69–010 

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. 


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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. 


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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 subSaharan 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. 


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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. ø135.¿ 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 subSaharan 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 


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(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. 


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(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 subSaharan 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 


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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 


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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. 

Æ 


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