The U.S. Agency for International Development (USAID) plays a central role in shaping and implementing U.S. global health policy. The agency is one of three agencies tasked with leading the Global Health Initiative (GHI), an initiative created by the Obama Administration to coordinate ongoing presidential health initiatives and raise investments in other health areas, including maternal and child health, neglected tropical diseases, and family planning and reproductive health ( Figure 1 ). USAID also coordinates and acts as an implementing partner in three presidential initiatives that comprise the bulk of U.S. global health assistance. The agency leads the implementation of the President's Malaria Initiative (PMI) and the Neglected Tropical Diseases (NTD) Program, and is an implementing partner of the President's Emergency Plan for AIDS Relief (PEPFAR), which is coordinated by the State Department. In addition, USAID manages its own bilateral health programs. This report highlights the health-related activities conducted by USAID worldwide, outlines how much the agency has spent on such efforts from FY2001 to FY2011, and highlights FY2012 proposed funding levels. Since USAID was created in 1961 through the Foreign Assistance Act of 1961, congressional support for global health, in general, and USAID's global health programs, in particular, have grown. Appropriations for USAID rose from $1.4 billion in FY2001 to $2.5 billion in FY2011. Funding growth occurred most precipitously during the George W. Bush Administration, when Congress provided unprecedented resources to fight new and re-emergent diseases, including HIV/AIDS, multi- and extremely drug-resistant tuberculosis (MDR- and XDR-TB), severe acute respiratory syndrome (SARS), H5N1 (bird flu), and H1N1 pandemic flu. Congressional support also followed the launching of several presidential health initiatives—PEPFAR (HIV/AIDS), PMI (malaria), NTD Program (neglected tropical diseases). Congress funds USAID's global health activities through the State, Foreign Operations and Related Programs (State-Foreign Operations) appropriations. Through this vehicle, Congress appropriates funds directly to USAID through the Global Health and Child Survival (GHCS) account and USAID uses additional funds from other accounts within State-Foreign Operations, including the Development Assistance and the Economic Support Fund accounts, to support its global health programs. Appropriators do not specify how much USAID should spend through these other accounts on its global health programs. The additional funds provided through other accounts for other USAID global health programs can be significant ( Table 1 ). Congress specifies support for five USAID global health program areas: Child Survival and Maternal Health aims to reduce morbidity and mortality from diseases like polio, measles, and diarrhea; provide vaccines and immunizations; support safe delivery; and address malnutrition. Vulnerable Children aims to provide services to vulnerable children and orphans, particularly those affected by blindness or war (support for children made vulnerable by HIV/AIDS is provided through HIV/AIDS funds). HIV/AIDS aims to prevent, treat, and address the impacts of HIV/AIDS—particularly among vulnerable populations such as women, girls, and orphans—through voluntary counseling and testing, awareness campaigns, and antiretroviral medicines, among other activities. Other Infectious Diseases aims to address a number of diseases and resultant outbreaks, such as those related to pandemic and avian influenza, malaria, TB, and neglected tropical diseases (NTDs). Family Planning and Reproductive Health aims to increase access to related services, such as reproductive health education, and to improve awareness about birth spacing, contraception, and sexually transmitted diseases. Funding for these programs has mostly been on an upward trajectory, though increased support has been aimed primarily at fighting infectious diseases. Successive waves of infectious disease outbreaks have garnered significant attention from Congress and have generated rigorous debate on balancing efforts to address infectious disease threats, including HIV/AIDS, malaria, pandemic influenza, and tuberculosis, with other long-standing health challenges like high maternal and child mortality rates, widespread morbidity from neglected tropical diseases, and strengthening the capacity of poor countries to address their own health challenges. In 2009, President Barack Obama announced the Global Health Initiative to increase investments in health areas that he deemed underfunded, bolster the health systems of weak and impoverished states, and improve the coordination of presidential health initiatives established during the Bush Administration (PEPFAR, PMI, and the NTD Program) as well as other USAID and Centers for Disease Control and Prevention (CDC) bilateral health