[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[S. 3775 Introduced in Senate (IS)]








109th CONGRESS
  2d Session
                                S. 3775

To amend the Foreign Assistance Act of 1961 to assist countries in sub-
  Saharan Africa in the effort to achieve internationally recognized 
   goals in the treatment and prevention of HIV/AIDS and other major 
diseases and the reduction of maternal and child mortality by improving 
 human health care capacity and improving retention of medical health 
      professionals in sub-Saharan Africa, and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             August 2, 2006

Mr. Durbin (for himself, Mr. Coleman, Mr. DeWine, Mr. Feingold, and Mr. 
Leahy) introduced the following bill; which was read twice and referred 
                 to the Committee on Foreign Relations

_______________________________________________________________________

                                 A BILL


 
To amend the Foreign Assistance Act of 1961 to assist countries in sub-
  Saharan Africa in the effort to achieve internationally recognized 
   goals in the treatment and prevention of HIV/AIDS and other major 
diseases and the reduction of maternal and child mortality by improving 
 human health care capacity and improving retention of medical health 
      professionals in sub-Saharan Africa, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``African Health Capacity Investment 
Act of 2006''.

SEC. 2. DEFINITIONS.

    In this Act, the term ``HIV/AIDS'' has the meaning given such term 
in section 104A(g) of the Foreign Assistance Act of 1961 (22 U.S.C. 
2151b-2(g)).

SEC. 3. FINDINGS.

