. and abroad and train research scientists. NIH also serves as a PEPFAR implementing agency by supporting research on HIV infection, co-morbidities, and new therapies and vaccines.
- Food and 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. As a PEPFAR implementing agency, FDA is charged with expediting the review of pharmaceuticals to ensure that OGAC can buy safe and effective antiretroviral drugs at the lowest possible prices. In recent years the FDA has made efforts to increase its overseas presence and coordination with partner governments to better promote its mission of protecting the health of U.S. citizens, especially through an emphasis on improving regulatory capacity abroad.38
- Health Resources and Services Administration (HRSA): HRSA builds human and organizational capacity and promotes health systems strengthening to deliver care in PEPFAR countries.
Other Departments And Agencies Involved In Global Health
The remainder of U.S. global health activities is carried out by programs at several other federal departments and agencies. These include:
- Department of Defense (DoD): Supports a broad set of humanitarian assistance and disaster relief, military-to-military health systems capacity-building, care delivery, international training and exchanges, disease surveillance, and health research and product development activities. For further details on these activities, see the Kaiser Family Foundation report, “The U.S. Department of Defense and Global Health.”39
- Department of Agriculture (USDA): Provides food assistance (primarily commodities) to low-income countries.
- The Peace Corps: Provides volunteers to communities in developing nations in support of PEPFAR; maternal and child health, basic health services, and other health areas.
- Environmental Protection Agency (EPA): Focuses on mitigating environmental hazards that represent inherently transnational threats, and building partnerships to enhance research, policy, and standards development capacity of developing nations.
- Department of Homeland Security (DHS): Lead agency on all matters of domestic security, facilitating communication among international and domestic partners during crises.
- Department of Labor (DoL): Focuses on promoting safe workplaces and preventing child labor and exploitation globally, including through HIV/AIDS workplace education programs.
- Department of Commerce (Commerce): Fosters public-private partnerships for HIV/AIDS as part of PEPFAR; compiles and manages country-level data on HIV.
- National Security Council (NSC): Located in the Executive Office of the President, serves as the principal forum for considering national security issues related to global health threats.
- Office of the U.S. Trade Representative (USTR): Located in the Executive Office of the President, promotes, negotiates, and shapes U.S. interests in global free trade, including protection of intellectual property rights.
Congressional Committees with Jurisdiction Over U.S. Global Health Efforts
Congress drafts program specific legislation, recommends overall funding levels, specifies how funds should or should not be spent, and appropriates funds to U.S. global health programs. More than 15 Congressional committees have jurisdiction and oversight over global health. The major committees with jurisdiction are listed below.
Authorization and Oversight Committees
- House Committee on Foreign Affairs: responsible for oversight and legislation relating to all foreign assistance, including programs operated by the State Department, the MCC, and USAID. Key subcommittee: Africa, Global Health, Global Human Rights, and International Organizations, which has jurisdiction over global health issues generally, including specific responsibility for the region of sub-Saharan Africa, as well as over issues relating to the United Nations and its agencies.
- Senate Committee on Foreign Relations: responsible for oversight and legislation relating to all foreign assistance, including programs operated by the State Department, the MCC, and USAID. Key subcommittees include: Africa and Global Health Policy as well as Multilateral International Development, Multilateral Institutions, and International Economic, Energy, and Environmental Policy.
- House Committee on Energy and Commerce: has jurisdiction over a number of areas of health care, including biomedical research, public health, and the regulation of drugs. Key subcommittees include: Health as well as Oversight and Investigations.
- Senate Committee on Health, Education, Labor, and Pensions: has jurisdiction over a number of areas of health care, including biomedical research, public health, and the regulation of drugs.
- Senate and House Appropriations Committees. Key subcommittees in each Appropriations Committee are: State, Foreign Operations, and Related Programs (with responsibility for the State Department and USAID) and Labor, Health and Human Services, Education, and Related Agencies (with responsibility for NIH and CDC).
A more complete reference document listing congressional committees with jurisdiction over global health by department, agency, and initiative can be found in Appendix A.
