The $6.8 billion FY2018 request included $6.5 billion for related efforts financed through State-Foreign Operations (SFOPS) appropriations and $0.3 billion for global health programs supported through Labor, Health and Human Services, and Education (Labor-HHS) appropriations. The United States has contributed substantially to improving global access to ART through PEPFAR and its support for the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). Almost 75% of FY2018 global health appropriations, for example, were aimed at controlling HIV/AIDS (61%), TB (3%), and malaria (10%). In contrast, Congress mostly maintained global health funding levels in FY2018 and is considering the FY2019 budget request. Strengthening Health Systems

The global spread of recent disease outbreaks, including Ebola and Zika, has intensified debates about the advantages and disadvantages of disease-specific funding. Congressional interest in bolstering weak health systems was particularly strong during the Ebola outbreak. Congressional discussions about health system strengthening have been waning though some interest remains. In the 115 th Congress, for example, H.R. Bolstering Pandemic Preparedness

Since 1980, infectious diseases have caused outbreaks that have been occurring with greater frequency and have been causing higher numbers of human infections. Outbreaks are caused by diseases that were once concentrated in tropical regions, including Ebola and Zika, are spreading through international travel. At the same time, long-standing diseases like tuberculosis and malaria are becoming increasingly resistant to available drugs and also threaten global health. The United States has been a key supporter in global efforts to bolster pandemic preparedness in low- and middle- income countries. It is unclear whether the 115 th Congress will provide supplemental funds to maintain ongoing global health security efforts. In its report on H.R. 5515 , National Defense Authorization Act for Fiscal Year 2019 , the House Committee on Armed Services indicated that the "2014 Ebola outbreak demonstrated the need for a prompt and efficient response to a highly infectious disease outbreak" and directed the Secretary of Defense, in coordination with the Assistant Secretary for Preparedness and Response at the Department of Health and Human Services, to brief the committee no later than June 1, 2019, on the development of an action plan focused on efforts to counter emerging infectious disease threats. The 115 th Congress is considering the FY2019 budget request, which includes over $7 billion for global health assistance, roughly 24% less than FY2018 enacted levels. The Trump Administration proposes reducing the USAID global health budget by nearly 40% through the elimination of funding for global health security, vulnerable children, and HIV/AIDS programs and reductions to other health programs. The Trump Administration also recommended cuts for PEPFAR programs managed by the State Department (-11%), the Global Fund (-31%), and CDC global health programs (-16%). Protecting Life in Global Health Assistance

In 1984, former President Ronald Reagan issued what has become known as the "Mexico City policy," which required foreign nongovernmental organizations receiving USAID family planning assistance to certify that they would not perform or actively promote abortion as a method of family planning, even if such activities were conducted with non-U.S. funds. The policy has been rescinded and reinstituted across Administrations. Under the Trump Administration, the policy was reinstated, renamed to Protecting Life in Global Health Assistance (PLGHA), and expanded to apply to all global health programs. Global health experts are working to measure the impact of the PLGHA policy. Opponents maintain that the policy imperils all global health programs because some health providers may not be able to disentangle FP/RH, HIV/AIDS, and maternal and child health services from one another, particularly in areas with limited access to health workers and facilities. Supporters of the policy maintain that although existing laws ban U.S. funds from being used to perform or promote abortions abroad, money is fungible and the PLGHA policy closes loopholes. Since the Mexico City Policy was first established, Members on both sides of the issue have introduced legislation to permanently enact or repeal the policy. 671 and S. 210 , Global Health, Empowerment, and Rights Act , would prohibit the application of the PLGHA to foreign NGOs. Authorizing PEPFAR