programs. Congress has generally supported presidential health initiatives, including the Global Health Initiative, and has mostly met funding requests associated with these efforts. On April 15, 2011, the President signed the Department of Defense and Full-Year Continuing Appropriations Act, 2011 ( P.L. 112-10 ), into law. The act provided $2.5 billion to USAID for global health programs in FY2011 but did not specify how much USAID should spend on each activity. As of June 28, 2011, many program details about FY2011 funding levels remain unavailable. The bulk of U.S. global health assistance is aimed at mitigating the impact of infectious diseases, through three presidential initiatives: PEPFAR (HIV/AIDS), PMI (malaria), and the NTD Program (neglected tropical diseases). In FY2010, for example, nearly 81% of all U.S. global health spending was aimed at these initiatives. The Global Health Initiative is distinct from PEPFAR, PMI, and the NTD Program, because it is not aimed at a particular disease and does not call for significant adjustments to ongoing efforts. Instead, the initiative intends to coordinate ongoing U.S. global health activities and, through GHI-Plus countries, identify strategies for improving the efficacy, impact, and sustainability of U.S. bilateral global health programs. USAID plays an important role in each of these initiatives, both as an implementing and coordinating agency. The sections below briefly describe each initiative and USAID's role in carrying out these efforts. In January 2003, President Bush announced PEPFAR, a government-wide initiative to combat global HIV/AIDS. PEPFAR supports a wide range of HIV/AIDS prevention, treatment, and care activities and is the largest commitment by any nation to combat a single disease. In FY2004, Congress authorized $15 billion to be spent over five years in support of bilateral HIV/AIDS programs and the Global Fund. In 2008, through 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 ), Congress authorized an additional $48 billion to be spent over five years in support of PEPFAR, which also included $4 billion for TB and $5 billion for malaria. PEPFAR is overseen by the Office of the Global AIDS Coordinator (OGAC) at the State Department. In this capacity, the State Department transfers most of the resources it receives from Congress for PEPFAR programs to implementing bilateral agencies and other multilateral organizations, including the Global Fund and the Joint United Nations Program on HIV/AIDS (UNAIDS) that carry out global HIV/AIDS efforts. USAID accounted for nearly half of all PEPFAR obligations between FY2004 and FY2010 ( Table 2 ). As of September 30, 2010, U.S. implementing agencies, including USAID, supported life-saving HIV treatments for more than 3.2 million people and medicine to prevent the transmission of HIV from mother to child for more than 600,000 HIV-positive pregnant women. The Appendix offers additional data by country ( Table A-2 ). In June 2005, President Bush announced PMI in order to expand and coordinate U.S. global malaria efforts. PMI was originally established as a five-year, $1.2 billion effort to halve the number of malaria-related deaths in 15 sub-Saharan African countries through the expansion of four prevention and treatment techniques: indoor residual spraying (IRS), insecticide-treated nets (ITNs), artemisinin-based combination therapies (ACTs), and intermittent preventative treatment for pregnant women (IPTp). The Obama Administration expanded the range of PMI to include Nigeria and the Democratic Republic of the Congo as focus countries and augmented the goal of the initiative to include halving the burden of malaria (including morbidity and mortality) among 70% of at-risk populations in Africa by 2014. PMI is led by USAID and jointly implemented by USAID and CDC. PMI is overseen by the U.S. Malaria Coordinator at USAID, who is advised by an Interagency Steering Group that includes representatives from USAID, HHS, the Department of State, DOD, the National Security Council (NSC), and the Office of Management and Budget (OMB). From FY2005 to FY2010, USAID obligated roughly $1.4 billion for PMI-related activities ( Table 3 ). Figure A-1 in the Appendix outlines PMI spending by country. It is important to note that these figures reflect spending on PMI only and do not include additional spending on global malaria programs through other USAID programs or other U.S. agencies, including CDC and NIH. As of December 31, 2011, USAID reported supporting the provision of 45.4 million insecticide-treated nets and 105.6 million malaria treatments, including 10.3 million tablets to prevent the transmission of malaria from mother to child. More detailed information about PMI results are outlined in the Appendix ( Figure A-2 ). In response to FY2006 appropriations language that directed USAID to make available at least $15 million for combating seven NTDs, the