Global Health: Appropriations to USAID Programs from FY2001 through FY2008

^Pr^ep^ar^{ed f}^o^r^M^e^m^b^ers^an^d^Com^mⁱ^t^t^ees^of^C^ong^r^e^ss

Congressional awareness about and support for global health has grown considerably, particularly
during the tenure of President George W. Bush. From FY2001 through FY2008, Congress
appropriated about $15.2 billion to the U.S. Agency for International Development (USAID) for
global health programs. Appropriations supported five key programs: child survival and maternal
health (CS/MH), vulnerable children (VC), human immunodeficiency virus/ acquired
immunodeficiency syndrome (HIV/AIDS), other infectious diseases (OID), and family planning
and reproductive health (FP/RH). Although a number of U.S. agencies and departments
implement global health programs, this report focuses on funding for global health programs
conducted by USAID. (For further discussion of the structure of USAID’s global health
programs, see CRS Report RL31433, U.S. Global Health Priorities: USAID’s Global Health
FY2003 Budget, by Tiaji Salaam-Blyther.) The role of other U.S. agencies and departments is
discussed in the context of intergovernmental partnerships, such as the President’s Emergency
Plan for AIDS Relief (PEPFAR).
From FY2001 through FY2008, much of the growth in global health spending targeted two
diseases: HIV/AIDS and malaria. During this period, Congress supported the President’s calls for
higher spending on these diseases through three key initiatives: The President’s International
Mother and Child HIV Prevention Initiative (FY2002-FY2004), PEPFAR (FY2004-FY2008), and
the President’s Malaria Initiative (FY2006-FY2010). PEPFAR has dominated much of overall
U.S. global health appropriations. Hence, this report analyzes funding for USAID’s global health
before and after PEPFAR authorization. This report will not be updated and does not analyze
debates about PEPFAR reauthorization or discuss possible impacts of such reauthorization.

USAID Global Health Programs: FY2001-FY2003.......................................................................1
USAID Global Health Programs: FY2004-FY2008.......................................................................2
Changes in USAID Global Health Appropriations Since PEPFAR Authorization.........................4
Figure 1. USAID Global Health Programs: FY2001-FY2003........................................................2
Figure 2. USAID Global Health Programs: FY2004-FY2008(current U.S. $ millions).................4
Table 1. USAID Global Health Programs: FY2001-FY2003..........................................................1
Table 2. USAID Global Health Programs: FY2004-FY2008..........................................................3
Table 3. U.S. Spending on Global HIV/AIDS, TB, and Malaria: FY2004-FY2008.......................5
Author Contact Information............................................................................................................6

Overall support for USAID’s global health programs grew from $1.5 billion in FY2001 to $1.9
billion in FY2003 (Table 1). Support grew in FY2002 and FY2003 only for HIV/AIDS
interventions, including U.S. contributions to the Global Fund to Fight HIV/AIDS, Tuberculosis,
and Malaria (Global Fund) (Figure 1). Support for child survival/maternal health programs
fluctuated during this period; appropriations did not reach FY2001 levels for vulnerable children
programs.
Increased funding for global HIV/AIDS programs was prompted in part by the International ¹
Mother and Child HIV Prevention Initiative. In FY2002, President Bush submitted his first
budget request including $500 million for the initiative, which sought to prevent the transmission
of HIV from mothers to infants and to improve health care delivery in Africa and the Caribbean.
Congress provided that up to $100 million (excluding rescissions) be made available to USAID
for the initiative in FY2003. In FY2004, Congress provided $150 million (excluding rescissions)
to CDC for PMTCT programs. Conferees also expressed an expectation that $150 million would
be made available for the initiative from the newly established Global HIV/AIDS Initiative
(GHAI; H.Rept. 108-401). Since the initiative expired in FY2004, Congress has included funds
for PMTCT programs in the GHAI account (Figure 1).
Table 1. USAID Global Health Programs: FY2001-FY2003
^{(current U.S.$ mil}^lions)
^{% Change:}
^FY20⁰¹^FY20⁰²^FY20⁰³^FY20^01-
^Progr^am^Enacted^Enacted^Enacted^FY20⁰³
^{Child Survival/Maternal Health (C}^S/MH)^361.¹^391.⁷^389.⁷^7.9%
^{Vulnerable Children (VC)}^36.7^32.3^34.3^-6.5%
^{HIV/AIDS 318.}⁰^424.⁰^523.⁸^64.7%
^Other^Infe^{ctious Diseases (OID)}^140.²^182.⁰^173.¹^23.7%
^{Family Planning/Reproductive He}^alth^425.^{0 425.}⁰^443.⁶^4.4%
^(FP/RH)
^{United Nations Children’s Fund}^109.^{8 120.}⁰^119.²^8.6%
^{(UNICEF) Gra}^nt
^{Global Fund}^$10^0.0^$50.0^$24^8.4^148.^4%
^{Total 1,49}^0.⁸^1,62^5.⁰^1,93^2.¹^29.6%
^Source:^{Compiled by CRS from}^approp^{riations legislati}^{on and corresponden}^{ce with USAID’s Budg}^{et Office.}

