Unexpected global health wins in the US foreign aid bill

  U.S. lawmakers released a foreign assistance appropriations bill for fiscal year 2026 that contains some positive — and surprising — news for the global health community. Broadly, the bill would provide some $50 billion for U.S. foreign assistance programs, which is nearly $20 billion more than President Donald Trump’s budget request. A joint explanatory statement that accompanies the bill specifically allocates $9.4 billion for global health — down from $12.4 billion allocated in fiscal years 2025 and 2024. The bill, and accompanying guidance, provided insight into the conflicting views between the U.S. Congress and the Trump administration over global health priorities. They also illustrated the uncertainty global health organizations have experienced over the past year as they’ve received shifting and often contradictory messages about whether they’ll receive funding from the U.S. government. There are areas where Congress and the White House aligned, such as for funding to fight HIV, polio, malaria, and tuberculosis. But there are also areas where they differ vastly. Congress supports funds for family planning, reproductive health, neglected tropical diseases, the United Nations Population Fund, or UNFPA, and Gavi, the Vaccine Alliance — whereas the Trump administration proposed nixing that funding. Congress also showed support for other United Nations agencies such as UNICEF and UNAIDS — despite the Trump administration’s volatility towards the U.N. The spending package “preserves core US global health investments, signaling continued bipartisan backing at a moment of real uncertainty,” Janeen Madan Keller, deputy director of the global health policy program and policy fellow at the Center for Global Development, told Devex. While appropriators from both bodies of Congress have agreed to the bill, it still needs a vote in both chambers, and then would head to Trump’s desk for approval — where he does have the option to veto it. The U.S. 2026 fiscal year started last October, but the government failed to pass the budget, leading to a federal shutdown. Congress then passed a temporary spending bill that provides funding to keep the government open through Jan. 30 of this year. The explanatory statement included $5.9 billion for HIV programming, $85 million for the fight against polio, $795 million for malaria, and $378.7 million for tuberculosis. The bill also noted at least $575 million should be made available for family planning and reproductive health, “including in areas where population growth threatens biodiversity or endangered species.” “Almost a year since the US administration decimated the U.S. Agency for International Development ... Congress is coming back with a bill that rejects the administration’s shortsighted decisions last year,” Mitchell Warren, executive director of AVAC, told Devex. “But this is just a start and major challenges remain: Will both houses of Congress approve the bill? Will the President sign it? And, perhaps more importantly, will the President actually spend Congressional appropriations and accept at last that it is Congress, and not him, who has the power of the purse?” he added. There are also operational questions about the U.S. State Department’s capacity to deliver and implement these programs, Keller said. In line with ‘America First’ The U.S. is amid a seismic shift in how it delivers global health programming. The State Department launched its new “America First” global health strategy in September, which emphasizes direct government bilateral agreements. The State Department has already signed over a dozen, with more to come. There have been public concerns around data sharing in these agreements. The joint explanatory statement acknowledged these concerns, calling for “a plan to safeguard personally identifiable information of patients within electronic medical records, laboratory systems, and surveillance systems required by new country agreements.” It also called upon Secretary of State Marco Rubio to submit copies of the new deals to Congress within 15 days of signing. Many of the budget allocations are aligned with the “America First” global health strategy, such as Congress allocating $5.9 billion for HIV programming. This would mean that “the core of the global HIV response remains intact,” Jirair Ratevosian, senior fellow at the Duke Global Health Institute, wrote on LinkedIn. The HIV funding would include $1.25 billion for the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which falls in line with previous Trump administration commitments. In November, the U.S. pledged $4.6 billion to the organization’s work between 2026 and 2029, and the Trump administration has praised it as having a “legacy of excellence.” “This bill shows that the Global Fund continues to enjoy broad bipartisan support and is widely recognized as a vital partner to the U.S. in achieving AIDS, tuberculosis and malaria targets in the America First Global Health Strategy,” Chris Collins, president and CEO of the Friends of the Global Fight, wrote in a press release. Lawmakers also acknowledged the U.S. still owes “sufficient” money to the Global Fund from previous commitments, and asked Rubio to settle those debts. But the bill also emphasized the need for countries to transition off