I 

111TH CONGRESS 

2D SESSION H. R. 4933 

To establish a strategy to coordinate all health-related United States foreign 

assistance, to assist developing countries in improving delivery of health 

services, and to establish an initiative to assist developing countries 

in strengthening their indigenous health workforces, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 24, 2010 

Ms. LEE of California introduced the following bill; which was referred to the 

Committee on Foreign Affairs, and in addition to the Committee on Financial Services, for a period to be subsequently determined by the 

Speaker, in each case for consideration of such provisions as fall within 

the jurisdiction of the committee concerned 

A BILL 

To establish a strategy to coordinate all health-related United 

States foreign assistance, to assist developing countries 

in improving delivery of health services, and to establish 

an initiative to assist developing countries in strengthening their indigenous health workforces, and for other 

purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 


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1 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

2 (a) SHORT TITLE.—This Act may be cited as the 

3 ‘‘Global Health Expansion, Access to Labor, Trans4 parency, and Harmonization Act of 2010’’ or the ‘‘Global 

5 HEALTH Act of 2010’’. 

6 (b) TABLE OF CONTENTS.—The table of contents for 

7 this Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Purpose. 

Sec. 3. United States Global Health Strategy. 

Sec. 4. Assistance for developing countries to improve delivery of health services. 

Sec. 5. Global Health Workforce Initiative. 

Sec. 6. Relation to other United States laws and policies. 

Sec. 7. Definitions. 

8 SEC. 2. PURPOSE. 

9 The purpose of this Act is to strengthen and improve 

10 the health systems of developing countries and the delivery 

11 of health services in developing countries to assist their 

12 national governments in reducing mortality and improving 

13 health outcomes among their populations, consistent with 

14 the United Nations Millennium Development Goals, by— 

15 (1) improving the coordination and effectiveness 

16 of all health-related United States foreign assistance 

17 by establishing under section 3 a comprehensive and 

18 integrated 5-year United States Global Health Strat19 egy that— 

20 (A) supports developing countries in their 

21 efforts to expand and develop their health sysVerDate Nov 24 2008 03:25 Mar 25, 2010 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H4933.IH H4933

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1 tems and increase their numbers of trained 

2 health workers; 

3 (B) encourages and supports developing 

4 countries to adopt policies that produce positive 

5 health outcomes; and 

6 (C) coordinates the global health-related 

7 work of United States global health programs 

8 and relevant United States executive branch 

9 agencies with the global health-related work of 

10 governments of other countries and inter11 national organizations; 

12 (2) providing assistance under section 4 for de13 veloping countries to improve the delivery of health 

14 services by their health systems; 

15 (3) supporting the efforts of developing coun16 tries to strengthen their indigenous health 

17 workforces and expand the supply and equitable dis18 tribution within such countries of skilled health 

19 workers by establishing under section 5 a Global 

20 Health Workforce Initiative; and 

21 (4) ensuring, as outlined in section 6, that the 

22 laws and policies of the United States and multilat23 eral organizations of which the United States is a 

24 member do not interfere with the ability of devel25 oping countries to establish and maintain skilled inVerDate Nov 24 2008 03:25 Mar 25, 2010 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H4933.IH H4933

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1 digenous health workforces, to obtain pharma2 ceuticals and other medical supplies and equipment, 

3 or to otherwise develop the capacity of their health 

4 systems. 

5 SEC. 3. UNITED STATES GLOBAL HEALTH STRATEGY. 

6 (a) ESTABLISHMENT.—Not later than 1 year after 

7 the date of the enactment of this Act, the President shall 

8 transmit to Congress and make publicly available a com9 prehensive and integrated 5-year United States Global 

10 Health Strategy (in this section referred to as the ‘‘Global 

11 Health Strategy’’) to coordinate all health-related United 

12 States foreign assistance and to integrate and harmonize 

13 such assistance with the work of relevant United States 

14 executive branch agencies, governments of other countries, 

15 and international organizations. 

16 (b) GOALS AND OBJECTIVES.— 

17 (1) GOALS.—The President shall ensure that 

18 the Global Health Strategy will assist countries in 

19 achieving the health-related goals and targets of the 

20 United Nations Millennium Development Goals and 

21 Targets, including— 

22 (A) reducing child mortality, with special 

23 emphasis on reducing the mortality rate of children under 5 years of age by 2 24 ⁄3 between 1990 

25 and 2015; 


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1 (B) improving maternal health, with spe2 cial emphasis on reducing the maternal mortality ratio by 3 3 ⁄4 between 1990 and 2015, and 

4 achieving universal access to reproductive 

5 health services by 2015; and 

6 (C) combating HIV/AIDS, tuberculosis, 

7 malaria, and other diseases, with special em8 phasis on halting and beginning to reverse by 

9 2015 the spread of HIV/AIDS and the inci10 dence of malaria and other major diseases. 

11 (2) ADDITIONAL OBJECTIVES.—The President 

12 shall ensure that the goals listed in paragraph (1) 

13 are achieved in a manner that, to the maximum ex14 tent practicable— 

15 (A) improves access to quality health serv16 ices for poor, vulnerable, or marginalized popu17 lations in countries receiving health-related 

18 United States foreign assistance; 

19 (B) ensures that skilled health workers are 

20 available in sufficient numbers and on a suffi21 ciently sustainable and equitably distributed 

22 basis within each country that their participa23 tion in programs supported by health-related 

24 United States foreign assistance does not nega25 tively impact the health workforce of any comVerDate Nov 24 2008 03:25 Mar 25, 2010 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H4933.IH H4933

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1 ponent of a developing country’s health system 

2 that is not supported by such assistance; and 

3 (C) advances the efforts of developing 

4 countries to develop health systems capable of 

5 providing universal access to a comprehensive 

6 package of primary health services. 

7 (3) RULE OF CONSTRUCTION.—The goals and 

8 objectives listed in this subsection are in addition to 

9 and shall not be construed to supplant the goals or 

10 objectives of any program under a law, regulation, 

11 Executive order, or international commitment of the 

12 United States. 

13 (c) CONSULTATION.—In developing the Global 

14 Health Strategy, the President shall consult with— 

15 (1) each executive branch agency administering 

16 United States foreign assistance related to— 

17 (A) improving global health; 

18 (B) strengthening financial management 

19 systems; 

20 (C) monitoring animal and plant popu21 lations; and 

22 (D) addressing environmental problems 

23 such as pollution and climate change; 

24 (2) personnel at United States embassies and 

25 country missions involved in the administration of 


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1 the types of United States foreign assistance de2 scribed in paragraph (1); 

3 (3) the appropriate congressional committees 

4 with jurisdiction over the agencies described in para5 graph (1); 

6 (4) civil society and nongovernmental organiza7 tions engaged in improving health care and health 

8 outcomes in developing countries, including indige9 nous community and faith-based organizations; 

10 (5) international organizations engaged in im11 proving health care and health outcomes in devel12 oping countries and of which the United States is a 

13 voting member, with which the United States coordi14 nates the delivery of foreign assistance, or to which 

15 the United States contributes funding for the pur16 pose of providing such assistance; 

17 (6) academic organizations, private foundations, 

18 businesses, and other organizations engaged in im19 proving health care and health outcomes in devel20 oping countries and not receiving United States 

21 funding for such purposes; 

22 (7) other donor nations engaged in improving 

23 health care and health outcomes in developing coun24 tries; 


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1 (8) countries receiving health-related United 

2 States foreign assistance; and 

3 (9) any other global, regional, or subregional 

4 organizations or partnerships engaged in improving 

5 health care and health outcomes in developing coun6 tries. 

7 (d) ELEMENTS OF UNITED STATES GLOBAL

8 HEALTH STRATEGY.—The Global Health Strategy shall 

9 include the following elements: 

10 (1) Plans for coordinating all health-related 

11 United States foreign assistance among the execu12 tive branch agencies authorized to deliver such as13 sistance in order to achieve the goals listed in sub14 section (b)(1) in a manner that facilitates harmoni15 zation with partners at the country level and takes 

16 maximum advantage of the expertise of personnel at 

17 the United States embassy and country mission 

18 level, including plans— 

19 (A) that incorporate all United States pro20 grams related to global health and their goals 

21 and strategies, including programs related to 

22 child survival and maternal health, vulnerable 

23 children, family planning and reproductive 

24 health, nutrition, health systems and infrastruc25 ture, health care workforces, HIV/AIDS, tuberVerDate Nov 24 2008 03:25 Mar 25, 2010 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H4933.IH H4933

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1 culosis, malaria, pandemic influenza, chronic 

2 and noncommunicable diseases, neglected dis3 eases, and other infectious diseases; 

4 (B) to assist countries in strengthening 

5 their financial management, accounting, audit6 ing, and reporting systems, and to ensure the 

7 effectiveness of such assistance; 

8 (C) to monitor the spread of disease 

9 among animal and plant populations, including 

10 livestock and wildlife; 

11 (D) to assist countries in addressing the 

12 health-related threats posed by environmental 

13 problems, including pollution and climate 

14 change; and 

15 (E) for oversight of all health-related 

16 United States foreign assistance, including an 

17 analysis of the capacity of each executive 

18 branch agency authorized to deliver such assist19 ance to conduct periodic audits, inspections, 

20 and investigations and an analysis of how over21 sight activities should be prioritized. 

