To Navigate Global Health Replenishments, Treat Them as U.S. National Security Tools

Commentary by Katherine E. Bliss and J. Stephen Morrison

Published December 18, 2024

This commentary is part of a report from the CSIS Global Development Department series entitled Global Development Recommendations for the Next Administration.

The next 12 months are critical for multilateral global health institutions, which have helped build healthy populations, promoted political stability, and supported U.S. national security interests. In an unprecedented confluence of replenishment cycles, three institutions-(1) Gavi, the Vaccine Alliance, (2) the Pandemic Fund, and (3) the Global Fund to Fight AIDS, Tuberculosis and Malaria-will all be seeking funding for multiyear work plans, just as the new administration and Congress settle into power. It promises to be an anxious moment of reckoning.

Since the early 2000s, the United States has championed the Global Fund, Gavi, and, more recently, the Pandemic Fund, each of which embraces a public-private partnership model and engages implementing countries in co-financing processes. But the organizations' current fundraising cycles are fraught with uncertainty. At home, the bipartisan consensus on global health is frayed, as a conservative critique debates the merit of global health programs, questioning the level of true ownership by partner countries and whether these investments advance U.S. security priorities, notably competition with China. Overseas, populism has led stalwart donors to exit the field or divert financing to climate change, domestic resettlement requirements, and crises associated with the wars in Ukraine and the Middle East.

The next administration must decide whether it cares enough to rebuild commitments at home and abroad, follow through on existing obligations, and protect longstanding investments in global health security.

The next administration must decide whether it cares enough to rebuild commitments at home and abroad, follow through on existing obligations, and protect longstanding investments in global health security.

• Gavi's five-year replenishment kicked off last June, with the alliance seeking $9 billion for the 2026-2030 period to make vaccines available for purchase at low cost by eligible countries. At the conference, the Biden administration pledged$1.58 billion over five years to Gavi, building on the Trump administration's earlier four-year pledge of $1.16 billion in 2020.
• Responding to Covid-19, in 2022 the United States helped launch the Pandemic Fund, which offers eligible low- and middle-income countries financing to strengthen outbreak preparedness and response. The fund is requesting $2 billion for the period between July 2025 to June 2027, with the United States committing $667 million earlier this year for work through 2026.
• Planning is also underway for the Global Fund's eighth three-year replenishment process, which will likely launch in mid-2025. During the fund's seventh replenishment, President Biden committed $6 billion over three years. With U.S. law restricting its commitment to one-third of the total monies raised by the fund in a given period, the U.S. pledge can be expected to leverage commitments from other donors anxious not to leave money on the table.

Success requires a committed White House and secretary of state focused on sustaining U.S. leadership in global health. Success will rest on forging a new, durable, and reform-centric compact with both Democratic and Republican members of Congress; placing global health commitments squarely in the U.S. national security strategy; ensuring, through active U.S. diplomacy, that other donors will continue to invest while partner governments assume greater financing and programmatic ownership of health programs; and winning consent to wind down open-ended commitments and instead focus upon clear transitional end points.

With such a compact, it can become possible for the incoming Trump administration to make an early signal of its intent to fulfill the existing multiyear pledge to Gavi. Leadership at the U.S. Agency for International Development (USAID)'s Global Health Bureau should be engaged with Gavi and other alliance board members in promoting good stewardship of the funds and close oversight supporting eligible countries in transitioning away from support as their economies grow. The Department of State's Bureau of Global Health Security and Diplomacy, working with the Department of the Treasury, should reassure the Pandemic Fund of its intent to fulfill its current commitment and to continue support as the fund moves into its next round. And as the Global Fund's eighth replenishment gets underway, the Department of State, working with the National Security Council and other agencies responsible for implementing the President's Emergency Plan for AIDS Relief (PEPFAR), should press Congress to reauthorize PEPFAR for at least three years and secure a commitment from Congress to fund a robust pledge to the Global Fund. The United States holds a permanent place on the Global Fund board and can use its position to advocate for greater coordination with PEPFAR and to promote alignment between the fund and Gavi in countries where both organizations play a prominent role.

Navigating the complex cycle of global health replenishments poses early challenges for the next administration, and there is a great deal at stake. It is very unlikely that the funding ambitions of these organizations' replenishments will be met. Realistically, there will need to be significant adjustments, but it will be important to avoid sudden ruptures and regressions in funding that are destabilizing. It remains possible, on a bipartisan basis, for the Trump administration to make the case that sustaining global health partnerships will build local capacities in health protection, prevent destabilizing epidemics, and strengthen global health security, reinforcing U.S. national security in the long term.

Stephen Morrison is senior vice president and director of the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C. Katherine E. Bliss is a senior fellow and director of Immunizations and Health Systems Resilience with the Global Health Policy Center at CSIS.

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