I 113th CONGRESS 2d Session H. R. 4997 IN THE HOUSE OF REPRESENTATIVES June 26, 2014 Ms. DeLauro (for herself, Ms. McCollum , and Ms. Lee of California ) introduced the following bill; which was referred to the Committee on Foreign Affairs A BILL To provide assistance to sub-Saharan Africa to combat obstetric fistula.

1. Short title and table of contents (a) Short title This Act may be cited as the United States Leadership to Eradicate Obstetric Fistula Act of 2014 . (b) Table of contents The table of contents for this Act is as follows: Sec. 1. Short title and table of contents. Sec. 2. Findings. Sec. 3. Definitions. Sec. 4. Comprehensive, integrated, 10-year strategy to combat obstetric fistula in sub-Saharan Africa. Sec. 5. Prevention, treatment, and monitoring of obstetric fistula in sub-Saharan African countries. Sec. 6. United States Advisory Committee for the Eradication of Obstetric Fistula. Sec. 7. Report. Sec. 8. Authorization of appropriations. 2. Findings Congress makes the following findings: (1) Obstetric fistula is a catastrophic childbirth injury which arises as a complication of obstructed labor. (2) An estimated 2 to 3 million women currently are afflicted by the devastating physical and social effects of obstetric fistula—a scourge of epidemic proportions. As many as 130,000 new cases occur each year. (3) Historically, obstetric fistula affected women in the United States and around the world. Advances in obstetric care and access to improved surgical techniques resulted in a drastic reduction in obstetric fistula by the early 20th century in the United States. (4) Today, obstetric fistula primarily affects the poorest women in the poorest parts of the world. It disproportionately affects women in sub-Saharan Africa and girls—some as young as 13 years old—who are subjected to child marriage and whose bodies are not fully capable of handling the demands of childbirth. Many of these young girls and women have been subjected to female genital mutilation, which can increase the risk for and be a direct cause of obstetric fistula. (5) Obstetric fistula, which usually results in fetal death by asphyxia, occurs when the tissues that normally separate a woman’s vagina from her bladder or rectum are destroyed by prolonged pressure from the fetal head trapped in the birth canal. (6) Obstetric fistula typically occurs because a woman does not have access to emergency obstetric care or because she does not have the financial means, transportation, or access to surgical repair. (7) Left untreated, an obstetric fistula afflicts a woman with devastating physical conditions: incontinence, painful ulcers, and constant and uncontrollable emission of offensive odors. These symptoms leave a woman indelibly and perpetually stigmatized by her condition. (8) Because obstetric fistula does not heal on its own, women affected by this condition are marginalized for the remainder of their lives. Expelled from their communities and denied education and health care, obstetric fistula victims are left in desperate economic circumstances. (9) Victims also suffer social ostracism that results in involuntary divorce, exclusion from religious activities, deepening poverty, malnutrition, deteriorating physical health, depression, and despair. As a result, victims are left defenseless and vulnerable. (10) This social isolation compounds already existing problems such as illiteracy and lack of economic opportunities. (11) Because obstetric fistula are not themselves fatal, millions of women live with this horrific condition and have been overlooked by the international medical community. At present, humanitarian aid and nongovernmental programs treat fistula cases on a small scale and are not equipped to systematically prevent, treat, and eradicate obstetric fistula. (12) Obstetric fistula can be prevented when women and their families are educated about the birthing process and are provided access to emergency obstetric care. (13) Today, doctors can surgically repair obstetric fistula with a low-cost, low-technology surgery. (14) The impact of an obstetric fistula-repair surgery is immediate and consequential. Women can be re-integrated into society and are afforded basic human necessities such as familial relationships, health care, and the opportunity to earn a living. (15) The prevention, treatment, and ultimately the eradication of obstetric fistula will advance the emancipation and empowerment of women, strengthen families and communities, and improve the overall economic, educational, and social well-being of affected societies. (16) Basic interventions to identify and repair obstetric fistula have achieved meaningful and cost-effective results. (17) The best available data suggests that existing programs can only repair 10 percent of new obstetric fistula cases each year, and less than 1 percent of existing obstetric fistula cases are repaired each year. (18) The challenge is to expand existing pilot programs into a scalable, comprehensive, and sustainable campaign to eradicate obstetric fistula. (19) Nongovernmental organizations with experience in obstetric care, surgery, and women’s rights have proven effective in making progress towards eliminating the scourge of obstetric fistula and can be a resource in assisting indigenous organizations in severely afflicted countries in their efforts to treat and care for women with obstetric fistula. (20) The nature of obstetric fistula—and the fact that it affects vulnerable women in poor and isolated communities which offer little or no access to obstetric care—demands a comprehensive, coordinated, long-term, international response focused on the prevention and