WikiLeaks Document Release http://wikileaks.org/wiki/CRS-RS22913 February 2, 2009 Congressional Research Service Report RS22913 Global Health: Appropriations to USAID Programs from FY2001 through FY2008 Tiaji Salaam-Blyther, Foreign Affairs, Defense, and Trade Division July 8, 2008 Abstract. 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. The role of other U.S. agencies and departments is discussed in the context of intergov- ernmental partnerships, such as the President's Emergency Plan for AIDS Relief (PEPFAR). ¢ http://wikileaks.org/wiki/CRS-RS22913 ¢ Prepared for Members and Committees of Congress ¢ 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 http://wikileaks.org/wiki/CRS-RS22913 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 http://wikileaks.org/wiki/CRS-RS22913 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 Mother and Child HIV Prevention Initiative.1 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 http://wikileaks.org/wiki/CRS-RS22913 (GHAI; H.Rept. 108-401). Since the initiative expired in FY2004, Congress has included funds for PMTCT programs in the GHAI account (Figure 1). 1 elbaT 3002YF-1002YF :smargorP htlaeH labolG DIASU . )snoil lim $.S.U tnerruc( :egnahC % 1002YF 2002YF 3002YF -1002YF margorP detcanE detcanE detcanE 3002YF )HM/SC( htlaeH lanretaM/lavivruS dlihC 1.163 7.193 7.983 %9.7 )CV( nerdlihC elbarenluV 7.63 3.23 3.43 %5.6- SDIA/VIH 0.813 0.424 8.325 %7.46 )DIO( sesaesiD suoitcefnI rehtO 2.041 0.281 1.371 %7.32 htlaeH evitcudorpeR/gninnalP ylimaF 0.524 0.524 6.344 %4.4 )HR/PF( dnuF s'nerdlihC snoitaN detinU 8.901 0.021 2.911 %6.8 tnarG )FECINU( dnuF labolG 0.001$ 0.05$ 4.842$ %4.841 latoT 8.094,1 0.526,1 1.239,1 %6.92 .eciffO tegduB s'DIASU htiw ecnednopserroc dna noitalsigel snoitairporppa morf SRC yb delipmoC :ecruoS 1 For more on U.S. global HIV/AIDS policies, see CRS Report RL33771, Trends in U.S. Global AIDS Spending: FY2000-FY2008, by Tiaji Salaam-Blyther. Also see The White House, "President Bush's International Mother and Child Prevention Initiative," June 19, 2002, at http://www.whitehouse.gov/news/releases/2002/06/20020619-1.html. 3002YF-1002YF :smargorP htlaeH labolG DIASU .1 erugiF )snoill im $ .S.U tnerruc( 600 500 400 300 200 100 http://wikileaks.org/wiki/CRS-RS22913 0 FY2001 FY2002 FY2003 CS/MH VC HIV/AIDS OID FP/RH UNICEF Grant Global Fund .eciffO tegduB s'DIASU htiw ecnednopserroc dna noitalsigel snoitairporppa morf SRC yb delipmoC :ecruoS 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 HIV/AIDS, particularly through the President's Emergency Plan for AIDS Relief (PEPFAR),2 they chided the Administration for requesting less for other global health interventions, particularly those related to child survival, maternal health, family planning, and reproductive health.3 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. 2 For more information on PEPFAR, see CRS Report RL33771, Trends in U.S. Global AIDS Spending: FY2000- FY2008, by Tiaji Salaam-Blyther. 