Global Health Engagement in the Department of Defense

Global Health Engagement in the Department of Defense

Global Health Engagement in the Department
December 6, 2022
of Defense
Bryce H. P. Mendez
Over the years, Congress has enacted legislation to establish requirements, authorize,
Analyst in Defense Health
and fund programs that build and promote relationships with other countries to enhance
Care Policy
certain social, economic, political, and security interests of the United States (e.g., P.L.

117-81 §1206; P.L. 116-92 §1210A; and P.L. 112-239 §715). The Department of
Defense (DOD) is among the federal departments and agencies that administer these

programs. In doing so, DOD civilian and military personnel develop and maintain relationships with counterparts
in many partner nations to enhance U.S. national security interests (i.e., sometimes described as military-to-
civilian or military-to-military exchanges). DOD uses its health capabilities to teach and enable military and
civilian populations of certain partner nations. These efforts are typically part of security cooperation,
humanitarian assistance, and disaster relief operations. Together, DOD generally refers to the use of these health
and medical activities in certain military operations as global health engagement (GHE).
DOD policy defines GHE as the
interaction between individuals or elements of DOD and those of a partner nation’s armed forces or civilian
authorities, in coordination with other U.S. Government departments and agencies, to build trust and
confidence, share information, coordinate mutual activities, maintain influence, and achieve interoperability
in health-related activities that support U.S. national security policy and military strategy.
Depending on existing security cooperation objectives, GHE can include military-to-military or military-to-
civilian activities (e.g., in-person or virtual subject-matter exchanges, embedded advisors with partner ministries
of defense, augmenting partner military capabilities to support civil authorities, collaborative medical or public
health research and development efforts, live training exercises, or direct medical care). These activities can be
conducted as bilateral engagements with partner nations, or as part of broader security cooperation activities or
multilateral health initiatives (e.g., Global Health Security Agenda).
The Assistant Secretary of Defense for Special Operations and Low-Intensity Conflict (ASD[SO/LIC]) provides
guidance and oversight for all GHE programs. ASD(SO/LIC) also leads the GHE Council, a DOD entity that
coordinates GHE programs across numerous components (e.g., military services, combatant commands, defense
agencies, or the Joint Staff). DOD may also coordinate GHE with, or in support of, interagency partners (e.g.,
U.S. Agency for International Development, Department of State, Department of Health and Human Services, or
Department of Homeland Security).
Congress typically authorizes and funds DOD GHE through the annual National Defense Authorization Act, DOD
Appropriations Act, or the State, Foreign Operations, and Related Programs Appropriations Act.
In considering future U.S. policies and investments in national security and global health, Congress may find
DOD GHE presents certain issues that may be of interest, such as:
 the role of DOD GHE in U.S. national security and global health policies;
 GHE funding;
 development of a professional GHE workforce; and
 GHE effectiveness.

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Contents
Introduction ..................................................................................................................................... 1
Background ..................................................................................................................................... 1
DOD Global Health Engagement (GHE) ........................................................................................ 2
GHE Activities .......................................................................................................................... 4
GHE Oversight and Responsibilities......................................................................................... 5
GHE Council ....................................................................................................................... 6
Planning GHE Activities ........................................................................................................... 7
Interagency Coordination .......................................................................................................... 8
Funding GHE Activities ............................................................................................................ 9
Evaluating GHE Activities ........................................................................................................ 9
Legislative Activity ....................................................................................................................... 10
Issues for Congress ........................................................................................................................ 12
GHE and U.S. Policies on National Security and Global Health ............................................ 12
GHE Funding .......................................................................................................................... 13
Funding Streams ............................................................................................................... 13
Funding Flexibilities ......................................................................................................... 13
DOD GHE Workforce ............................................................................................................. 14
GHE Specialists ................................................................................................................ 14
Security Cooperation Workforce (SCW) .......................................................................... 15
DOD GHE Effectiveness ........................................................................................................ 16
Congressional Outlook .................................................................................................................. 17

Figures
Figure 1. DOD Global Health Engagement Framework ................................................................. 4
Figure 2. Veterinary GHE in Chiantla, Guatemala .......................................................................... 5
Figure 3. DOD Component Responsibilities for GHE Activities .................................................... 6
Figure 4. GHE Planning Process ..................................................................................................... 8
Figure 5. DOD Security Cooperation AM&E Framework ............................................................ 10

Tables
Table 1. GHE-related Legislative Activity ..................................................................................... 11

Table B-1. Selected DOD GHE Activities..................................................................................... 19
Table C-1. Selected DOD and DOS Funding Sources for Security Cooperation Efforts
and GHE Activities ..................................................................................................................... 22

Appendixes
Appendix A. Acronyms ................................................................................................................. 18
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Appendix B. Historical Examples of GHE Activities ................................................................... 19
Appendix C. Selected DOD and DOS Funding Sources for GHE Activities ................................ 22
Appendix D. Methodology for CRS Interviews of DOD GHE Subject Matter Experts ............... 24

Contacts
Author Information ........................................................................................................................ 25

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Introduction
Over the years, Congress has enacted legislation to establish requirements, authorize, and fund
programs that build and promote relationships with other countries to enhance certain social,
economic, political, and security interests of the United States. The Department of Defense
(DOD), among other federal departments and agencies, has a long history of participating in, or
administering programs to advance these interests through security cooperation and global health
engagement (GHE) activities.
This report provides background on DOD GHE activities, describes how the department aligns
GHE with the National Security Strategy and existing U.S. policies on global health and
summarizes how the department plans, funds, and carries out its GHE activities. These activities
present several issues for Congress, including the potential for misalignment of GHE activities
with broader U.S. strategies, use of funding mechanisms to enhance transparency, and DOD GHE
workforce development.
Appendix A provides a list of acronyms used throughout this report.
Background
Since at least 1900, the U.S. military has conducted certain activities in overseas locations
intended to protect the health and well-being of servicemembers from emerging infectious
diseases and other health risks (also referred to as force health protection).1 For example, during
the Spanish-American War, the U.S. Army dispatched a team of medical researchers to Cuba to
learn more about Yellow Fever to develop preventive measures and treatments.2 Currently, DOD
continues to conduct U.S. military medical research and epidemiological activities in overseas
locations and has since expanded its objectives to protect not only the health of U.S.
servicemembers abroad, but also that of the military and civilian populations of certain partner
nations. In addition to conducting medical research activities abroad, DOD also exercises its
health capabilities as part of security cooperation, humanitarian assistance, and disaster relief
operations. Together, DOD generally refers to the use of these health and medical activities in
certain military operations as global health engagement (GHE).3
In 2005, DOD began formalizing GHE as a term after the publication of National Security
Presidential Directive-44, Management of Interagency Efforts Concerning Reconstruction and
Stabilization.4 This directive required U.S. government agencies to plan and coordinate efforts to

1 See “Special Order No. 122, Department of the Army, Washington, D.C. May 24, 1900,” Military Medicine, vol. 166,
no. Supplement 1 (September 1, 2001), p. 19, at https://academic.oup.com/milmed/article/166/suppl_1/19/4925711.
Force health protection (FHP) refers to the measures taken to “promote, protect, improve, conserve, and restore the
mental and physical well being of Service members across the range of military activities and operations.” For more on
FHP, see Department of Defense Directive (DODD) 6200.04, Force Health Protection (FHP), updated April 23, 2007,
p. 10, at https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodd/620004p.pdf.
2 Ibid; Enrique Chaves-Carballo, “Clara Maass, Yellow Fever and Human Experimentation,” Military Medicine, vol.
178 (May 2013), p. 557, at https://academic.oup.com/milmed/article/178/5/557/4222873; and Michael McCarthy, “A
century of the US Army yellow fever research,” The Lancet, vol. 357, no. 9270 (June 2, 2001), p. P1772, at
https://www.thelancet.com/action/showPdf?pii=S0140-6736%2800%2904943-6.
3 Department of Defense Instruction (DODI) 2000.30, Global Health Engagement (GHE) Activities, July 12, 2017, p.
19, at https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/200030_dodi_2017.pdf.
4 Gerald V. Quinnan, Jr., “The Future of Department of Defense Global Health Engagement,” Joint Forces Quarterly,
no. 80 (January 2016), p. 39, at https://ndupress.ndu.edu/Portals/68/Documents/jfq/jfq-80/jfq-80_37-44_Quinnan.pdf;
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assist partner nations that are “at risk of, in, or in transition from conflict or civil strife.”5 As part
of its stability activities during Operation Iraqi Freedom in Iraq and Operation Enduring Freedom
in Afghanistan, deployed medical personnel engaged with the host nation by providing direct
medical care, conduct training for local medical or support staff, and consultations with local
public health leaders.6 Observers have noted that DOD’s efforts were an “ad hoc, short-term
focus, resulting in numerous unintended consequences,” often leaving local civilians with
“unrealistic expectations” that the U.S. military would continue to provide for their health care
needs.7 The lessons learned from stability operations in Iraq and Afghanistan contributed to
DOD’s formalizing GHE and to ongoing revisions of the department’s conduct of these activities.
DOD Global Health Engagement (GHE)
In 2013, Congress defined health engagements as a “health stability operation conducted by DOD
outside the United States in coordination with a foreign government or international organization
to establish, reconstitute, or maintain the health sector of a foreign country.”8 Subsequently, the
department established a formal GHE definition (see text box) and described GHE activities as
actions that “establish, reconstitute, maintain or improve the capabilities or capacities of the
partner nation’s military or civilian health sector, or those of the DOD.”9
What is Global Health Engagement?
DOD defines GHE as the:
“[i]nteraction between individuals or elements of DoD and those of a [partner nation’s] armed forces or
civilian authorities, in coordination with other U.S. Government departments and agencies, to build trust
and confidence, share information, coordinate mutual activities, maintain influence, and achieve
interoperability in health-related activities that support U.S. national security policy and military
strategy.”10
The purpose of GHE is to improve DOD’s “relationship and interoperability” with partner nations
and their human and animal health capabilities and capacities.11 In addition to supporting force
health protection efforts, DOD uses GHE as a soft power12 tool to support goals and objectives