22 (2) Plans that describe how health-related 

23 United States foreign assistance will help developing 

24 countries strengthen and improve their health sys25 tems and the delivery of health services to achieve 


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1 their national health goals and the goals of all 

2 United States programs related to global health, in3 cluding the goals listed in subsection (b)(1), by 

4 means that include— 

5 (A) assisting developing countries to cre6 ate, strengthen, and implement their own evi7 dence-based national health strategies, includ8 ing subnational health strategies where appro9 priate; 

10 (B) providing technical assistance and sup11 port to national ministries of health, or their 

12 equivalents, and other relevant ministries in 

13 overseeing the health systems of their countries 

14 and monitoring and evaluating the effectiveness 

15 of such systems in reducing mortality and im16 proving health outcomes; 

17 (C) supporting the construction, expansion, 

18 rehabilitation, and maintenance of health facili19 ties at the national and local level, and ensuring 

20 the equitable distribution and use of such facili21 ties among and within urban, peri-urban, and 

22 rural areas in each country; 

23 (D) providing assistance to national min24 istries of health, or their equivalents, and other 

25 relevant ministries in recruiting, training, and 


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1 retaining skilled health workers, managers, and 

2 administrators and in ensuring the equitable 

3 distribution of such personnel in health facilities 

4 throughout each country; 

5 (E) supporting the development and imple6 mentation of national health workforce plans 

7 for achieving a combined total of at least 2.3 

8 doctors, nurses, and trained midwives per 1,000 

9 residents, and comparable numbers of other 

10 health workers, such as paraprofessionals, com11 munity health workers, managers, and adminis12 trative and support staff, and ensuring such 

13 workers are equitably distributed within each 

14 country; 

15 (F) providing assistance to developing 

16 countries to create and transparently manage 

17 their own supply-chain management systems 

18 and to use existing nongovernmental systems, 

19 where appropriate, to— 

20 (i) efficiently and equitably distribute 

21 medical and laboratory supplies, including 

22 diagnostics, pharmaceuticals, technology, 

23 and equipment, to health facilities through24 out the country; and 


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1 (ii) perform any maintenance nec2 essary to ensure the continued operation of 

3 medical and laboratory equipment; 

4 (G) supporting the development, improve5 ment, and implementation of financial manage6 ment systems and the training of financial 

7 management personnel in order to track health 

8 expenditures by the national governments of de9 veloping countries, ensure the equitable and ef10 fective allocation of such expenditures, antici11 pate and budget for annual resource needs, eq12 uitably mobilize additional domestic resources, 

13 and increase the accountability of the health 

14 systems of such countries to their people, in15 cluding accountability at the subnational and 

16 community levels; 

17 (H) supporting the establishment, improve18 ment, and implementation, where appropriate, 

19 of mechanisms to operate, manage, regulate, 

20 monitor, and evaluate a country’s health sys21 tem, particularly its effectiveness in reducing 

22 mortality and improving health outcomes 

23 among the general population and for poor, vul24 nerable, or marginalized populations; 


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1 (I) supporting the development and imple2 mentation of national health information sys3 tems to securely track, compile, and manage 

4 data collected by a country’s health system at 

5 the individual, community, and population level, 

6 with appropriate privacy safeguards, in order to 

7 measure the impact of health services on health 

8 outcomes, and to provide a basis for adjust9 ments to the health system; 

10 (J) supporting meaningful community in11 volvement and participation, inclusive of poor, 

12 vulnerable, or marginalized populations and 

13 their representative indigenous and civil society 

14 organizations, in decisionmaking related to na15 tional and subnational health strategies and the 

16 delivery of health services, including in deci17 sions related to the adoption of health policies 

18 and the total amount and distribution of health 

19 funding; 

20 (K) further promoting the community in21 volvement and participation described in sub22 paragraph (J) by strengthening partnerships 

23 between government, civil society, and indige24 nous nongovernmental organizations, including 

25 community and faith-based organizations seekVerDate Nov 24 2008 03:25 Mar 25, 2010 Jkt 089200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\H4933.IH H4933

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1 ing to improve health conditions in their coun2 tries and communities; 

3 (L) supporting evidence-based public 

4 health education initiatives that teach healthy 

5 habits and behaviors, increase health literacy, 

6 and encourage greater utilization of the health 

7 system; 

8 (M) assisting countries to coordinate, regu9 late, and harmonize the delivery of health serv10 ices provided by the United States and non11 governmental organizations, including commu12 nity and faith-based organizations, private 

13 foundations, international organizations, and 

14 other donors, and to coordinate or integrate 

15 such services with the health system to the 

16 maximum extent practicable; 

17 (N) supporting indigenous nongovern18 mental organizations, including community and 

19 faith-based organizations, that seek to improve 

20 the efficiency, transparency, and delivery of 

21 health services to poor, vulnerable, or marginal22 ized populations; and 

23 (O) using, to the maximum extent prac24 ticable, local and regional entities for the provi25 sion of technical assistance, and where the caVerDate Nov 24 2008 03:25 Mar 25, 2010 Jkt 089200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\H4933.IH H4933

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1 pacity of such entities is insufficient, supporting 

2 capacity building to enable them to provide 

3 such assistance. 

4 (3) Plans to strengthen the ability of countries 

5 receiving health-related United States foreign assist6 ance to detect, identify, and respond to emerging 

7 public health threats by— 

8 (A) developing and improving laboratory 

9 capacity, including constructing or rehabili10 tating laboratory facilities and providing any 

11 necessary technology, equipment, or supplies; 

12 (B) supporting the recruitment, training, 

13 and retention of public health professionals with 

14 the expertise to monitor, respond to, and con15 tain the spread of disease, including laboratory 

16 personnel, epidemiologists, and animal and 

17 plant inspectors; 

18 (C) supporting the development of inte19 grated and comprehensive surveillance and noti20 fication systems at the national and regional 

21 level that are integrated within the health sys22 tem to address the spread of emerging diseases 

23 among human, animal, and plant populations 

24 that may pose potential threats to public health; 

25 and 


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1 (D) facilitating partnerships between 

2 health systems and relevant United States Gov3 ernment agencies to strengthen national and re4 gional disease surveillance and notification sys5 tems to address the spread of emerging diseases 

6 among human, animal, and plant populations. 

7 (4) Plans to improve research collaboration with 

8 countries receiving health-related United States for9 eign assistance, including plans related to— 

10 (A) basic, clinical, and applied research on 

11 diseases that primarily impact developing coun12 tries, including research on medical technology 

13 and equipment, protocols, procedures, stand14 ards, and strategies to combat such diseases; 

15 (B) operations research to facilitate the de16 velopment and administration of effective health 

17 systems and health-related programs; 

18 (C) support for developing indigenous re19 search capacity, including the establishment of 

20 independent and scientific peer review processes 

21 to help countries pursue their own research 

22 agendas; 

23 (D) encouraging the development of sus24 tainable, country-driven partnerships between 


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1 indigenous and United States-based research 

2 institutions; and 

3 (E) strengthening regional research part4 nerships. 

5 (5) Plans for encouraging and assisting na6 tional governments of developing countries to pursue 

7 policies and legal frameworks that improve health 

8 outcomes and make progress toward the goals listed 

9 in subsection (b)(1), including policies and legal 

10 frameworks that— 

11 (A) are medically accurate and evidence12 based and adhere to the latest global public 

13 health standards for prevention, treatment, and 

14 care; 

15 (B) integrate and deliver, to the maximum 

16 extent practicable, a comprehensive package of 

17 primary health services at the local clinic level, 

18 with appropriate and functional systems for re19 ferral to secondary and tertiary medical facili20 ties that provide services including— 

21 (i) preventive care; 

22 (ii) prenatal and perinatal services; 

23 (iii) immunizations and vaccinations; 

24 (iv) family planning and reproductive 

25 health services; 


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1 (v) chronic and infectious disease 

2 management; 

3 (vi) maternal and child health serv4 ices; 

5 (vii) psychosocial and mental health 

6 services; 

7 (viii) nutritional support; and 

8 (ix) emergency response and triage; 

9 (C) promote and improve the status of 

10 women and youth, ensuring their ability to ac11 cess and use health services without fear or risk 

12 of gender-based violence, reprisal, discrimina13 tion, stigmatization, or other mistreatment; 

14 (D) work to remove stigmatization of and 

15 discrimination against poor, vulnerable, or mar16 ginalized populations and to protect the rights 

17 of such populations; 

18 (E) provide for the equitable allocation and 

19 distribution of health resources among rural, 

20 peri-urban, and urban areas, including facilities, 

21 personnel, medicines, medical technology and 

22 equipment, and health financing; 

23 (F) ensure that all individuals, especially 

24 the poorest of the poor, have access to highVerDate Nov 24 2008 03:25 Mar 25, 2010 Jkt 089200 PO 00000 Frm 00018 Fmt 6652 Sfmt 6201 E:\BILLS\H4933.IH H4933

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1 quality, confidential, affordable health services, 

2 including by— 

3 (i) encouraging the elimination of user 

4 fees or their replacement with equitable fi5 nancing strategies where appropriate; and 

6 (ii) addressing other persistent bar7 riers to such access, including those related 

8 to housing, transportation, language, and 

9 similar issues; 

10 (G) promote sustainable working condi11 tions and policies that protect the health and 

12 safety of patients and health workers within 

13 their communities and in all medical facilities; 

14 (H) provide comprehensive, confidential, 

15 high-quality health services to health workers, 

16 including for chronic and infectious diseases; 

17 (I) respect the rights and dignity of health 

18 workers and patients; 

19 (J) coordinate the delivery of health serv20 ices with other core development programs to 

21 better address the social determinants of health, 

22 including programs to reduce poverty, expand 

23 educational opportunities, provide access to 

24 clean water and sanitation services, improve 

25 food security and nutrition, protect women’s 


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1 rights, improve access to legal services, protect 

2 the environment, and spur economic growth; 

3 and 

4 (K) facilitate the development and imple5 mentation of sustainable policies, legal frame6 works, and capacity-building activities that ac7 tively engage and support civil society organiza8 tions and community members, including indi9 viduals from poor, vulnerable, or marginalized 

10 populations, to monitor and enforce policies re11 lated to the provision of health services. 