Major Statutes Guiding U.S. Global Health Efforts
The U.S. global health response has been defined by numerous governing statutes, authorities, and policy decisions, with most legislative and policy activity occurring in the past decade. Two major acts have established the main agencies that carry out global health activities and specify where and how funds should be directed:
- The Public Health Service Act of 1944: consolidated and revised all existing legislation relating to the Public Health Service (PHS, which had been created a few decades earlier), outlined the policy framework for federal-state cooperation in public health; and established regulatory authorities that transferred the PHS to the Department of Health, Education and Welfare (HEW), now known as the Department of Health and Human Services.
- The Foreign Assistance Act of 1961: reorganized U.S. foreign assistance programs, including separating military and non-military aid, and mandated the creation of an agency to administer economic assistance programs, which led to the establishment of USAID. While amendments and other changes have been made to the Foreign Assistance Act over time, it has only been reauthorized once, in 1985.
In addition to the general foreign assistance statutes listed above, the legislation that created PEPFAR in 2003 and its re-authorization in 2008 are also key statutes for U.S. global health policy.
- PEPFAR legislation (originally authorized in 2003): titled the United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003 (P.L. 108-25), the original PEPFAR authorization legislation created OGAC and authorized $15 billion over 5 years to combat global HIV/AIDS (as well as TB and malaria). In 2008, PEPFAR was reauthorized by the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (P.L. 110-293 or “Lantos-Hyde”), for an additional 5 years (FY 2009-FY 2013) at up to $48 billion. In 2013, the PEPFAR Stewardship and Oversight Act of 2013 (P.L. 113-56) extended a number of existing authorities and strengthened the oversight of the program through updated reporting requirements, among other things.40
Other Acts of Congress have also been significant for global health. A timeline of the statutes, authorities, and policies governing U.S. global health policy can be found in Appendix B.
What Are The Major U.S. Global Health Program Areas And Efforts?
While the U.S. government has been engaged in international health activities for more than a century, the provision of development assistance for health began primarily in the 1960s and 1970s, with support for maternal and child health and family planning efforts. Efforts have grown markedly since the early 2000s, and have largely focused on disease-specific initiatives, including PEPFAR and the PMI.
Each of these programs works in a particular set of countries, and typically has its own dedicated budget, staff, objectives, and monitoring and evaluation practices, and historically, these have not been well coordinated. The current U.S. government approach aims to build upon and consolidate the successes of existing U.S. global health programs and initiatives (such as U.S. global HIV/AIDS efforts) and establishes cross-cutting principles (e.g., encourage country ownership and invest in country-led plans) and strategies for these efforts. It also aims to improve coordination and cooperation among U.S. agencies.41
This section gives an overview of the key U.S. global health programs that address the major global health challenges identified earlier.
The U.S. first provided funding to address the global AIDS epidemic in 1986, although funding and attention did not increase significantly until the last decade. In 1999, President Clinton announced the Leadership and Investment in Fighting an Epidemic (LIFE) Initiative and, in 2002, President Bush announced the International Mother and Child HIV Prevention Initiative. A major increase in support for global HIV/AIDS programs occurred when President Bush announced the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003, which has been the largest commitment by any nation to combat a single disease in history.43,44 Its first five-year authorization through the United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003 (P.L. 108-25) was for $15 billion (Congress appropriated more over this period). PEPFAR was reauthorized by the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, And Malaria Reauthorization Act of 2008 (P.L. 110-293 or “Lantos-Hyde”) for an additional five years starting in 2008, expanding goals for HIV, TB, and malaria efforts. In 2013, the PEPFAR Stewardship and Oversight Act of 2013 (P.L. 113-56) extended a number of existing authorities and strengthened the oversight of the program through updated reporting requirements, among other things.40
PEPFAR is an interagency initiative that supports a range of HIV prevention, treatment, and care efforts worldwide, including prevention of mother-to-child transmission of HIV and the provision of antiretroviral drugs to millions. In 2011, Secretary of State Clinton called for an “AIDS-free generation” as a goal of the U.S. government, and in 2012, PEPFAR released a blueprint for achieving this goal.45,46 The current PEPFAR strategy, PEPFAR 3.0 – Controlling the Epidemic: Delivering on the Promise of an AIDS-free Generation, was released in 2014 and reflects a shift in its approach to controlling the epidemic, including targeting resources to key populations, especially adolescent girls and young women, and geographic areas that are most affected by HIV.47
PEPFAR’s original authorization established an Office of the U.S. Global AIDS Coordinator at the Department of State, headed by a coordinator who is appointed by the President and requires Senate confirmation. The U.S. Global AIDS Coordinator has the rank of Ambassador and reports directly to the Secretary of State. The coordinator is responsible for all programs, activities, and funding for global HIV/AIDS efforts. Along with OGAC, the White House and the National Security Council (NSC) are involved in policy development for PEPFAR. USAID and CDC are the main PEPFAR implementing agencies and receive direct funding from Congress. Other implementing agencies include: NIH, HRSA, and FDA at HHS; DoL; Commerce; the Peace Corps; and DoD.