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Figure 1. USAID Global Health Programs: FY2001-FY2003
^{(current U.S. $ mi}^llions)
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^Source:^{Compiled by CRS from}^approp^{riations legislati}^{on and corresponden}^{ce with USAID’s Budg}^{et Office.}

From FY2004 through FY2008, congressional debate increasingly focused on how to support the
global fight against HIV/AIDS, tuberculosis (TB), and malaria while maintaining support for
other global health programs. While some Members applauded the Administration’s focus on ²
HIV/AIDS, particularly through the President’s Emergency Plan for AIDS Relief (PEPFAR),
they chided the Administration for requesting less for other global health interventions,
particularly those related to child survival, maternal health, family planning, and reproductive ³
health. Other Members questioned the ability of recipient countries to absorb burgeoning
HIV/AIDS funds because of overtaxed health infrastructures. Congress urged the Administration
to better integrate HIV/AIDS and other health programs, particularly those related to TB and
nutrition.

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Still, appropriations for HIV/AIDS, TB, and malaria programs far outpaced support for USAID’s
other health programs. From FY2004 through FY2008, Congress provided $4.6 billion for
USAID’s child survival and maternal health, vulnerable children, and family planning and
reproductive health initiatives (Table 2). During that same time period, Congress appropriated
$19.7 billion for global HIV/AIDS, TB, and malaria programs (Table 3).
Table 2. USAID Global Health Programs: FY2004-FY2008
^{(current U.S.$ mil}^lions)
^{% Change:}
^FY20^04-
^Progr^{am FY20}⁰⁴^FY20⁰⁵^FY20⁰⁶^FY20⁰⁷^FY20⁰⁸^FY20⁰⁸
^{CS/MH 442.}⁹^451.⁷^447.⁸^427.⁹^521.⁹^17.8%
^{VC 36.0}^35.3^29.7^19.6^20.5^-43.0%
^{HIV/AIDS 555.}⁵^384.⁷^373.⁸^345.⁹^371.¹^-33.2%
^OID^200.^{5 215.}⁸^445.¹^586.⁴^707.^{9 253.}^1%
^TB^{[85.1] [92.0]}^[91.5]^[94.9]^[16^{2.2] [90.6%]}
^Malaria^[79.9]^[90.8]^[10^2.0]^[24^8.0]^[34^9.6]^[33^7.5%]
^H5N^{1 (Avian Flu)}^n/a^[16.3]^[16^1.5]^[16^1.5]^[11^5.0]^[60^5.5%]^a
^Other^[35.5]^[16.7]^[90.1]^[82.0]^[81.1]^[12^8.5%]
^{FP/RH 429.}⁵^437.⁰^435.⁰^435.⁶^457.²^6.5%
^{Global Fund (GF)}^397.⁶^248.⁰^247.⁵^247.⁵^0.0^b^c
^{Total with GF}^2,06^2.0^1,77^2.5^1,97^8.9^2,06^2.9^2,07^8.6^0.8%
^{Total without GF}^1,66^4.4^1,52^4.5^1,73^1.4^1,81^5.4^2,07^8.6^24.9%^d
^Source:^{Compiled by CRS from}^approp^{riations legislati}^{on and corresponden}^{ce with USAID’s Budg}^{et Office.}
^Notes:^{Contributions to UNICE}^{F are not included in t}^{his table be}^{cause Congre}^{ss has}^ap^propriated^{those fu}^nds
^{to GHAI since}^FY20^04.
^{Abbreviations:}^CS/MH—^{Child Survival/Maternal Health; VC—V}^{ulnerable C}^{hildren; OID—Othe}^r^Infectious
^{Diseases; FP/RH—Fami}^{ly Planning/Reproductive Health.}
^a.^{Because Congre}^{ss bega}^{n f}^unding^{global avian flu interven}^{tions in F}^Y200^{5, this pe}^rcentage^{reflects c}^{hanges in}
^approp^{riations from FY20}^{05 t}^hro^{ugh FY2}⁰⁰^8.
^b.^{In FY2}⁰⁰^{8, Congress}^{provided the full U.S. contribution to the}^{Global Fund from Foreign O}^perations
^Approp^{riations to GHAI.}
^c.^{CRS did not calculate changes in}^appro^{priations to the Global Fu}ⁿ^{d, because t}^{he Global Fund is}^{not a}
^{bilateral program that t}^{he U}^{nited States controls or throug}^{h whic}^{h the U}^{nited States provides direct}
^assistance.
^d.^{The final row reflects a}^p^p^ropriat^{ions to USAID’s gl}^{obal health pro}^{grams without con}^{sidering U.S.}
^{contributions to th}^{e Global Fund.}

