[Congressional Record Volume 152, Number 105 (Wednesday, August 2, 2006)]
[Senate]
[Pages S8614-S8616]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. DURBIN (for himself, Mr. Coleman, Mr. DeWine, Mr. 
        Feingold, and Mr. Leahy):
  S. 3775. 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; to the Committee on Foreign Relations.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:
  Mr. DURBIN. Mr. President, I ask unanimous consent that the text of 
the bill be printed in the Record.

                                S. 3775

       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

[[Page S8615]]

     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.

[[Page S8616]]

       ``(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.''.
                                 ______