USAID is the lead U.S. government agency on global tuberculosis control and began its efforts in 1998. The U.S. response to TB grew over time and, in 2003, the passage of PEPFAR highlighted the U.S. commitment to addressing TB and authorized U.S. contributions to the Global Fund, significantly increasing the amount of support for TB programs by the U.S. government. PEPFAR’s reauthorization in 2008 established specific funding levels and targets for TB. In 2015, the USG released its five-year USG TB Strategy 2015-2019, which outlines current USG TB goals. The same year, the USG also released its National Action Plan for Combating Multidrug-Resistant Tuberculosis, which identifies interventions and articulates a strategy to respond to the domestic and global challenges of MDR-TB.50 USAID’s TB efforts are focused on the diagnosis, treatment, and control of TB and multi-drug and extensively drug resistant (MDR/XDR) TB. Countries are selected to receive bilateral support for TB based on the prevalence and incidence of TB, HIV/AIDS prevalence, prevalence and/or potential for drug resistance, and case detection and treatment success rates. Political commitment and technical and managerial feasibility are also considered in country selections.
The U.S. has been involved in efforts to combat malaria since the 1950s through activities at the CDC and USAID. Early efforts focused on technical assistance, but also included some direct financial support for programs overseas. U.S. efforts expanded over time, and the 2003 passage of PEPFAR highlighted the U.S. commitment to addressing malaria and authorized multilateral support to combat the disease through contributions to the Global Fund. In 2005, President Bush announced the U.S. President’s Malaria Initiative,53 initially a five-year expansion of existing U.S. government efforts to address malaria in 15 endemic countries. The PMI is an interagency initiative led by USAID, and implemented in partnership with CDC. It is overseen by the U.S. Global Malaria Coordinator, who is appointed by the President, and an Interagency Advisory Group made up of representatives of USAID, CDC, State, DoD, NSC, and the Office of Management and Budget. The coordinator reports to the USAID Administrator, and has direct authority over both the PMI efforts and non-PMI USAID malaria programs. U.S. efforts to control malaria include the distribution of insecticide-treated bed nets (ITNs), indoor residual spraying (IRS), intermittent preventive treatment in pregnancy (IPTp), treatment with artemisinin-based combination therapy (ACT), and the provision of technical assistance to affected countries.
Historically, the U.S. government had supported the NTD response through research and surveillance. More recently, in 2006, U.S. attention to NTDs increased when Congress first appropriated funds to USAID for integrated NTD control, marking the launch of the USAID NTD program. In 2008, the program was expanded under President Bush’s U.S. NTD Initiative. The USAID NTD program seeks to control seven NTDs in target countries in Africa, Asia, and Latin America through mass drug administration programs. USAID serves as the lead implementing agency for U.S. global NTD efforts, with several other agencies, including CDC, NIH, DoD, and the FDA, also involved.
Research on international FP and population issues was first authorized by Congress in the Foreign Assistance Act of 1961. In 1965, USAID launched its first FP program and, in 1968, began purchasing contraceptives to distribute in developing countries. USAID serves as the lead agency on FP/RH. Its efforts aim to reduce high-risk pregnancies; allow sufficient time between pregnancies; provide information, counseling, and access to condoms to prevent HIV transmission; reduce the number of abortions; support women’s rights; and stabilize population growth. Funding is allocated to countries based on factors that include unmet need for family planning services, high-risk births, contraceptive use, and population pressures on land and water resources.
