U.S. funding for global health activities has grown significantly over the past decade. Much of the growth in U.S. global health spending has been motivated by infectious disease outbreaks, including human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), severe acute respiratory syndrome (SARS), H5N1 avian influenza (avian flu), extremely drug-resistant tuberculosis (XDR-TB), and the 2009 influenza pandemic. Estimates of U.S. global health assistance vary, due in part to fragmented funding streams and a lack of consensus on what should be considered U.S. global health assistance. Congress provides funds for U.S. global health assistance through a number of appropriations vehicles: Foreign Operations; Labor, Education, and Health; and Defense. The greatest proportion of these funds is provided for the President's Emergency Plan for AIDS Relief (PEPFAR), which supports global HIV/AIDS programs implemented by a number of agencies and departments, including the U.S. Agency for International Development (USAID), the Department of Health and Human Services (HHS) and its implementing agencies, the Department of Commerce, the Department of Defense (DOD), the Department of Labor (DOL), and the Peace Corps. PEPFAR funds are also used for U.S. contributions to the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund), a multilateral organization that supports global HIV/AIDS, TB, and malaria programs. PEPFAR programs aside, the bulk of congressional appropriations for global health efforts are provided to USAID. Congress also provides funds to the Centers for Disease Control and Prevention (CDC) for global health activities. In addition to funds Congress provides directly to U.S. agencies and departments for global health efforts, U.S. agencies and departments also use portions of their budgets for global health programs. For example, CDC regularly allots a part of its tuberculosis budget for international interventions, though Congress does not specify that the funds should be used for those purposes. Agencies and departments might also transfer funds among each other. At times, for instance, USAID transfers some funds to CDC for research and evaluation activities. In addition to these funding sources, U.S. agencies implement programs that simultaneously address development and health challenges, such as those related to 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. A number of advocacy groups consider some of these activities as part of health assistance. This report defines global health assistance as those activities that Congress funds specifically to address global health challenges, unless otherwise indicated (such as global TB activities implemented by CDC). Congress provides funds to USAID and CDC for U.S. global health assistance, and DOD for bilateral HIV programs. It also appropriates funds to the Office of the Global AIDS Coordinator (OGAC) at the Department of State for PEPFAR activities. The bulk of those funds are ultimately transferred to the Department of Commerce, DOD, DOL, HHS, the Peace Corps, and USAID for implementation of global HIV/AIDS activities. Through Foreign Operations Appropriations, Congress specifies support for five key USAID global health programs: child survival and maternal health , aimed at, among other things, reducing morbidity and mortality from key diseases such as polio, measles, and diarrhea, providing vaccines and immunizations, supporting safe delivery, and addressing malnutrition; vulnerable children , aimed at providing services to vulnerable children and orphans, particularly those affected by blindness and war (support for children made vulnerable by HIV/AIDS is provided through HIV/AIDS funds); HIV/AIDS , aimed at preventing and treating HIV/AIDS, particularly among vulnerable populations such as women, girls, and orphans, through voluntary counseling and testing, awareness campaigns, and antiretroviral medicines; other infectious diseases , aimed at addressing a number of diseases and resultant outbreaks, such as those related to pandemic and avian influenza, malaria, tuberculosis (TB), and neglected diseases; and family planning and reproductive health , aimed at increasing access to related services, such as reproductive health education to improve awareness about birth spacing, contraception, and sexually transmitted diseases. Through Labor/HHS Appropriations, Congress specifies support for five key CDC global health programs: HIV/AIDS , aimed at improving capacity in laboratory services and health systems; strengthening in-country capacity to design and implement HIV/AIDS surveillance systems and surveys; and supporting host government capacity to monitor and evaluate the process, outcome, and impact of HIV prevention, care, and treatment programs; M alaria , aimed at designing technical and programmatic strategies, which include training, supervision, laboratory, communications, monitoring and evaluation, and surveillance systems; evaluating impact of long-lasting insecticide-treated nets (LLINs) and monitoring the spread of insecticide resistance; improving surveillance; and evaluating the performance of health workers; Global Disease Detection (GDD) , aimed at strengthening and supporting public health surveillance, training, and laboratory methods; building in-country capacity; and enhancing rapid response capacity for emerging infectious diseases; Immunizations , aimed primarily at immunizing children younger than five years against polio and measles; and Other Global Health programs are aimed at building public health capacity among country leaders, particularly within Ministries of Health. Although Congress does not appropriate funds to CDC specifically for global tuberculosis and pandemic influenza preparedness and response efforts, CDC allots a portion of its overall TB and pandemic preparedness funds for international assistance. In addition to funds that Congress provides to USAID, CDC, and DOD for bilateral HIV/AIDS programs, it appropriates funds to the Department of State to manage PEPFAR funds. The bulk of these funds are subsequently transferred to the above mentioned agencies, as well as the Departments of Commerce and Labor and the Peace Corps. Congress also provides funds to the Departments of State and Health and Human Services for U.S. contributions to the Global Fund ( Table B -4 ). In addition to those areas specified by Congress as global health assistance, websites sponsored by implementing U.S. agencies and departments detail a more expansive view of global health aid (discussed more extensively in Appendix A ). For example, USAID cites its work related to health system strengthening and environmental health. CDC collaborates closely with international organizations, such as the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) to respond to health emergencies, such as cholera outbreaks and pandemic influenza. At the beginning of the George W. Bush Administration, Congress provided $1.4 billion to USAID for global health activities, primarily through the Child Survival and Health (CSH) Programs Fund in the FY2001 Foreign Operations Appropriations Act ( P.L. 106-429 ). In addition, through the FY2001 Consolidated Appropriations Act ( P.L. 106-554 ), Congress provided CDC $529.5 million to conduct domestic and global immunization activities. Included in this amount was $91.2 million for global polio eradication efforts. Prompted by President Clinton's request for support of his LIFE Initiative, Congress also provided funds to a number of U.S. agencies and departments to initiate global HIV/AIDS programs. Specifically, the FY2001 Consolidated Appropriations Act provided DOL $10 million and CDC $104.5 million for global HIV/AIDS activities; and the FY2001 Department of Defense Appropriations ( P.L. 106-259 ), provided DOD $10 million for international HIV/AIDS programs. By the end of the George W. Bush Administration, in FY2008, Congress had nearly doubled its support for USAID's global health programs from FY2001 levels, having provided the agency almost $2.1 billion. The increase in support for USAID's global health activities reflected greater investments in countering infectious diseases, particularly pandemic and avian flu, malaria, and TB. Although appropriations language in each of the fiscal years during the Bush Administration specified that global health interventions would include water and sanitation programs that directly address the needs of mothers and children, support for water and sanitation efforts were funded through the Development Assistance (DA) account and has not been included in annual conference reports on USAID global health appropriations or in annual budget justification language related to global health assistance. Until FY2008, Congress had primarily funded USAID's global health programs through the Child Survival and Health Account. In FY2008, Congress created a new account that combined appropriations for USAID global health activities funded through the CSH account with appropriations to OGAC for the Global HIV/AIDS Initiative and a U.S. contribution to the Global Fund. This new funding stream is now called the Global Health and Child Survival (GHCS) account. By the end of FY2008, Congress had expanded the list of global health efforts that it would fund through CDC and had increased support for CDC's global health programs by about 66% from FY2001 levels. In FY2001, Congress made available $224.1 million to CDC for global health efforts. By FY2008, that figure rose to $372.2 million for global health activities in seven key areas: HIV/AIDS, malaria, TB, global disease detection (GDD), immunizations, pandemic and avian influenza, and other global health programs (which includes training of foreign health practitioners). There were fluctuations, however, during this period: Congress boosted appropriations for the International Mother and Child HIV Prevention Initiative in FY2002-FY2004; increased support for GDD in FY2004-FY2008; and funded pandemic and avian influenza interventions at peak levels in FY2006. Funding for disease interventions has accounted for the greatest increases in U.S. global health spending in recent Congresses. For example, over the past 10 years, U.S. policymakers have shown high levels of interest in supporting and expanding U.S. efforts to fight global HIV/AIDS.