12 (6) Plans to support the efforts of national gov13 ernments of developing countries in responding to 

14 health-related threats posed by environmental prob15 lems, including pollution and climate change. 

16 (7) Plans for a review of, including rec17 ommendations to adjust, laws and policies of the 

18 United States Government that impact the provision 

19 of health-related United States foreign assistance, 

20 including— 

21 (A) recruitment, training, and retention of 

22 the United States health workforce, including 

23 through the immigration of foreign health pro24 fessionals to the United States; 


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1 (B) negotiation and enforcement of bilat2 eral, multilateral, and other international trea3 ties and trade and investment agreements, in4 cluding any provisions related to the delivery of 

5 health services or the supply of medical tech6 nology and equipment, diagnostics, or pharma7 ceutical products; 

8 (C) negotiation and voting practices within 

9 international financial institutions; and 

10 (D) negotiation and voting practices within 

11 the World Health Organization, the Global 

12 Fund to Fight AIDS, Tuberculosis and Ma13 laria, the Global Alliance for Vaccines and 

14 Immunisation, and any other international or15 ganizations of which the United States is a vot16 ing member and to which the United States 

17 contributes funding. 

18 (8) Plans for establishing an integrated moni19 toring and evaluation system, coordinated at the 

20 country level with any such systems previously in ex21 istence, in order to assess the effectiveness of all 

22 health-related United States foreign assistance. 

23 (9) Annual resource plans for implementing the 

24 Global Health Strategy, achieving the goals listed in 

25 subsection (b)(1), and achieving the relevant goals of 


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1 all United States programs related to global health, 

2 including, to the extent practicable, annual budgets, 

3 annual projected resource needs, and long-term 

4 funding commitments of— 

5 (A) the United States Government; 

6 (B) international organizations of which 

7 the United States is a voting member and to 

8 which the United States contributes funding for 

9 the purpose of providing health-related assist10 ance to developing countries; and 

11 (C) countries receiving health-related 

12 United States foreign assistance. 

13 (e) STRATEGY COORDINATOR.— 

14 (1) IN GENERAL.—The President shall des15 ignate an individual as coordinator of the Global 

16 Health Strategy (in this section referred to as the 

17 ‘‘Strategy Coordinator’’). 

18 (2) DUTIES.—The duties of the Strategy Coor19 dinator shall include— 

20 (A) coordinating the Global Health Strat21 egy among all relevant executive branch agen22 cies; 

23 (B) serving as a point of reference for 

24 Congress and the public regarding the imple25 mentation of the Global Health Strategy; and 


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1 (C) producing the annual report required 

2 by subsection (g). 

3 (f) PERFORMANCE GOALS AND INDICATORS.—In 

4 order to measure and evaluate the effectiveness of the 

5 Global Health Strategy in achieving the goals described 

6 in subsection (b)(1) and in order to provide a basis to peri7 odically review and adjust the Global Health Strategy, the 

8 President shall establish, where appropriate, objective and 

9 quantifiable performance goals and indicators for each ele10 ment required by subsection (d). 

11 (g) REPORT.—Not later than 1 year after the Presi12 dent’s transmission to Congress of the Global Health 

13 Strategy under subsection (a) and annually thereafter, the 

14 President shall transmit to Congress a report that in15 cludes— 

16 (1) a description of the impact and effectiveness 

17 of all health-related United States foreign assistance 

18 in achieving the goals listed in subsection (b)(1) and 

19 the additional objectives listed in subsection (b)(2); 

20 (2) a description of the progress made toward 

21 achieving the performance goals established under 

22 subsection (f); 

23 (3) a description of any audits, inspections, or 

24 investigations of health-related United States foreign 

25 assistance completed during the year preceding the 


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1 transmission of the report, including their results, 

2 and a brief summary of any plans to undertake simi3 lar audits, inspections, or investigations during the 

4 subsequent year; and 

5 (4) a detailed programmatic list of expenditures 

6 for all United States programs related to global 

7 health for the fiscal year preceding the transmission 

8 of the report, including the amounts and percentages 

9 of funding that each program allocated for— 

10 (A) the direct provision of health services, 

11 including directly supporting health workforces 

12 that provide such services; 

13 (B) the purchase of commodities, including 

14 medicines; 

15 (C) the construction, expansion, rehabilita16 tion, or maintenance of health facilities within 

17 a country’s health system; and 

18 (D) any technical assistance provided to 

19 carry out the goals and objectives of the pro20 gram. 

21 (h) EVALUATION OF THE GLOBAL HEALTH STRAT22 EGY BY THE INSTITUTE OF MEDICINE.— 

23 (1) IN GENERAL.—The Strategy Coordinator 

24 shall enter into a contract with the Institute of Med25 icine of the National Academies, or, if the Institute 


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1 declines, another appropriate entity, to complete an 

2 evaluation of the effectiveness of the Global Health 

3 Strategy not later than 4 years after the President’s 

4 transmission to Congress of such strategy under 

5 subsection (a). 

6 (2) ELEMENTS OF STUDY.—The contract re7 quired by paragraph (1) shall provide for— 

8 (A) an assessment of the level of coordina9 tion of health-related United States foreign as10 sistance, including at the country-mission level; 

11 (B) an assessment of the progress made 

12 toward the goals listed in subsection (b)(1) and 

13 the additional objectives listed in subsection 

14 (b)(2); 

15 (C) an assessment of the contributions of 

16 the Global Health Strategy to strengthening 

17 health systems, improving the delivery of health 

18 services, ensuring a sustainable supply of health 

19 workers, and improving the accountability of 

20 health systems of developing countries to the 

21 people of such countries; 

22 (D) an assessment of the progress made 

23 toward reviewing and evaluating the impact of 

24 existing laws and policies of the United States 

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1 related United States foreign assistance, includ2 ing any recommendations for the adjustment of 

3 such laws and policies; 

4 (E) recommendations for improving the 

5 Global Health Strategy; and 

6 (F) an assessment of any additional fac7 tors that the entity with which the Strategy Co8 ordinator contracts under paragraph (1), in 

9 consultation with the appropriate congressional 

10 committees and the Strategy Coordinator, con11 siders appropriate. 

12 (i) AUTHORIZATION OF APPROPRIATIONS.— 

13 (1) IN GENERAL.—In addition to amounts oth14 erwise made available for such purposes, there are 

15 authorized to be appropriated to the President such 

16 sums as may be necessary for each of the fiscal 

17 years 2011 through 2015 to carry out this section. 

18 (2) AVAILABILITY OF FUNDS.—Amounts appro19 priated pursuant to the authorization of appropria20 tions in paragraph (1) are authorized to remain 

21 available until expended. 

22 SEC. 4. ASSISTANCE FOR DEVELOPING COUNTRIES TO IM23 PROVE DELIVERY OF HEALTH SERVICES. 

24 (a) AUTHORIZATION.— 


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1 (1) IN GENERAL.—The President is authorized 

2 to provide assistance to developing countries to im3 prove the delivery of health services by the health 

4 systems of such countries. 

5 (2) AUTHORIZED ACTIVITIES.—The assistance 

6 authorized by paragraph (1) includes assistance for 

7 the following activities in order to assist a country 

8 in providing health services: 

9 (A) Direct support to implement particular 

10 elements of a country’s national health strategy, 

11 including— 

12 (i) construction, expansion, rehabilita13 tion, and maintenance of health facilities 

14 at the national and local level, including 

15 ensuring the equitable distribution and use 

16 of such facilities among and within urban, 

17 peri-urban, and rural areas of the country; 

18 (ii) recruiting, training, and retaining 

19 skilled health workers, managers, and ad20 ministrators, including ensuring the equi21 table distribution of such personnel in 

22 health facilities throughout the country; 

23 (iii) developing a supply-chain man24 agement system to— 


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1 (I) efficiently, transparently, and 

2 equitably purchase and distribute 

3 medical and laboratory supplies, in4 cluding diagnostics, pharmaceuticals, 

5 technology, equipment, and other 

6 health commodities, to health facilities 

7 throughout the country; and 

8 (II) perform any maintenance 

9 necessary to ensure the continued op10 eration of medical and laboratory 

11 equipment; and 

12 (iv) providing the items described in 

13 clause (iii)(I) or funds for the purchase of 

14 such items. 

15 (B) Technical assistance and operational 

16 support in conjunction with direct assistance 

17 described in subparagraph (A) for national gov18 ernments to develop, implement, and evaluate 

19 the relevant elements of their national health 

20 strategies and any associated plans and policies. 

21 (C) Support for indigenous civil society 

22 and nongovernmental organizations to monitor 

23 and evaluate the development and effectiveness 

24 of their country’s health system and national 

25 health strategy. 


