Budget debates in US, UK could augur poorly for global health funding

This was originally published in Global Health TV on July 25, 2017.

Global health financing has not been in such jeopardy since the large investments in it started in 1991 – the year in which global health funding started an upward trajectory that moved higher in all but three years.

In particular, the rise of Donald Trump of the United States and Theresa May of the United Kingdom —the leaders of the two largest donor nations — have raised concerns about the prospects for development assistance broadly, and global health specifically.

In 2016, development assistance for health (DAH) reached $37.6 billion, eking out a miniscule 0.1% increase from 2015 that followed a pattern of little growth since 2010 (DAH grew 11.4% annually from 2000 to 2010 but only 1.8% since 2010), according to “Financing Global Health 2016,” published by the Institute for Health Metrics and Evaluation in April. DAH peaked at $38 billion in 2013, dropped to $36 billion in 2014 and has recovered slightly in the two subsequent years. This infographic provides a snapshot.

The U.S. and the U.K. have been the two top contributors to DAH but both countries have political environments that have called into question their future commitments to foreign aid and global health.

Trump’s 2018 budget request to Congress contains unprecedented cuts (more than $2 billion) to global health. If those cuts are enacted, writes the Kaiser Family Foundation, they will bring funding below 2008 levels. Family planning support would be eliminated. Kaiser predicts the cuts could result in the following scenarios starting in 2018:

• Additional new HIV infections between 49,100 to 198,700;
• Women and couples receiving contraceptives would decline from 6.5 million to almost 25 million; and
• Additional abortions between 819,000 and more than 3 million.

More than half of the $2 billion in cuts to global health would come from international HIV/AIDS programs. In a new paper, the Center for Strategic and International Studies says the cuts would jeopardize U.S. leadership on HIV/AIDS and “raise the possibility that the pandemic will reignite, threatening U.S. and global health security.”

However, in the U.S. political system, Congress has the last word on the budget, and even Republican senators say these cuts will not stand. But however the final budget turns out, it could still perpetuate the recent stagnation in global health financing.

A series of hearings earlier this month featuring Secretary of State Rex Tillerson and U.S. Agency for International Development Administrator-designate Mark Green revealed how the Trump Administration is of two minds about foreign aid.

Tillerson testified at four hearings on the proposed budget cuts. Republicans and Democrats alike lambasted the proposed cuts. Sen. Lindsay Graham, the Republican chairman of the Senate subcommittee that oversees foreign aid, said these cuts would put lives at risk. Tillerson defended the cuts, saying “Our budget will never determine our ability to be effective. Our people will.”

Good news came with the nomination of former Ambassador and Congressman Mark Green to lead USAID. Green was well received by both political parties in his testimony before the Senate Foreign Relations Committee on June 15, and he talked with pride about the work of USAID (we also learned that his parents were born South African and British).

For global health advocates, one of the most worrisome aspects of Trump Administration policy has been the reinstatement and expansion of the Mexico City Policy. This policy requires foreign non-governmental organizations to certify that they will not “perform or actively promote abortion as a method of family planning” using funds from any source as a condition for receiving U.S. family planning assistance.

Green tried to calm concerns about the policy. “The State Department is undertaking an intensive six-month review to study the impacts of the expanded policy and whether it leads to interruption of services on the ground,” said Green in his testimony. “USAID will be part of that and we will play it straight. You can count on us to be honest brokers in that process.”

In the U.K., meanwhile, a different scenario has been playing out. In 2013, the UK became the fifth country to reach the UN goal of dedicating 0.7% of its gross national income to foreign aid, driven in large part by former Prime Minister David Cameron. But after the Brexit upset in 2016, Theresa May became prime minister and appointed conservative Member of Parliament Priti Patel as her international development secretary.

At the time, Patel roundly criticized British aid as being a waste of money and promised a major overhaul of the aid budget, according to the Daily Mail.

“My approach will be built on some core conservative principles — that the way to end poverty is wealth creation, not aid dependency; that wealth is ultimately created by people, not by the state; that poor countries need more investment and trade, not less,” she was quoted in The Guardian. “And we need to empower the poorest to work and trade their way out of poverty, not treat them as passive recipients of our support.”

In March 2017, a cross-party parliamentary committee on international development concluded that “ODA [official development assistance] spending is in the national interest and is a strong investment contributing to create a more prosperous world, which pays far-reaching dividends including to UK taxpayers at home.” The committee did not find evidence of wasteful spending. In fact, they found the spending to be effective.

Recently, Patel has struck a more positive tone about ODA. She announced a new aid package for east Africa, boasted about the scale of UK development assistance and, when asked about the future of UK aid, said: “It’s never been so needed. We face more global challenges in 2017 than every before.”

We don’t know if global health funding will go up or down but one thing is clear: Green and Patel are both interested in finding approaches to foreign aid that go beyond treating people as passive recipients of cash and that spark more economic investment and trade. It will be interesting to see what that means for global health.