and Executive Office of the President, National Security Presidential Directive-44, Management of Interagency Efforts
Concerning Reconstruction and Stabilization, December 7, 2005, at https://www.health.mil/Reference-
Center/Policies/2005/12/07/National-Security-Presidential-Directive-44-on-Reconstruction.
5 Ibid.
6 Stability activities refer to “various military missions, tasks, and activities conducted outside the United States in
coordination with other instruments of national power to maintain or reestablish a safe and security environment and
provide essential governmental services, emergency infrastructure reconstruction, and humanitarian relief.” For more
on stability activities, see Joint Publication (JP) 3-07, “Stability,” August 3, 2016, at
https://www.jcs.mil/Doctrine/Joint-Doctrine-Pubs/3-0-Operations-Series/.
7 J. Christopher Davis and Kathleen H. Hicks, Global Health Engagement: Sharpening a Key Tool for the Department
of Defense, Center for Strategic and International Security (CSIS), October 2014, p. 3, at http://csis-website-
prod.s3.amazonaws.com/s3fs-public/legacy_files/files/publication/140930_Daniel_DODGlobalHealth_Web.pdf.
8 P.L. 112-239, §715. Congress established this definition as part of a requirement for DOD to develop a process that
ensures health engagements are “effective and efficient in meeting the national security goals of the United States.”
9 DODI 2000.30, Global Health Engagement (GHE) Activities, July 12, 2017, p. 19.
10 Ibid.
11 Ibid., p. 3.
12 According to former U.S. Assistant Secretary of Defense for International Security Affairs Joseph Nye, soft power
refers to the ability to “obtain preferred outcomes by attraction rather than coercion or payment.” For more on soft
power, see Joint Doctrine Note 1-18, Strategy, April 25, 2018, p. II-8, at
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outlined in various U.S. national security and global health policies and strategies.13 These,
among others, include the:
 National Security Strategy;14
 National Defense Strategy;15
 National Military Strategy;16
 National Biodefense Strategy;17
 National Health Security Strategy;18
 Global Health Security Strategy;19
 President’s Emergency Plan for AIDS Relief;20
 President’s Malaria Initiative;21 and
 Global Health Security Agenda (GHSA).22
Some observers have raised questions about the effectiveness of what they describe as a
proliferation of strategic guidance documentation within DOD, arguing that it can lead to
conflicting or muddled guidance; guidance cherry-picking; discordant dialogue; and entrenched,
competing staffs.23 Despite these observations, Congress has often mandated periodic revisions
and publication of certain strategy documents.24

https://www.jcs.mil/Portals/36/Documents/Doctrine/jdn_jg/jdn1_18.pdf; and Joseph Nye, “Soft power: the origins and
political progress of a concept,” Palgrave Communications, February 17, 2017, at
https://www.nature.com/articles/palcomms20178.
13 CRS interview with DOD GHE officials, April 2021. See Appendix D for more on CRS interviews.
14 See The White House, Interim National Security Strategic Guidance, March 2021, at
https://www.whitehouse.gov/wp-content/uploads/2021/03/NSC-1v2.pdf.
15 See DOD, Fact Sheet: 2022 National Defense Strategy, March 28, 2022, at
https://media.defense.gov/2022/Mar/28/2002964702/-1/-1/1/NDS-FACT-SHEET.PDF.
16 See Joint Staff, Description of the National Military Strategy 2018, 2018, at https://www.jcs.mil/Portals/
36/Documents/Publications/UNCLASS_2018_National_Military_Strategy_Description.pdf.
17 The White House, National Biodefense Strategy, 2018, at https://trumpwhitehouse.archives.gov/wp-
content/uploads/2018/09/National-Biodefense-Strategy.pdf.
18 See Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response,
National Health Security Strategy 2019-2022, 2019, at
https://www.phe.gov/Preparedness/planning/authority/nhss/Documents/NHSS-Strategy-508.pdf.
19 See The White House, United States Government Global Health Security Strategy, 2019, at
https://trumpwhitehouse.archives.gov/wp-content/uploads/2019/05/GHSS.pdf.
20 See Department of State, Office of the U.S. Global AIDS Coordinator and Special Representative for Global Health
Diplomacy, The United States President’s Emergency Plan for AIDS Relief, at https://www.state.gov/pepfar/; and CRS
In Focus IF10797, PEPFAR Stewardship and Oversight Act: Expiring Authorities, by Tiaji Salaam-Blyther.
21 See U.S. Agency for International Development, U.S. President’s Malaria Initiative, at https://www.pmi.gov/; and
CRS In Focus IF11146, Global Trends: Malaria.
22 See Executive Office of the President, Executive Order 13747, Advancing the Global Health Security Agenda to
Achieve a World Safe and Security from Infectious Disease Results, November 4, 2016, at
https://www.govinfo.gov/content/pkg/FR-2016-11-09/pdf/2016-27171.pdf; and CRS In Focus IF11461, The Global
Health Security Agenda (GHSA): 2020-2024, by Tiaji Salaam-Blyther.
23 Mara Karlin and Christopher Skaluba, “Strategic Guidance for Countering the Proliferation of Strategic Guidance,”
War on the Rocks, July 20, 2017, at https://warontherocks.com/2017/07/strategic-guidance-for-countering-the-
proliferation-of-strategic-guidance/.
24 For example, 50 U.S.C. §3043 requires the President to annually transmit to Congress a National Security Strategy
and 42 U.S.C. §300hh-1 requires the Secretary of Health and Human Services to transmit to Congress a quadrennial
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GHE Activities
In conducting security cooperation with partner nations,25 DOD has three main GHE priorities:
(1) build partner nation capacity, (2) bolster the civilian population’s confidence in the partner
nation’s governance, and (3) lower the partner nation’s susceptibility to destabilizing influences.26
Given those priorities, DOD has organized GHE activities into four categories: force health
protection; building partner capacity and interoperability; humanitarian assistance and foreign
disaster relief; and nuclear, chemical, and biological defense programs (see Figure 1).27
Figure 1. DOD Global Health Engagement Framework

Source: CRS adapted graphic based on DODI 2000.30, Global Health Engagement (GHE) Activities, July 12, 2017,
p. 4.
Note: R&D = Research and Development.
GHE may include military-to-military or military-to-civilian activities (e.g., in-person or virtual
subject-matter exchanges, embedded advisors with partner ministries of defense, augmenting
partner military capabilities to support civil authorities, collaborative medical or public health
research and development efforts, live training exercises, or direct medical care). These activities
may be conducted on an ad hoc or recurring basis, as bilateral or multilateral partnerships, or as
part of larger DOD-implemented security cooperation or security assistance efforts (e.g., African
Peacekeeping Rapid Response Partnership, Asia Pacific Regional Initiative, or the European
Deterrence Initiative).28

National Health Security Strategy.
25 DOD conducts security cooperation activities under various authorities included in Titles 10, 22, and 50 of the U.S.
Code. For more, see DODD 5132.03, DoD Policy and Responsibilities Relating to Security Cooperation, December 29,
2016, p. 18, at https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodd/513203_dodd_2016.pdf. For more
on security cooperation, see CRS In Focus IF11677, Defense Primer: DOD “Title 10” Security Cooperation, by
Christina L. Arabia; and CRS Video WVB00435, FY2022 Security Cooperation Priorities, by Christina L. Arabia.
26 DODI 2000.30, Global Health Engagement (GHE) Activities, July 12, 2017, pp. 4-5.
27 Ibid., p. 4.
28 For more on these security cooperation efforts, see Uniformed Services University, Center for Global Health
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GHE Example: Building Partner Capacity
Figure 2 is an example of a military-to-civilian GHE activity in the Chiantla region of Guatemala. U.S. Army
veterinarians and animal specialists from Joint Task Force-Bravo, in coordination with the Guatemalan Ministry of
Agriculture, work with local livestock owners to administer vaccines and medications to animals as a public health
measure to reduce the prevalence of food-borne il ness transmission and zoonotic diseases, and protect local food
sources.
Figure 2. Veterinary GHE in Chiantla, Guatemala
December 2021

