Congress’s bipartisan deal to spend billions more fighting HIV and malaria abroad

World leaders hobnob during the Global Fund Seventh Replenishment Conference on September 21, 2022. The conference led to $15.7 billion in commitments to the fund over the next three years. | Mandel Ngan/AFP via Getty Images

At the surface, Congress is a total mess. Below, it’s actually getting some big stuff done.

On December 23, while many of us were doing last-minute holiday shopping, Congress passed a big $1.7 trillion spending package, keeping the government funded through September 30, which marks the end of this fiscal year. You’ve likely heard of some of the bill’s more newsworthy provisions, such as a change to the Electoral Count Act to prevent an attempt like Donald Trump’s in 2021 to overturn a presidential election result, or the $45 billion in support for Ukraine’s defense against Russia’s invasion.

But tucked into the package was a surprisingly large boost in funding for something that doesn’t usually generate headlines: global health programs. The Global Fund to Fight AIDS, Tuberculosis, and Malaria, an international organization that provides financing for country-level programs like drug distribution and bednets in developing countries where those diseases are widespread, saw its funding from the US grow from $1.56 billion to $2 billion, a more than 28 percent year-over-year boost. Funding for USAID’s Global Health Programs, which include nutrition programs, efforts against infectious disease, and more, rose from $700 million to $900 million, and the Centers for Disease Control and Prevention’s Global Public Health Protection division, which works abroad to strengthen health systems’ ability to respond to outbreaks, saw a $40 million boost as well.

An analysis by the Center for Global Development finds that global health support from the State Department and USAID grew overall from $9.83 billion in fiscal year 2022 to $10.56 billion in 2023, a 7.4 percent increase.

These numbers are not huge in the context of a $1.7 trillion spending bill, but they’re significant. “What was interesting about FY23 in the omnibus was that almost all global health areas increased, with the exception of family planning,” Adam Wexler, associate director of global health and HIV policy at the Kaiser Family Foundation, told me. (Family planning funding tends to be particularly fraught given how heated debates over abortion and birth control are in Congress.)

And the increases stand out for another reason: They’re bipartisan. Global health funding has a number of Republican champions in Congress, like Rep. Hal Rogers (R-KY), the outgoing ranking member of the appropriations subcommittee handling foreign aid funding; Rep. Michael McCaul (R-TX), who chairs the Committee on Foreign Affairs; and Rep. Ann Wagner (R-MO), McCaul’s deputy on that committee, among others. “The Global Fund has been one of the most successful programs in the history of government,” as Sen. Lindsey Graham (R-SC), the head Republican on the Senate appropriations subcommittee covering the fund, once said.

On February 22 of last year, McCaul and Rep. Barbara Lee (D-CA), then the chair of the appropriations subcommittee and the leading Democrat on these issues, organized a letter from 137 members of the House to President Biden asking for a “robust and increased three-year US pledge” for the Global Fund. Twenty-one of the signatories were Republicans, including not just moderates but Trump-loyalist members like Reps. Elise Stefanik (R-NY) and Joe Wilson (R-SC) (the same guy who yelled “you lie!” during one of Obama’s addresses to Congress).

This may seem unusual in a Congress that can’t seem to agree on anything — but it isn’t. Global health funding has in fact been a major area of bipartisan cooperation for years, so far mostly avoiding Congress’s increasing polarization on many other, higher-profile issues. And it’s managed that in part because it has remained under the radar and received little press attention.

It’s a prime instance of what Simon Bazelon and Matt Yglesias have called Secret Congress: an area where legislators are able to make progress out of the media spotlight, on issues that don’t inflame public passions. And given how progress on killer global diseases has slowed in recent years, putting millions of lives at risk, we should hope that this pattern continues.

How Secret Congress saved lives

While global health funding saw boosts across the board in the FY2023 omnibus, the star of the show was the Global Fund. Founded in 2002, the fund is a multilateral organization that collects money from governments and private donors (principally the Bill & Melinda Gates Foundation) and disburses it to local groups working on HIV/AIDS, TB, and malaria. The fund has always received bipartisan support. It was founded partially at the impetus of, and with significant funding from, the George W. Bush administration. That support continued during the Obama years. While the anti-globalist Trump administration sought massive cuts to the US contribution — especially worrying given that the US is the fund’s single biggest donor, providing over a third of its resources — Congress, with the help of Republican members like Rogers, McCaul, and Wagner, rejected them.

The fund plans on the basis of “replenishments” every three years, during which donors negotiate pledges for funding the subsequent three years of efforts. The funding boost this year originated in the Biden administration’s efforts for the seventh replenishment. For one thing, the United States agreed to host the Replenishment conference last year from September 19 to 21 in Washington, a major signal of US support for the global development community.

On March 28, the administration released its FY2023 budget proposal, which included its proposal for $2 billion in annual funding for the Global Fund and an overall $6 billion three-year pledge. This was followed in June by the House Appropriations Subcommittee for State, Foreign Operations, and Related Programs (SFOPS), then led by Rep. Barbara Lee and ranking member Rep. Hal Rogers, approving the $2 billion for 2023. In July, the Senate Appropriations Subcommittee, chaired by Sen. Chris Coons (D-DE) with ranking member Sen. Graham, did the same.

Chris Collins, president of Friends of the Global Fight, which advocates for increased Global Fund commitments from the US, told me the Biden administration effort was led at a high level, with Secretary of State Antony Blinken and National Security Adviser Jake Sullivan playing active roles.

