1.This Act may be cited as
the African Health Capacity Investment
Act of 2007
.
2.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)).
3.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,
laboratory staff, 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 and community healthworkers 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 and access to emergency obstetrical care 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)(15) 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)(16) Nurses play particularly
important roles in sub-Saharan African health care systems, but approximately ¼
of sub-Saharan African countries have fewer than 50 nurses per 100,000 people
or less than ½ the staffing levels recommended by the World Health
Organization.
(18)(17) Paraprofessionals and
community health workers can be trained more quickly than nurses or doctors and
are critically needed in sub-Saharan Africa to meet immediate health care
needs.
(19)(18) Imbalances in the
distribution of countries' health workforces represents
a global problem, but the impact is particularly acute in sub-Saharan
Africa.
(20)(19) 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)(20) 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)(21) 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)(22) 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)(23) 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)(24) 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)(25) 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)(26) 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)(27) 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)(28) 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.
4.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 and community
health workers 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 people of the United
States willing to work in underserved areas, and take other steps to increase
the number of health personnel in the United States.
5.Assistance to
increase human capacity in the health sector in sub-Saharan
AfricaChapter 1 of part I of
the Foreign Assistance Act of 1961 (22 U.S.C.
2151 et seq.) is amended—
(1)by redesignating the section 135 that was
added by section 5 of the Senator Paul Simon Water for the Poor Act of 2005
(Public Law 109–121; 22 U.S.C. 2152h note) as section 136; and
(2)by adding at the end the following new
section:
137.Assistance to
increase human capacity in the health sector in sub-Saharan Africa
(a)
(1)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)Such programs
shouldmay 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 and
community health workers, 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)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)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)Not later than 180 days after the date of the 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)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)The analysis described in paragraph (2)(C)
should 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)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)
(A)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
compilationThe President should make the assessments and
compilations required by subsection (a)(3)(B)(v), in coordination with the
entities listed in subparagraph (A).
(5)To
ensure coordination with national strategies and objectives and other
international efforts, the President should develop the strategy described
in paragraph (1) by coordinating with the
following:
(A)Other donors.
(B)Implementers.
(C)International
agencies.
(D)Nongovernmental
organizations working to increase human health capacity in sub-Saharan
Africa.
(E)The World Bank.
(F)The International
Monetary Fund.
(G)The Global Fund to Fight
AIDS, Tuberculosis, and Malaria.
(H)The World Health
Organization.
(I)The International Labour
Organization.
(J)The United Nations
Development Programme.
(K)The United Nations
Programme on HIV/AIDS.
(L)The European
Union.
(M)The African Union.
(c)
(1)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 sharingThe 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.
(3)Not later than 3 years after the date on which the
President submits the strategy required in subsection (b), the
presidentPresident shall submit to the
appropriate congressional committees a further report on the implementation of
this section.
(d)In
this section:
(1)Appropriate
congressional committeesThe
term appropriate congressional committees means the Committee on
Foreign Relations and the Committee on Appropriations of the Senate and the
Committee on
International
RelationsForeign Affairs and the
Committee on Appropriations of the House of Representatives.
(2)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)The term health professional means a
person whose occupation or training helps to identify, prevent, or treat
illness or disability.
(4)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)).
(5)The
term paraprofessional means an individual who is trained and
employed as a health agent for the provision of basic assistance in the
identification, prevention, or treatment of illness or disability.
(6)The term community health worker
means a community based caregiver who has received instruction and is employed
to provide basic health services in specific catchment areas, most often the
areas where they themselves live.
(e)Authorization
of Appropriations
(1)There are authorized to be appropriated to the President
to carry out the provisions of this section—
(A)$150,000,000 for
fiscal year 2008;
(B)$200,000,000 for
fiscal year 2009; and
(C)$250,000,000 for
fiscal year 2010.
(2)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.
.
October 9, 2007
Reported with amendments