    Congress makes the following findings:
            (1) The World Health Report, 2003, Shaping the Future, 
        states, ``The most critical issue facing health care systems is 
        the shortage of people who make them work.''.
            (2) The World Health Report, 2006, Working Together for 
        Health, states, ``The unmistakable imperative is to strengthen 
        the workforce so that health systems can tackle crippling 
        diseases and achieve national and global health goals. A strong 
        human infrastructure is fundamental to closing today's gap 
        between health promise and health reality and anticipating the 
        health challenges of the 21st century.''.
            (3) The shortage of health personnel, including doctors, 
        nurses, pharmacists, counselors, paraprofessionals, and trained 
        lay workers is one of the leading obstacles to fighting HIV/
        AIDS in sub-Saharan Africa.
            (4) The HIV/AIDS pandemic aggravates the shortage of health 
        workers through loss of life and illness among medical staff, 
        unsafe working conditions for medical personnel, and increased 
        workloads for diminished staff, while the shortage of health 
        personnel undermines efforts to prevent and provide care and 
        treatment for those with HIV/AIDS.
            (5) Workforce constraints and inefficient management are 
        limiting factors in the treatment of tuberculosis, which 
        infects over \1/3\ of the global population.
            (6) Over 1,200,000 people die of malaria each year. More 
        than 75 percent of these deaths occur among African children 
        under the age of 5 years old and the vast majority of these 
        deaths are preventable. The Malaria Initiative of President 
        George W. Bush seeks to reduce dramatically the disease burden 
        of malaria through both prevention and treatment. 
        Paraprofessionals can be instrumental in reducing mortality and 
        economic losses associated with malaria and other health 
        problems.
            (7) For a woman in sub-Saharan Africa, the lifetime risk of 
        maternal death is 1 out of 16. In highly developed countries, 
        that risk is 1 out of 2,800. Increasing access to skilled birth 
        attendants is essential to reducing maternal and newborn 
        mortality in sub-Saharan Africa.
            (8) The Second Annual Report to Congress on the progress of 
        the President's Emergency Plan for AIDS Relief identifies the 
        strengthening of essential health care systems through health 
        care networks and infrastructure development as critical to the 
        sustainability of funded assistance by the United States 
        Government and states that ``outside resources for HIV/AIDS and 
        other development efforts must be focused on transformational 
        initiatives that are owned by host nations''. This report 
        further states, ``Alongside efforts to support community 
        capacity-building, enhancing the capacity of health care and 
        other systems is also crucial for sustainability. Among the 
        obstacles to these efforts in many nations are inadequate human 
        resources and capacity, limited institutional capacity, and 
        systemic weaknesses in areas such as: quality assurance; 
        financial management and accounting; health networks and 
        infrastructure; and commodity distribution and control.''.
            (9) Vertical disease control programs represent vital 
        components of United States foreign assistance policy, but 
        human resources for health planning and management often 
        demands a more systematic approach.
            (10) Implementation of capacity-building initiatives to 
        promote more effective human resources management and 
        development may require an extended horizon to produce 
        measurable results, but such efforts are critical to 
        fulfillment of many internationally recognized objectives in 
        global health.
            (11) The November 2005 report of the Working Group on 
        Global Health Partnerships for the High Level Forum on the 
        Health Millennium Development Goals entitled ``Best Practice 
        Principles for Global Health Partnership Activities at Country 
        Level'', raises the concern that the collective impact of 
        various global health programs now risks ``undermining the 
        sustainability of national development plans, distorting 
        national priorities, diverting scarce human resources and/or 
        establishing uncoordinated service delivery structures'' in 
        developing countries. This risk underscores the need to 
        coordinate international donor efforts for these vital programs 
        with one another and with recipient countries.
            (12) The emigration of significant numbers of trained 
        health care professionals from sub-Saharan African countries to 
        the United States and other wealthier countries exacerbates 
        often severe shortages of health care workers, undermines 
        economic development efforts, and undercuts national and 
        international efforts to improve access to essential health 
        services in the region.
            (13) Addressing this problem, commonly referred to as 
        ``brain drain'', will require increased investments in the 
        health sector by sub-Saharan African governments and by 
        international partners seeking to promote economic development 
        and improve health care and mortality outcomes in the region.
            (14) Virtually every country in the world, including the 
        United States, is experiencing a shortage of health workers. 
        The Joint Learning Initiative on Human Resources for Health and 
