How the US spends on global health security

Attention to health security among aid donors has skyrocketed in the past year. The United States has historically been the biggest funder in this area, investing $4 billion in grants and contracts before the COVID-19 pandemic, and it has remained an important funder since then. Legislation currently making its way through Congress would provide guidance and funding for more robust U.S.-led efforts. But health security is a nebulous category of funding. What it includes can vary between donors — covering anything from infectious diseases to biological weapons and poverty reduction — and is often unclear. So how does the U.S. define health security in its global work, and where are these billions of dollars going? A deep dive into data provided through the Foreign Aid Explorer platform offers insights. The first properly identified health security project appears in U.S. foreign aid data in 2013, as part of a disbursement from the Department of Health and Human Services to the World Health Organization. The term “health security” shows up in the data once before this, but the context was unrelated to U.S. objectives. Valued at $66,213, the 2013 activity was designed to help WHO regional offices build capacity and networks to address emerging infectious diseases in the Americas. But the following year saw health security become an increasing focus in global foreign policy, associated with pandemic preparedness and responses. Following outbreaks of Middle East respiratory syndrome in 2012, the H7N9 bird flu strain in 2013, and Ebola in 2014, the G-7 group of nations endorsed the Global Health Security Agenda — and the U.S. stepped up its work in this space. Although the first work in this area was led by HHS, the State Department has been the biggest contributor to U.S. foreign assistance efforts on health security to date. Since 2016, it has disbursed $256.4 million to programs with health security objectives, while HHS disbursed $172.9 million since 2014, and the U.S. Agency for International Development contributed an additional $26.7 million. State and USAID: A broader definition The health security activities funded by the State Department and USAID are closely aligned in scope. Both have focused on sexually transmitted diseases such as HIV/AIDS, accounting for 40% of their total spending. Other priority funding areas are basic health care at 14% of spending, family planning at 10%, reproductive health care at 10%, and infectious disease control at 7%, with COVID-19 control accounting for $15.3 million in disbursements since 2020. In total, the State Department and USAID incorporate 20 activity purposes under the banner of health security, including social protection, human rights, water, and environmental policy. Human Resources for Health in 2030 — described as a “flagship project to strengthen the global health workforce” — has been the focal point of this work. Its objectives include creating a fit-for-purpose and fit-to-practice health workforce to end preventable child and maternal deaths, controlling the HIV/AIDS epidemic, and tackling infectious diseases, all of which fall under the work of the Global Health Security Agenda. So far, $76.6 million has been disbursed through this program since it launched in 2015, including $24.6 million since 2020. Meeting Targets and Maintaining Epidemic Control is the next biggest program, with $75.8 million in disbursements and objectives associated with AIDS relief and infectious disease control, including COVID-19. Meanwhile, Medicines, Technologies and Pharmaceutical Services, with $53.6 million in disbursements linked to health security, enables low- and middle-income countries to strengthen their pharmaceutical systems for “sustainable access to and appropriate use of safe, effective, quality-assured, and affordable essential medical products and medicines-related pharmaceutical services.” Infectious disease surveillance, health supply chains, and the creation of a “next generation One Health workforce” also appear as priorities in the health security funding data. HHS’ narrower approach By contrast, HHS has a much narrower approach to health security, reflecting its own national objectives, including preventing emerging and infectious diseases from reaching U.S. borders. Its foreign assistance for health security has focused on the global work of the Centers for Disease Control and Prevention. In 2014, it invested $17.6 million in CDC’s Global Disease Detection Program, which, among other things, provided technical assistance to help countries respond to disease outbreaks. The GDD Program was set up in 2004, highlighting that although the U.S. started regularly identifying projects as health security-related in 2014, not all of this work was new; it was, instead, a new way of framing and prioritizing it. HHS has since invested a total of $154.4 million in 18 health security activities managed by CDC. That includes an $81.4 million activity aimed at “protecting and improving health globally” through system strengthening and a total of $49.8 million for the GDD Program. Infectious diseases account for $151.5 million — or 98% — of total CDC health security activities within foreign aid. Health and population, and medical education and training, have also been supported. Outside of its work with CDC, HHS has focused its global health security work on collaborations with WHO, as well as other research, NGO, and government partners, for “expanding efforts … to protect and improve public health globally,” according to a description of its Global Health Security Partner Engagement program. Although the Foreign Aid Explorer doesn’t include information on these partners, additional grant data suggests leading partners include the African Field Epidemiology Network, The Task Force for Global Health, the Association of Public Health Laboratories, and Johns Hopkins University. Some of these partners may receive funding outside of the official development assistance budget. While health security remains a small component of U.S. health programming overall, analyzing the available data indicates a clear focus on infectious diseases within the country’s approach. But building the capacity of countries to detect, prevent, and respond to outbreaks before they spread further means health systems more broadly may also benefit. Update, July 21, 2021: This story was amended to clarify a caption on a chart.