By-disease investment trends for the first 15 American global health agreements
And other updates from today's GHSD "Global Health Engagement Call"
Today the Bureau of Global Health Security and Diplomacy resumed its monthly “Global Health Engagement” calls. The sensitive but unclassified briefing, open to anyone with a “.gov” email address, drew upwards of 500 people from US missions, embassies and offices around the world for an overview of the ongoing work to move agreements signed under the America First Global Health Strategy from concept to concrete programs.
It’s exciting that GHSD has turned on the information tap for its global community of government workers. Up until January 20, 2025, a similar call would have been held with the global network of people impacted by and working on the health issues in question, including HIV/AIDS, TB and malaria. I’m not aware of a call like that in the books at the moment, so will share a couple of the slides shared with me earlier today that feel particularly relevant.
The first, pictured below, is a summary of the by-disease funding trends for all of the 15 MoUs signed so far for all of the covered health areas. Regular readers know I’ve been banging on about the by-disease funding breakdowns for sometime. These breakdowns exist for every country but they are not included in the MoUs, which instead focus on commodities, laboratory systems, health workers, data systems, and so on.
There is merit to financing aspects of health systems (the categories used in the MoUs), as this approach moves away from disease-specific “vertical” programming which has, for decades, been both a source of actual concern and a scapegoat for critics of the global HIV response more broadly.1 But the US funds are not being allocated or tracked solely at the level of health system function and productivity. Disease-specific fund lines do exist, just not in the MoUs themselves.
Up until now, analysis of by-disease funding has relied largely on the contents of press releases from the State Department, which are informative but not remotely exhaustive.
The graphic I’ve produced below is the most comprehensive information available to date about the funding trends for HIV (on the left) and for all the other disease areas (malaria, maternal child health (non-polio), TB, GHS (this is global health security) and polio. The slide doesn’t have actual numbers in it, so full quantitative analysis of the percentage decreases in any area isn’t possible. But here are some things I notice, just to get the conversation started:
No health area ever goes to zero dollars
There is roughly a 25% reduction in HIV funding (the sum total of the HIV budgets for fifteen countries with signed MoUs) between year 1 (2026) and year 4 (2029). (To calculate this figure, I eyeballed 2026 as 2,250,000,000 and 2029 as 1,650,000,000)
There is roughly a 30 percent reduction in HIV funding between year 4 and year 5 (which I eyeballed as 1,150,000,000). That 2030 figure is also in the neighborhood of a 50 percent reduction compared to year 1.
My estimates are absolutely rough and ready and wrong to some extent. But the trajectory is not: HIV funding drops precipitously (perhaps even more than across the prior four years) between years 4 and 5. In prior years, the decline is there but more gradual. This is the window in which to truly move to country- and community-led systems that work for all.
Malaria funding drops far more quickly - which, as a non-malaria person from New York who knows that disease-bearing mosquitoes are now active in the daytime in the United States, and who heard Senator Cory Booker use precious time at a hearing with Secretary of State Marco Rubio asking about malaria, I note with curiosity.
Global health security is flat—but reliant on other systems (see below)
Alt text: A screenshot of cropped and color-filtered (how are we liking silver fox? is that the name?) screenshot of a slide shown at the newly-resumed US government calls for people working on health. I’ve described the contents above. The little blue bar with dots is my computer trying to help me do another screenshot at the same time. If you’d like a cleaner image please consider becoming a paid subscriber. I know this is boring and uncomfortable. It is for me too. My last ask secured six paid subscriptions. I love each of you! And: there is no secret funding source for my work. It is unpaid labor, like a lot of civil society and community labor. Is this the world we all want to be in? My friends - if you have a business credit card, a Slack channel, a Zappo’s VIP account - please upgrade. It makes people who cannot upgrade able to get the info.
The other notable feature of this morning’s update is a slide on the approach to global health security that came through too blurry to warrant reproduction. But the slide, which is titled, “Global Health Security - Focus on Surveillance and Response” includes these bullet points:
The United States will engage bilaterally to the maximum extent possible to strengthen global surveillance for disease threats, with increased focus in the countries where there is highest risk.
and
While the United States will start with a preference for bilateral relationships the USG will also engage in multilateral relationships for targeted purposes.
All of the bolded language above is, in the slide, also underlined. “Multilateral relationships for targeted purposes” sparks a linguistic glee in me that hasn’t been there since the Bridge Planning document that asked for a review of the “changed award landscape.” It makes me want to find screen grabs of the Throuple episode on Schitt’s Creek, and spelunk through the pleasurable tension between ‘multilateral” and “targeted” as directional words. I am not doing any of this. I’m just saying, for now, that the US is still figuring out what it is going to do as a global health actor in the world and that what it said to its people today raises more questions than answers.
One of my favorite articles about the “potentially destructive polarization” between vertical (by disease or health area) and horizontal (health systems-focused) financing is here: https://pmc.ncbi.nlm.nih.gov/articles/PMC2335098/. Written in 2008 by the great minds of Gorik Ooms, Paul Zeitz and Brook Baker, it remains a classic. I was delighted to find, when I went searching for this, that some esteemed thinkers at—hold on to your hats—PEPFAR had published a similar article in September 2025. https://academic.oup.com/jid/article/232/Supplement_2/S121/8259927?login=false I haven’t been this excited to find unfettered thinking from US government employees on the internet since I found the CDC’s page on ending a sentence with a preposition. Did you miss that rabbit hold? Message me and I will tell you where it is at.