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                                                       Calendar No. 414
110th Congress                                                   Report
 1st Session                                                    110-192


                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.



  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 
                                           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 
    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 

The Foreign Assistance Act of 1961

           *       *       *       *       *       *       *

                                 PART I

Chapter 1--Policy; Development Assistance Authorizations

           *       *       *       *       *       *       *


           *       *       *       *       *       *       *

                    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 
                          (ii) health worker recruitment 
                          (iii) the creation or improvement of 
                        computerized health workforce databases 
                        and other human resource information 
                          (iv) implementation of measures to 
                        reduce corruption in the health sector; 
                          (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 
                          (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 
                  (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 
                  (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 
                  (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 
                          (x) The United Nations Development 
                          (xi) The United Nations Programme on 
                          (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