The U.S. government has been involved in efforts to improve MCH since the 1960s, initially focused on pioneering research on oral rehydration therapy (ORT). Other early programs included fortifying international food aid with vitamin A, and efforts to control malaria (because the bulk of malaria illness and death occurs in children). Funding for USAID’s child survival activities nearly doubled in 1985, and in 2001, USAID introduced a newborn survival strategy. In 2012, USAID, along with many other partners, held a child survival summit in 2012 to re-energize support for child survival programs.60 USAID’s MCH strategy focuses on bringing a range of “high impact interventions” to scale, and on health systems strengthening (e.g., health workforce, pharmaceutical management, etc.). Funding is allocated to countries based on factors that include high maternal and child mortality burdens, government willingness to partner, and country capacity to implement programs.
USAID has been involved in efforts to improve nutrition for more than 40 years. USAID’s nutrition program aims to prevent undernutrition through interventions such as nutrition education, nutrition during pregnancy, promotion of exclusive breastfeeding, and micronutrient supplementation. Nutrition efforts are coordinated with the U.S. Feed the Future (FtF) Initiative. Introduced in 2009 following the G-8 Summit in L’Aquila, Italy, FtF is the U.S. government’s global hunger and food security initiative. The initiative, led by USAID and USDA, works to reduce hunger, increase food security, and improve nutrition by investing in agricultural development and nutrition efforts, with an emphasis on country ownership, improving coordination, leveraging multilateral institutions, and ensuring long-term accountability, while addressing the underlying causes of hunger and poverty. FtF works closely with U.S. global health efforts to achieve nutrition targets.
USAID’s water, sanitation, and hygiene (WASH) activities aim to build capacity, strengthen water and sanitation utilities, mobilize domestic resources, improve household and community-level hygiene and sanitation, and work with disaster relief efforts to implement water and sanitation activities. U.S. government efforts to address WASH issues are guided by the Senator Paul Simon Water for the Poor Act of 2005 (P.L. 109-121) and the Senator Paul Simon Water for the World Act of 2014 (P.L. 113-289), which requires the State Department, USAID (the main implementing agency), and other U.S. government agencies to develop and implement a U.S. government Global Water Strategy to provide “first-time or improved access to safe drinking water, sanitation, and hygiene to the world’s poorest on an equitable and sustainable basis” and to identify priority water countries for U.S. WASH efforts.65 These efforts provide assistance to developing countries through capacity building activities and partnerships as well as direct investment in WASH infrastructure and science and technology. USAID’s WASH efforts, which are led by the USAID Global Water Coordinator, focus on providing clean water and ensuring water security through U.S. global health and food security efforts, while the State Department’s efforts, which are led by the State Department’s Special Advisor for Water Resources, focus on diplomatic efforts related to WASH issues and water resources.66
With the growing recognition that the burden from non-communicable diseases (NCDs) is growing in low- and middle-income countries, attention to NCDs in the context of U.S. government programs has increased. For example, the U.S. played an important role in organizing the 2012 U.N. summit on NCDs, and participated in negotiations on global NCD targets and the development of best practices to combat NCDs. Funding for NCD programs, though, remains only a small proportion of overall U.S. government global health spending.
Global Health Security
Since the 1990s there has been growing concern about new infectious diseases that threaten human health. In the last several years alone we have seen the emergence and spread of threats such as Ebola, Zika, H1N1 influenza, and antibiotic resistance. Global health security efforts are meant to reduce the threat of such diseases, but supporting preparedness, detection, and response capabilities worldwide. The U.S. has supported a number of global health security programs through agencies such as the Department of Defense, CDC, USAID, and the State Department.67 In February 2014, the U.S. along with nearly 50 countries and international organizations launched the Global Health Security Agenda (GHSA), a 5-year partnership effort that aims to accelerate progress in building country capacity to prevent, detect, and respond to infectious diseases. Through the GHSA, U.S. government agencies work with host governments and partners to help countries establish five-year plans to achieve global health security targets. In November 2016, President Obama signed an executive order to solidify US commitment to the GHSA and establishing global health security as a national priority.68
In Which Countries Does The U.S. Support Global Health Programs?69
Decisions on where the U.S. focused its global health programs are based on a number of factors. The burden of disease faced by countries is an important factor in determining support, with more support generally directed to countries facing a higher burden of disease. For example, PEPFAR and PMI funds have been directed principally at those countries with the some of the highest burdens of HIV/AIDS and malaria, respectively. Still, other factors also influence where the U.S. directs its health assistance, including the presence of willing and able recipient partner governments, a history of positive relations and goodwill between the countries, strategic and national security priorities, funding, and personnel availability.