agency launched the NTD Program in September 2006. Originally, the NTD Program aimed to support the provision of 160 million NTD treatments to 40 million people in 15 countries. President Bush reaffirmed his commitment to the program in 2008 and proposed spending $350 million from FY2008 through FY2013 on expanding the fight against seven NTDs to 30 countries. The Obama Administration amended the targets of the NTD program and called for the United States to support the administration of nearly 1 billion NTD treatments in 30 countries. As of February 17, 2011, USAID has reportedly supported the delivery of more than 387 million NTD medicines to treat roughly 170 million people. In May 2009, President Obama announced the Global Health Initiative, a six-year plan projected to cost $63 billion. GHI aims to develop a comprehensive U.S. global health strategy for existing U.S. global health programs, including the programs and initiatives outlined above. GHI calls for shifting the U.S. approach to global health from one focused on specific diseases to one that comprehensively addresses a variety of health challenges through strengthening health systems and improving coordination and integration of distinct global health programs. In June 2010, eight countries were chosen as "GHI Plus Countries" and are serving as "learning laboratories" to inform future U.S. global health efforts. In partnership with national governments, USAID, CDC, and the Department of State are completing multi-year joint strategic plans for each GHI Plus Country. These strategic plans aim to identify unnecessary programmatic duplications, find opportunities for integration, and better align U.S. programs with the priorities of national governments. These plans are not intended to replace current disease-specific strategies, but rather to serve as an overarching strategic guide under which each program will operate. GHI is currently coordinated by an executive director at the Department of State who reports to both the Secretary of State and the GHI Operations Committee, which comprises the USAID Administrator, the Global AIDS Coordinator, and the Director of CDC. The Operations Committee is charged with oversight and management of the initiative. Leadership of GHI is expected to transition from the State Department to USAID in FY2012, should USAID meet a set of benchmarks related to management capacity, outlined in the Quadrennial Diplomacy and Development Review. The State Department will continue to lead PEPFAR, even after USAID assumes leadership of GHI. The Obama Administration requests an estimated $3.1 billion in support of USAID's global health efforts through the GHCS account for FY2012. After PEPFAR was launched, U.S. efforts to address HIV/AIDS dominated congressional discussions and appropriations for global health. Since announcing GHI in 2009, the President has gradually increased requests for non-HIV/AIDS programs. Congress has fully funded these requests, which has led to a slight shift in how USAID global health funds are distributed ( Figure 3 ). The vast majority of USAID's global health programs are funded through the Global Health and Child Survival account. The account is also used to fund the coordination of PEPFAR programs by the Department of State. These amounts are not included in the figure below. Additional funds that USAID uses to support its global health programs through other accounts in the State-Foreign Operations appropriations are also not included in the figure below, as Congress does not typically direct spending for global health through these other accounts (see Table 1 ). The Obama Administration requests that in FY2012, Congress provide approximately 25% more for USAID's global health activities funded through the GHCS account than in FY2010. The majority of the increases are aimed at areas the Administration has prioritized through GHI, including strengthening national health systems and raising investments in areas where progress has lagged. The most notable increases include $846 million for child survival and maternal health programs, up 78.5% from the $474 million Congress provided in FY2010; $100 million for neglected tropical diseases, up 54% from the $65 million provided in FY2010; and $626 million for family planning and reproductive health, up 19% from the $525 million provided in FY2010. Since the George W. Bush Administration, successive Congresses have mostly appropriated funds for USAID's global health programs in excess of presidential requests. As concerns about the U.S. economy have heightened, however, Congress has sought ways to reduce federal spending. Some Members of the 112 th Congress have begun to question U.S. foreign aid levels, in general, and to argue for the reduction or elimination of health assistance. Although some Members of Congress argue that cuts to these programs could yield important savings, others contend