Source: U.S. Southern Command, “JTF-Bravo medics perform Guatemala global health engagement,”
accessed November 20, 2022, at https://www.southcom.mil/MEDIA/IMAGERY/igphoto/2002918474/; and U.S.
Southern Command, "Joint Task Force-Bravo Veterinary Team Nurture Animals and Partnerships," press
release, June 13, 2022, at https://www.southcom.mil/MEDIA/NEWS-ARTICLES/Article/3064188/joint-task-
force-bravo-veterinary-team-nurture-animals-and-partnerships/.
Appendix B lists additional examples of DOD GHE activities conducted between calendar years
2010 and 2020.
GHE Oversight and Responsibilities
DOD policy assigns various DOD components with responsibilities for oversight, planning,
coordination, funding, or execution of GHE activities (see Figure 3).29 The Under Secretary of
Defense for Policy is assigned primary oversight of GHE and delegates responsibilities to the
Assistant Secretary of Defense for Special Operations and Low Intensity Conflict
(ASD[SO/LIC]).30 ASD(SO/LIC) is responsible for:
 coordinating the development of GHE-related policy and guidance with the
Chairman of the Joint Chiefs of Staff and DOD component leaders;

Engagement, African Peacekeeping Rapid Response Partnership, at https://cghe.usuhs.edu/programs#aprrp; and CRS
In Focus IF10946, The European Deterrence Initiative: A Budgetary Overview, by Paul Belkin and Hibbah Kaileh.
29 DODI 2000.30, Global Health Engagement (GHE) Activities, July 12, 2017, pp. 6-11.
30 Ibid, p. 6.
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 coordinating with the Defense Security Cooperation Agency for “budget
allocation and prioritization of GHE activities” for geographic combatant
commanders (GCCs);31 and
 serving as the DOD GHE Council chair.32
Figure 3. DOD Component Responsibilities for GHE Activities
Responsibilities
DOD Component
Develop
Oversight
Plan
Coordinate
Fund
Execute
Policy
Office of the Under Secretary of

-
-
-
-
-
Defense for Policy
Office of the Assistant Secretary of
Defense for Special Operations and





-
Low Intensity Conflict (ASD[SO/LIC])
Office of the Assistant Secretary of
Defense for Homeland Defense and




-
-
Global Security (ASD[HD/GS])
Office of the Assistant Secretary of




-
-
Defense for Health Affairs (ASD[HA])
Office of the Assistant Secretary of
Defense for Nuclear, Chemical, and




-
-
Biological Defense Programs
(ASD[NCB])
Defense Security Cooperation





-
Agency (DSCA)
Joint Chiefs of Staff (JCS)


-

-
-
Military Departments (i.e., Army,





-
Navy, Air Force)
Geographic Combatant
-
-




Commanders (GCCs)

Source: CRS analysis of DODI 2000.30, Global Health Engagement (GHE) Activities, July 12, 2017, pp. 6-11.
Notes: Bul et () means DOD component is tasked with a GHE responsibility; dash (-) means DOD component
is not tasked with a GHE responsibility.
GHE Council
The GHE council comprises representatives from DOD components with assigned GHE
responsibilities. Chaired by the ASD(SO/LIC), the council is a coordinating body whose purpose
is to “increase information sharing, improve collaboration, eliminate redundancy, increase
efficiency, and promote best practices” among the various DOD components and their GHE
responsibilities.33 The council is organized into three groups:
 a Senior Group (i.e., ASDs and Joint Staff leaders);

31 For more on combatant commands, see CRS In Focus IF10542, Defense Primer: Commanding U.S. Military
Operations.
32 Ibid., pp. 6-7.
33 Ibid., p. 14.
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 a Deputy Group (i.e., Deputy ASDs and representatives from the Joint Staff,
military departments, and DSCA); and
 an Action Officer Group (i.e., representatives from the organizations in the
Deputy Group and other DOD GHE stakeholders).34
Planning GHE Activities
DOD generally uses a security cooperation planning framework to consider, develop, and
organize its GHE activities (see Figure 4Error! Reference source not found.).35 As part of this
framework, DOD components consider national security goals and objectives.36 DOD policy
describes GCCs as being responsible for carrying out GHE activities with support from other
DOD components.37 Generally, each GCC develops a campaign plan and theater strategy that
includes a “series of related military operations aimed at accomplishing strategic and operational
objectives within a given time and space.”38 Campaign plans include regional or country-specific
security cooperation sections intended to describe desired military objectives, align activities and
investments with other agencies, and identify resource requirements.39 In developing security
cooperation sections, DOD undertakes a multi-step process that takes into account the
Department of State’s Integrated Country Strategy.40 The planning process typically includes a
GCC assessment of a partner nation’s military or civilian needs, determination of specific
activities to enhance mutual security objectives (between the United States and the partner
nation), and identification of resources and authorities required to conduct an engagement.41
Military medical planners are typically involved in the formulation of GCC security cooperation
sections and work with other military planners and security cooperation specialists to develop
appropriate GHE activities. GCCs usually require and request additional personnel, resources, or
military capabilities from other DOD components (e.g., DSCA, military services, Defense Health
Agency) or interagency partners to support or carry out their planned GHE activities.42

34 Ibid., pp. 15-16.
35 DOD uses the Security Cooperation Planning Framework to plan for security cooperation activities, include GHE.
The framework includes a 12-step process that considers strategic national security goals and objectives, operational
and campaign plans, and tactical level initiatives to conduct security cooperation activities. For more on the framework,
see JP 3-20, Security Cooperation, May 23, 2017, pp. III-8-III-11.
36 Ibid., p.12; and DOD Directive 5132.03, DoD Policy and Responsibilities Relating to Security Cooperation,
December 29, 2016, pp. 3-4, at https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/
dodd/513203_dodd_2016.pdf. For more on DOD’s security cooperation planning process, see Chapter III of JP 3-20,
Security Cooperation, May 23, 2017, at https://www.jcs.mil/Portals/36/Documents/Doctrine/pubs/
jp3_20_20172305.pdf.
37 DODI 2000.30, Global Health Engagement (GHE) Activities, July 12, 2017, p. 11.
38 JP 5-0, Joint Planning, December 1, 2020, p. I-8, at https://irp.fas.org/doddir/dod/jp5_0.pdf; and JP 3-20, Security
Cooperation, May 23, 2017, p. I-9.
39 JP 5-0, Joint Planning, December 1, 2020, pp. V-13 to V-14.
40 An Integrated Country Strategy (ICS) is a “four-year strategic plan that articulates whole-of-government priorities in
a given country and incorporates higher level planning priorities.” For more on ICS, see Section 301.2, Chapter 18 of
the Foreign Affairs Manual, updated July 31, 2020, at https://fam.state.gov/FAM/18FAM/18FAM030102.html; and
Chapter 19 of DSCA, Security Cooperation Management, May 2021, p. 2, at
https://www.dscu.edu/documents/publications/greenbook/19-Chapter.pdf?id=1.
41 CRS analysis of Chapter III of JP 3-20, Security Cooperation, May 23, 2017.
42 JP 3-20, Security Cooperation, May 23, 2017, pp. III-14 and III-17.
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Figure 4. GHE Planning Process

Source: Uniformed Services University of the Health Sciences, “Fundamentals of Global Health Engagement,”
GHE Planning, accessed November 20, 2022, p. 8, at https://cghe.usuhs.edu/training-and-education/fundamentals-
of-global-health-engagement/foghe-resources.
Notes: M&E = Monitoring and Evaluation. NSS = National Security Strategy. NDS = National Defense Strategy.
NMS = National Military Strategy. GHE = Global Health Engagement. CCMD = Combatant Command.” CSCS =
Country-specific Security Cooperation Section. For a more detailed schema of the broader security cooperation
planning framework, see Joint Publication 3-20, Security Cooperation, p. III-9, May 23, 2017, at
https://www.jcs.mil/Portals/36/Documents/Doctrine/pubs/jp3_20_20172305.pdf.
Interagency Coordination
DOD policy requires the GCC to coordinate its GHE activities with interagency liaison officers
and U.S. country team personnel.43 Certain GCCs have permanent or ad hoc representatives
assigned from other federal entities (e.g., U.S. Agency for International Development [USAID])
or embedded nonmilitary advisors (e.g., Department of State foreign policy advisor [POLAD])
that consult or coordinate on certain military operations.44 The planning process often includes
coordination to ensure DOD GHE activities are “consistent with the U.S. Embassy’s Integrated
Country Strategy and its applicable health, social, economic, and environmental mission goals