treatment of obstetric fistula, including— (A) safe-childbirth education and obstetric fistula prevention, care, and treatment; post-operative care, including rehabilitation, social reintegration, and post-surgical follow-up; basic and applied research and clinical work; and training of health care workers and educators, particularly local, grassroots educators and medical workers; (B) designation of a university-based medical center in the United States, designated as the International Obstetric Fistula Institute for Sub-Saharan Africa established under section 5(d), responsible for marshaling surgical and other necessary health resources to effectuate the campaign against obstetric fistula; for building prevention and treatment capacity in sub-Saharan Africa, including coordinating partnerships with sub-Saharan African institutions and governments; and for developing and managing community education and mobilization programs at home and abroad; (C) development of health care infrastructure and delivery systems through Centers of Clinical Excellence for Obstetric Fistula Care for Sub-Saharan Africa as well as through cooperative and coordinated public efforts and public-private partnerships; (D) strengthening universities, research centers, and training programs for health professionals through institutional capacity-building partnerships; (E) development and implementation of a United States Obstetric Fistula Treatment and Prevention Corps which recruits and trains doctors—especially obstetricians, gynecologists, urologists, general surgeons, and anesthesiologists—nurses, and other community-development and public-health personnel to serve regions affected by obstetric fistula and which partners United States medical professionals with sub-Saharan African professionals, promoting a joint effort to eradicate this devastating condition; (F) coordination of efforts to make the treatment of obstetric fistula a higher priority in sub-Saharan African hospitals, specifically aimed at ameliorating the paucity of training related to obstetric fistula treatment; and (G) coordination of efforts between the medical community, nongovernmental organizations, national governments, and private sector organizations, including faith-based organizations. (21) The United States has the capacity to lead and enhance the effectiveness of the international community’s response by— (A) providing substantial resources, medical expertise, and training, particularly of health care personnel and community workers and leaders; (B) making United States surgeons and health care professionals available to serve, train, and build workforce capacity in afflicted countries through a United States Obstetric Fistula Treatment and Prevention Corps; (C) encouraging governments and faith-based and community organizations to adopt policies that treat obstetric fistula and its causes as a multi-sector, public-health problem that profoundly affects women’s health, women’s empowerment, education, the economy, and promotion of strong and successful families; (D) encouraging education about healthy practices, including education about the health risks associated with child marriage and female genital mutilation; (E) building successful communities by preventing obstetric fistula and the ensuing social stigma which often separates an obstetric fistula victim from her family; (F) contributing to public health and health-care delivery system research to improve obstetric fistula prevention, treatment, and reintegration; (G) encouraging active involvement and cooperation across sectors, including the medical and scientific communities, charitable foundations, private and voluntary organizations and nongovernmental organizations, faith-based organizations, community-based organizations, and other not-for-profit entities; and (H) engaging in medical diplomacy, with a particular focus on the further empowerment and emancipation of women. (22) Unaddressed obstetric emergencies and untreated obstetric fistula result in the needless, systematic degradation and marginalization of women. It should be the policy of the United States to help eradicate this preventable and curable condition. (23) Strong coordination must exist among the implementing agencies of the United States to ensure effective and efficient use of financial, medical, and technical resources within the United States Government with respect to international obstetric fistula eradication. (24) Obstetric fistula is a medical condition which historically affected women around the globe. The United States long ago eliminated this needlessly oppressive condition because of access to skilled medical professionals and medical care. Obstetric fistula can be prevented and repaired. No woman should suffer a lifetime of debilitating physical and social consequences—as obstetric fistula victims do—simply because she lacks access to basic obstetric care. 3. Definitions In this Act: (1) Advisory Committee The term Advisory Committee means the United States Advisory Committee for the Eradication of Obstetric Fistula established under section 6. (2) Clinical Center of Excellence The term Center of Clinical Excellence means a Center of Clinical Excellence for Obstetric Fistula Care in sub-Saharan Africa established under section 5(d)(5). (3) Corps The term Corps means the United States Obstetric Fistula Treatment and Prevention Corps established under section 5(d)(6). (4) Institute The term Institute means the International Obstetric Fistula Institute for Sub-Saharan Africa established under section 5(d)(1). (5) Relevant executive branch agencies The term relevant executive branch agencies means the Department of State, the United States Agency for International Development, and any other department or agency of the United States that participates in international health and humanitarian activities pursuant to the authorities of such department or agency or the Foreign Assistance Act of 1961. (6) Secretary The term Secretary means the Secretary of State. (7) Sub-Saharan Africa The terms sub-Saharan Africa , sub-Saharan African , and sub-Saharan African country shall have the meanings given to such terms for purposes of this Act by the Secretary. 