While most health experts applaud increases in U.S. support for global HIV/AIDS interventions,
many are concerned that other low-cost life-saving interventions are overlooked and underfunded,
particularly those related to child survival and maternal health. Critics of how U.S. global health
funds are apportioned point out that child and maternal mortality rates remain dangerously high in
sub-Saharan Africa and that the continent is the only region in the world where those rates
continue to rise. In addition to these concerns, some global health analysts point out that despite
significant foreign investments in HIV/AIDS, many developing countries are ill-equipped to treat
the majority of patients suffering from non-infectious diseases and address basic health care.
Global health advocates urge Congress to provide more for health system strengthening, which
would enable governments to address any disease that might afflict its population. Supporters of
this idea assert that much of USAID’s activities that are not related to PEPFAR operate in an
integrative fashion and simultaneously address a wide range of health challenges. Throughout the
first term of PEPFAR (FY2004-FY2008), aggregated appropriations to USAID’s global health
programs changed little (Figure 2). If FY2008 appropriations are excluded, support from
FY2004-FY2007 to three of USAID’s five global health initiatives fell (CS/MH, VC, and
HIV/AIDS) and average funding increased only to FP/RH (by 1.4%) and OID (by 192.5%)—
which was driven largely by increases for malaria and avian influenza programs.
Figure 2. USAID Global Health Programs: FY2004-FY2008(current U.S. $ millions)
^Source:^{Compiled by CRS from}^approp^{riations language and}^corr^espondence^{with USAID’s Budget Office.}