43 DODI 2000.30, Global Health Engagement (GHE) Activities, July 12, 2017, p. 11. A U.S. country team is an
“interagency group made up of the heads of each State Department section in the embassy and the heads of other U.S.
Government agencies represented at the post.” Department of State (DOS), “Country Team,” June 10, 2019, at
https://diplomacy.state.gov/glossary/country-team-2/.
44 JP 3-08, Interorganizational Cooperation, updated October 18, 2017, pp. IV-5-IV-6, at
https://www.jcs.mil/Portals/36/Documents/Doctrine/pubs/jp3_08.pdf.
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and objectives and, if applicable, complementary to USAID’s Country Development Cooperation
Strategy.”45
Other DOD components also participate in formal and informal interagency coordination to
develop, resource, and plan GHE activities as part of broader whole-of-government efforts. For
example, the ASD(HD/GS) and ASD(HA) participate in the GHSA Interagency Review Council,
a working group organized under the National Security Council to coordinate whole-of-
government efforts to “prevent, detect, and respond to infectious disease threats” with certain
partner nations.46 Additionally, DOD regularly assigns a liaison to the U.S. Centers for Disease
Control and Prevention (CDC) Director’s staff to coordinate “complementary activities” between
the two entities, including those on “global health security.”47
Funding GHE Activities
Congress typically appropriates funding for DOD GHE activities through the annual Department
of Defense Appropriations Act; or the State, Foreign Operations, and Related Programs
Appropriations Act. A range of DOD components are responsible for funding GHE activities,
including the ASD(SO/LIC), DSCA, Defense Threat Reduction Agency (DTRA), the military
services, and the GCCs.48 In general, the components use the Planning, Programming, Budgeting,
and Execution (PPBE) process to request, prioritize, and allocate funding for GHE activities in a
five-year spending plan known as the Fiscal Year Defense Program (FYDP).49 GHE funding
allocated through the PPBE process is typically assigned from a component’s operation and
maintenance (O&M) account, as well as other congressionally designated amounts included in
other accounts specified for security cooperation. DOS also funds certain DOD security
cooperation efforts, including GHE, through programs authorized by Title 22, Chapter 32 of the
United States Code, and the Foreign Assistance Act of 1961 (P.L. 87-195, as amended). Table C-
1 lists selected DOD and DOS accounts typically used to fund DOD-administered security
cooperation efforts and GHE activities.
Evaluating GHE Activities
ASD(SO/LIC) is responsible for issuing guidance and conducting oversight of assessment,
monitoring, and evaluation (AM&E) for GHE activities.50 In general, most DOD components use
the Security Cooperation AM&E framework and standards to “foster accurate and transparent
reporting to key stakeholders on the outcomes and sustainability of security cooperation” and
“identify best practices and lessons learned” to inform future policies, programs, and initiatives

45 DODI 2000.30, Global Health Engagement (GHE) Activities, July 12, 2017, p. 11.
46 Ibid., pp. 7-8. The GHSA Interagency Review Council includes representatives from the Departments of Defense,
State, Homeland Security, Health and Human Services, Agriculture, Justice, and other sub-cabinet level agencies.
47 Jean-Paul Chretien et al., “Department of Defense Global Emerging Infections Surveillance,” Military Medicine, vol.
171 (Supplement 2006), p. 12, at https://academic.oup.com/milmed/ article/171/suppl_1/12/4647688; and DOD,
“Department of Defense (DoD) Liaison to the Centers for Disease Control and Prevention (CDC),” Position
Description, January 2021.
48 For more on DOD and DOS security cooperation funding, see CRS Video WVB00397, The Security Cooperation
Budget, by Christina L. Arabia; and CRS Report WPE11831, Defense Institute 201 Series, by Christina L. Arabia.
49 For more on the Planning, Programming, Budgeting, and Execution process, see CRS In Focus IF10429, Defense
Primer: Planning, Programming, Budgeting, and Execution (PPBE) Process, by Brendan W. McGarry; and CRS
Report R47178, DOD Planning, Programming, Budgeting, and Execution (PPBE): Overview and Selected Issues for
Congress, by Brendan W. McGarry.
50 DODI 2000.30, Global Health Engagement (GHE) Activities, July 12, 2017, pp. 6-7.
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(see Figure 5).51 DOD policy generally requires AM&E to occur before, during, and after a GHE
activity to ensure a program is:
 designed to meet specific objectives;
 implemented as planned; and
 measured for effects.52
DOD components planning or conducting GHE activities are typically responsible for also
completing AM&E.
Figure 5. DOD Security Cooperation AM&E Framework

Source: DODI 5132.14, Assessment, Monitoring, and Evaluation Policy for the Security Cooperation Enterprise, January
13, 2017, p. 13.
Legislative Activity
Since 2009, Congress has considered or enacted requirements to expand the scope and improve
the evaluation of GHE in order to advance U.S. national security goals. Table 1 lists GHE-related
legislative activity from the 111th through the 116th Congresses.

51 DODI 5132.14, Assessment, Monitoring, and Evaluation Policy for the Security Cooperation Enterprise, January 13,
2017, p. 3, at https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/513214_dodi_2017.pdf.
52 Ibid.
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Table 1. GHE-related Legislative Activity
111th-116th Congresses (2009-2020)
Bill or
Report
Congress
Number
Section Title
Description
116th
H.R. 6395
Department of Defense Section 732 requires the Secretary of Defense to
(P.L. 116-283) Pandemic
develop a strategy for pandemic preparedness and
Preparedness.
response that includes, among other items, a review of
the placement and utilization of GHE liaisons, and
scope of GHE activities.
116th
H.R. 6395
COVID-19 Global War
Section 722 would require the Secretary of Defense to
on Pandemics.
develop a strategy for pandemic preparedness and
response that includes, among other items, a review of
the placement and utilization of GHE liaisons, and
scope of GHE activities.
115th
H.Rept. 115-
Global Health
The report directs the Secretary of Defense to brief
676 (p. 131)
Engagement
the House Armed Services Committee, not later than
Organization
April 1, 2019, on the feasibility of consolidating and
Consolidation.
integrating the Center for Global Health Engagement at
the Uniformed Services University of the Health
Sciences (USUHS) and the Defense Institute of Medical
Operations.
114th
S.Rept. 114-
Global Health.
The report encourages the ASD(HA) and USUHS to
63 (p. 204)
establish a “learning tool to assess the efficiency and
effectiveness” of GHE in meeting national security
goals.
113th
S.Rept. 113-
Global Health
The report encourages the ASD(HA) and USUHS to
85 (p. 193)
Engagements.
establish a “learning tool to assess the efficiency and
effectiveness” of GHE in meeting national security
goals.
113th
S.Rept. 113-
Global Health.
The report encourages the ASD(HA) and USUHS to
211 (p. 255)
establish a “learning tool to assess the efficiency and
effectiveness” of GHE in meeting U.S. national security
goals.
112th
H.R. 4310
Requirement to Ensure
Section 715 requires the Secretary of Defense to
(P.L. 112-239) the Effectiveness and
develop a process to ensure that GHE activities are
Efficiency of Health
effective and efficient in meeting U.S. national security
Engagements.
goals.
112th
H.R. 4310
Requirement to Ensure
Section 714 would require the Secretary of Defense to
the Effectiveness and
develop a process to ensure that GHE activities are
Efficiency of Health
effective and efficient in meeting U.S. national security
Engagements.
goals.
Source: Congress.gov, November 2022.
Note: CRS did not identify any related legislation introduced or considered during the 111th Congress.
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Issues for Congress
GHE and U.S. Policies on National Security and Global Health
Since the early 2000s, U.S. national security and global health experts have called for the
development of whole-of-government strategies to address global health issues that could “affect
nearly every aspect of Americans’ safety and prosperity.”53 These experts have noted that though
DOD has “long made significant contributions to science through military medicine,” their
“strategic thinking about global health and security issues is evolving very slowly.”54 DOD has
since grown from its modern GHE roots in overseas force health protection and stability
activities. DOD has typically been a contributor to broader whole-of-government strategies to
address global health, health security, and health diplomacy issues.55
In March 2021, the Biden Administration stated in the Interim National Security Strategic
Guidance that it will work to “restore U.S. leadership on global health and health security, and
build the world’s collective preparedness and capacity to detect and rapidly contain infectious
diseases and biological threats.”56 As federal departments and agencies consider their
responsibilities and priorities to meet existing U.S. policy on national security and global health
security, DOD may also reevaluate how GHE is used to support military-specific requirements
and broader global health objectives. Reexamining the purpose of GHE could also inform how
DOD administers, coordinates, and resources these activities.
As DOD demonstrated during the Coronavirus Disease 2019 (COVID-19) pandemic, it possesses
substantial resources, personnel, and logistics experience to conduct domestic and global
operations.57 Combined with their efforts to build strong partnerships through security
cooperation activities, some observers would contend that DOD is well positioned to enable
additional global health initiatives led by other federal entities.58 Other observers maintain that
while DOD will have opportunities to “contribute to broader U.S. government global health