The US is represented at the Global Fund by John Nkengasong, who serves as US global AIDS coordinator and special representative for health diplomacy, and Loyce Pace, assistant secretary for global affairs at the Department of Health and Human Services. Nkengasong is a remarkable figure; Cameroonian by birth, he’s a virologist who in his doctoral research was the first to identify the genetic subtypes of HIV in circulation in Africa. He was also the first leader of the Africa CDC in Ethiopia, an attempt to build a version of the US CDC in Africa, and organized the continent-wide response to Covid.

The push for a major investment was partly a result of concerns that the Covid pandemic would overshadow existing health threats. “The administration did not want to be seen to favor future pandemic risk preparedness (and the newly established Pandemic Fund) at the expense of existing global health priorities like [Global Fund] that remain hugely important,” Amanda Glassman, executive vice president and senior fellow at the Center for Global Development, told me. “The US was trying to make the case that the global community should do both.”

The multilateral nature of the fund also meant that the administration could leverage its pledges: If it pledged more, it could convince partner countries to pledge more in turn. Under US law, the country can’t fund more than one-third of the Global Fund’s total budget, which effectively means that when the US increases funding, other donors have to match it 2:1 if they want to keep the US funding. The nearly 30 percent increase in the US pledge helped spur an overall three-year pledge total of $15.7 billion, compared to $14 billion in the sixth replenishment. And because the Global Fund requires recipient countries in sub-Saharan Africa and South Asia to increase funding for the health of their own people, the US-led boost is “leveraging both other donors and implementing countries to do more and take on more of the burden,” Collins explained.

How effective is it?

Increasing funding for measures against HIV/AIDS, malaria, and tuberculosis is of course a good thing. But how big a deal it is depends on how effectively the money is spent.

While the Global Fund has argued that its work thus far has saved at least 50 million lives over the past 20 years, the truth is that there have been no compelling, independent studies estimating the fund’s impact on mortality. The Global Fund does provide money for programs that we know on a micro level save lives, like antiretroviral drugs for HIV and bednets and preventive treatments for malaria, to the tune of tens of billions of dollars. That should save many, many lives, but the 50 million number is at best an educated guess, the sort any nonprofit likes to make when it’s asking for funding.

Glassman argues the fund could be doing more to prioritize investments in cost-effective interventions, and maximize the impact it can get from the increased level of funding. While progress against both malaria and HIV has been slowing in recent years, it seems that Covid is not principally to blame, suggesting that something else is going wrong with the world’s response to these diseases. “The [Covid] disruption in services was pretty minimal in most of [sub-Saharan Africa] except for childhood immunization,” Glassman said. “Unfortunately, the cost-effectiveness of the different procurement and delivery strategies utilized by the different [Global Fund] grantees is not studied or reported by the [Global Fund] or UNAIDS, and these issues are inexplicably absent from the discussion during replenishments.”

Some of the problem is a lack of data. The Global Fund works directly with NGOs and government agencies in affected countries, and those countries’ spending patterns are often opaque, making it hard to estimate how much a given intervention cost, and how much in the way of public health improvements a given dollar spent on that intervention can produce.

Elsewhere in the aid budget, Congress has put a big emphasis on improving evidence bases and scaling up evidence-based projects. Development Innovation Ventures, a project at USAID meant to identify particularly cost-effective interventions, got a funding bump from $30 million to $40 million. The task in the future will be trying to expand these initiatives so that multilateral projects like the Global Fund get more scrutiny, too.

That requires continued support from the odd bedfellows in Congress that have sustained the fund and related programs for decades. Ultimately, when asked, Republicans in the House and Senate explain their support for the Global Fund and global health funding in the same terms that Democrats and global health practitioners do: they think it saves lives, and that that’s a worthy use of their role in office. “Most people want to make sure their taxpayer dollars go to a good cause. Once you understand what the Global Fund has done, and can do and will do, the critics kind of melt away,” Graham said at an event where he was honored for his support for the fund.

“It’s the best thing that I’ve been able to do” as a member of Congress, Rep. Kay Granger (R-TX), now the chair of the House Appropriations Committee, said at that same event.

The Republican caucus for global health is at least partially a legacy of the George W. Bush years. The then-president made infectious diseases in poor countries a key priority, launching the Global Fund and President’s Emergency Plan for AIDS Relief (PEPFAR), which have dedicated over $110 billion to date to fighting HIV, malaria, and tuberculosis. He also launched the President’s Malaria Initiative (PMI) in 2005, substantially increasing resources fighting that disease specifically. One study estimated that PMI specifically prevented 185 million cases of malaria and saved 940,049 lives from 2005 to 2017; multiple studies have found that PEPFAR reduced deaths from all causes by about 20 percent in countries receiving assistance, translating to millions of lives saved.

Shortly before Congress approved its major package of global health funding, Michael Gerson, the Bush administration speechwriter credited as a driving force behind those programs, died of cancer at 58. He wrote a whole book, Heroic Conservatism, that among other things distilled the conservative case for investing in global health. In it, he recounts the story of a friend visiting an HIV and AIDS clinic in Zambia in 2005, where patients told her they came “because we heard the Americans are going to help us.” Gerson continues: “That is a familiar refrain in history. In Nazi-occupied Europe … in the gulags of the Soviet Union … there were many who said, ‘We heard the Americans are going to help us.’ That is what America has been, and should always be.”

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