Over the last decade, driven in part by recognition that global health efforts help bolster broader U.S. foreign policy goals, global health programs have received unprecedented attention and resources ( Figure 1 ). U.S. support for global health has been rooted in humanitarian concerns, but since the 1990s, it has been especially motivated by concern over emergent and reemerging infectious diseases and the threats they pose to international development, stability, and security. Outbreaks of diseases like severe acute respiratory syndrome (SARS), pandemic influenza, and HIV/AIDS have led a succession of Presidents to give global health a high priority and to launch several health initiatives in response. In 1996, for example, President Bill Clinton issued a presidential decision directive (PDD) that deemed infectious diseases a threat to U.S. national and international security and called for U.S. global health efforts to be coordinated with those aimed at counterterrorism. Following the release of the directive, President Clinton requested $100 million in 1999 to fund the Leadership and Investment in Fighting an Epidemic (LIFE) Initiative to expand U.S. global HIV/AIDS efforts. President George W. Bush recognized the impact of infectious diseases on global security as well in his 2002 and 2006 national security strategy papers. Along with these statements, President Bush created several global health initiatives, including the President's Emergency Plan for AIDS Relief (PEPFAR), the President's Malaria Initiative (PMI), and the Neglected Tropical Diseases (NTD) Program. President Barack Obama also recognized the risk of infectious diseases and linked the capacity of developing countries to prevent and respond to disease outbreaks to U.S. national security. In 2009, President Obama announced the Global Health Initiative (GHI) to coordinate the health initiatives established during the Bush Administration as well as other United States Agency for International Development (USAID) and Centers for Disease Control and Prevention (CDC) bilateral health programs, increase investments in health areas that he deemed underfunded, and bolster the health systems of weak and impoverished states. Through the State Department's 2010 Quadrennial Diplomacy and Development Review (QDDR) and the 2010 National Security Strategy, the Obama Administration has emphasized the importance of coordinating defense, health, and development efforts and cited the strategic value of improving health around the world, particularly across the Middle East. The Administration sees the GHI as an integral part of a "smart power" approach to foreign policy, whereby diplomacy, development (including health), and defense are leveraged as mutually reinforcing tools. During the Clinton, Bush, and Obama administrations, successive Congresses have demonstrated strong support for global health programs and have, for the most part, appropriated funds for global health in excess of presidential requests. Congressional priorities for global health have largely aligned with those of past administrations, though there has been debate about how certain programs should be prioritized and implemented. In agreement with past administrations, Congress has aimed the majority of global health funding at HIV/AIDS. At the same time, since the launch of the Global Health Initiative, Congress has also supported calls by the Obama Administration to increase investments in health areas other than HIV/AIDS, particularly malaria, maternal and child health, and neglected tropical diseases. Despite strong support by past Congresses for global health programs, some Members of the 112 th Congress have questioned levels of non-security foreign aid in general and have argued for the reduction or elimination of development and health assistance. Although some Members of Congress contend that cuts to these programs could yield important savings, others contend that such reductions would have little impact on the federal deficit but could significantly imperil the lives of vulnerable populations reliant on U.S. assistance. Congress funds bilateral and multilateral health assistance through three appropriations: State, Foreign Operations and Related Programs (State-Foreign Operations); Labor, Health and Human Services, and Education (Labor-HHS); and Department of Defense. These funds support global health efforts managed and conducted by USAID, CDC, and the Department of Defense (DOD) as well as PEPFAR-related efforts that are coordinated by the Department of State and implemented by several U.S. agencies ( Figure 2 ). Under PEPFAR, the United States also supports multilateral efforts to combat HIV/AIDS, including through contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and the Joint United Nations Program on HIV/AIDS (UNAIDS). The Obama Administration's Global Health Initiative represents an effort to improve the alignment and coordination of these various programs, and to track the multiple lines of funding for these programs under a comprehensive global health budget. The Obama Administration named the State Department the head of this effort until September 2012, when leadership of GHI is supposed to transfer to USAID if certain benchmarks are achieved. Nearly 90% of U.S. global health programs are funded through the Global Health Programs (GHP) account (formerly called the Global Health and Child Survival (GHCS) account) in State-Foreign Operations