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1 (3) ELIGIBLE ENTITIES.—In carrying out para2 graph (1), the President is authorized to provide as3 sistance directly to— 

4 (A) the national government of each devel5 oping country that has a national health strat6 egy, including assistance to the national min7 istry of health and the national ministry of fi8 nance, or their equivalents, and other relevant 

9 ministries; 

10 (B) indigenous nongovernmental, commu11 nity, and faith-based organizations and civil so12 ciety groups within each developing country 

13 that has a national health strategy; 

14 (C) United States-based nongovernmental 

15 organizations and academic organizations that 

16 provide health-related services or assistance in 

17 developing countries; and 

18 (D) international organizations involved in 

19 delivering health-related assistance and of 

20 which the United States is a voting member, 

21 with which the United States coordinates the 

22 delivery of foreign assistance, or to which the 

23 United States contributes funding for the pur24 pose of providing such assistance. 


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1 (4) RELATIONSHIP TO NATIONAL HEALTH

2 STRATEGIES AND UNITED STATES GLOBAL HEALTH

3 STRATEGY.—Assistance provided under paragraph 

4 (1) shall be— 

5 (A) aligned to the fullest extent possible 

6 with the national health strategy of each coun7 try receiving such assistance; and 

8 (B) in accordance with the goals and addi9 tional objectives of the United States Global 

10 Health Strategy listed in section 3(b)(1) and 

11 section 3(b)(2), respectively. 

12 (5) CONTRACT AUTHORITY.—The President 

13 may enter into contracts to provide the assistance 

14 authorized by paragraph (1). 

15 (b) PRINCIPLES OF NATIONAL HEALTH STRATE16 GIES.—The President shall encourage each country receiv17 ing direct assistance described in subsection (a)(2)(A) to 

18 incorporate into its national health strategy, to the max19 imum extent practicable, the following principles: 

20 (1) Goals and targets to reduce morbidity and 

21 mortality and improve health outcomes, including to 

22 reach commonly agreed-upon international and re23 gional health targets. 

24 (2) Plans to provide universal access to a com25 prehensive package of primary health services. 


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1 (3) Plans to increase the equitable distribution 

2 of health services among rural, peri-urban, and 

3 urban areas of the country, including plans to en4 sure the availability of the facilities, personnel, med5 ical and laboratory supplies, technology and equip6 ment, financing, and other resources necessary to 

7 provide such services. 

8 (4) Plans to ensure that poor, vulnerable, or 

9 marginalized populations have access to the services 

10 and necessary resources described in paragraph (3). 

11 (5) Transparent annual budget plans with cost 

12 estimates for reaching the goals and targets de13 scribed in paragraph (1), including a description of 

14 any funding gaps and plans to fill such gaps through 

15 increased and equitable mobilization of national re16 sources and in partnership with external donors, in17 cluding the United States, and other funding 

18 sources. 

19 (6) Appropriate mechanisms and tools to mon20 itor and evaluate the effectiveness of the country’s 

21 health system in improving health-service delivery 

22 and to measure progress toward achieving the goals 

23 and targets described in paragraph (1), with a par24 ticular focus on expanding access to health services 

25 for poor, vulnerable, or marginalized populations. 


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1 (7) Appropriate financial management and au2 diting mechanisms for health financing in order to 

3 track health expenditures by the national govern4 ment, ensure the equitable distribution of such ex5 penditures within the country, anticipate and budget 

6 for the annual resource needs of the health system, 

7 and increase the accountability of the health system 

8 to the country’s people. 

9 (8) Meaningful participation of indigenous civil 

10 society and nongovernmental organizations, includ11 ing community and faith-based organizations, af12 fected communities, and poor, vulnerable, or 

13 marginalized populations, in the development and 

14 implementation of the national health strategy, in15 cluding program and budget decisions, monitoring 

16 and evaluation, and implementation. 

17 (9) Promotion of the ability of women and 

18 youth to access and use health services without fear, 

19 gender-based violence, reprisal, discrimination, or 

20 other mistreatment. 

21 (10) Plans to reduce stigmatization of and dis22 crimination against poor, vulnerable, or marginalized 

23 populations, to promote their rights, and to promote 

24 their ability to access and use health services. 


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1 (11) Medically accurate and evidence-based 

2 policies and program plans that adhere to the latest 

3 global public health standards for prevention, treat4 ment, and care and that are contextualized within 

5 each country. 

6 (12) Plans to ensure that all individuals, espe7 cially the poorest of the poor, are able to exercise 

8 their rights and have access to high-quality, con9 fidential, affordable health services, including by— 

10 (A) encouraging the elimination of user 

11 fees or their replacement with equitable financ12 ing strategies where appropriate; and 

13 (B) addressing other persistent barriers to 

14 such access, including those related to housing, 

15 transportation, language, and similar issues. 

16 (13) Support for the creation of sustainable 

17 working conditions and policies that protect the 

18 health and safety of patients and health workers 

19 within their communities and in all medical facilities, 

20 including through following recommended occupa21 tional health and safety standards for health work22 ers, including standards for training and protective 

23 technology, equipment, and supplies, as well as 

24 through other forms of infection prevention and con25 trol. 


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1 (14) Access for health workers employed in the 

2 country’s health system to comprehensive, confiden3 tial, high-quality health services, including preven4 tion and treatment of chronic and infectious diseases 

5 and psychosocial and mental health services. 

6 (15) Promotion of multisectoral harmonization 

7 through coordination and collaboration between the 

8 delivery of health services and other development 

9 programs and plans that impact public health, in10 cluding programs and plans to address emerging 

11 public health threats and health-related threats 

12 posed by environmental problems and to advance ap13 plied research into diseases affecting the country. 

14 (16) Support for the development and imple15 mentation of sustainable policies, legal frameworks, 

16 and capacity-building activities that actively engage 

17 civil society organizations and community members, 

18 including individuals from poor, vulnerable, or 

19 marginalized populations, to monitor and enforce 

20 policies related to the provision of health services. 

21 (c) PARTNERSHIP AGREEMENTS.— 

22 (1) IN GENERAL.—The President may enter 

23 into a partnership agreement with a developing 

24 country receiving assistance under this section in 

25 which the country receives additional assistance to— 


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1 (A) encourage the inclusion, adoption, and 

2 implementation of the principles listed in sub3 section (b) as part of the country’s national 

4 health strategy and any associated plans or 

5 policies; and 

6 (B) encourage the country to increase the 

7 amount of national resources it commits to ex8 panding and improving the delivery of health 

9 services. 

10 (2) NO REDUCTION OF ASSISTANCE.—A part11 nership agreement under paragraph (1) shall not re12 sult in a reduction of the total level of health-related 

13 United States foreign assistance provided to a coun14 try below the level of such assistance provided to 

15 such country in the previous fiscal year. 

16 (d) MONITORING AND EVALUATION SYSTEM.— 

17 (1) IN GENERAL.—The President shall establish 

18 an integrated monitoring and evaluation system to 

19 measure the effectiveness of assistance provided 

20 under this section including, where appropriate, ob21 jective and quantifiable performance goals and indi22 cators to measure progress toward the development 

23 and implementation of national health strategies in 

24 accordance with the principles listed in subsection 

25 (b). 


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1 (2) HARMONIZATION WITH SYSTEMS OF RECIPI2 ENT COUNTRIES.—To the maximum extent possible, 

3 the system established under paragraph (1) shall be 

4 harmonized with the monitoring and evaluation sys5 tems of countries receiving assistance under this sec6 tion. 

7 (e) REPORT.—Not later than 1 year after the date 

8 of the enactment of this Act and annually thereafter, the 

9 President shall transmit to Congress a report describing 

10 the impact and effectiveness of the assistance provided 

11 under this section, including— 

12 (1) a detailed description, with respect to each 

13 country receiving assistance under this section, of 

14 the effectiveness of such assistance in improving the 

15 delivery of health services by the health system, in16 cluding how such assistance was aligned with each 

17 country’s national health strategy and any associ18 ated plans or policies, as they existed before such 

19 country began receiving such assistance; 

20 (2) a brief summary of plans to address gaps 

21 in the delivery of health services among countries re22 ceiving assistance under this section during the fol23 lowing year and the resources that will be required 

24 to carry out such plans; 


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1 (3) a detailed description of any partnership 

2 agreements entered into under subsection (c) and 

3 any potential strategies for further encouraging 

4 countries to incorporate the principles listed in sub5 section (b) into their national health strategies; and 

6 (4) a detailed programmatic list of expenditures 

7 under this section for the previous fiscal year, in8 cluding the amounts and percentages of funding al9 located for— 

10 (A) the direct provision of health services, 

11 including directly supporting health workforces 

12 that provide such services; 

13 (B) the purchase of commodities, including 

14 medicines; 

15 (C) the construction, expansion, rehabilita16 tion, or maintenance of health facilities within 

17 a country’s health system; and 

18 (D) any technical assistance provided 

19 under this section, including a list of any con20 tractors providing such assistance and the im21 pact of such assistance in improving health out22 comes and health service delivery. 

23 (f) CERTIFICATION REQUIREMENT.— 


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1 (1) IN GENERAL.—The President shall certify 

2 to Congress that each contract described in para3 graph (2)— 

4 (A) has been openly and transparently se5 cured and provides the highest quality goods 

6 and services at the lowest cost; and 

7 (B) wherever possible, makes use of indige8 nous entities within the country receiving as9 sistance. 

10 (2) CONTRACTS DESCRIBED.—A contract de11 scribed in this paragraph is a contract related to the 

12 construction, expansion, rehabilitation, or mainte13 nance of health facilities, the purchase of commod14 ities, or technical assistance that is entered into— 

15 (A) by the United States Government to 

16 provide health-related United States foreign as17 sistance under this section; or 

18 (B) by a foreign country or other entity to 

19 carry out a program or activity receiving 

20 health-related United States foreign assistance 

21 under this section. 