Table 3. U.S. Spending on Global HIV/AIDS, TB, and Malaria: FY2004-FY2008
^{(current U.S.$ mil}^lions)
^FY20^04-
^FY20⁰⁴^FY20⁰⁵^FY20⁰⁶^FY20⁰⁷^FY20⁰⁸^FY20⁰⁸
^Progr^am^Actual^Actual^Actual^CR^Estimate^Total
^{USAID HIV/AIDS (excluding}^555.^{5 384.}^{7 373.}⁸^345.⁹^371.¹^2,03^1.0
^{Global Fund)}
^{USAID Tuberc}^ulosis^85.1^92.0^91.5^94.9^162.²^525.⁷
^{USAID Malaria}^a^79.9^90.8^102.⁰^248.⁰^349.⁶^870.³
^{USAID Global Fund}^397.^{6 248.}^{0 247.}⁵^247.⁵^0.0^1,14^0.6
^Contribution
^FY200^{4 Global Fund}^b^{(87.8) 87.8}^n/a^n/a^n/a^0.0
^Carryover
^{State Department}^Global^488.^{1 1,37}^{3.5 1,77}^7.0^2,86^9.0^4,11^6.4^10,6^24.0
^{HIV/AIDS Initiative (GHAI)}
^GHAI^{Global Fund}^{0.0 0.0}^198.⁰^377.⁵^545.⁵^1,12^1.0
^Contribution
^{Foreign Military Financing}^c^{1.5 1.9 1.9}^1.6^—^6.9
^{Subtotal, Foreign}^1,51^9.^{9 2,27}^8.^{7 2,79}^1.⁷^4,18^4.⁴^5,54^4.⁸^16,3¹⁹^.5
^{Operations A}^ppr^opriations
^{CDC HIV/AIDS}^d^266.^{9 123.}^{8 122.}⁶¹²^1.5^119.⁴^754.²
^{CDC Tuberc}^ulosis^2.0^2.3^0.0^0.0^0.0^4.3
^{CDC Malaria}^9.0^9.1^9.0^8.9^8.7^44.7
^{CDC Interna}^{tional Research}^9.0^14.0^0.0^0.0^0.0^23.0
^{National Institutes of}^Health^e^317.^{2 370.}^{0 373.}⁰^372.⁰^363.⁶^1,79^5.8
^{(NIH) AIDS Research}
^NIH^{Global Fund contri}^bution^149.¹^99.2^99.0^99.0^294.⁸^741.¹
^Departme^{nt of Labor}^(DOL)^9.9^1.9^0.0^0.0^0.0^11.8
^HIV/AIDS
^{Subtotal, Labor/HHS}^763.^{1 620.}^{3 603.}⁶^601.⁴^786.⁵^3,37^4.⁹
^Appr^opriations
^Departme^{nt of Defen}^{se (DOD)}^{4.3 7.5 5.2}^0.0^8.0^25.0
^HIV/AIDS
^{Total HIV/AIDS and Global}^2,11^1.^{3 271}^2.3^3,19^8.⁰^4,43^4.⁰^5,81^8.⁸^18,2⁷⁴^.4
^Fund
^Grand^Total^2,28^7.^{3 2,90}^6.^{5 3,40}^0.⁵^4,78^5.⁸^6,33^9.³^19,7¹⁹^.4
^Sources:^Prepa^{red by CRS from}^appro^{priations bill figures and int}^{erviews with officials from CDC, NIH, and t}^he
^{Office of the}^{Global AIDS Coord}^{inator (OGAC).}
^Notes:^{Agencies and departme}ⁿ^{ts might obligate more fu}^{nds to g}^{lobal HIV/AIDS, T}^{B, and malaria}^{efforts tha}ⁿ
^{were ap}^{propriated. The figur}^{es f}^{or FY200}^{8 are at a}^p^p^{ropriated levels and include rescissions. Division G, Section}
⁵²⁸^{of the FY2}⁰⁰^{8 Consolidated Approp}^{riations Act, rescinds 1.7}^{5% of all FY200}^{8 La}^{bor/HHS ap}^p^ropriations
^{and Division J, Secti}^{on 69}^{9P of th}^{at Act rescinds}^0.81^{% of all FY20}^{08 State/Foreign O}^{perations ap}^pr^opriations.
^a.^{The Administration asserts ope}^ra^{tions for PMI bega}^{n in FY2}⁰⁰^{6; C}^{ongress did not app}^{ropriate f}^und^{s to the}
^{initiative, however, until FY2007}^{when Cong}^ress^{provided $25}^0.9^mill^{ion for global malaria programs,}
^{including $1}^{49.0 million to expan}^{d PMI.}

^b.^{In FY20}^{04, $}^87.^{8 million of U.}^{S. c}^{ontributions to the}^{Global Fund}^{was withheld per}^{legislative provi}^sions
^{that pro}^{hibit U.S. contributions to the Fund to e}^{xceed 3}^{3% of all c}^{ontributions. The FY20}⁰⁵^Consolidated
^Approp^{riations Act released thes}^{e funds}^{to the}^{Global Fund, subje}^{ct to the 3}^3%^proviso.
^c.^Approp^{riations for Foreign Military Financing a}^{re us}^{ed to pu}^rchase^equipm^{ent for}^{DOD HIV/AIDS}
^programs.
^d.^{Lower spe}^{nding levels after FY2}⁰^{04 r}^{eflect the}^{shift of f}^{unds initially reserved}^{for the}^Inte^{rnational Mother}
^{and Child HIV Prevention I}^{nitiative to GHAI. Whe}^{n the}^{initiative expired in FY2}⁰⁰^{4, these c}^hange^s^were
^{made perma}^{nent a}^{nd were}^applie^{d to subse}^que^{nt fiscal years.}
^e.^{Although ap}^prop^{riations bills do}^{not specify}^fu^{nding for NI}^{H’s inte}^{rnational HIV resear}^{ch initiatives,}
^{sufficient f}^{unds a}^{re p}^{rovided to the Office of A}^{IDS Research (OA}^{R) to undertake su}^{ch e}^{fforts. Data was}
^{reported to CRS by OAR.}
^Tⁱ^a^j^{i Salaam}^-^B^l^y^th^er
^Sp^{ecialist i}ⁿ^Glo^b^a^{l Health}
^t^s^al^aa^m^@^crs^.^l^o^c.^g^o^v^,^7-⁷⁶⁷⁷