        Development estimates that the global shortage exceeds 
        4,000,000 workers. Shortages in sub-Saharan Africa, however, 
        are far more acute than in any other region of the world. The 
        World Health Report, 2006, states that ``[t]he exodus of 
        skilled professionals in the midst of so much unmet health need 
        places Africa at the epicentre of the global health workforce 
        crisis.''.
            (15) Ambassador Randall Tobias, now the Director of United 
        States Foreign Assistance and Administrator of the United 
        States Agency for International Development, has stated that 
        there are more Ethiopian trained doctors practicing in Chicago 
        than in Ethiopia.
            (16) According to the United Nations Development Programme, 
        Human Development Report 2003, approximately 3 out of 4 
        countries in sub-Saharan Africa have fewer than 20 physicians 
        per 100,000 people, the minimum ratio recommended by the World 
        Health Organization, and 13 countries have 5 or fewer 
        physicians per 100,000 people.
            (17) Nurses play particularly important roles in sub-
        Saharan African health care systems, but approximately \1/4\ of 
        sub-Saharan African countries have fewer than 50 nurses per 
        100,000 people or less than \1/2\ the staffing levels 
        recommended by the World Health Organization.
            (18) Paraprofessionals can be trained more quickly than 
        nurses or doctors and are critically needed in sub-Saharan 
        Africa to meet immediate health care needs.
            (19) Imbalances in the distribution of countries' health 
        workforces represents a global problem, but the impact is 
        particularly acute in sub-Saharan Africa.
            (20) In Malawi, for example, more than 95 percent of 
        clinical officers are in urban health facilities, and about 25 
        percent of nurses and 50 percent of physicians are in the 4 
        central hospitals of Malawi. Yet the population of Malawi is 
        estimated to be 87 percent rural.
            (21) In parts of sub-Saharan Africa, such as Kenya, 
        thousands of qualified health professionals are employed 
        outside the health care field or are unemployed despite job 
        openings in the health sector in rural areas because poor 
        working and living conditions, including poor educational 
        opportunities for children, transportation, and salaries, make 
        such openings unattractive to candidates.
            (22) The 2002 National Security Strategy of the United 
        States stated, ``The scale of the public health crisis in poor 
        countries is enormous. In countries afflicted by epidemics and 
        pandemics like HIV/AIDS, malaria, and tuberculosis, growth and 
        development will be threatened until these scourges can be 
        contained. Resources from the developed world are necessary but 
        will be effective only with honest governance, which supports 
        prevention programs and provides effective local 
        infrastructure.''.
            (23) Public health deficiencies in sub-Saharan Africa and 
        other parts of the developing world reduce global capacities to 
        detect and respond to potential crises, such as an avian flu 
        pandemic.
            (24) On September 28, 2005, Secretary of State Condoleezza 
        Rice declared that ``HIV/AIDS is not only a human tragedy of 
        enormous magnitude; it is also a threat to the stability of 
        entire countries and to the entire regions of the world.''.
            (25) Foreign assistance by the United States that expands 
        local capacities, provides commodities or training, or builds 
        on and enhances community-based and national programs and 
        leadership can increase the impact, efficiency, and 
        sustainability of funded efforts by the United States.
            (26) African health care professionals immigrate to the 
        United States for the same set of reasons that have led 
        millions of people to come to this country, including the 
        desire for freedom, for economic opportunity, and for a better 
        life for themselves and their children, and the rights and 
        motivations of these individuals must be respected.
            (27) Helping countries in sub-Saharan Africa increase 
        salaries and benefits of health care professionals, improve 
        working conditions, including the adoption of universal 
        precautions against workplace infection, improve management of 
        health care systems and institutions, increase the capacity of 
        health training institutions, and expand education 
        opportunities will alleviate some of the pressures driving the 
        migration of health care personnel from sub-Saharan Africa.
            (28) While the scope of the problem of dire shortfalls of 
        personnel and inadequacies of infrastructure in the sub-Saharan 
        African health systems is immense, effective and targeted 
        interventions to improve working conditions, management, and 
        productivity would yield significant dividends in improved 
        health care.
            (29) Failure to address the shortage of health care 
        professionals and paraprofessionals, and the factors pushing 
        individuals to leave sub-Saharan Africa will undermine the 
        objectives of United States development policy and will subvert 
        opportunities to achieve internationally recognized goals for 
        the treatment and prevention of HIV/AIDS and other diseases, in 
        the reduction of child and maternal mortality, and for economic 
        growth and development in sub-Saharan Africa.

