Global Health Engagement in the Department of Defense

Congressional research reportDec 6, 2022

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Global Health Engagement in the Department

of Defense

December 6, 2022

Congressional Research Service

https://crsreports.congress.gov

R47326

SUMMARY

Global Health Engagement in the Department

of Defense

R47326

December 6, 2022

Bryce H. P. Mendez

Analyst in Defense Health

Over the years, Congress has enacted legislation to establish requirements, authorize,

Care Policy

and fund programs that build and promote relationships with other countries to enhance

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-tocivilian 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-tocivilian 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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Global Health Engagement in the Department of Defense

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/ReferenceCenter/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-websiteprod.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/wpcontent/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-theproliferation-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 illness 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-taskforce-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

Oversight

Develop

Policy

Plan

Coordinate

Fund

Execute

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: Bullet () 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/fundamentalsof-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-ofgovernment 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 C1 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)

Congress

Bill or

Report

Number

Section Title

Description

116th

H.R. 6395

(P.L. 116-283)

Department of Defense

Pandemic

Preparedness.

Section 732 requires the Secretary of Defense to

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.

116th

H.R. 6395

COVID-19 Global War

on Pandemics.

Section 722 would require the Secretary of Defense to

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. 115676 (p. 131)

Global Health

Engagement

Organization

Consolidation.

The report directs the Secretary of Defense to brief

the House Armed Services Committee, not later than

April 1, 2019, on the feasibility of consolidating and

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. 11463 (p. 204)

Global Health.

The report encourages the ASD(HA) and USUHS to

establish a “learning tool to assess the efficiency and

effectiveness” of GHE in meeting national security

goals.

113th

S.Rept. 11385 (p. 193)

Global Health

Engagements.

The report encourages the ASD(HA) and USUHS to

establish a “learning tool to assess the efficiency and

effectiveness” of GHE in meeting national security

goals.

113th

S.Rept. 113211 (p. 255)

Global Health.

The report encourages the ASD(HA) and USUHS to

establish a “learning tool to assess the efficiency and

effectiveness” of GHE in meeting U.S. national security

goals.

112th

H.R. 4310

(P.L. 112-239)

Requirement to Ensure

the Effectiveness and

Efficiency of Health

Engagements.

Section 715 requires the Secretary of Defense to

develop a process to ensure that GHE activities are

effective and efficient in meeting U.S. national security

goals.

112th

H.R. 4310

Requirement to Ensure

the Effectiveness and

Efficiency of Health

Engagements.

Section 714 would require the Secretary of Defense to

develop a process to ensure that GHE activities are

effective and efficient in meeting U.S. national security

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/s3fspublic/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/globalhealth-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/departmentdefense-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-ofgovernment 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, selfstudy, 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/wpcontent/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/afi44162.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. 181183.

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/PublicSector/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

Evaluation

GHE

Global Health Engagement

ASD(HA)

Assistant Secretary of Defense for

Health Affairs

GHSA

Global Health Security Agenda

ASD(HD/GS)

Assistant Secretary of Defense for

Homeland Defense and Global

Security

HCA

Humanitarian and Civic Assistance

ASD(NCB)

Assistant Secretary of Defense for

Nuclear, Chemical, and Biological

Defense Programs

HHS

Department of Health and Human

Services

ASD(SO/LIC)

Assistant Secretary of Defense for

Special Operations and Low

Intensity Conflict

ICS

Integrated Country Strategy

CDC

U.S. Centers for Disease Control

and Prevention

IHS

International Health Specialist

CGHE

Center for Global Health

Engagement

INDOPACOM

U.S. Indo-Pacific Command

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

Agency

POLAD

Political Advisor

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

Calendar

Year

Ongoing

GHE