The U.S. operates programs in more than 60 countries, with other countries reached through regional programs or contributions to multilateral organizations. Among the countries receiving bilateral global health funding through the Global Health Programs (GHP), Economic Support Fund (ESF), Development Assistance (DA), and Food for Peace (FFP) accounts in FY2015, the majority are located in Africa (33 countries). The U.S. also operates programs in the Western Hemisphere (10 countries), East Asia and Pacific (9 countries), South and Central Asia (8 countries), the Near East (4 countries), and Europe and Eurasia (1 country). The U.S. often operates programs in a number of different areas (HIV/AIDS, TB, NTDs, etc.) in a given country (see Figure 6 and Table 1).
|Table 1: Number of Countries by Program Area and Region, FY 2015|
|Region||HIV/AIDS||TB||Malaria||NTDs||MCH||FP/RH||Nutrition||WASH||Other Public Health Threats|
|East Asia and Pacific||6||4||2||5||5||3||2||2||0|
|Europe and Eurasia||1||1||0||0||0||0||0||0||0|
|South and Central Asia||3||6||0||2||6||5||4||5||1|
For updated information on the countries where U.S. global health programs are present, please see
What Is the U.S. Global Health Budget?
The U.S. government is the largest donor to global health in the world.70 U.S. government funding for global health has grown significantly since 2001, in large part due to the creation of initiatives such as PEPFAR and PMI. More recently, however, U.S. funding for global health has begun to flatten. Most U.S. funding for global health is provided bilaterally, with the majority of multilateral funding provided to the Global Fund. While funding is channeled through multiple agencies and programs, most funding for global health is part of the international affairs budget at the State Department.
The majority of U.S. government funding for global health is captured under the Global Health Programs (GHP) account at USAID and the State Department. Additional funding for global health is provided through the Economic Support Fund (ESF), Development Assistance (DA), and Food for Peace (FFP) accounts at USAID, the International Organizations and Programs (IO&P) and the Contributions to International Organizations (CIO) accounts at the State Department, and through the CDC, NIH, and DoD.
Specified funding for global health grew from $5.3 billion in FY 2006 to $10.0 billion in FY 2010 and has since remained relatively flat, totaling an estimated $10.2 billion in FY 2016 (see Figure 7).71
Bilateral vs Multilateral Aid
Most U.S. global health funding is provided bilaterally. In FY 2016, 80% of the U.S. global health budget was provided through bilateral programs. U.S. contributions to multilateral institutions account for the other 20%, the majority of which is provided to the Global Fund.72
U.S. Global Health Funding By Sector
Bilateral HIV programs have received the most U.S. global health funding of any sector, accounting for approximately 50% of U.S. global health funding between FY 2006 and FY 2016 (see Figure 8). The Global Fund accounted for the next largest share over the period, followed by MCH (including nutrition), and malaria.73 The largest share of global health funding in FY 2016 is for bilateral HIV ($5.2 billion), followed by the Global Fund ($1.35 billion), MCH ($1.2 billion), malaria ($861 million), FP/RH ($608 million), TB ($240 million),74 nutrition ($147 million), Global Health Security ($128 million), NTDs ($100 million), and vulnerable children ($22 million).75 An additional $293 million is provided for other global health activities, which include contributions to WHO, PAHO, and research activities at the Fogarty International Center (see Figure 9).
U.S. Global Health Funding By Agency
Most U.S. global health funding is provided under the international affairs budget, which includes funding for USAID and the State Department. The State Department receives the majority of funding, largely due to the fact that PEPFAR’s funding is channeled through the State Department (see Figure 10). Prior to the creation of PEPFAR, the majority of U.S. global health funding was provided through USAID. In FY 2016, the State Department received $6.0 billion, followed by USAID ($3.1 billion), HHS ($1.1 billion), and DoD ($13.3 million).
