[Senate Report 110-192] [From the U.S. Government Publishing Office] Calendar No. 414 110th Congress Report SENATE 1st Session 110-192 ====================================================================== AFRICAN HEALTH CAPACITY INVESTMENT ACT OF 2007 _______ October 9, 2007.--Ordered to be printed Filed under the authority of the order of the Senate of October 4, 2007 Mr. Biden, from the Committee on Foreign Relations, submitted the following R E P O R T [To accompany S. 805] The Committee on Foreign Relations, having had under consideration S. 805, 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, reports favorably thereon and recommends that the bill do pass. CONTENTS Page I. Purpose..........................................................1 II. Committee Action.................................................1 III. Discussion.......................................................2 IV. Cost Estimate....................................................2 V. Evaluation of Regulatory Impact..................................4 VI. Changes in Existing Law..........................................4 I. PURPOSE The purpose of S. 805 is to assist countries in sub-Saharan Africa in the effort to achieve better outcomes in the fight against HIV/AIDS and other health challenges through the recruitment, training, and retention of health workers; improvements in infrastructure; and reforms in management and health systems. II. COMMITTEE ACTION S. 805 was introduced by Senators Durbin, Coleman, Feingold, Dodd, Kerry, and Bingaman on March 7, 2007. An additional 21 members cosponsored the legislation. On September 11, 2007, the committee ordered the bill, with amendments, reported favorably by voice vote. III. DISCUSSION As reports by the World Health Organization and others have demonstrated, the single greatest obstacle in the fight against HIV/AIDS and other major global health challenges is the shortage of health care professionals and managers. The dearth of such professionals in sub-Saharan Africa is particularly acute. The lack of personnel in Africa has been aggravated by the HIV/AIDS pandemic and by the "brain drain" of health professionals to wealthier countries. Countries in Africa also lack adequate health systems, in terms of both infrastructure and management. S. 805 seeks to help the nations of sub-Saharan Africa address these critical shortages of trained personnel and shortfalls in health systems by authorizing a variety of activities to promote the recruiting, training, retention, and proper deployment of health workers and to improve health systems. Specific tools include assistance to address systemic issues by strengthening national health plans; improving fiscal, personnel, and data management; and reducing corruption. In order to improve the training and retention of health workers, including community health workers, the bill authorizes assistance to promote workplace safety and to enhance training, educational, and career development opportunities and retention incentives. It authorizes assistance for basic infrastructural improvements, especially in rural and other underserved areas, and to create a global clearinghouse to share knowledge and best practices in health capacity development. This legislation requires the President to establish a monitoring and evaluation system to measure the effectiveness of these undertakings and to transmit to Congress a strategy for coordinating, implementing, and monitoring United States assistance programs for human health care capacity in sub- Saharan Africa. This strategy is to include a description of coordination among U.S. agencies and with other bilateral and multilateral donors as well as with the African Union and individual African governments. It also requires an analysis of how international financial institutions can most effectively assist countries in their efforts to increase investments in the health and education sectors while maintaining prudent fiscal balance. One year after submission of the strategy, the President is required to provide Congress with a report on the implementation of the strategy and a document assessing best practices to be shared with governments of developing countries and others seeking to promote health capacity. A final report on implementation is required not later than three years after submission of the strategy. S. 805 authorizes the appropriation of $150,000,000 for fiscal year 2008, $200,000,000 for fiscal year 2009, and $250,000,000 for fiscal year 2010 to support activities to promote health capacity in sub-Saharan Africa. IV. COST ESTIMATE In accordance with Rule XXVI, paragraph 11(a) of the Standing Rules of the Senate, the committee provides this estimate of the costs of this legislation prepared by the Congressional Budget Office. United States Congress, Congressional Budget Office, Washington, DC, September 19, 2007. Hon. Joseph R. Biden, Jr., Chairman, Committee on Foreign Relations, U.S. Senate, Washington, DC. Dear Mr. Chairman: The Congressional Budget Office has prepared the enclosed cost estimate for H.R. 1678, the Torture Victims Relief Reauthorization Act of 2007. If you wish further details on this estimate, we will be pleased to provide them. The CBO staff contact is Sunita D'Monte. Sincerely, Peter R. Orszag. ------ Congressional Budget Office Cost Estimate September 20, 2007. S. 805 would authorize the appropriation of $150 million in 2008 and $600 million over the 2008-2010 period for foreign assistance programs to develop and improve the local capacity to provide health care in countries of sub-Saharan Africa. The bill would require the President to monitor and evaluate the effectiveness of such assistance and to coordinate assistance with other donors. As shown in the following table, CBO estimates that implementing the bill would cost $23 million in 2008 and $523 million over the 2008-2012 period, assuming that the authorized amounts are appropriated and that outlays will follow historical spending patterns for similar programs. The costs of this legislation fall within budget function 150 (international affairs ). Enacting the bill would not affect direct spending or revenues. ESTIMATED BUDGETARY IMPACT OF S. 805 By Fiscal Year, in Millions of Dollars ---------------------------------------------------------------------------------------------------------------- 2008 2009 2010 2011 2012 ---------------------------------------------------------------------------------------------------------------- CHANGES IN SPENDING SUBJECT TO APPROPRIATION Authorization Level...................................... 150 200 250 0 0 Estimated Outlays........................................ 23 90 155 165 90 ---------------------------------------------------------------------------------------------------------------- The bill would authorize financial and technical assistance, including aid provided through international or nongovernmental organizations, to develop and improve the health care sectors of sub-Saharan African economies by: Developing and implementing workforce plans, fiscal and personnel management systems, and computerized workforce databases, Recruiting and training health care workers, Improving health care facilities and infrastructure, especially in rural and under-served areas, and Establishing a global clearinghouse to share knowledge regarding human resources for health care. S. 805 contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act and would not affect the budgets of state, local, or tribal governments. The CBO staff contact for this estimate is Sunita D'Monte. This estimate was approved by Peter H. Fontaine, Assistant Director for Budget Analysis. V. Evaluation of Regulatory Impact Pursuant to Rule XXVI, paragraph 11(b) of the Standing Rules of the Senate, the committee has determined that there is no regulatory impact as a result of this legislation. VI. Changes in Existing Law In compliance with Rule XXVI, paragraph 12 of the Standing Rules of the Senate, changes in existing law made by the bill, as reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new matter is printed in italic, existing law in which no change is proposed is shown in roman). The Foreign Assistance Act of 1961 * * * * * * * PART I Chapter 1--Policy; Development Assistance Authorizations * * * * * * * SEC. [135.] 136. ASSISTANCE TO PROVIDE SAFE WATER AND SANITATION. * * * * * * * SEC. 137. 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 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) 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 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) 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.--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) 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. (3) Follow-up report.--Not later than 3 years after the date on which the President submits the strategy required in subsection (b), the president shall submit to the appropriate congressional committees a further report on the implementation of this section. (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)). (5) Paraprofessional.--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) Community health workers.--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) In general.--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) 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.