SEC. 4. SENSE OF CONGRESS.

    It is the sense of Congress that--
            (1) the United States should help sub-Saharan African 
        countries that have not already done so to develop national 
        human resource plans within the context of comprehensive 
        country health plans involving a wide range of stakeholders;
            (2) comprehensive, rather than piecemeal approaches to 
        advance multiple sustainable interventions will better enable 
        countries to plan for the number of health care workers they 
        need, determine whether they need to reorganize their health 
        workforce, integrate workforce planning into an overall 
        strategy to improve health system performance and impact, 
        better budget for health care spending, and improve the 
        delivery of health services in rural and other underserved 
        areas;
            (3) in order to promote systemic, sustainable change, the 
        United States should seek, where possible, to strengthen 
        existing national systems in sub-Saharan African countries to 
        improve national capacities in areas including fiscal 
        management, training, recruiting and retention of health 
        workers, distribution of resources, attention to rural areas, 
        and education;
            (4) because foreign-funded efforts to fight HIV/AIDS and 
        other diseases may also draw health personnel away from the 
        public sector in sub-Saharan African countries, the policies 
        and programs of the United States should, where practicable, 
        seek to work with national and community-based health 
        structures and seek to promote the general welfare and enhance 
        infrastructures beyond the scope of a single disease or 
        condition;
            (5) paraprofessionals and community-level health workers 
        can play a key role in prevention, care, and treatment 
        services, and in the more equitable and effective distribution 
        of health resources, and should be integrated into national 
        health systems;
            (6) given the current personnel shortages in sub-Saharan 
        Africa, paraprofessionals represent a critical potential 
        workforce in efforts to reduce the burdens of malaria, 
        tuberculosis, HIV/AIDS, and other deadly and debilitating 
        diseases;
            (7) it is critically important that the governments of sub-
        Saharan African countries increase their own investments in 
        education and health care;
            (8) international financial institutions have an important 
        role to play in the achievement of internationally agreed upon 
        health goals, and in helping countries strike the appropriate 
        balance in encouraging effective public investments in the 
        health and education sectors, particularly as foreign 
        assistance in these areas scales up, and promoting 
        macroeconomic stability;
            (9) public-private partnerships are needed to promote 
        creative contracts, investments in sub-Saharan African 
        educational systems, codes of conduct related to recruiting, 
        and other mechanisms to alleviate the adverse impacts on sub-
        Saharan African countries caused by the migration of health 
        professionals;
            (10) colleges and universities of the United States, as 
        well as other members of the private sector, can play a 
        significant role in promoting training in medicine and public 
        health in sub-Saharan Africa by establishing or supporting in-
        country programs in sub-Saharan Africa through twinning 
        programs with educational institutions in sub-Saharan Africa or 
        through other in-country mechanisms;
            (11) given the substantial numbers of African immigrants to 
        the United States working in the health sector, the United 
        States should enact and implement measures to permit qualified 
        aliens and their family members that are legally present in the 
        United States to work temporarily as health care professionals 
        in developing countries or in other emergency situations, as in 
        S. 2611, of the 109th Congress, as passed by the Senate on May 
        25, 2006;
            (12) the President, acting through the United States 
        Permanent Representative to the United Nations, should exercise 
        the voice and vote of the United States--
                    (A) to ameliorate the adverse impact on less 
                developed countries of the migration of health 
                personnel;
                    (B) to promote voluntary codes of conduct for 
                recruiters of health personnel; and
                    (C) to promote respect for voluntary agreements in 
                which individuals, in exchange for individual 
                educational assistance, have agreed either to work in 
                the health field in their home countries for a given 
                period of time or to repay such assistance;
            (13) the United States, like countries in other parts of 
        the world, is experiencing a shortage of medical personnel in 
        many occupational specialties, and the shortage is particularly 
        acute in rural and other underserved areas of the country; and
            (14) the United States should expand training opportunities 
        for health personnel, expand incentive programs such as student 
        loan forgiveness for Americans willing to work in underserved 
        areas, and take other steps to increase the number of health 
        personnel in the United States.

SEC. 5. ASSISTANCE TO INCREASE HUMAN CAPACITY IN THE HEALTH SECTOR IN 
              SUB-SAHARAN AFRICA.

    Chapter 1 of part I of the Foreign Assistance Act of 1961 (22 
U.S.C. 2151 et seq.) is amended by adding at the end the following new 
section:

``SEC. 135. ASSISTANCE TO INCREASE HUMAN CAPACITY IN THE HEALTH SECTOR 
              IN SUB-SAHARAN AFRICA.