appropriations. Funding through the GHP account supports bilateral and multilateral global health programs managed by USAID and HIV/AIDS programs coordinated and managed by the Department of State under PEPFAR. Charts outlining global health spending provided through State-Foreign Operations and Labor-HHS are included in the Appendix . Congress also makes funds available for global health through other accounts within State-Foreign Operations, including the Development Assistance and the Economic Support Fund accounts. Appropriators do not, however, specify how much should be made available for global health activities through these accounts. Through Labor-HHS appropriations, Congress finances bilateral health programs implemented by CDC, and provides resources to support international HIV/AIDS and malaria research conducted by the National Institutes of Health (NIH). Congress has historically supported an additional contribution to the Global Fund through Labor-HHS appropriations, although beginning in FY2012 the contribution has come from State-Foreign Operations appropriations alone. Defense appropriations fund HIV-prevention efforts conducted by DOD and provide resources to DOD to support global malaria research. In addition to funds Congress provides specifically for global health, U.S. agencies and departments may use other portions of their budgets on global health programs. For example, CDC uses some of its funds to support global TB programming, although it does not receive a direct appropriation to do so. U.S. agencies and departments also transfer funds among each other. For instance, the Department of State transfers the majority of the funds it receives from Congress for global HIV/AIDS activities to implementing agencies such as USAID and CDC. Likewise, USAID may transfer funds to CDC for field research and evaluation of global health programs. U.S. agencies also receive funds to implement programs that simultaneously address development and health challenges. These efforts may include improving access to clean water, addressing the negative consequences of climate change and rapid urbanization, supporting the vulnerable in conflict or post-conflict environments, and responding to natural emergencies. In light of these different funding streams and a lack of consensus on exactly which programs and activities constitute global health assistance, estimates of U.S. global health spending by U.S agencies, think tanks, and other observers vary. A number of advocacy groups, for example, consider water and sanitation activities as part of global health assistance. Similarly, the websites of some U.S. agencies and departments describe a broader view of global health aid than what is provided through congressional appropriations. For example, USAID cites its work related to health system strengthening and environmental health as global health activities. CDC also includes collaborative responses to global health emergencies, such as cholera outbreaks and pandemic influenza, with international organizations like the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) among its global health work. The section below describes bilateral health activities funded by Congress. This includes global health programs implemented by USAID and CDC as well as interagency presidential global health initiatives including the President's Emergency Plan for AIDS Relief (PEPFAR), the President's Malaria Initiative (PMI), the Neglected Tropical Disease Program (NTD Program), and the Global Health Initiative. While the presidential initiatives are described, activities conducted by each agency as part of these initiative are not detailed here, such as PEPFAR-related efforts by DOD and NIH. Likewise, funding for multilateral organizations, like the Global Fund, is not discussed in detail. Through State-Foreign Operations appropriations, Congress supports the following overarching USAID global health program areas: Saving Mothers and Children , which includes programs focusing on maternal and child health, malaria, nutrition, family planning and reproductive health, and social services (vulnerable children). This portfolio aims to save the lives of women and children through reduced morbidity and mortality from common diseases and undernutrition; provide services to vulnerable children and orphans; increase access to family planning and reproductive health; and improve awareness about birth spacing, contraception, and sexually transmitted diseases. Creating an AIDS-free Generation , which aims to prevent, treat, and address the impacts of HIV/AIDS—particularly among vulnerable populations such as women, girls, and orphans—through voluntary counseling and testing, awareness campaigns, and supplying antiretroviral medicines, among other activities. Fighting Other Infectious Diseases , which aims to address a number of diseases and resultant outbreaks, including through programs targeting tuberculosis (TB), pandemic influenza and other emerging threats, and neglected tropical diseases (NTDs). Through Labor-HHS appropriations, Congress supports the following CDC global health program areas: HIV/AIDS , which aims to improve capacity in laboratory services and health systems; strengthen in-country capacity to design and implement HIV/AIDS surveillance systems and surveys; and support host-government capacity to monitor and evaluate the process, outcome, and impact of HIV prevention, care, and treatment programs.