22 (g) AUTHORIZATION OF APPROPRIATIONS.— 

23 (1) IN GENERAL.—In addition to amounts oth24 erwise made available for such purposes, there are 

25 authorized to be appropriated to the President such 


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1 sums as may be necessary for each of the fiscal 

2 years 2011 through 2015 to carry out this section. 

3 (2) AVAILABILITY OF FUNDS.—Amounts appro4 priated pursuant to the authorization of appropria5 tions in paragraph (1) are authorized to remain 

6 available until expended. 

7 SEC. 5. GLOBAL HEALTH WORKFORCE INITIATIVE. 

8 (a) ESTABLISHMENT.—The President is authorized 

9 to establish a Global Health Workforce Initiative (in this 

10 section referred to as the ‘‘Initiative’’) to provide technical 

11 and direct financial assistance to entities described in sub12 section (c) to support the recruitment, training, retention, 

13 effectiveness, and equitable distribution within each coun14 try of skilled indigenous health workers as part of the 

15 health systems of developing countries in order to achieve 

16 a combined total of at least 2.3 doctors, nurses, and 

17 trained midwives per 1,000 residents, and comparable 

18 numbers of other health workers, such as paraprofes19 sionals, community health workers, managers, and admin20 istrative and support staff. 

21 (b) PARTICIPATING COUNTRIES.— 

22 (1) SELECTION.— 

23 (A) IN GENERAL.—Not later than 90 days 

24 after the date of the enactment of this Act, the 

25 President shall select for participation in the 


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1 Initiative not fewer than 12 developing coun2 tries and may, in consultation with Congress, 

3 subsequently select additional developing coun4 tries. 

5 (B) PARTICIPATING COUNTRY DEFINED.— 

6 A country selected under subparagraph (A) is 

7 referred to in this section as a ‘‘participating 

8 country’’. 

9 (2) MANDATORY CRITERIA.—The President 

10 shall not select a country under paragraph (1)(A) 

11 unless it meets the following criteria: 

12 (A) The government of the country has ex13 pressly requested the assistance of the United 

14 States Government to support the expansion of 

15 the country’s indigenous health workforce. 

16 (B) The country is currently developing or 

17 implementing a national health strategy. 

18 (C) The country is already receiving 

19 health-related United States foreign assistance 

20 and is able to effectively use additional funding 

21 from the United States or other external 

22 sources to expand its indigenous health work23 force, reduce morbidity and mortality, and im24 prove health outcomes among its population. 


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1 (D) The country is experiencing a critical 

2 shortage of health workers, which is a signifi3 cant obstacle to reducing mortality and improv4 ing health outcomes among its people and to 

5 achieving the United Nations Millennium Devel6 opment Goals and other such international 

7 health targets. 

8 (E) The country is taking concrete steps to 

9 sustainably expand its indigenous health work10 force, such as direct budgetary investments, the 

11 development and implementation of supportive 

12 policies, the development of educational, train13 ing, and clinical care and practice standards, 

14 and direct agreements or partnerships at the 

15 national or regional level with other countries or 

16 international organizations. 

17 (F) A health professional training institu18 tion is currently located in the country, or the 

19 country is in the process of establishing such an 

20 institution or has a partnership with such an 

21 institution in another country in the region. 

22 (3) ADDITIONAL CRITERIA.—The President 

23 should ensure that countries selected under para24 graph (1)(A) are diverse with respect to— 


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1 (A) total size and demography of the popu2 lation; 

3 (B) prevalence and incidence of disease 

4 and any associated mortality rates; 

5 (C) levels of development and functionality 

6 of the health system; 

7 (D) the extent to which financial resources 

8 are available or have been committed by the 

9 country or by external funding sources to ex10 pand the indigenous health workforce; 

11 (E) the size of the indigenous health work12 force; and 

13 (F) gross national product and per capita 

14 income. 

15 (c) ELIGIBLE ENTITIES.—The following entities are 

16 eligible to receive funding under the Initiative: 

17 (1) The national government of each partici18 pating country, including the national ministry of 

19 health and the national ministry of finance, or their 

20 equivalents. 

21 (2) Indigenous nongovernmental, community, 

22 and faith-based organizations and civil society 

23 groups engaged in improving health care and health 

24 outcomes in 1 or more participating countries. 


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1 (3) United States-based nongovernmental and 

2 academic organizations that provide health-related 

3 services or assistance in developing countries. 

4 (4) International organizations involved in de5 livering health-related assistance and of which the 

6 United States is a voting member, with which the 

7 United States coordinates the delivery of foreign as8 sistance, or to which the United States contributes 

9 funding for the purpose of providing such assistance. 

10 (d) AUTHORIZED ACTIVITIES.—The activities for 

11 which the President may provide funding under the Initia12 tive include the following: 

13 (1) Technical assistance and direct support for 

14 countries to develop, strengthen, implement, evalu15 ate, and adjust the national health workforce plans 

16 described in subsection (f). 

17 (2) Programs to prepare and encourage individ18 uals to seek careers as health professionals and to 

19 serve as teachers in health professional training in20 stitutions, including through— 

21 (A) basic education programs; 

22 (B) expanding the capacity of the edu23 cational system to provide access to secondary24 level and advanced math and science education; 


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1 (C) teaching basic health literacy and sup2 porting basic disease prevention education; and 

3 (D) additional educational opportunities 

4 targeted to health professionals to enable and 

5 prepare them to become effective teachers. 

6 (3) Expansion and improvement of health edu7 cation and training of new health workers, includ8 ing— 

9 (A) new construction, expansion, rehabili10 tation, and maintenance of health professional 

11 training institutions, including residential hous12 ing facilities for students, teachers, and admin13 istrators; 

14 (B) hiring and retention of teachers and 

15 administrators to fully staff health professional 

16 training institutions and other health worker 

17 training facilities and programs, including 

18 through continuing education, professional de19 velopment, and research opportunities and such 

20 financial incentives as direct salary support and 

21 housing assistance; 

22 (C) providing financial incentives to stu23 dents enrolled in health professional training in24 stitutions, including financial aid, housing as25 sistance, and loan repayment in exchange for 


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1 defined periods of service in the country’s 

2 health system; 

3 (D) supporting distance learning and 

4 community- and hospital-based clinical training; 

5 (E) encouraging students to pursue careers 

6 in primary care in the health system of their 

7 country of residence, especially to meet the 

8 needs of rural areas and underserved popu9 lations, while also supporting students who 

10 choose to pursue careers in health administra11 tion and management or in needed tertiary care 

12 fields; 

13 (F) establishing professional standards for 

14 the entire range of health workers, including 

15 doctors, nurses, trained midwives, paraprofes16 sionals, community health workers, health ad17 ministrators and managers, and support per18 sonnel; 

19 (G) improving the quality and diversity of 

20 health education and training courses and 

21 strengthening existing curricula, including 

22 through the integration of program planning, 

23 mangagement, leadership training, and profes24 sional standards to better meet national and 

25 local circumstances; 


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1 (H) integrating the use of information and 

2 communications technologies, including the 

3 management of medical records and medical 

4 and laboratory supply inventories, into all 

5 health education and training courses; 

6 (I) providing health workers with the ap7 propriate training to pursue health-related re8 search, including basic, clinical, applied, and op9 erations research to improve the efficiency and 

10 effectiveness of health interventions and encour11 age the development of innovative tools and ap12 proaches to support national health goals; 

13 (J) improving the management of health 

14 professional training institutions and other 

15 health worker training facilities and programs 

16 and reducing student attrition rates; and 

17 (K) encouraging partnerships between and 

18 among health professional training institutions 

19 and other health worker training facilities and 

20 programs, including on a regional level and 

21 among participating countries. 

22 (4) Retention programs to encourage health 

23 workers to remain employed as part of the health 

24 system, including— 


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1 (A) direct salary support, housing assist2 ance, and other financial incentives to enable 

3 public-sector employers of health workers to 

4 compete with private-sector employers of health 

5 workers; 

6 (B) providing comprehensive, confidential, 

7 high-quality health services to health workers, 

8 including prevention and treatment of chronic 

9 and infectious diseases and psychosocial and 

10 mental health services; 

11 (C) creating sustainable working conditions 

12 and policies that protect the health and safety 

13 of patients and health workers within their 

14 communities and in all medical facilities, includ15 ing through— 

16 (i) following recommended occupa17 tional health and safety standards for 

18 health workers, including standards for 

19 training and protective technology, equip20 ment, and supplies and standards for blood 

21 and injection safety; and 

22 (ii) other forms of infection prevention 

23 and control, including rapid access to 

24 postexposure prophylaxis in the event of 

25 exposure to HIV; 


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1 (D) ensuring that all medical facilities 

2 maintain stocks of medical and laboratory sup3 plies, including diagnostics, pharmaceuticals, 

4 technology, and equipment, that meet or exceed 

5 recommended standards for resource-poor set6 tings; 

7 (E) encouraging efficient and effective 

8 matching of patient needs with health workers 

9 of appropriate skill levels, while providing op10 portunities to expand the scope of practice for 

11 all nonphysician health workers; 

12 (F) providing continuing education, dis13 tance learning, career advancement, and re14 search and development opportunities, including 

15 through national- and regional-level exchange 

16 programs; 

17 (G) establishing programs to reinforce re18 spect for the rights and dignity of patients and 

19 health workers; and 

20 (H) reevaluating and supporting the re21 moval of any other government policies, whether 

22 at the local, regional, national, or international 

23 level, that discourage health workers from 

24 choosing to continue their employment in the 

25 health system. 