    ``(a) Assistance.--
            ``(1) Authority.--The President is authorized to provide 
        assistance, including providing assistance through 
        international or nongovernmental organizations, for programs in 
        sub-Saharan Africa to improve human health care capacity.
            ``(2) Types of assistance.--Such programs should include 
        assistance--
                    ``(A) to provide financial and technical assistance 
                to sub-Saharan African countries in developing and 
                implementing new or strengthened comprehensive national 
                health workforce plans;
                    ``(B) to build and improve national and local 
                capacities and sustainable health systems management in 
                sub-Saharan African countries, including financial, 
                strategic, and technical assistance for--
                            ``(i) fiscal and health personnel 
                        management;
                            ``(ii) health worker recruitment systems;
                            ``(iii) the creation or improvement of 
                        computerized health workforce databases and 
                        other human resource information systems;
                            ``(iv) implementation of measures to reduce 
                        corruption in the health sector; and
                            ``(v) monitoring, evaluation, and quality 
                        assurance in the health field, including the 
                        utilization of national and district-level 
                        mapping of health care systems to determine 
                        capacity to deliver health services;
                    ``(C) to train and retain sufficient numbers of 
                health workers, including paraprofessionals, to provide 
                essential health services in sub-Saharan African 
                countries, including financing, strategic technical 
                assistance for--
                            ``(i) health worker safety and health care, 
                        including HIV/AIDS prevention and off-site 
                        testing and treatment programs for health 
                        workers;
                            ``(ii) increased capacity for training 
                        health professionals and paraprofessionals in 
                        such subjects as human resources planning and 
                        management, health program management, and 
                        quality improvement;
                            ``(iii) expanded access to secondary level 
                        math and science education;
                            ``(iv) expanded capacity for nursing and 
                        medical schools in sub-Saharan Africa, with 
                        particular attention to incentives or 
                        mechanisms to encourage graduates to work in 
                        the health sector in their country of 
                        residence;
                            ``(v) incentives and policies to increase 
                        retention, including salary incentives;
                            ``(vi) modern quality improvement processes 
                        and practices;
                            ``(vii) continuing education, distance 
                        education, and career development opportunities 
                        for health workers;
                            ``(viii) mechanisms to promote productivity 
                        within existing and expanding health 
                        workforces; and
                            ``(ix) achievement of minimum 
                        infrastructure requirements for health 
                        facilities, such as access to clean water;
                    ``(D) to support sub-Saharan African countries with 
                financing, technical support, and personnel, including 
                paraprofessionals and community-based caregivers, to 
                better meet the health needs of rural and other 
                underserved populations by providing incentives to 
                serve in these areas, and to more equitably distribute 
                health professionals and paraprofessionals;
                    ``(E) to support efforts to improve public health 
                capacities in sub-Saharan Africa through education, 
                leadership development, and other mechanisms;
                    ``(F) to provide technical assistance, equipment, 
                training, and supplies to assist in the improvement of 
                health infrastructure in sub-Saharan Africa;
                    ``(G) to promote efforts to improve systematically 
                human resource management and development as a critical 
                health and development issue in coordination with 
                specific disease control programs for sub-Saharan 
                Africa; and
                    ``(H) to establish a global clearinghouse or 
                similar mechanism for knowledge sharing regarding human 
                resources for health, in consultation, if helpful, with 
                the Global Health Workforce Alliance.
            ``(3) Monitoring and evaluation.--
                    ``(A) In general.--The President shall establish a 
                monitoring and evaluation system to measure the 
                effectiveness of assistance by the United States to 
                improve human health care capacity in sub-Saharan 
                Africa in order to maximize the sustainable development 
                impact of assistance authorized under this section and 
                pursuant to the strategy required under subsection (b).
                    ``(B) Requirements.--The monitoring and evaluation 
                system shall--
                            ``(i) establish performance goals for 
                        assistance provided under this section;
                            ``(ii) establish performance indicators to 
                        be used in measuring or assessing the 
                        achievement of performance goals;
                            ``(iii) provide a basis for recommendations 
                        for adjustments to the assistance to enhance 
                        the impact of the assistance; and
                            ``(iv) to the extent feasible, utilize and 
                        support national monitoring and evaluation 
                        systems, with the objective of improved data 
                        collection without the imposition of 
                        unnecessary new burdens.
    ``(b) Strategy of the United States.--
            ``(1) Requirement for strategy.--Not later than 180 days 
        after the date of enactment of this Act, the President shall 