3 At a FY2007 House Foreign Operations Appropriations Subcommittee hearing on USAID's FY2007 budget request on April 26, 2006, for example, Representative Nita Lowey questioned the effectiveness of increasing spending on the Millennium Challenge Corporation (MCC) and PEPFAR, while proposing a reduction or no change in spending for other development assistance and non-AIDS programs. .dnuF labolG eht ot snoitubirtnoc .S.U gniredisnoc tuohtiw smargorp htlaeh labolg s'DIASU ot snoitairporppa stcelfer wor lanif ehT .d .ecnatsissa tcerid sedivorp setatS detinU eht hcihw hguorht ro slortnoc setatS detinU eht taht margorp laretalib a ton si dnuF labolG eht esuaceb ,dnuF labolG eht ot snoitairporppa ni segnahc etaluclac ton did SRC .c .IAHG ot snoitairporppA snoitarepO ngieroF morf dnuF labolG eht ot noitubirtnoc .S.U lluf eht dedivorp ssergnoC ,8002YF nI .b .8002YF hguorht 5002YF morf snoitairporppa ni segnahc stcelfer egatnecrep siht ,5002YF ni snoitnevretni ulf naiva labolg gnidnuf nageb ssergnoC esuaceB .a .htlaeH evitcudorpeR/gninnalP ylimaF--HR/PF ;sesaesiD suoitcefnI rehtO--DIO ;nerdlihC elbarenluV--CV ;htlaeH lanretaM/lavivruS dlihC--HM/SC :snoitaiverbbA .4002YF ecnis IAHG ot sdnuf esoht detairporppa sah ssergnoC esuaceb elbat siht ni dedulcni ton era FECINU ot snoitubirtnoC :setoN .eciffO tegduB s'DIASU htiw ecnednopserroc dna noitalsigel snoitairporppa morf SRC yb delipmoC :ecruoS d %9.42 6.870,2 4.518,1 4.137,1 5.425,1 4.466,1 FG tuohtiw latoT %8.0 6.870,2 9.260,2 9.879,1 5.277,1 0.260,2 FG htiw latoT c b0.0 5.742 5.742 0.842 6.793 )FG( dnuF labolG %5.6 2.754 6.534 0.534 0.734 5.924 HR/PF ]%5.821[ ]1.18[ ]0.28[ ]1.09[ ]7.61[ ]5.53[ rehtO a]%5.506[ ]0.511[ ]5.161[ ]5.161[ ]3.61[ a/n )ulF naivA( 1N5H ]%5.733[ ]6.943[ ]0.842[ ]0.201[ ]8.09[ ]9.97[ airalaM ]%6.09[ ]2.261[ ]9.49[ ]5.19[ ]0.29[ ]1.58[ BT http://wikileaks.org/wiki/CRS-RS22913 %1.352 9.707 4.685 1.544 8.512 5.002 DIO %2.33- 1.173 9.543 8.373 7.483 5.555 SDIA/VIH %0.34- 5.02 6.91 7.92 3.53 0.63 CV %8.71 9.125 9.724 8.744 7.154 9.244 HM/SC 8002YF 8002YF 7002YF 6002YF 5002YF 4002YF margorP -4002YF :egnahC % )snoil lim $.S.U tnerruc( 8002YF-4002YF :smargorP htlaeH labolG DIASU . 2 elbaT $19.7 billion for global HIV/AIDS, TB, and malaria programs (Table 3). reproductive health initiatives (Table 2). During that same time period, Congress appropriated USAID's child survival and maternal health, vulnerable children, and family planning and other health programs. From FY2004 through FY2008, Congress provided $4.6 billion for Still, appropriations for HIV/AIDS, TB, and malaria programs far outpaced support for USAID's £ 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 http://wikileaks.org/wiki/CRS-RS22913 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. 