53 Eugene V. Bonventre, Kathleen H. Hicks, and Stacy M. Okutani, “U.S. National Security and Global Health,” Center
for Strategic and International Studies, April 2009, p. 3, at https://csis-website-prod.s3.amazonaws.com/s3fs-
public/legacy_files/files/publication/090421_Bonventre_USNationalSecurity_Rev.pdf.
54 Ibid.
55 Health security refers to the “existence of strong and resilient public health systems that can prevent, detect, and
respond to infectious disease threats, where they occur in the world.” For more on health security, see Centers for
Disease Control and Prevention, Global Health, Global Health Security Agenda, “What is Global Health Security?”
accessed July 30, 2022, at https://www.cdc.gov/globalhealth/security/what.htm. Health diplomacy refers to “the
intersection of public health and foreign affairs.” For more on health diplomacy, see Department of Health and Human
Services, “Global Health Diplomacy,” accessed July 30, 2022, at https://www.hhs.gov/about/agencies/oga/global-
health-diplomacy/index.html.
56 The White House, Interim National Security Strategic Guidance, March 2021, p. 16, at
https://www.whitehouse.gov/wp-content/uploads/2021/03/NSC-1v2.pdf.
57 For example, see CRS In Focus IF11480, Overview: The Department of Defense and COVID-19; and CRS Insight
IN11273, COVID-19: The Basics of Domestic Defense Response, coordinated by Michael J. Vassalotti.
58 Gerald V. Quinnan, Jr., "The Future of Department of Defense Global Health Engagement," Joint Forces Quarterly,
no. 80 (January 2016), pp. 37-44; Eugene V. Bonventre, Kathleen H. Hicks, and Stacy M. Okutani, "U.S. National
Security and Global Health," Center for Strategic and International Studies, April 2009, p. 5; and Thomas Cullison and
J. Stephen Morrison, "Department of Defense Contributions to the U.S. COVID-19 Response, at Home and Abroad,"
Center for Strategic and International Studies, December 16, 2021, at, https://www.csis.org/analysis/department-
defense-contributions-us-covid-19-response-home-and-abroad.
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initiatives,” the “global health community will look to see if DOD leadership sustains its
commitment to ‘smart global health engagement.’”59
Congress could consider clarifying DOD’s role and responsibilities to conduct GHE activities in
the context of advancing U.S. policies on national security and global health. In providing such
direction, Congress could further define or codify how DOD leads or enables whole-of-
government global health initiatives, or limit DOD’s contributions to certain efforts.
GHE Funding
Funding Streams
Unlike certain other DOD programs, projects, and activities, GHE has no single source of
funding. As noted earlier and in Appendix C, at least 10 DOD appropriations accounts and one
DOS account have been used to fund GHE. Within those accounts, different budget activities or
line items can be used to fund GHE depending on their relevance, location, or sponsoring entity.
The existing approach to funding GHE activities may provide certain flexibility across DOD to
prioritize resources for certain security cooperation efforts (e.g., GHE vs. non-GHE activities)
depending on strategy, organizational need, urgency, or other influencing factors. While this
flexibility may allow for increased investments in GHE on an ad hoc basis, DOD component
leaders can also choose to reprioritize their resources, with or without GHE Council input, to fund
other security cooperation efforts over its GHE activities.
Congress could consider authorizing or appropriating funds in a manner that streamlines how
GHE activities are resourced to eliminate intra-departmental competition with other security
cooperation priorities. Efforts to streamline such resources could be explored through a
requirement for DOD to submit a consolidated GHE budget; establishment of one or more
appropriations accounts, budget activities, or line items specifically for DOD GHE activities; or
designation of a singular DOD entity that is responsible and accountable for all GHE funds.
Congress could revise existing, or establish more stringent prior approval requirements used for
certain reprogramming actions to enhance its visibility of funding initially intended for security
cooperation or GHE activities.60
Funding Flexibilities
DOD may use congressionally appropriated funds only for specified purposes and only for use
within a certain timeframe. For example, the Department of Defense Appropriations Act, 2022
(Division C of P.L. 117-103), provided certain amounts for the Operation and Maintenance,
Defense-Wide account, of which certain components fund security cooperation and GHE
activities, and specified that such funds would “remain available until September 30, 2023.”61
Although DOD components plan and request for resources to conduct security cooperation and
GHE activities throughout the FYDP, changes in U.S. policies or strategies could result in an
unforeseen requirement. DOD may address these scenarios by amending a budget request,

59 J. Christopher Davis and Kathleen H. Hicks, Global Health Engagement, Center for Strategic & International
Security (CSIS), Sharpening a Key Tool for the Department of Defense, Washington, DC, October 2014, pp. 13-14.
60 For more on DOD prior approval requirements and reprogramming actions, see CRS Report R46421, DOD Transfer
and Reprogramming Authorities: Background, Status, and Issues for Congress, by Brendan W. McGarry.
61 See Division C of the Consolidated Appropriations Act, 2022 (P.L. 117-103).
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transferring or reprogramming existing funding, or requesting additional appropriations from
Congress.62
Certain strategies call for multi-year initiatives to achieve broader health security goals. For
example, the Global Health Security Agenda (GHSA) includes a number of country-specific
actions to meet certain targets by 2024.63 The United States, as a GHSA member, has committed
to a number of actions that require relevant federal departments and agencies to fulfill their
individual tasks over the next several years.64 Given the multi-year effort, observers have noted
that the relevant DOD GHE activities that support these tasks are “funded with same-year
dollars.”65 Though annual appropriations provide Congress and DOD an opportunity to modify its
funding priorities more frequently, they also create certain complexities of timing for policy and
investment commitments.
Congress could consider multi-year appropriations to address existing barriers to GHE workforce
or resource investments, long-term planning and capacity building efforts, or interagency
cooperation and contributions to broader whole-of-government efforts (e.g., GHSA). Congress
could also consider requiring certain oversight activities (e.g., periodic reports or briefings) for
GHE as a way to increase transparency into DOD’s execution of such funds.
DOD GHE Workforce
GHE Specialists
Despite a growing demand for GHE, certain observers have noted that the “U.S. military does not
have distinct primary duty designators for global health experts.”66 Instead, GHE activities are
often planned and carried out by individuals in a diverse range of other military occupations (e.g.,
medical planners, health care providers, public health practitioners, security cooperation
specialists, or foreign area officers or regional specialists). Some military services have
established a formal GHE-specific occupation as a secondary duty designator. In 2000, the Air
Force created an international health specialist (IHS) program to develop a cadre of GHE
experts.67 To become an IHS, commissioned medical officers or medical enlisted personnel must
meet the Air Force’s core competencies that can be acquired through “personal experience, self-
study, web-based training, and formal education usually over a significant period of time.”68 In
2017, the Navy established a similar occupational specialty for commissioned medical officers

62 For example, see DOD, Financial Management Regulation 7000.14-R, Volume 3: Budget Execution – Availability
and Use of Budgetary Resources, Chapter 6: Reprogramming of DOD Appropriated Funds, January 2020, at
https://comptroller.defense.gov/Portals/45/documents/fmr/Volume_03.pdf.
63 For more on GHSA targets, see GHSA, “Commitments to the Global Health Security Agenda 2024 Targets,”
accessed April 21, 2022, at https://web.archive.org/web/20220616022111/https://ghsagenda.org/wp-
content/uploads/2020/11/Commitment-Visualization_REV9Nov20.pdf.
64 The White House, National Biodefense Strategy, 2018, pp. 22-25.
65 Thomas R. Cullison, Charles W. Beadling, and Elizabeth Erickson, “Global Health Engagement: A Military
Medicine Core Competency,” Joint Forces Quarterly, vol. 80 (1st Quarter 2016), p. 60.
66 Edwin K. Burkett and Diana L. Aguirre, “Tiers for Education and Training in Global Health for Military
Engagement,” Military Medicine, vol. 185, no. 9 (September/October 2020), p. 411.
67 James A. Chambers, “Global Health Engagement: Good to Great Over the Next 15 Years,” Military Medicine, vol.
181 (February 2016), p. 98.
68 Air Force Instruction 44-162, International Health Specialist (IHS) Program and Global Health Engagement (GHE),
updated March 28, 2019, pp. 12-14, at https://static.e-publishing.af.mil/production/1/af_sg/publication/afi44-162/afi44-
162.pdf.
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(i.e., global health specialists).69 In May 2022, the Air Force Medical Readiness Agency reported
that a total of 309 officers and 95 enlisted personnel had the IHS designator, while the Navy
reported that 291 officers had the global health specialist designator.70 The Marine Corps, Army,
and Space Force do not have any GHE-specific occupations.71
Each military service is responsible for recruiting, training, and maintaining appropriate forces to
meet the needs of the commandant commanders, while at the same time, developing new
capabilities that could be employed in a range of military operations. The knowledge, skills, and
abilities required of an Air Force IHS appears to be similar and comparable to a Navy global
health specialist. However, the Air Force requires formal language education and competency that
is assessed through the Defense Language Proficiency Test.72 While most military services
conduct GHE, there are no standardized core competencies applied across all of the services for
those who plan, conduct, or evaluate these activities.73
In recent years, Congress has conducted oversight activities to ensure the military services
maintain “critical wartime medical readiness skills and core competencies of health care
providers within the Armed Forces.”74 Additionally, Congress has enacted legislation to: limit
certain reductions in military medical personnel, require DOD to assess its military medical
workforce requirements, and direct the Government Accountability Office (GAO) to assess the
anticipated effects of potential military medical workforce reductions.75 As part of ongoing
interest in DOD’s strategy to recruit and retain military medical personnel, Congress could
establish a line of inquiry that seeks to describe DOD’s current and future GHE workforce
requirements, if any; and facilitate standardization and sustainment of core GHE competencies.
Security Cooperation Workforce (SCW)
In 2016, Congress mandated the creation of a DOD Security Cooperation Workforce
Development Program in response to concern over the department’s ability to train and maintain
a skilled security cooperation workforce.76 The conference report accompanying the National
Defense Authorization Act for Fiscal Year 2017 (NDAA; P.L. 114-328) stated:
Despite the increasing emphasis on security cooperation to further its strategic objectives,
the conferees are concerned that the Department of Defense—whether in implementing