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1 (5) Improving health workforce administration 

2 and management, including— 

3 (A) direct salary support to hire and retain 

4 qualified health administrators and managers of 

5 hospitals, clinics, and other such health facili6 ties; 

7 (B) training and education in human re8 source management, leadership, and financial 

9 planning for health administrators and man10 agers and their support staff; 

11 (C) developing national standards and pro12 tocols for clinical practice and program man13 agement and other quality improvement proce14 dures and measurements for health administra15 tors and managers to follow and enforce; 

16 (D) integrating staffing, resource, and re17 ferral systems between the community-level and 

18 primary, secondary, and tertiary medical facili19 ties; 

20 (E) developing and implementing strate21 gies to improve staffing systems and health 

22 worker productivity, including through regular 

23 and supportive supervision; and 

24 (F) developing, implementing, and evalu25 ating health workforce policies and regulations 


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1 to most effectively meet the needs of patient 

2 populations and health workers. 

3 (6) Ensuring the equitable distribution of 

4 health resources and health workers to meet the 

5 needs of rural areas and underserved populations, 

6 including by— 

7 (A) providing direct salary support, hous8 ing assistance, transportation, and other finan9 cial or nonfinancial benefits or incentives to 

10 health workers working in such areas or among 

11 such populations; 

12 (B) improving basic health-related infra13 structure to improve access to health facilities 

14 in such areas and among such populations; 

15 (C) strengthening procurement and dis16 tribution supply-chain management systems to 

17 ensure that medical and laboratory supplies, in18 cluding diagnostics, pharmaceuticals, tech19 nology, and equipment, can reach such areas 

20 and such populations; 

21 (D) improving management and adminis22 trative support in such areas and among such 

23 populations; 

24 (E) ensuring and prioritizing continuing 

25 onsite educational opportunities for health 


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•HR 4933 IH

1 workers in such areas or among such popu2 lations; and 

3 (F) evaluating, developing, and imple4 menting education and health workforce policies 

5 and regulations that incentivize the recruit6 ment, training, and retention of health workers 

7 most likely to work in such areas or among 

8 such populations. 

9 (7) Establishing and expanding the use of in10 formation and communications technologies, includ11 ing the management of human resources, medical 

12 records, and medical and laboratory supply inven13 tories, to— 

14 (A) enhance the skills and knowledge of 

15 health workers; 

16 (B) improve consultation and referral sys17 tems; and 

18 (C) provide information to health adminis19 trators, managers, and planners. 

20 (8) Preservice and in-service health worker edu21 cation and training programs to build respect for the 

22 rights and dignity of all patients and coworkers that 

23 are tailored to local contexts and developed with the 

24 participation of health workers and indigenous civil 


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1 society organizations and include information 

2 about— 

3 (A) the rights and status of women and 

4 girls; 

5 (B) stigmatization of and discrimination 

6 against individuals living with diseases and 

7 against other poor, vulnerable, or marginalized 

8 populations; and 

9 (C) the legal, human, and civil rights of all 

10 individuals, including the right of access to 

11 health services. 

12 (9) Technical support for the national ministry 

13 of health, or its equivalent, of each participating 

14 country in its leadership of the health system and 

15 the development of the indigenous health workforce, 

16 including support to— 

17 (A) coordinate resources, funding, and 

18 strategy throughout the government; 

19 (B) effectively mobilize government re20 sources and funding to support the indigenous 

21 health workforce; 

22 (C) improve governance, accountability, 

23 and responsiveness to the population and to 

24 civil society organizations; 


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1 (D) reduce corruption within the health 

2 system; and 

3 (E) coordinate with and regulate the pri4 vate-sector health workforce and any health 

5 workers employed by nongovernmental, commu6 nity, and faith-based organizations, inter7 national organizations, private funding sources, 

8 or donor nations. 

9 (10) Support for participating countries to ac10 cess funding related to health workforces and health 

11 systems from multilateral organizations or other ex12 ternal funding sources. 

13 (11) Direct support to indigenous civil society 

14 organizations that promote and advocate for an ef15 fective health system and an expanded indigenous 

16 health workforce in order for such organizations 

17 to— 

18 (A) monitor and evaluate health programs, 

19 expenditures, and national health workforce 

20 plans of their governments; 

21 (B) access other sources of domestic and 

22 international financing, on behalf of themselves 

23 or on behalf of the health systems of their coun24 tries, including national health workforces; 


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1 (C) improve the quality, accessibility, af2 fordability, and equitability of health services; 

3 and 

4 (D) measure progress toward attaining the 

5 goals of the Initiative. 

6 (12) Research on evidence-based policies and 

7 practices related to health workforces and health 

8 systems to improve the delivery of primary care in 

9 participating countries. 

10 (13) Establishing a system to annually monitor 

11 and make publicly available aggregate, nonpersonally 

12 identifiable information regarding the emigration of 

13 indigenously trained health workers from partici14 pating countries, including— 

15 (A) the country where the health profes16 sional was born; 

17 (B) the country where the health profes18 sional was educated and trained; 

19 (C) the country to which the health profes20 sional is immigrating in order to engage in 

21 health-related employment; and 

22 (D) a general classification of the title and 

23 specialty of the health professional before and 

24 after emigration. 


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1 (e) CONTRACT AUTHORITY.—The President may 

2 enter into contracts to carry out the Initiative. 

3 (f) NATIONAL HEALTH WORKFORCE PLANS.— 

4 (1) IN GENERAL.—The President shall encour5 age participating countries to develop, strengthen, 

6 and implement national health workforce plans 

7 that— 

8 (A) are integrated with their national 

9 health strategies, where appropriate; 

10 (B) are based on the situational analysis 

11 described in paragraph (2); and 

12 (C) contain the elements described in para13 graph (3). 

14 (2) SITUATIONAL ANALYSIS.—The situational 

15 analysis described in this paragraph is a situational 

16 analysis of the country’s indigenous health work17 force, including an initial assessment of the number 

18 per 1,000 residents of each type of health worker, 

19 including doctors, nurses, trained midwives, para20 professionals, community health workers, managers, 

21 administrators, and support staff, and of the extent 

22 to which each such type of health worker is equi23 tably distributed within such country. 

24 (3) PLAN ELEMENTS.—The elements described 

25 in this paragraph are the following: 


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1 (A) Performance goals and indicators, in2 cluding interim benchmarks, over a multiyear 

3 period, to achieve a combined total of at least 

4 2.3 doctors, nurses, and trained midwives per 

5 1,000 residents, and comparable numbers of 

6 other health workers, such as paraprofessionals, 

7 community health workers, managers, adminis8 trators, and support staff, and to ensure that 

9 such personnel are equitably distributed within 

10 the country and can carry out their positions 

11 effectively. 

12 (B) Objectives and plans of action to— 

13 (i) recruit, prepare, and encourage in14 dividuals to seek careers in the health pro15 fessions; 

16 (ii) expand and improve health edu17 cation and training programs for health 

18 workers; 

19 (iii) encourage health workers to re20 main employed in the health system; 

21 (iv) reduce the emigration of health 

22 workers and its impact on the indigenous 

23 health workforce and health system; 


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1 (v) improve health workforce adminis2 tration and management in the health sys3 tem; 

4 (vi) increase access to and the place5 ment of skilled health workers among 

6 rural, poor, and other underserved popu7 lations; 

8 (vii) expand the use of information 

9 and communications technologies, includ10 ing the management of medical records 

11 and medical and laboratory supply inven12 tories; 

13 (viii) provide preservice and in-service 

14 education and training programs to combat 

15 stigma and discrimination among health 

16 workers and reinforce respect for the 

17 rights and dignity of patients; 

18 (ix) improve the health and safety of 

19 health workers; 

20 (x) identify and describe budgetary 

21 gaps related to expanding recruitment, 

22 training, and retention of the indigenous 

23 health workforce and any financial re24 source mobilization efforts to close such 

25 gaps; and 


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1 (xi) monitor and evaluate the imple2 mentation of the plan, including identifying 

3 and addressing barriers to implementation, 

4 and provide a basis for adjustments to the 

5 plan as required. 

6 (C) Participation and input into the devel7 opment, implementation, monitoring, and eval8 uation of all aspects of the plan from indige9 nous civil society and nongovernmental, commu10 nity, and faith-based organizations dedicated to 

11 improving public health and expanding the in12 digenous health workforce, with representation 

13 from a multisectoral group of stakeholders, in14 cluding health workers and communities. 

15 (g) GLOBAL HEALTH WORKFORCE INITIATIVE

16 STRATEGY.— 

17 (1) IN GENERAL.—Not later than 1 year after 

18 the date of the enactment of this Act, the President 

19 shall transmit to Congress and make publicly avail20 able a 5-year strategy for implementing and moni21 toring the Initiative established under this section. 

22 (2) CONTENT.—The strategy required by para23 graph (1) shall include— 

24 (A) a description of how assistance pro25 vided under this section will be coordinated 


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1 among United States Government agencies with 

2 responsibilities related to global health; 

3 (B) a description of how assistance pro4 vided under this section will be coordinated with 

5 each country, international organization, and 

6 other donor; 

7 (C) a description of how assistance pro8 vided under this section will support and en9 courage countries to develop the national health 

10 workforce plans described in subsection (f); 

11 (D) a description, for programs carried out 

12 in each participating country, of performance 

13 goals and indicators for each activity listed in 

14 subsection (d); 

15 (E) plans of action to reach the perform16 ance goals and indicators required by subpara17 graph (D); and 

18 (F) a description of the consultation re19 quired by paragraph (3). 