        develop and transmit to the appropriate congressional 
        committees a strategy for coordinating, implementing, and 
        monitoring assistance programs for human health care capacity 
        in sub-Saharan Africa.
            ``(2) Content.--The strategy required by paragraph (1) 
        shall include--
                    ``(A) a description of a coordinated strategy, 
                including coordination among agencies and departments 
                of the Federal Government with other bilateral and 
                multilateral donors, to provide the assistance 
                authorized in subsection (a);
                    ``(B) a description of a coordinated strategy to 
                consult with sub-Saharan African countries and the 
                African Union on how best to advance the goals of this 
                Act; and
                    ``(C) an analysis of how international financial 
                institutions can most effectively assist countries in 
                their efforts to expand and better direct public 
                spending in the health and education sectors in tandem 
                with the anticipated scale up of international 
                assistance to combat HIV/AIDS and other health 
                challenges, while simultaneously helping these 
                countries maintain prudent fiscal balance.
            ``(3) Focus of analysis.--It is suggested that the analysis 
        described in paragraph (2)(C) focus on 2 or 3 selected 
        countries in sub-Saharan Africa, including, if practical, 1 
        focus country as designated under the President's Emergency 
        Plan for AIDS Relief (authorized by the United States 
        Leadership Against Global HIV/AIDS, Tuberculosis, and Malaria 
        Act of 2003 (Public Law 108-25)) and 1 country without such a 
        designation.
            ``(4) Consultation.--The President is encouraged to develop 
        the strategy required under paragraph (1) in consultation with 
        the Secretary of State, the Administrator for the United States 
        Agency for International Development, including employees of 
        its field missions, the Global HIV/AIDS Coordinator, the Chief 
        Executive Officer of the Millennium Challenge Corporation, the 
        Secretary of the Treasury, the Director of the Bureau of 
        Citizenship and Immigration Services, the Director of the 
        Centers for Disease Control and Prevention, and other relevant 
        agencies to ensure coordination within the Federal Government.
            ``(5) Coordination.--
                    ``(A) Development of strategy.--To ensure 
                coordination with national strategies and objectives 
                and other international efforts, the President should 
                develop the strategy described in paragraph (1) by 
                consulting appropriate officials of the United States 
                Government and by coordinating with the following:
                            ``(i) Other donors.
                            ``(ii) Implementers.
                            ``(iii) International agencies.
                            ``(iv) Nongovernmental organizations 
                        working to increase human health capacity in 
                        sub-Saharan Africa.
                            ``(v) The World Bank.
                            ``(vi) The International Monetary Fund.
                            ``(vii) The Global Fund to Fight AIDS, 
                        Tuberculosis, and Malaria.
                            ``(viii) The World Health Organization.
                            ``(ix) The International Labour 
                        Organization.
                            ``(x) The United Nations Development 
                        Programme.
                            ``(xi) The United Nations Programme on HIV/
                        AIDS.
                            ``(xii) The European Union.
                            ``(xiii) The African Union.
                    ``(B) Assessment and compilation.--The President 
                should make the assessments and compilations required 
                by subsection (a)(3)(B)(v), in coordination with the 
                entities listed in subparagraph (A).
    ``(c) Report.--
            ``(1) In general.--Not later than 1 year after the date on 
        which the President submits the strategy required in subsection 
        (b), the President shall submit to the appropriate 
        congressional committees a report on the implementation of this 
        section.
            ``(2) Assessment of mechanisms for knowledge sharing.--The 
        report described in paragraph (1) shall be accompanied by a 
        document assessing best practices and other mechanisms for 
        knowledge sharing about human resources for health and capacity 
        building efforts to be shared with governments of developing 
        countries and others seeking to promote improvements in human 
        resources for health and capacity building.
    ``(d) Definitions.--In this section:
            ``(1) Appropriate congressional committees.--The term 
        `appropriate congressional committees' means the Committee on 
        Foreign Relations and the Committee on Appropriations of the 
        Senate and the Committee on International Relations and the 
        Committee on Appropriations of the House of Representatives.
            ``(2) Brain drain.--The term `brain drain' means the 
        emigration of a significant proportion of a country's 
        professionals working in the health field to wealthier 
        countries, with a resulting loss of personnel and often a loss 
        in investment in education and training for the countries 
        experiencing the emigration.
            ``(3) Health professional.--The term `health professional' 
        means a person whose occupation or training helps to identify, 
        prevent, or treat illness or disability.
            ``(4) HIV/AIDS.--The term `HIV/AIDS' has the meaning given 
        such term in section 104A(g) of the Foreign Assistance Act of 
        1961 (22 U.S.C. 2151b-2(g)).
    ``(e) Authorization of Appropriations.--
            ``(1) In general.--There are authorized to be appropriated 
        to the President to carry out the provisions of this section--
                    ``(A) $100,000,000 for fiscal year 2007;
                    ``(B) $150,000,000 for fiscal year 2008; and
                    ``(C) $200,000,000 for fiscal year 2009.
            ``(2) Availability of funds.--Amounts made available under 
        paragraph (1) are authorized to remain available until expended 
        and are in addition to amounts otherwise made available for the 
        purpose of carrying out this section.''.
                                 <all>