American financial support through the U.S. President’s Emergency Plan for AIDS Relief, or PEPFAR, asking that the State Department create a multiyear transition strategy toward country ownership. In the event of a public health emergency of international concern, such as a pandemic, the bill leaves up to $200 million available for the response. It also noted that no funding can be made available to China’s Wuhan Institute of Virology — which the Trump administration has criticized for its handling of the early days of the COVID-19 pandemic. Congress allocated global health security $615.6 million, which includes contributions to the Pandemic Fund and the Coalition for Epidemic Preparedness Innovations, or CEPI. Nutrition programming was awarded $165 million, with at least half allocated toward interventions such as American-made ready-to-use therapeutic foods, or RUTF. Rubio is also expected to consult with Congress about a new public-private partnership to streamline and scale up procurement and delivery of RUTF and American-made prenatal vitamins. Some $2 million is allocated for maternal and neonatal tetanus, and another $29.9 million is set aside for “vulnerable children,” including those who are blind. The Senate report asked Rubio to brief Congress on health security impacts of drug-resistant infections, it also asked him to submit a strategy for expanding market access for U.S. pharmaceutical products, and submit a report on supporting countries with their fight against noncommunicable diseases. It also noted the State Department will continue to transfer funding and collaborate with the Centers for Disease Control and Prevention in areas such as surveillance, laboratories, and outbreak response. Funding for the World Health Organization was excluded — as the Trump administration is in the process of withdrawing from the organization. The House committee report alleged WHO has had a “persistent mismanagement of global health crises” and said it lacks accountability and is susceptible to inappropriate political influence by certain member states. “The Committee remains deeply concerned by the WHO’s reluctance to condemn the [People’s Republic of China’s] actions, its shift away from core communicable disease functions, and adoption of deeply biased, anti-Israel resolutions that perpetuate harmful and historically antisemitic narratives,” it stated. The U.S. still owes its WHO membership dues for the biennium 2024-2025. Where Congress diverges There were also some unexpected line items that contrast with the Trump administration's rhetoric. Congress included $300 million for Gavi, despite U.S. health secretary Robert F. Kennedy Jr. stating in June that the U.S. won’t contribute to the organization until it works to “re-earn the public trust.” The legislation also included notable surprise allocations of at least $575 million to family planning and reproductive health funding — $523.95 million under global health and $51 million under national security — which the Trump administration slashed in its proposed budget. The bill also included $32.5 million for UNFPA. But on Jan. 7, Trump ordered the United States withdrawal from 66 international organizations, including UNFPA. Additionally, last year, the Trump administration terminated 44 of its UNFPA grants, totaling $335 million. Trump’s budget proposal also included eliminating funding for UNFPA. The bill noted that if funds appropriated to UNFPA cannot be made available to the organization due to any laws, those funds will be transferred to other global health programs for family planning and maternal and reproductive health activities. “​​This language has been included in appropriations law for many years but only relevant during times when Congress signals its support for UNFPA's lifesaving work by dedicating funding to it, but Executive decisions preclude UNFPA from receiving the funding,” according to a UNFPA spokesperson. The bill also dictated that UNFPA can’t use those funds in China, and it must maintain American funds in a separate account from its other funds. The house report noted that it’s “deeply concerned by United Nations entities that consider abortion as a foundational component of comprehensive health care, sexual and reproductive rights, and reproductive health and family planning resources by their own organizational definitions. In the context of constrained resources, the Committee must be assured, prior to supporting funds, that multilateral organizations comply with statutory prohibitions and requirements related to abortion included in this Act and prior acts.” UNFPA doesn’t fund nor perform abortions, and abortion is never promoted as, or considered a method of family planning, according to the organization. And while the Trump administration has been broadly volatile toward the United Nations, lawmakers included $45 million for UNAIDS, which matches 2021 levels. UNAIDS is currently facing an uncertain future due to funding constraints. Congress also included funds for UNICEF, consistent with prior year levels. Lawmakers also included $108.8 million for neglected tropical diseases, which the Trump administration’s budget proposal slashed funding for. Update, Jan. 15, 2026: This article has been updated to reflect details on the breakdown of family planning and reproductive health funding.