2 erugiF )snoillim $ .S.U tnerruc(8002YF-4002YF :smargorP htlaeH labolG DIASU . .eciffO tegduB s'DIASU htiw ecnednopserroc dna egaugnal snoitairporppa morf SRC yb delipmoC :ecruoS .IMP dnapxe ot noillim 0.941$ gnidulcni ,smargorp airalam labolg rof noillim 9.052$ dedivorp ssergnoC nehw 7002YF litnu ,revewoh ,evitaitini eht ot sdnuf etairporppa ton did ssergnoC ;6002YF ni nageb IMP rof snoitarepo stressa noitartsinimdA ehT .a .snoitairporppa snoitarepO ngieroF/etatS 8002YF lla fo %18.0 sdnicser tcA taht fo P996 noitceS ,J noisiviD dna snoitairporppa SHH/robaL 8002YF lla fo %57.1 sdnicser ,tcA snoitairporppA detadilosnoC 8002YF eht fo 825 noitceS ,G noisiviD .snoissicser edulcni dna slevel detairporppa ta era 8002YF rof serugif ehT .detairporppa erew naht stroffe airalam dna ,BT ,SDIA/VIH labolg ot sdnuf erom etagilbo thgim stnemtraped dna seicnegA :setoN .)CAGO( rotanidrooC SDIA labolG eht fo eciffO eht dna ,HIN ,CDC morf slaiciffo htiw sweivretni dna serugif llib snoitairporppa morf SRC yb deraperP :secruoS 4.917,91 3.933,6 8.587,4 5.004,3 5.609,2 3.782,2 latoT dnarG dnuF 4.472,81 8.818,5 0.434,4 0.891,3 3.2172 3.111,2 labolG dna SDIA/VIH latoT SDIA/VIH 0.52 0.8 0.0 2.5 5.7 3.4 )DOD( esnefeD fo tnemtrapeD snoitairporppA 9.473,3 5.687 4.106 6.306 3.026 1.367 SHH/robaL ,latotbuS SDIA/VIH 8.11 0.0 0.0 0.0 9.1 9.9 )LOD( robaL fo tnemtrapeD 1.147 8.492 0.99 0.99 2.99 1.941 noitubirtnoc dnuF labolG HIN ehcraeseR SDIA )HIN( 8.597,1 6.363 0.273 0.373 0.073 2.713 htlaeH fo setutitsnI lanoitaN 0.32 0.0 0.0 0.0 0.41 0.9 hcraeseR lanoitanretnI CDC 7.44 7.8 9.8 0.9 1.9 0.9 airalaM CDC 3.4 0.0 0.0 0.0 3.2 0.2 sisolucrebuT CDC 2.457 4.911 5.121 6.221 8.321 9.662 dSDIA/VIH CDC snoitairporppA snoitarepO 5.913,61 8.445,5 4.481,4 7.197,2 7.872,2 9.915,1 ngieroF ,latotbuS 9.6 -- 6.1 9.1 9.1 5.1 cgnicnaniF yratiliM ngieroF noitubirtnoC 0.121,1 5.545 5.773 0.891 0.0 0.0 dnuF labolG IAHG http://wikileaks.org/wiki/CRS-RS22913 )IAHG( evitaitinI SDIA/VIH 0.426,01 4.611,4 0.968,2 0.777,1 5.373,1 1.884 labolG tnemtrapeD etatS brevoyrraC 0.0 a/n a/n a/n 8.78 )8.78( dnuF labolG 4002YF noitubirtnoC 6.041,1 0.0 5.742 5.742 0.842 6.793 dnuF labolG DIASU 3.078 6.943 0.842 0.201 8.09 9.97 aairalaM DIASU 7.525 2.261 9.49 5.19 0.29 1.58 sisolucrebuT DIASU )dnuF labolG 0.130,2 1.173 9.543 8.373 7.483 5.555 gnidulcxe( SDIA/VIH DIASU latoT etamitsE RC lautcA lautcA lautcA margorP 8002YF 8002YF 7002YF 6002YF 5002YF 4002YF -4002YF )snoil lim $.S.U tnerruc( 8002YF-4002YF :airalaM dna ,BT,SDIA/VIH labolG no gnidnepS .S.U .3 elbaT tsalaam@crs.loc.gov, 7-7677 Specialist in Global Health http://wikileaks.org/wiki/CRS-RS22913 Tiaji Salaam-Blyther .RAO yb SRC ot detroper saw ataD .stroffe hcus ekatrednu ot )RAO( hcraeseR SDIA fo eciffO eht ot dedivorp era sdnuf tneiciffus ,sevitaitini hcraeser VIH lanoitanretni s'HIN rof gnidnuf yficeps ton od sllib snoitairporppa hguohtlA .e .sraey lacsif tneuqesbus ot deilppa erew dna tnenamrep edam erew segnahc eseht ,4002YF ni deripxe evitaitini eht nehW .IAHG ot evitaitinI noitneverP VIH dlihC dna rehtoM lanoitanretnI eht rof devreser yllaitini sdnuf fo tfihs eht tcelfer 4002YF retfa slevel gnidneps rewoL .d .smargorp SDIA/VIH DOD rof tnempiuqe esahcrup ot desu era gnicnaniF yratiliM ngieroF rof snoitairporppA .c .osivorp %33 eht ot tcejbus ,dnuF labolG eht ot sdnuf eseht desaeler tcA snoitairporppA detadilosnoC 5002YF ehT .snoitubirtnoc lla fo %33 deecxe ot dnuF eht ot snoitubirtnoc .S.U tibihorp taht snoisivorp evitalsigel rep dlehhtiw saw dnuF labolG eht ot snoitubirtnoc .S.U fo noillim 8.78$ ,4002YF nI .b