69 Department of the Navy, Bureau of Medicine and Surgery Instruction 6400.10, Navy Global Health Engagement
Activities, November 23, 2021, at
https://www.med.navy.mil/Portals/62/Documents/BUMED/Directives/Instructions/BUMEDINST%206400.10.pdf.
70 Email communication with Air Force Medical Readiness Agency and Navy Bureau of Medicine and Surgery
officials, May 2022.
71 Matthew A. Levine, Eric A. Lutz, and Derek Licina, “Global Health Engagement Playbooks: Aligning Tactics with
Strategy Using Standardized Engagement Packages,” Military Medicine, vol. 183 (September/October 2018), pp. 181-
183.
72 Edwin K. Burkett and Diana L. Aguirre, “Tiers for Education and Training in Global Health for Military
Engagement,” Military Medicine, vol. 185, no. 9 (September/October 2020), p. 412.
73 Thomas R. Cullison, Charles W. Beadling, and Elizabeth Erickson, “Global Health Engagement: A Military
Medicine Core Competency,” Joint Forces Quarterly, vol. 80 (1st Quarter 2016), p. 60, at
https://ndupress.ndu.edu/Portals/68/Documents/jfq/jfq-80/jfq-80_54-61_Cullison-et-al.pdf.
74 P.L. 114-328, §725.
75 For example, see P.L. 114-328, §725; P.L. 116-92, §719; P.L. 116-283, §717; P.L. 117-81, §731; and explanatory
statement accompanying the Department of Defense Appropriations Act, 2022 (Division C of P.L. 117-103) in
Congressional Record, vol. 168 (March 9, 2022), pp. H2156-H2157.
76 P.L. 114-328, §1250, codified in 10 U.S.C. §384.
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State Department programs or its own programs—has not devoted sufficient attention and
resources to the development, management, and sustainment of the Department’s security
cooperation workforce to ensure effective assessment, planning, monitoring, execution,
evaluation, and administration of security cooperation programs and initiatives. As a result
of this inattention, security cooperation initiatives are not always planned and implemented
in such a way as to most effectively advance national security objectives, and the Military
Departments are left to pursue their unique service objectives, which may not always align
with broader foreign policy objectives or integrate with Department of Defense efforts.77
The program’s purpose is to “improve the quality and professionalism of the security cooperation
workforce” and requires the DSCA director to issue department-wide guidance on professional
career paths for a military and civilian security cooperation workforce and to identify training and
certification requirements.78 In May 2021, DOD issued policy to implement these requirements
and establish a process for individuals to obtain the SCW certification.79 Each DOD component is
responsible for identifying SCW-related positions in which certification would be required.80
SCW certification is not required to be an Air Force IHS or Navy Global Health Specialist.81
Certain DOD officials have noted that requiring GHE professionals to complete the SCW
development and certification program could provide the department and the Services with
professionals who have a broader understanding of security cooperation and the applicability of
GHE.82 Other experts have noted, “there does not appear to be a central workforce strategy nor
joint human capital development framework for requirements across the DOD and in support of
interagency partners.”83
Congress could consider assessing the utility and effectiveness of DOD’s SCW certification and
further legislate requirements that explicitly apply or exempt the GHE workforce from SCW
training and certification requirements.
DOD GHE Effectiveness
Some observers have noted opportunities for DOD to establish an assessment and evaluation
system that measures the “health and security outcomes” of its GHE activities.84 In 1993, a GAO
report on DOD’s Humanitarian and Civic Assistance (HCA) program, which conducts some GHE
activities, stated that certain projects did not “meet foreign policy objectives.”85 In reviewing

77 H.Rept. 114-840, pp. 1202-1204.
78 P.L. 114-328, §1250.
79 DOD Instruction 5132.15, Implementation of the Security Cooperation Workforce Certification Program, May 7,
2021, at https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/513215p.PDF. For more on the SCW
certification, see https://www.dscu.edu/documents/brochures/brochure-basic-certification.pdf.
80 Ibid., p. 8.
81 CRS analysis of Department of the Air Force, Air Force Instruction 44-162, International Health Specialist (IHS)
Program and Global Health Engagement (GHE), updated March 28, 2019; and Department of the Navy, Bureau of
Medicine and Surgery Instruction 6400.10, Navy Global Health Engagement Activities, November 23, 2021.
82 CRS interview with DOD GHE officials, April 2021.
83 Mark Ediger, Derek Licina, and Emily LaMarsh, “Enhancing the US Military Health System's global health
engagement strategy,” 2022, p. 4, at https://www2.deloitte.com/content/dam/Deloitte/global/Documents/Public-
Sector/gx-gps-global-health-engagement-stratege-white-paper-thought-leadership.pdf.
84 Eugene V. Bonventre, Kathleen H. Hicks, and Stacy M. Okutani, “U.S. National Security and Global Health: An
Analysis of Global Health Engagement by the U.S. Department of Defense,” Center for Strategic and International
Studies, April 2009, p. 16.
85 U.S. Government Accountability Office, Changes Needed to the Humanitarian and Civic Assistance Program,
GAO/NSIAD-94-57, November 1993, pp. 6-7, at https://www.gao.gov/assets/nsiad-94-57.pdf.
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certain HCA projects conducted in South America, GAO found that “medical exercises did not
have long-term goals so progress could be measured in terms of raising the general health of the
population.”86 In the FY2013 NDAA (P.L. 107-314), Congress directed DOD to establish a
process and tools to ensure that DOD GHE activities are “effective and efficient in meeting the
national security goals of the United States.”87 In response to this congressional requirement, the
Uniformed Services University of the Health Sciences (USUHS) led a review of AM&E methods
used by various DOD components and developed a new evaluation framework called the
“Measures Of effectiveness in Defense Engagement and Learning” (MODEL).
The new AM&E framework was designed to be used for GHE and broader security cooperation
activities.88 Despite investments to develop the MODEL approach, DOD policy later directed that
GHE activities be evaluated using the AM&E framework used for security cooperation.89 Though
DOD GHE uses its own security cooperation AM&E framework to evaluate intervention fidelity
(i.e., is the program being delivered as designed?) and to measure short-, medium-, or long-term
effects on partner nations, it is unclear how whole-of-government efforts are measured.
Additionally, it is unclear how DOD’s AM&E framework is congruent with measurement
approaches used by other federal departments and agencies.
Congress could conduct oversight activities to better understand how DOD has implemented
GHE assessment requirements outlined in the FY2013 NDAA (P.L. 112-239), how those methods
align with broader security cooperation AM&E requirements outlined in the FY2016 NDAA (P.L.
114-92), and whether DOD GHE activities actually meet national strategic objectives.90
Congressional Outlook
DOD continues to use GHE as an element of security cooperation and a soft power tool to
achieve certain national security objectives. Simultaneously, DOD GHE is also employed to
contribute to whole-of-government global health, health security, and health diplomacy efforts. In
considering future appropriations and authorizations for DOD, DOS, USAID, Department of
Health and Human Services (HHS), and other federal entities, Congress may opt to rebalance the
demand and resources for DOD GHE to better meet U.S. policy objectives on national security
and/or global health security. In doing so, Congress could potentially expand, curtail, or sustain
DOD GHE capabilities and the department’s utility to affect the health and well-being of partner
nations and the national security of the United States.

86 Ibid.
87 P.L. 112-239, §715.
88 For more on MODEL, see Glendon Diehl et al., “The MODEL Report (2013-2016): Aiming for Measured Success in
DoD AME,” Uniformed Services University of the Health Sciences Center for Global Health Engagement, 2016, at
https://reliefweb.int/report/world/model-report-2013-2016-aiming-measured-success-dod-ame; Glen Diehl and
Solomon Major, “MOE vs. M&E: Considering the Difference Between Measuring Strategic Effectiveness and
Monitoring Tactical Evaluation,” Military Medicine, vol. 180 (January 2015), pp. 77-82.
89 DODI 2000.30, Global Health Engagement (GHE) Activities, July 12, 2017, p. 6.
90 See P.L. 112-239, §715; and P.L. 114-92, §1202.
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Appendix A. Acronyms
Glossary of Acronyms
AFRICOM
U.S. Africa Command
GCC
Geographic Combatant Command
AM&E
Assessment, Monitoring, and
GHE
Global Health Engagement
Evaluation
ASD(HA)
Assistant Secretary of Defense for
GHSA
Global Health Security Agenda
Health Affairs
ASD(HD/GS) Assistant Secretary of Defense for
HCA
Humanitarian and Civic Assistance
Homeland Defense and Global
Security
ASD(NCB)
Assistant Secretary of Defense for
HHS
Department of Health and Human
Nuclear, Chemical, and Biological
Services
Defense Programs
ASD(SO/LIC) Assistant Secretary of Defense for
ICS
Integrated Country Strategy
Special Operations and Low
Intensity Conflict
CDC
U.S. Centers for Disease Control
IHS
International Health Specialist
and Prevention
CGHE
Center for Global Health
INDOPACOM U.S. Indo-Pacific Command
Engagement
DHA
Defense Health Agency
JCS
Joint Chiefs of Staff
DHP
Defense Health Program
MODEL
Measures Of effectiveness in
Defense Engagement and Learning
DOD
Department of Defense
NCB
Nuclear, Chemical, Biological
DOS
Department of State
O&M
Operation and Maintenance
DSCA
Defense Security Cooperation
POLAD
Political Advisor
Agency
DTRA
Defense Threat Reduction Agency
PPBE
Planning, Programming, Budgeting,
and Execution
EUCOM
U.S. European Command
SOUTHCOM
U.S. Southern Command
FHP
Force Health Protection
USAID
U.S. Agency for International
Development
FYDP
Future Years Defense Program
USUHS
Uniformed Services University of
the Health Sciences
GAO
Government Accountability Office