20 (3) CONSULTATION.—In developing the strat21 egy required by paragraph (1), the President shall 

22 ensure proper consultation with— 

23 (A) each executive branch agency author24 ized to deliver health workforce-related foreign 


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1 assistance, including personnel at United States 

2 embassies and country missions; 

3 (B) the appropriate congressional commit4 tees with jurisdiction over the agencies de5 scribed in subparagraph (A); 

6 (C) civil society and nongovernmental, 

7 community, and faith-based organizations en8 gaged in improving health care and health out9 comes and in addressing health workforce needs 

10 in developing countries; 

11 (D) participating countries; 

12 (E) international organizations engaged in 

13 delivering health-related assistance and of 

14 which the United States is a voting member, 

15 with which the United States coordinates the 

16 delivery of foreign assistance, or to which the 

17 United States contributes funding for the pur18 pose of providing such assistance; 

19 (F) private foundations, businesses, and 

20 organizations that provide a significant amount 

21 of health-related assistance and do not receive 

22 United States funding for the purpose of pro23 viding such assistance; 


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1 (G) other donor nations that provide 

2 health-related assistance to developing coun3 tries; and 

4 (H) any other global, regional, or sub5 regional organizations or partnerships engaged 

6 in improving health care and health outcomes 

7 in developing countries. 

8 (h) MONITORING AND EVALUATION SYSTEM.— 

9 (1) IN GENERAL.—The President shall establish 

10 an integrated monitoring and evaluation system to 

11 measure the effectiveness of foreign assistance pro12 vided under the Initiative. 

13 (2) HARMONIZATION WITH SYSTEMS OF PAR14 TICIPATING COUNTRIES.—To the maximum extent 

15 possible, the monitoring and evaluation system re16 quired by paragraph (1) shall be harmonized with 

17 and may be modified to reflect the monitoring and 

18 evaluation systems of participating countries. 

19 (3) ELEMENTS OF MONITORING AND EVALUA20 TION SYSTEM.—The monitoring and evaluation sys21 tem required by paragraph (1) shall— 

22 (A) establish country-specific performance 

23 goals; 

24 (B) establish performance indicators to be 

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1 ment of the performance goals established 

2 under subparagraph (A), including indicators 

3 for— 

4 (i) the recruitment of health workers 

5 through the absorption capacity of the edu6 cational system; 

7 (ii) the training of health workers 

8 through the absorption capacity, intake, 

9 and output of health professional training 

10 institutions; 

11 (iii) the retention of health workers by 

12 the health system; 

13 (iv) health worker immigration and 

14 emigration; 

15 (v) the distribution and density of 

16 health workers, including the relative den17 sity and absorption capacity of urban and 

18 rural health workforces and health facili19 ties; 

20 (vi) vacancy rates for health-related 

21 jobs; 

22 (vii) the health and safety of health 

23 workers; 

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1 pacity to deliver quality health services; 

2 and 

3 (ix) improvements in health outcomes 

4 tied directly to the efforts of health work5 ers; 

6 (C) provide a basis for recommendations of 

7 adjustments to the strategy established under 

8 subsection (g) to enhance the impact of assist9 ance provided under the Initiative and support 

10 the integration of such recommendations into 

11 the national planning processes of participating 

12 countries; and 

13 (D) provide regular public accessibility to 

14 all collected data in a clear and readable for15 mat. 

16 (i) REPORT.— 

17 (1) IN GENERAL.—Not later than 1 year after 

18 the date of the enactment of this Act and annually 

19 thereafter, the President shall transmit to Congress 

20 a report describing the impact and effectiveness of 

21 the assistance provided under the Initiative. 

22 (2) CONTENT.—The report required by para23 graph (1) shall include— 

24 (A) an assessment and description, for ac25 tivities within each participating country, of 


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1 progress toward achieving the goals of the Ini2 tiative; 

3 (B) an assessment and description of the 

4 financial, policy, and other obstacles to achiev5 ing the performance goals established under 

6 subsection (h)(3)(A) and the steps taken to 

7 overcome such obstacles; 

8 (C) an assessment and description, for 

9 each participating country, of progress toward 

10 and obstacles to developing, strengthening, and 

11 implementing a national health workforce plan 

12 described in subsection (f), including any assist13 ance provided by the United States to overcome 

14 such obstacles; and 

15 (D) an evaluation of knowledge about 

16 strengthening health workforces that was ac17 quired through implementing the Initiative in 

18 each participating country. 

19 (j) AUTHORIZATION OF APPROPRIATIONS.— 

20 (1) IN GENERAL.—In addition to amounts oth21 erwise made available for such purposes, there are 

22 authorized to be appropriated to the President to 

23 carry out this section— 

24 (A) $300,000,000 for fiscal year 2011; 

25 (B) $350,000,000 for fiscal year 2012; 


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1 (C) $400,000,000 for fiscal year 2013; 

2 (D) $450,000,000 for fiscal year 2014; 

3 and 

4 (E) $500,000,000 for fiscal year 2015. 

5 (2) AVAILABILITY OF FUNDS.—Amounts appro6 priated pursuant to the authorization of appropria7 tions in paragraph (1) are authorized to remain 

8 available until expended. 

9 SEC. 6. RELATION TO OTHER UNITED STATES LAWS AND 

10 POLICIES. 

11 (a) SENSE OF CONGRESS ON LAWS AND POLICIES

12 RELATED TO THE UNITED STATES DOMESTIC HEALTH

13 WORKFORCE.—It is the sense of Congress that the Presi14 dent, in consultation with Congress, the States, public and 

15 private medical and health organizations and groups, 

16 health professional training institutions, and patients, 

17 should take steps to address the urgent shortage of health 

18 professionals in the United States without exacerbating 

19 the shortage of health professionals in developing coun20 tries, including by— 

21 (1) identifying and recommending changes to 

22 United States laws, regulations, and policies that 

23 incentivize the immigration of foreign-educated 

24 health professionals into the United States from 

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1 sionals or further increase the reliance of the United 

2 States health care system on such professionals; 

3 (2) supporting policies that mitigate the im4 pacts of recruiting foreign-educated health profes5 sionals away from their countries of origin for 

6 health-related employment in the United States and 

7 ensure the continued availability of qualified health 

8 professionals in such countries, including— 

9 (A) establishing relationships or partner10 ship agreements with national and local au11 thorities, hospitals, clinics, and health profes12 sional training institutions in source countries 

13 to— 

14 (i) set mutually agreed-upon time 

15 frames and processes for training and de16 parture of foreign-educated health profes17 sionals; 

18 (ii) allow and provide for opportuni19 ties for foreign-educated health profes20 sionals to periodically return to their coun21 tries of origin to provide technical assist22 ance and support to their home commu23 nities or to work in a health care facility, 

24 particularly for countries experiencing a 

25 critical lack of indigenous health workers; 


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1 (iii) provide opportunities for visiting 

2 faculty and health professionals from the 

3 United States to provide direct technical 

4 assistance and support for the training of 

5 health professionals in source countries; 

6 (iv) support the direct purchase of 

7 medical or laboratory supplies, pharma8 ceuticals, diagnostics, technology, and 

9 equipment for use within the source coun10 try, in accordance with the law governing 

11 such products in such country; 

12 (v) match a portion of the remittances 

13 sent by recruited foreign-educated health 

14 professionals and direct such matching 

15 funds to health care organizations or na16 tional or local health authorities in their 

17 countries of origin; and 

18 (vi) create scholarships with health 

19 professional training institutions in source 

20 countries to support the training and re21 tention of new indigenous health profes22 sionals, particularly to provide health serv23 ices to poor, vulnerable, or marginalized 

24 populations; 


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1 (B) respecting contractual obligations and 

2 other agreements of foreign-educated health 

3 professionals to serve the health systems of 

4 their countries of origin in exchange for public 

5 education or scholarships provided in such 

6 countries, including by encouraging foreign-edu7 cated health professionals to honor such agree8 ments, and, where appropriate, requiring evi9 dence that such agreements have been satisfied; 

10 and 

11 (C) ending active overseas recruitment 

12 in— 

13 (i) countries or areas within countries 

14 where a temporary health crisis is causing 

15 a severe shortage of health professionals; 

16 (ii) countries that are experiencing a 

17 chronic shortage of health workers, with 

18 fewer than a combined total of 2.3 doctors, 

19 nurses, and trained midwives per 1,000 

20 residents; and 

21 (iii) countries that request the end of 

22 such recruitment, in whole or in part; 

23 (3) advocating the mandatory adoption of the 

24 policies described in paragraph (2) by recruiting or25 ganizations that receive United States funding; 


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1 (4) establishing programs that allow foreign2 educated health professionals working in the United 

3 States to return to their countries of origin to par4 ticipate in health-related United States foreign as5 sistance programs without impacting their immigra6 tion status in the United States; 

7 (5) annually monitoring and making publicly 

8 available aggregate, nonpersonally identifiable infor9 mation related to foreign-educated health profes10 sionals who are recruited to or who otherwise immi11 grate to the United States, including information re12 lated to— 

13 (A) their countries of birth; 

14 (B) the countries where they were edu15 cated and trained to become health profes16 sionals; 

17 (C) the countries in which they engaged in 

18 health-related employment immediately prior to 

19 entering the United States; and 

20 (D) the States to which they were re21 cruited or in which they otherwise intend to en22 gage in health-related employment; 

23 (6) developing a health workforce plan for the 

24 United States that includes a specific focus on re25 cruiting and training significant numbers of new 


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1 health professionals to address the urgent shortage 

2 of health professionals in the United States, in ac3 cordance with the principles of paragraphs (1) 

4 through (4); and 

5 (7) supporting the World Health Organization 

6 in developing and implementing a Global Code of 

7 Practice on the International Recruitment of Health 

8 Personnel that is consistent with paragraphs (1) 

9 through (4) and that takes into consideration the 

10 views of all relevant stakeholders. 

