Global health funding by the United States

The United States is the largest donor of multilateral global health funds. According to the Office of Management and Budget, the U.S. government contributes <1% of the federal budget for foreign aid including global health activities. In 2023, the U.S. contributed 12.9 billion USD towards global health activities across several health verticals including HIV, Tuberculosis, Malaria and COVID-19.

HIV
The U.S. began funding global HIV initiatives in 1986, with efforts increasing substantially in 2003 with the launch of the President’s Emergency Plan for AIDS Relief (PEPFAR) by U.S. President George W. Bush, the largest program dedicated to a single disease globally. PEPFAR accounts for the majority (89%) of U.S. global HIV funding, which includes support for UNAIDS and international HIV research. Managed by the Department of State's Bureau for Global Health Security and Diplomacy, PEPFAR funding is detailed in annual congressional appropriations and also supports agencies like USAID, CDC, and DoD. The National Institutes of Health (NIH) also contributes to international HIV research. From FY 2015 to FY 2024, global HIV funding represented 42%-50% of the U.S. global health budget, with FY 2024 allocations totaling $5.4 billion, including $4.9 billion for PEPFAR and $575 million for NIH research.

The Biden administration recently announced a six percent cut to the PEPFAR budget for FY 2025 with a proposed budget $4.4 billion.

Malaria
The U.S. has participated in global malaria efforts since the 1950s and is currently the second largest donor, following the Global Fund to Fight AIDS, Tuberculosis and Malaria. The President’s Malaria Initiative (PMI), led by USAID and co-implemented with the CDC, drives U.S. malaria activities. Additional support comes from NIH and DoD. U.S. bilateral funding for malaria rose from $854 million in FY 2015 to about $1 billion in FY 2024, representing 9% of the U.S. global health budget. Despite increases over the past decade, funding has stabilized in recent years.

Tuberculosis
The U.S. Agency for International Development (USAID) initiated a global tuberculosis (TB) control program in 1998, the U.S. has become one of the leading donors to global TB control. U.S. bilateral TB funding, managed by USAID, includes contributions to the TB Drug Facility and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Over the past decade, U.S. funding for TB has significantly increased, rising from $242 million in FY 2015 to $406 million in FY 2024, now comprising about 3% of the U.S. global health budget of 12.9 billion USD.

The Global Fund
The Global Fund to Fight AIDS, Tuberculosis and Malaria is an independent, multilateral institution that funds HIV, TB, and malaria programs in low- and middle-income countries using contributions from public and private donors. The U.S., its largest donor since providing the founding contribution in 2001, includes these contributions as part of PEPFAR. However, U.S. contributions are subject to restrictions, including a funding match requirement. While U.S. contributions peaked at $2.0 billion in FY 2023, they decreased to $1.7 billion in FY 2024 due to these restrictions. Additionally, the U.S. Congress allocated $3.5 billion in emergency funds in FY 2021 to mitigate COVID-19 impacts on HIV programs.

Maternal and Child Health
The U.S. has been involved in Maternal & Child Health (MCH) efforts since the 1960s and is the largest donor to global MCH activities. Funding, which includes support for polio eradication and contributions to Gavi, the Vaccine Alliance (GAVI), and UNICEF, is managed by USAID, CDC, and the State Department. From FY 2015 to FY 2024, MCH funding increased from $1.18 billion to $1.29 billion, driven mainly by increased allocations to GAVI and polio, while bilateral MCH funding remained steady. In FY 2024, MCH funding comprised 10% of the U.S. global health budget, making it the third largest category.

Dr. Ezekiel Emanuel, a senior advisor to President Obama in the early 2010s, recommended funding MCH initiatives at the expense of future funding increases for PEPFAR. Dr. Emanuel claimed that PEPFAR "is not the best use of international health funding," and "fails to address many of the developing world's most serious health issues." Anand Reddi and Sarah Leeper rebutted Emanuel by stating "The idea that differing global health initiatives must compete with each other lacks not only ethical legitimacy but also scientific merit. Maternal and child health, need not to be framed in opposition to PEPFAR. Confronting illness in isolation -- whether by funding PEPFAR at the expense of programs that target maternal or child health or vice versa -- cannot be our way forward. We should be advocating for funding both PEPFAR and maternal and child health together instead of favoring one program over another."

Health Systems Strengthening
In 2024, U.S. Global Health Funding includes $10 million for the Global Health Worker Initiative, the first time Congress has provided funding for this initiative that increase education and training of healthcare workers in resource limited settings.