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Appendix B. Historical Examples of GHE Activities
Table B-1. Selected DOD GHE Activities
Calendar Year 2010-2020
Lead
Calendar
GHE
GHE Activity
Description
Combatant
Year
Category
Command
The Defense Threat Reduction Agency
Nuclear,
Engagement
(DTRA) performs health engagement
Chemical, and
activities to
activities with an emphasis on health
Ongoing
Biological
address
security and biological threat reduction
Multiple GCCs
(NCB) Defense
biological
efforts. Globally, DTRA spends over $270
Programs
threats
mil ion annually to address biological
reduction
threats associated with weapons of mass
destruction.a
Medical
U.S. Naval Forces Africa hosts a periodic
humanitarian
maritime security cooperation program,
activities and
Africa Partnership Station, to develop and
Building Partner
engineering
improve maritime response capabilities
Ongoing
Capacity and
projects
while building regional integration. Medical
AFRICOM
Interoperability
tailored to the
and engineering engagements are often
needs of
incorporated based on the partner needs
African partner and priorities.b
nations
Overseas
The Naval Medical Research Unit
NCB Defense
medical labs
(NAMRU) administers medical labs,
Programs
that focus on
including some in overseas locations (e.g.,
AFRICOM
Ongoing
surveillance on
Egypt, Peru, Singapore), that work to meet
SOUTHCOM
infectious and
the public health and disease surveil ance
INDOPACOM
Force Health
drug-resistant
needs of the United States and partner
Protection
diseases
nations.c
Joint U.S.-Thai
NCB Defense
Army medical
Programs
lab that
focuses on
As a partnership between the U.S. Army
infectious
and the Royal Thai Army, the Armed
1958/
disease
Forces Research Institute of Medical
INDOPACOM
Ongoing
diagnoses and
Sciences (AFRIMS) monitors new, emerging
monitoring,
disease threats as part of the Global
Force Health
vaccine
Emerging Diseases Surveillance system.d
Protection
development,
and disease
prevention
A U.S. military field hospital (i.e., medical
Field hospital
tents and equipment) donated to South
Building Partner
and medical
Africa for COVID-19 response. AFRICOM
2020
Capacity and
equipment
also provided in-person training to South
AFRICOM
Interoperability
donation
African medical and support teams selected
to run the mobile hospital.e
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Calendar
GHE
Lead
GHE Activity
Description
Year
Category
Combatant
Command
The Defense Health Agency (DHA) tested
medical scenarios to identify and resolve
Building Partner
any technical issues that may arise in a real-
Capacity and
world event during the 2020 Coalition
Interoperability
Warrior Interoperability Exercise. The
exercise included 22 NATO partners and
Testing large-
tested the secure transmission of patient
2020
scale medical
health information and medical records,
EUCOM
scenarios
and treatment of wounded
servicemembers from point-of-injury to
higher echelons of care. DHA also
Force Health
evaluated simulated transport of injured
Protection
servicemembers to military treatment
facilities during a mass casualty situation
and disease surveillance.f
In support of the U.S. Agency for
International Development, Operation
Humanitarian
United Assistance was a U.S. military
Assistance and
HA/FDR in
HA/FDR response to the Ebola outbreak in
2013-2014
Foreign Disaster response to
West Africa. The operation provided Ebola
AFRICOM
Relief (HA/FDR) Ebola outbreak treatment units, medical research labs, and
a 25-bed medical unit to care for infected
partner nation health care workers.g
Through the Ministry of Defense Advisor
(MoDA) program, DOD personnel are
embedded in partner nation government
Expand
agencies to assist with the development of
Building Partner
partner nation
health capabilities. Since 2012, the MoDA
2012/
Capacity and
military
program has periodically assigned a DOD
EUCOM
Ongoing
Interoperability
medical
medical advisor to certain Eastern
capabilities
European countries (e.g., Georgia, Ukraine)
to assist with the expansion of military
medical capabilities (e.g., wounded warrior
care, health system development).h
In response to a magnitude 7.0 earthquake
that hit the capital city of Port au Prince,
Haiti, the U.S. Southern Command
HA/FDR in
(SOUTHCOM) conducted Operation
2010
HA/FDR
response to a
United Response, an HA/FDR mission. The
SOUTHCOM
natural disaster operation included coordinated efforts
from numerous U.S. governmental and
non-governmental organizations to provide
humanitarian relief to Haiti.i
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Calendar
GHE
Lead
GHE Activity
Description
Year
Category
Combatant
Command
Operation Beyond the Horizon (BTH) in
Guatemala and other Central American
countries provides humanitarian and
community services. This mission conducts
civil-military operations in support of the
2008/
Building Partner
Medical and
partner government. In addition to
Capacity and
engineering
SOUTHCOM
Ongoing
engineering/construction projects, the
Interoperability
engagements
Medical Readiness Training Exercises
(MEDRETEs) provide medical, dental, and
veterinarian services furnished by U.S.
military and local health care providers to
partner nation patients in remote areas. j
Operation Continuing Promise is an annual
Annual
U.S. Navy mission to provide medical,
missions to
2007/
dental, and veterinary care to local
Force Health
provide
populations in Central and South America.
SOUTHCOM
Ongoing
Protection
medical,
The Navy’s hospital ship, USNS Comfort,
dental, and
or another support ship typically
veterinary care spearheads the mission.
Sources:
a. Center for Strategic and International Studies (CSIS), “A Greater Mekong Health Security Partnership: A
Report of the CSIS Task Force on Health and Smart Power in Asia,” July 2013, p. 10, at https://csis-website-
prod.s3.amazonaws.com/s3fs-
public/legacy_files/files/publication/130719_Morrison_GreaterMekongHealth_WEB.pdf.
b. CSIS, “U.S. Navy Humanitarian Assistance in an Era of Austerity,” March 2013, p. 1, at
https://www.csis.org/analysis/us-navy-humanitarian-assistance-era-austerity.
c. Navy Medicine Research and Development, “R&D Commands,” accessed April 14, 2022, at
https://www.med.navy.mil/Naval-Medical-Research-Center/R-D-Commands/.
d. U.S. Army, Armed Forces Research Institute of Medical Sciences, accessed April 13, 2022, at
https://afrims.health.mil/.
e. Al Phil ips, “U.S. Donates Field Hospital to South Africa for COVID-19 Response,” DOD News, November
18, 2020, at https://www.defense.gov/Explore/Features/Story/Article/2418481/us-donates-field-hospital-to-
south-africa-for-covid-19-response.
f.
Military Health System Communications Office, “DHA Proves Power of Col aboration in Medical IT War
Games,” August 18, 2020, at https://health.mil/News/Articles/2020/08/18/DHA-proves-power-of-
col aboration-in-medical-IT-war-games.
g. Joint Staff, “Operation United Assistance: The DOD Response to Ebola in West Africa,” January 6, 2016, at
https://www.jcs.mil/Portals/36/Documents/Doctrine/ebola/OUA_report_jan2016.pdf.
h. DOD, DOD Expeditionary Civilians, “Georgia MoDA Position Description,” January 31, 2019; and DOD, DOD
Expeditionary Civilians, “Ukraine MoDA Position Description,” January 31, 2019.
i.
Gary Cecchine et al., The U.S. Military Response to the 2010 Haiti Earthquake: Considerations for Army Leaders,
RAND Corporation, 2013, at
https://www.rand.org/content/dam/rand/pubs/research_reports/RR300/RR304/RAND_RR304.pdf.
j.
SOUTHCOM, “New Horizons, Beyond the Horizon 2019,” accessed April 13, 2022, at
https://www.southcom.mil/Media/Special-Coverage/New-Horizons-Beyond-the-Horizon-2019/.
k. SOUTHCOM, “Continuing Promise 2018, accessed April 14, 2022, at
https://www.southcom.mil/Media/Special-Coverage/Continuing-Promise-
2018/#:~:text=The%20purpose%20of%20Continuing%20Promise,South%20America%20and%20the%20Carib
bean.

