IN THE SENATE OF THE UNITED STATES
March 7, 2007
Mr. Durbin (for himself, Mr. Coleman, Mr. Feingold, Mr. Dodd, Mr. Kerry, and Mr. Bingaman) introduced the following bill; which was read twice and referred to the Committee on Foreign Relations
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.
This Act may be cited as
African Health Capacity Investment
Act of 2007.
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)).
Congress makes the following findings:
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
The World Health
Report, 2006, Working Together for Health, states,
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
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.
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.
Workforce constraints and inefficient management are limiting factors in the treatment of tuberculosis, which infects over 1/3 of the global population.
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.
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.
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
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..
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.
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.
2005 report of the Working Group on Global Health Partnerships for the High
Level Forum on the Health Millennium Development Goals entitled
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
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.
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.
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
exodus of skilled professionals in the midst of so much unmet health need
places Africa at the epicentre of the global health workforce
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.
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.
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.
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.
Imbalances in the distribution of countries' health workforces represents a global problem, but the impact is particularly acute in sub-Saharan Africa.
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.
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.
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
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.
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
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.
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.
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.
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.
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.
Sense of Congress
It is the sense of Congress that—
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;
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;
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;
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;
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;
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;
it is critically important that the governments of sub-Saharan African countries increase their own investments in education and health care;
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;
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;
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;
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;
the President, acting through the United States Permanent Representative to the United Nations, should exercise the voice and vote of the United States—
to ameliorate the adverse impact on less developed countries of the migration of health personnel;
to promote voluntary codes of conduct for recruiters of health personnel; and
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;
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
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.
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 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
by adding at the end the following new section:
Assistance to increase human capacity in the health sector in sub-Saharan Africa
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.
Types of assistance
Such programs should include assistance—
to provide financial and technical assistance to sub-Saharan African countries in developing and implementing new or strengthened comprehensive national health workforce plans;
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—
fiscal and health personnel management;
health worker recruitment systems;
the creation or improvement of computerized health workforce databases and other human resource information systems;
implementation of measures to reduce corruption in the health sector; and
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;
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—
health worker safety and health care, including HIV/AIDS prevention and off-site testing and treatment programs for health workers;
increased capacity for training health professionals and paraprofessionals in such subjects as human resources planning and management, health program management, and quality improvement;
expanded access to secondary level math and science education;
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;
incentives and policies to increase retention, including salary incentives;
modern quality improvement processes and practices;
continuing education, distance education, and career development opportunities for health workers;
mechanisms to promote productivity within existing and expanding health workforces; and
achievement of minimum infrastructure requirements for health facilities, such as access to clean water;
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;
to support efforts to improve public health capacities in sub-Saharan Africa through education, leadership development, and other mechanisms;
to provide technical assistance, equipment, training, and supplies to assist in the improvement of health infrastructure in sub-Saharan Africa;
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
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.
Monitoring and Evaluation
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).
The monitoring and evaluation system shall—
establish performance goals for assistance provided under this section;
establish performance indicators to be used in measuring or assessing the achievement of performance goals;
provide a basis for recommendations for adjustments to the assistance to enhance the impact of the assistance; and
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.
Strategy of the United States
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.
The strategy required by paragraph (1) shall include—
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);
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
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.
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.
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.
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:
Nongovernmental organizations working to increase human health capacity in sub-Saharan Africa.
The World Bank.
The International Monetary Fund.
The Global Fund to Fight AIDS, Tuberculosis, and Malaria.
The World Health Organization.
The International Labour Organization.
The United Nations Development Programme.
The United Nations Programme on HIV/AIDS.
The European Union.
The African Union.
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).
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.
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.
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.
In this section:
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.
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.
The term health professional means a person whose occupation or training helps to identify, prevent, or treat illness or disability.
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)).
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.
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.
Authorization of Appropriations
There are authorized to be appropriated to the President to carry out the provisions of this section—
$150,000,000 for fiscal year 2008;
$200,000,000 for fiscal year 2009; and
$250,000,000 for fiscal year 2010.
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.