11 (b) SENSE OF CONGRESS ON LAWS AND POLICIES

12 RELATED TO BILATERAL AND INTERNATIONAL TRADE.— 

13 It is the sense of Congress that the President should pur14 sue trade and investment agreements and policies that 

15 support the goals of the United States Global Health 

16 Strategy and maximize the ability of national governments 

17 to improve health outcomes and reduce mortality among 

18 their populations, including by ensuring that any trade 

19 agreement— 

20 (1) encourages broad access for poor, vulner21 able, or marginalized populations to quality, afford22 able pharmaceuticals, medical products, and medical 

23 devices, including generics, if such items are covered 

24 by such agreement; 


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1 (2) allows for the negotiation of lower prices for 

2 pharmaceuticals, especially if no generic alternative 

3 exists or the original product cannot be purchased at 

4 an affordable cost; 

5 (3) adheres to the principles of the 2001 World 

6 Trade Organization (in this subsection referred to as 

7 the ‘‘WTO’’) Doha Declaration on Trade-Related 

8 Aspects of Intellectual Property Rights (in this sub9 section referred to as the ‘‘Declaration’’), including 

10 measures that the Agreement on Trade-Related As11 pects of Intellectual Property Rights permits coun12 tries to take to protect public health and ensure ac13 cess to essential medicines; 

14 (4) is negotiated, implemented, monitored, and 

15 enforced with the input and participation, in an ad16 visory capacity, of a broad range of indigenous and 

17 United States-based civil society organizations that 

18 are dedicated to improving and protecting public 

19 health; 

20 (5) expressly allows for the adoption of public 

21 interest licensing agreements for medications devel22 oped with significant public funding, such as— 

23 (A) open licensing; 

24 (B) nonenforcement of patents; 


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1 (C) licensing of such products to inter2 national drug purchase facilities and patent 

3 pools; and 

4 (D) other mechanisms to make medica5 tions available at reduced cost; 

6 (6) disavows the use of trade threats, such as 

7 placement on ‘‘watchlists’’ or the removal of trade 

8 benefits, against countries using WTO-compliant 

9 trade flexibilities, in accordance with the principles 

10 of the Declaration, in order to protect public health 

11 and ensure access to essential medicines; and 

12 (7) does not result in costs of pharmaceuticals, 

13 medical products, or medical devices that are 

14 unaffordable for the general population, and does 

15 not subject national governments to any limitations 

16 with respect to the use, distribution, or manufac17 turing of such items that are inconsistent with the 

18 principles of the Declaration. 

19 (c) UNITED STATES PARTICIPATION IN INTER20 NATIONAL FINANCIAL INSTITUTIONS.— 

21 (1) OPPOSITION TO CERTAIN USER FEES.—The 

22 Secretary of the Treasury shall instruct the United 

23 States Executive Director at each international fi24 nancial institution to oppose and vote against any 

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1 spective institution that would require or result in 

2 the imposition of user fees or service charges on 

3 poor individuals in connection with such institution’s 

4 financing programs for primary education or pri5 mary health care, including prevention, care, and 

6 treatment for HIV/AIDS, malaria, and tuberculosis 

7 and care related to infant, child, reproductive, and 

8 maternal well-being. 

9 (2) OPPOSITION TO CERTAIN IMF SPENDING

10 CAPS.—The Secretary of the Treasury shall instruct 

11 the United States Executive Director at the Inter12 national Monetary Fund to oppose and vote against 

13 any loan, project, agreement, memorandum, instru14 ment, or program of the International Monetary 

15 Fund that would not exempt government spending 

16 on health care, health infrastructure, and education 

17 from national budget caps and restraints, hiring and 

18 wage ceilings, and other limits imposed by the Inter19 national Monetary Fund. 

20 (d) PARTICIPATION OF HEALTH WORKERS IN

21 UNITED STATES GLOBAL HEALTH PROGRAMS.—For all 

22 United States programs related to global health that pro23 vide foreign assistance, it shall be the policy of the United 

24 States Government to ensure that— 


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1 (1) all health workers participating in such pro2 grams follow recommended occupational health and 

3 safety standards and have the proper training and 

4 access to the necessary protective technology, equip5 ment, and supplies, including those for blood and in6 jection safety, to establish and sustain safe and sani7 tary working conditions in accordance with accepted 

8 forms of effective infection prevention and control, 

9 including rapid access to postexposure prophylaxis in 

10 the event of exposure to HIV; 

11 (2) all health workers participating in such pro12 grams have access to comprehensive, confidential, 

13 high-quality health services, including prevention 

14 and treatment for chronic and infectious diseases 

15 and psychosocial and mental health services; 

16 (3) all health workers participating in such pro17 grams receive training about respect for the rights 

18 and dignity of all patients and coworkers that is tai19 lored to local contexts, developed with the participa20 tion of health workers and indigenous civil society 

21 organizations, and includes information about— 

22 (A) the rights and status of women and 

23 girls; 


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1 (B) stigmatization of and discrimination 

2 against individuals living with diseases and 

3 other marginalized groups; and 

4 (C) the legal, civil, and human rights of all 

5 individuals, including the right of access to 

6 health services; and 

7 (4) community health workers are— 

8 (A) recognized for their work; 

9 (B) integrated into countries’ health sys10 tems through— 

11 (i) a functional process by which com12 munity health workers may refer patients 

13 to other appropriate health workers; and 

14 (ii) the provision of ongoing support 

15 and supervision; 

16 (C) paid adequate salaries and offered tan17 gible pathways for career advancement; and 

18 (D) when possible, recruited from under19 served and rural communities. 

20 SEC. 7. DEFINITIONS. 

21 In this Act, the following definitions apply: 

22 (1) COMMUNITY HEALTH WORKER.—The term 

23 ‘‘community health worker’’ means a health worker 

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1 rectly to individuals and who does not have the ad2 vanced training of a health professional. 

3 (2) HEALTH PROFESSIONAL.—The term 

4 ‘‘health professional’’ means a health worker who 

5 provides health services and has received advanced 

6 training regarding the provision of such services, in7 cluding doctors, nurses, midwives, pharmacists, 

8 pharmacy technicians, dentists, laboratory techni9 cians, and clinical officers. 

10 (3) HEALTH PROFESSIONAL TRAINING INSTITU11 TION.—The term ‘‘health professional training insti12 tution’’ means an institution that trains health pro13 fessionals in accordance with generally accepted 

14 standards of clinical practice and confers a degree or 

15 diploma on each graduate of a training program. 

16 (4) HEALTH SYSTEM.—Used in relation to a 

17 country, the term ‘‘health system’’ means all compo18 nents, public and private, of the health care mobili19 zation, financing, and delivery system of such coun20 try, including health workers, health professionals, 

21 clinics, hospitals, pharmacies, institutions per22 forming health-related research, producers of phar23 maceuticals and medical equipment, and government 

24 health-service agencies. 


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1 (5) HEALTH WORKER.—The term ‘‘health 

2 worker’’ means any individual who provides or sup3 ports the provision of health services, directly or in4 directly, including health professionals, paraprofes5 sionals, community health workers, social workers, 

6 caregivers, nutritionists, health administrators and 

7 managers, and government officials who set health 

8 care policy. 

9 (6) INTERNATIONAL FINANCIAL INSTITU10 TION.—The term ‘‘international financial institu11 tion’’ means the following institutions: 

12 (A) The International Bank for Recon13 struction and Development. 

14 (B) The International Development Asso15 ciation. 

16 (C) The International Finance Corpora17 tion. 

18 (D) The Multilateral Investment Guar19 antee Agency. 

20 (E) The International Centre for Settle21 ment of Investment Disputes. 

22 (F) The Inter-American Development 

23 Bank. 

24 (G) The Asian Development Bank. 

25 (H) The Asian Development Fund. 


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1 (I) The African Development Bank. 

2 (J) The African Development Fund. 

3 (K) The International Monetary Fund. 

4 (L) The North American Development 

5 Bank. 

6 (M) The European Bank for Reconstruc7 tion and Development. 

8 (7) NATIONAL HEALTH STRATEGY.—Used in 

9 relation to a country, the term ‘‘national health 

10 strategy’’ means any set of policies, whether or not 

11 formally enumerated and however called, aimed at 

12 improving health outcomes in such country by im13 proving and increasing access to the health system 

14 of such country. 

15 (8) POOR, VULNERABLE, OR MARGINALIZED

16 POPULATIONS.—The term ‘‘poor, vulnerable, or 

17 marginalized populations’’ means— 

18 (A) indigenous populations; 

19 (B) racial, ethnic, religious, and national 

20 minorities; 

21 (C) children who have lost one or both par22 ents; 

23 (D) women and girls; 

24 (E) individuals with physical or mental dis25 abilities; 


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1 (F) individuals living with chronic or infec2 tious diseases; 

3 (G) sexual minorities, including men who 

4 have sex with men; 

5 (H) sex workers; 

6 (I) drug users; 

7 (J) incarcerated and formerly incarcerated 

8 individuals; 

9 (K) individuals of foreign national origin; 

10 (L) refugees and internally displaced popu11 lations; 

12 (M) the elderly; 

13 (N) individuals who live in rural areas; and 

14 (O) any other group that has difficulty ac15 cessing health services because of economic, po16 litical, or social status. 

Æ 


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