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Appendix C. Selected DOD and DOS Funding
Sources for GHE Activities
Table C-1. Selected DOD and DOS Funding Sources for Security Cooperation
Efforts and GHE Activities
Federal
Depart
Account
DOD
Description
ment
Component
DOD
Operation and Maintenance (O&M),
Defense Security
DSCA-administered or funded
Defense-Widea
Cooperation
security cooperation programs.
Agency (DSCA)
DOD
O&M, Defense-Wide, Direct War
DSCA
DSCA-administered or funded
and Enduring Costs (DWE)b
security cooperation programs for
OCO.
DOD
O&M, Defense-Wide, Overseas
DSCA
Activities to build partner nation
Humanitarian, Disaster, and Civic
capacity for essential humanitarian
Aidc
services.
DOD
O&M, Defense-Wide, Defense
Defense Threat
Activities to prevent proliferation or
Threat Reduction Agencyd
Reduction Agency
use of weapons of mass destruction
(DTRA)
(e.g., biological threat reduction
program).
DOD
O&M, Defense-Wide, DWE,
DTRA
DWE-related activities to prevent
Defense Threat Reduction Agencye
proliferation or use of weapons of
mass destruction (e.g., biological
threat reduction program).
DOD
O&M, Defense-Wide, United States
SOCOM
SOCOM-administered security
Special Operations Command
cooperation activities (i.e., planning,
(SOCOM)f
assessments, monitoring).
DOD
O&M, Defense-Wide, Defense
Office of the
Broad health and medical-related
Health Program (DHP)g
Assistant Secretary
activities encompassing education,
of Defense for
training, research, and direct care.
Health Affairs
DOD
O&M, Armyh
Department of the
Service-administered funds for
Army (DA)
humanitarian and civic assistance
programs.
DOD
O&M, Navyi
Department of the
Service-administered funds for
Navy (DON)
humanitarian and civic assistance
programs.
DOD
O&M, Air Forcej
Department of the
Service-administered funds for
Air Force (DAF)
humanitarian and civic assistance
programs.
DOS
International Security Assistancek
DSCA
DOS-funded, DSCA-administered
security cooperation programs (e.g.,
International Military Education and
Training).
Source: CRS analysis of DOD budget justification documents for the President’s Budget Request Fiscal Year
(FY) 2022, Division C (Defense) of the FY2022 Consolidated Appropriations Act (P.L. 117-103), and Explanatory
Statement accompanying the FY2022 Consolidated Appropriations Act, Congressional Record, vol. 168 (March 9,
2022,), pp. H1866-H2183.
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Notes: For more on these funding sources, see:
a. DOD, “Fiscal Year (FY) 2022 Budget Estimates, Operation and Maintenance, Defense-Wide, Defense
Security Cooperation Agency,” May 2021, at
https://comptrol er.defense.gov/Portals/45/Documents/defbudget/fy2022/budget_justification/pdfs/01_Opera
tion_and_Maintenance/O_M_VOL_1_PART_1/DSCA_OP-5.pdf.
b. DOD, “Fiscal Year (FY) 2022 Budget Estimates, Operation and Maintenance, Direct War and Enduring Cost
Appendix, Defense Security Cooperation Agency,” May 2021, at
https://comptrol er.defense.gov/Portals/45/Documents/defbudget/fy2022/budget_justification/pdfs/01_Opera
tion_and_Maintenance/O_M_VOL_1_PART_2/DSCA_DWE.pdf.
c. DOD, “Fiscal Year (FY) 2022 Budget Estimates, Operation and Maintenance, Defense-Wide Overseas
Humanitarian, Disaster, and Civic Aid,” May 2021, at
https://comptrol er.defense.gov/Portals/45/Documents/defbudget/fy2022/budget_justification/pdfs/01_Opera
tion_and_Maintenance/O_M_VOL_1_PART_2/OHDACA_OP-5.pdf.
d. DOD, “Fiscal Year (FY) 2022 Budget Estimates, Operation and Maintenance, Defense-Wide, Defense
Threat Reduction Agency,” May 2021, at
https://comptrol er.defense.gov/Portals/45/Documents/defbudget/fy2022/budget_justification/pdfs/01_Opera
tion_and_Maintenance/O_M_VOL_1_PART_1/DTRA_OP-5.pdf.
e. DOD, “Fiscal Year (FY) 2022 Budget Estimates, Operation and Maintenance, Defense-Wide, Defense
Threat Reduction Agency,” May 2021, at
https://comptrol er.defense.gov/Portals/45/Documents/defbudget/fy2022/budget_justification/pdfs/01_Opera
tion_and_Maintenance/O_M_VOL_1_PART_2/DTRA_DWE.pdf.
f.
DOD, “Fiscal Year (FY) 2022 Budget Estimates, Operation and Maintenance, Defense-Wide, United States
Special Operations Command,” May 2021, at
https://comptrol er.defense.gov/Portals/45/Documents/defbudget/fy2022/budget_justification/pdfs/01_Opera
tion_and_Maintenance/O_M_VOL_1_PART_1/SOCOM_OP-5.pdf.
g. DOD, “Fiscal Year (FY) 2022 Budget Estimates, Defense Health Program,” Consolidated Health Support, pp.
57-58, at
https://comptrol er.defense.gov/Portals/45/Documents/defbudget/fy2022/budget_justification/pdfs/09_Defen
se_Health_Program/10-Vol_I_Sec_6C-OP-5_Consolidated_Health_Support_DHP_PB22.pdf.
h. DA, “Fiscal Year (FY) 2022 Budget Estimates, Operation and Maintenance, Army,” Volume 1, May 2021, p.
734, at
https://www.asafm.army.mil/Portals/72/Documents/BudgetMaterial/2022/Base%20Budget/Operation%20and
%20Maintenance/OMA_VOL_1_FY_2022_PB.pdf.
i.
DON, “Fiscal Year (FY) 2022 Budget Estimates, Operation and Maintenance, Navy,” May 2021, pp. 19-20, at
https://www.secnav.navy.mil/fmc/fmb/Documents/22pres/OMN_Book.pdf; and DON, “Fiscal Year (FY) 2022
Budget Estimates, Operation and Maintenance, Marine Corps,” May 2021, at
https://www.secnav.navy.mil/fmc/fmb/Documents/22pres/OMMC_Book.pdf.
j.
DAF, “Fiscal Year (FY) 2022 Budget Estimates, Operation and Maintenance, Air Force,” May 2021, p. 5, at
https://www.saffm.hq.af.mil/Portals/84/documents/FY22/OM_/FY22PB%20Volume%20I%20-%20AF%20-
%20FINAL%20to%20PRINT.pdf.
k. DOS, “Congressional Budget Justification,” Foreign Operations, Appendix 2, Fiscal Year 2022, June 2021, at
https://www.state.gov/wp-content/uploads/2021/06/FY-2022-C-J-Appendix-2-FINAL-6-25-2021.pdf.

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Appendix D. Methodology for CRS Interviews of
DOD GHE Subject Matter Experts
Background
Between 2019 and 2021, CRS interviewed various DOD subject matter experts on GHE policy,
activity design, implementation, program evaluation, and education and training. To identify
potential interviewees, CRS used a purposive selection of key informants identified using a
snowball sampling technique.91 In general, interviewees either held GHE leadership positions in
DOD, or were current military GHE planners.
Methodology
CRS conducted in-person or telephonic interviews with key informants from the following DOD
entities:
 Center for Global Health Engagement, Uniformed Services University of the
Health Sciences;
 U.S. Indo-Pacific Command;
 Military services; and the
 Office of the Assistant Secretary of Defense for Nuclear, Chemical, and
Biological Defense Programs.
Using a semi-structured interview format, key informants were asked to respond to the
following questions and to provide additional relevant context:
 What is your understanding of the principal aim of DOD GHE?
 How do the following activities relate to GHE: direct patient care, medical
assistance with logistics/supply chain, disease surveillance, building partner
capacity, or subject matter exchange?
 Has GHE changed over the past two decades? If so, please elaborate.
 How do you know that GHE is successful? How are processes and outcomes
measured?
 What are the top challenges in designing a GHE activity?
 What would you like Congress to know about DOD GHE?
 Are there any additional comments you would like to add regarding this topic?
Interviewee responses were collated, reviewed, analyzed, and triangulated with responses of other
key informants and relevant peer-reviewed literature for emerging GHE themes, recurring
opportunities or challenges, and other points of interest to inform this report.

91 Snowball sampling is a qualitative research technique used to “generate a pool of participants for a research study
through referrals made by individuals who share a particular characteristic of research interest.” For more on snowball
sampling techniques, see Richard Wright and Michael Stein, "Snowball Sampling," in Encyclopedia of Social
Measurement, ed. Kimberly Kempf-Leonard (Elsevier, 2005), pp. 495-500, at https://doi.org/10.1016/B0-12-369398-
5/00087-6.
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Author Information

Bryce H. P. Mendez

Analyst in Defense Health Care Policy

Acknowledgments
U.S. Army Major (Dr.) Erin Tompkins contributed research and analysis to this report during her tenure as
a Defense Health Fellow at CRS from 2020 through 2021.

Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan
shared staff to congressional committees and Members of Congress. It operates solely at the behest of and
under the direction of Congress. Information in a CRS Report should not be relied upon for purposes other
than public understanding of information that has been provided by CRS to Members of Congress in
connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not
subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in
its entirety without permission from CRS. However, as a CRS Report may include copyrighted images or
material from a third party, you may need to obtain the permission of the copyright holder if you wish to
copy or otherwise use copyrighted material.

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