U.S. Global Health Funding By Region And Country
More than 80% of country funding is allocated for global health activities in Africa (see Figure 11), followed by South and Central Asia (6.5%), East Asia and Pacific (3.6%), Western Hemisphere (3.2%), Near East (2.2%), and Europe and Eurasia (0.5%). All of the top ten recipient countries of U.S. global health funding in FY 2015 were in Africa (see Figure 12). The top three recipients were: Nigeria, Kenya, and Tanzania. African countries comprised the top 10 most heavily funded countries for malaria, nine of 10 HIV/AIDS recipients, six of 10 FP/RH, and five of 10 MCH and nutrition recipients. Countries in South/Central Asia also received significant amounts of funding in multiple areas, particularly TB.
How Does The U.S. Engage With Multilateral Organizations On Global Health?
In addition to its own bilateral programs, the U.S. government has a long history of involvement with international health organizations, 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 WHO a few decades later, and continuing through to the present with the Global Fund, which the U.S. helped to launch in 2001. Approximately 20% of U.S. global health funding was allocated to multilateral organizations in FY2016, including $1.35 billion for the Global Fund alone. Still, funding is only one of the ways the U.S. supports and engages with multilateral organizations (Figure 13). Some of the other ways include:
- Membership: The U.S. is a member nation of the large multilateral health organizations, including the WHO, PAHO, and the Global Fund.
- Governance: The U.S. sits on the Board or main organizing body of several of the major multilateral health organizations, such as the Global Fund, the WHO World Health Assembly, and UNAIDS, providing it with decision-making authority and other governance roles.
- Organizational Contributions: The U.S. provides funding to multilateral health organizations for their operations and other activities through scheduled assessments and often through additional, project or program-specific support.
- International Health Standards, Treaties, and Agreements: The need to set international standards for preventing the spread of infectious diseases at ports and borders without unduly restricting trade and travel fostered the creation of the earliest international health organizations in the 19th Century; those efforts served as precursors to the development of the International Health Regulations (IHR) of today. The IHR are an international legal instrument that entered into force in 2007, requiring countries to report certain disease outbreaks and public health events to the WHO. Other significant international health agreements include the MDGs, the UN Declaration of Commitment on HIV/AIDS, and the WHO International Framework Convention for Tobacco Control (WHO FCTC).
- Technical Assistance: The U.S. provides technical assistance to international organizations directly and indirectly, such as by providing assistance to Global Fund country applicants in preparing proposals for funding and providing U.S. government scientists to serve as experts on WHO technical committees.
- Staffing: The U.S. provides additional staff capacity to international organizations by detailing government employees for varying periods of time.
Main Multilateral Health Organizations With U.S. Involvement
- The World Health Organization (WHO): The WHO, created in 1948, is the directing and coordinating authority for health within the United Nations system. The U.S. was a founding member, joining in that year. The WHO provides international leadership on global health matters, shaping the health research agenda, setting norms and standards (such as the IHR), providing technical support to countries, and monitoring and assessing health trends. It is governed by the World Health Assembly (attended by all Member States) and an Executive Board of 34 members, of which the U.S. is currently a member through 2017.
- The 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 “works to improve health and living standards of the people of the Americas” and serves as the WHO Regional Office for the Americas and as the health organization of the Inter-American System.
- The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund): Created in 2001, the Global Fund is an independent, public-private, multilateral institution which finances HIV, TB, and malaria programs in low- and middle-income countries. The U.S. government was involved in the creation of the Global Fund and serves on its Board. It is also the largest single donor to the Global Fund in the world. Contributions provided by the U.S. and other donors are in turn provided by the Fund to country-driven projects based on technical merit and need.
- The 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 United Nations system. It is made up of 11 UN 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.
- Gavi, the Vaccine Alliance (Gavi): A public-private partnership created in 2000 to “save children’s lives and protect people’s health by increasing access to immunizations in poor countries.”76
The U.S. also contributes to several other multilateral organizations including The United Nations Children’s Fund (UNICEF), the Food and Agriculture Organization (FAO), the World Food Programme (WFP), the United Nations Development Programme (UNDP), and the United Nations Population Fund (UNFPA). Lastly, the U.S. government also provides contributions to some of the world’s Multilateral Development Banks (MDBs, such as the World Bank and the Inter-American Development Bank), autonomous international agencies that finance development programs in low- and middle-income countries using borrowed money or funds contributed by donor countries.Introduction Conclusion