that such reductions would have little impact on the federal deficit but could significantly imperil the lives of vulnerable populations reliant on U.S. health assistance. Congressional debate over funding levels for global health programs is tied to broader, longstanding discussions over the value, design, and funding levels of foreign aid programs. These debates are related to concern over aid effectiveness and reform of USAID, as well as the U.S. federal budget deficit and efforts to reduce government spending. Some Members have long-questioned the impact of U.S. global health investments, have called attention to corruption practices by various recipient governments receiving global health assistance, and have encouraged greater commitment to global health issues by these states. In March 2011, Members of the House Appropriations Subcommittee on State-Foreign Operations raised some of these concerns at oversight and budget hearings. In relation to the Administration's FY2012 budget request, some Members of Congress have argued that investing significant resources in global health represents "misplaced priorities" in a difficult fiscal environment. Some have also argued that delaying spending cuts for global health now might necessitate more drastic cuts in the future. USAID is reportedly responding to concerns over aid effectiveness. For example, USAID Administrator Rajiv Shah created a new suspension and debarment task force, led by Deputy Administrator Don Steinber, to monitor, investigate, and respond to suspicious activity. USAID also requests $19.7 million to implement a new evaluation policy that would require all major projects to undergo an independent evaluation with results being released within three months of completion. Finally, Administrator Shah announced USAID would begin to fund programs based on "unit cost of impact" and that USAID would aim investments at programs that were the most efficient and effective and divest from those that had "a unit cost of impact that is unnecessarily high."

Summary: A number of U.S. agencies and departments implement U.S. government global health interventions. The U.S. Agency for International Development (USAID) plays a particularly central role. The agency is responsible for coordinating two important presidential health initiatives—the President's Malaria Initiative (PMI) and the Neglected Tropical Diseases (NTD) Program. USAID serves as an implementing agency of the largest U.S. global health program—the President's Emergency Plan for AIDS Relief (PEPFAR)—and is set to assume leadership over the Global Health Initiative (GHI) in September 2012 (presuming it meets a set of benchmarks related to management capacity, as outlined in the Quadrennial Diplomacy and Development Review). In addition, Congress appropriates the most funds to USAID for global health efforts, excluding provisions for presidential health initiatives, which are carried out by several agencies, including USAID. Congress appropriates funds to USAID for global health activities through five main budget lines: Child Survival and Maternal Health (CS/MH), Vulnerable Children (VC), HIV/AIDS, Other Infectious Diseases (OID), and Family Planning and Reproductive Health (FP/RH). From FY2001 through FY2010, Congress appropriated nearly $20 billion to USAID for global health programs, including contributions to the United Nations' Children's Fund (UNICEF) and the Global Fund to Fight AIDS, Malaria, and Tuberculosis (Global Fund). From FY2001 through FY2010, the greatest budgetary growth was aimed at fighting infectious diseases, mainly malaria, tuberculosis (TB), and pandemic influenza. President Barack Obama indicated early in his Administration that global health is a priority and that his Administration would continue to focus global health efforts on addressing HIV/AIDS. When releasing his FY2012 budget request, President Obama indicated that his Administration would increase investments in global health programs and, through the Global Health Initiative, improve the coordination of all global health programs. The President requested that in FY2012, Congress provide $3.8 billion for USAID's global health programs funded through the Global Health and Child Survival (GHCS) account. There is a growing consensus that U.S. global health assistance needs to become more efficient and effective. There is some debate, however, on the best strategies. This report explains the role USAID plays in U.S. global health assistance, highlights how much the agency has spent on global health efforts from FY2001 to FY2012, discusses how funding to each of its programs has changed during this period, and raises some related policy questions. For more information on all U.S. global health assistance, see CRS Report R41851, U.S. Global Health Assistance: Background and Issues for the 112th Congress, by [author name scrubbed] and [author name scrubbed].