Foreign aid is back from the dead — but it’s in the hands of the people who tried to kill it

There’s a dire shortage of good news in global health, so let me start with some.

Earlier this month, Congress passed — and President Donald Trump signed — a law to spend $9.4 billion on global health work in more than 50 countries. That’s funding for HIV treatment, childhood vaccines, malaria and TB programs, and much more — at roughly the same level as last year.

After a year in which the administration vilified and dismantled USAID, froze and refroze lifesaving health programs, and proposed slashing global health funding by more than 60 percent, this is a genuinely surprising development.

Some of the details in the new law are even more striking. Congress — including Republicans who co-wrote the bill — put $524 million toward family planning work; the administration had pushed to defund it entirely. Gavi, an international alliance that vaccinates more than half the world’s children, got $300 million despite Health Secretary Robert F. Kennedy Jr.’s vocal opposition toward it.

In the more than two decades since Congress began funding programs to fight HIV, malaria, and tuberculosis abroad, you could assume that money would actually get spent. That’s the law.

But that’s no longer a safe assumption.

Last year, Congress also appropriated billions for this work, but the administration chose not to spend more than a third of it. Some of the money meant for global health programs was used to pay for the White House budget director’s security detail, and the rest just sat there, unspent.

So now, American foreign aid — at least for lifesaving global health work — is back on paper. But whether it actually reaches the patients and programs that need it is another matter.

The money was on paper last year, too. According to an analysis by the Center for Global Development, US spending on global health fell by more than a third, the consequences of which have been devastating.

Consider the Global Fund, a massive international body that finances HIV, tuberculosis, and malaria programs in more than 100 countries. The US had pledged $6 billion to the fund for 2023 through 2025, and Congress approved the money to pay for it.

But the US failed to deliver on that pledge, and as of mid-2025, less than a third of that $6 billion had reached the Global Fund. Facing a shortfall driven largely by US inaction, the Global Fund had to slash $1.4 billion from grants it had already made to lifesaving programs.

These cuts came just as the administration was also terminating hundreds of PEPFAR programs that funded HIV and TB care on the ground. In Lesotho, where TB rates are among the highest in the world, the result was that clinics simply shut down. One patient visited nine HIV/TB clinics before finding one still open, an aid worker with direct knowledge of operations in the country told Vox.

What’s different this time

Under the Constitution, when Congress appropriates money, the executive branch is required by law to spend it as Congress dictates. But last year, the administration simply didn’t — and largely got away with it.

This time, Congress is trying to force the issue.

The new law sets specific funding floors for malaria, maternal and child health, tuberculosis, and nutrition, and uses unusually forceful language requiring the State Department to report its spending plans to Congress and to make quarterly payments to the Global Fund. Julianne Weis, co-founder of Aid on the Hill, which tracks foreign aid legislation, said these oversight requirements didn’t exist at this level of scrutiny before.

But laws didn’t stop the administration last year. AVAC, an HIV advocacy organization, sued the government over the unspent funds; that case is still active.

The real test is whether Congress enforces its own law. “Congress abdicated their responsibility [last year] for ensuring that the president spent what they had appropriated,” said Mitchell Warren, head of AVAC. Whether this Congress will act differently is an open question.

“There’s a huge question about the intent of the State Department to spend that money, and frankly the ability — the operational capacity — to do so,” said Jocilyn Estes, a policy expert at the Center for Global Development, a nonpartisan think tank.

That capacity problem is stark. Before USAID was gutted, its TB program alone had nearly 200 dedicated staff — 40 in DC and 150 around the world — managing about $406 million a year across 24 countries. Today, according to a person with direct knowledge of the program, two people at the State Department oversee that same portfolio. The President’s Malaria Initiative, which manages $795 million in funding, went from 66 staffers to five.

And going forward, a growing share of US global health funding is supposed to flow in a fundamentally different way. Under the administration’s “America First Global Health Strategy,” the US is abandoning the old USAID practice of working with aid organizations and is instead striking deals with foreign governments — an approach that experts say requires more specialized staff, not less.

The administration has signed 16 such deals so far — but they don’t cover key areas that Congress just funded, like family planning, which received roughly $524 million despite the administration actively working to eliminate it. Weis is skeptical that the White House will follow through, even with the law’s attempted safeguards. “There’s going to be a lot of money left over that is not spent,” she said.

Still, the new law is a sign that Republicans and Democrats in Congress are reasserting that the US should continue to do lifesaving global health work. “What this law mostly says is that Congress is back,” AVAC’s Warren told me. For decades, foreign aid has had strong bipartisan support on Capitol Hill, even when presidents have tried to reshape it.

But Warren isn’t celebrating yet. “I’ll declare victory when every dollar Congress appropriated is spent by the administration.”

The fiscal year ends in September. That’s when we’ll know.