Legislation that authorizes appropriations for PEPFAR and describes congressional priorities for the initiative expires September 30, 2018. PEPFAR continues to receive bipartisan support and is being maintained by the Trump Administration, though at lower levels than previous administrations. Following the release of the FY2018 budget and Strategy, some HIV/AIDS advocates and Members of Congress questioned the Administration's commitment to controlling the global AIDS epidemic and expressed concern about whether people on ART would lose coverage due to spending cuts. The Trump Administration proposal to maintain treatment levels is a departure from the Bush and Obama Administrations, under which executive and legislative priorities for PEPFAR included steadily increasing the number of people receiving ART through PEPFAR programs. Some Members of Congress have challenged the Trump Administration's approach to PEPFAR, raising questions about whether executive and legislative consensus around broadening the reach of PEPFAR and advancing the global goal of achieving an AIDS-free generation is fraying. Appendix. Global Health Funding Tables, by Agency and Appropriation Vehicle
Congressional interest in and support for global health programs has remained strong for several years. In FY2018, Congress provided $8.7 billion for global health programs through State, Foreign Operations appropriations and $488.6 million through Labor, Health and Human Services, and Education (Labor-HHS) appropriations. These funds are managed by several U.S. agencies and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund)—a multilateral organization aimed at combating the three diseases worldwide. Concern about infectious diseases, especially HIV/AIDS, tuberculosis, and malaria (HTAM), continues to drive budget growth. In FY2001, roughly 47% of the U.S. global health budget was aimed at these three diseases. By FY2018, almost 75% of U.S. global health funding was provided for fighting HTAM. The Appendix outlines U.S. funding for global health by agency and program. The 115th Congress may debate several pressing global health issues, including the following:
Strengthening Health Systems. The global spread of recent disease outbreaks, including Ebola and Zika, has intensified debates about the advantages and disadvantages of disease-specific funding. Congressional interest in bolstering weak health systems was particularly strong during the Ebola outbreak. Congressional discussions about health system strengthening have been waning, though some interest remains, including in proposed legislation (see for example H.Res. 342, 115th Congress). Bolstering Pandemic Preparedness. Since 1980, infectious diseases have caused outbreaks that have been occurring with greater frequency and have been leading to higher numbers of human infections. Outbreaks caused by diseases that were once concentrated in tropical regions, including Ebola and Zika, are spreading through international travel. At the same time, long-standing diseases like tuberculosis and malaria are becoming increasingly resistant to available drugs and also threaten global health.
The United States has been a key supporter in global efforts to bolster pandemic preparedness in low- and middle- income countries. It is unclear whether the 115th Congress will sustain high levels of supports, including through funding, for global health security efforts. In its report on H.R. 5515, National Defense Authorization Act for Fiscal Year 2019, the House Committee on Armed Services directed the Secretary of Defense, in coordination with the Assistant Secretary for Preparedness and Response at the Department of Health and Human Services, to develop an action plan to counter emerging infectious disease threats.
Considering the FY2019 Budget Request. The 115th Congress is considering the FY2019 budget request, which includes over $7 billion for global health assistance, roughly 24% less than FY2018 enacted levels. The Trump Administration proposes reducing the USAID global health budget by nearly 40% through the elimination of funding for global health security, vulnerable children, and HIV/AIDS programs and reductions to other health programs. The Trump Administration also recommended cuts for PEPFAR programs managed by the State Department (-11%), the Global Fund (-31%), and CDC global health programs (-16%). Protecting Life in Global Health Assistance. In 1984, former President Ronald Reagan issued what has become known as the "Mexico City policy," which required foreign nongovernmental organizations receiving USAID family planning assistance to certify that they would not perform or actively promote abortion as a method of family planning, even if such activities were conducted with non-U.S. funds. The policy has been rescinded and reinstituted across Administrations. Under the Trump Administration, the policy was reinstated, renamed to Protecting Life in Global Health Assistance (PLGHA), and expanded to apply to all global health programs.
Global health experts are working to measure the impact of the PLGHA policy. Opponents maintain that the policy imperils all global health programs because some health providers may not be able to disentangle FP/RH, HIV/AIDS, and maternal and child health services from one another, particularly in areas with limited access to health workers and facilities. Supporters maintain that although existing laws ban U.S. funds from being used to perform or promote abortions abroad, money is fungible and the PLGHA policy closes loopholes. Since the Mexico City Policy was first established, Members on both sides of the issue have introduced legislation to permanently enact or repeal the policy (for example, see H.R. 671 and S. 210, Global Health, Empowerment, and Rights Act, 115th Congress).
Authorizing the extension of PEPFAR. Legislation that authorizes appropriations for PEPFAR and describes congressional priorities for the initiative expires September 30, 2018. PEPFAR continues to receive bipartisan support and is being maintained by the Trump Administration, though at lower levels than previous administrations. Following the release of the FY2018 budget and Strategy, some HIV/AIDS advocates and Members of Congress questioned the Administration's commitment to controlling the global AIDS epidemic and expressed concern about whether people on ART would lose coverage due to spending cuts. The Administration has pledged to maintain the current level of antiretroviral treatment provided through PEPFAR
Plans to maintain treatment levels are a departure from the Bush and Obama Administrations, under which executive and legislative priorities for PEPFAR included steadily increasing the number of people receiving ART through PEPFAR programs. Some Members of Congress have challenged the Trump Administration's approach to PEPFAR, raising questions about whether executive and legislative consensus around broadening the reach of PEPFAR and advancing the global goal of achieving an AIDS-free generation is fraying.