4. Comprehensive, integrated, 10-year strategy to combat obstetric fistula in sub-Saharan Africa (a) In general The President, acting through the Administrator of the United States Agency for International Development, shall establish a comprehensive, integrated, 10-year strategy to combat obstetric fistula in sub-Saharan Africa that strengthens the capacity of the United States to be an effective leader in the movement for international women’s health and empowerment. (b) Elements Such strategy shall maintain sufficient flexibility and remain responsive to the needs of women afflicted with obstetric fistula or who stand at risk of suffering from obstetric fistula and shall include the following: (1) A plan for implementation and coordination of programs and activities under this Act, including grants and contracts for prevention, treatment, and monitoring of obstetric fistula under section 5. (2) Specific objectives, multi-sector approaches, and specific strategies to treat women who suffer from obstetric fistula and to prevent further occurrences of obstetric fistula. (3) Assignment of priorities for relevant executive branch agencies. (4) Public health and health care delivery system research on the prevention, repair, and rehabilitation of obstetric fistula. (5) Development, implementation, and evaluation of evidence-based systems of care connecting maternity and obstetric fistula care facilities with local care delivery and community education programs. Such systems of care should promote rapid and long-term prevention of obstetric fistula, including— (A) referral to prenatal care to identify and mitigate risk factors for obstetric fistula; (B) culturally appropriate childbirth education, preparation, and planning; (C) access to skilled obstetric care; and (D) promoting prompt detection of prolonged labor and appropriate action to address it. (6) Provision that the reduction of health and social risks which increase the likelihood of obstetric fistula shall be a priority of all prevention efforts in terms of funding, educational messages, and activities promoting a decrease in child marriage and the adolescent pregnancy rate, prompt detection of prolonged labor, and immediate intervention in cases of obstructed labor through improved access to emergency obstetric services provided by partner hospitals. (7) Improvement of coordination and reduce duplication among relevant executive branch agencies, foreign governments, and international organizations. (8) Projection of general levels of resources needed to achieve the stated objectives. (9) Expansion of public-private partnerships and the leveraging of resources. (10) Maximization of United States capabilities in the areas of medical training and research and application of those capabilities in sub-Saharan Africa. Such efforts may include the provision of grants by relevant executive branch agencies for institutional capacity-building partnerships between United States and foreign institutions, as well as between in-country institutions, for the purpose of mobilizing in-country capacity, resources, and expertise to prevent and repair cases of obstetric fistula. (11) Priorities for the distribution of resources based on factors such as the size and demographics of the population suffering from obstetric fistula, the needs of that population, and the existing infrastructure or funding levels that may exist to treat and prevent obstetric fistula. (12) A long-term commitment to the eradication of obstetric fistula by expanding health system capacity and training opportunities for doctors and other health service providers in sub-Saharan Africa. (13) A plan to maximize United States efforts in workforce training, capacity-building, and retention relating to obstetric fistula prevention, treatment, rehabilitation, and research. Such plan shall be coordinated with existing United States and in-country workforce capacity-building plans and efforts. Such plan may include training of foreign health workers at United States institutions and train-the-trainer programs. (14) A plan for institutional capacity-building partnerships to strengthen universities, research centers, health-profession training programs, and government institutes to build the in-country capacity needed to eradicate obstetric fistula. (c) Report Not later than 1 year after the date of the enactment of this Act, the President shall submit to Congress a report that contains the strategy required under this section. 5. Prevention, treatment, and monitoring of obstetric fistula in sub-Saharan African countries (a) In general The President, acting through the Administrator of the United States Agency for International Development, is authorized to provide grants to or enter into contracts with an eligible entity described in subsection (b) to carry out activities to prevent, treat, and monitor obstetric fistula in sub-Saharan African countries in accordance with this section. (b) Eligible entity described In this section, the term eligible entity means a major, university-based medical center in the United States. (c) Application and selection (1) Application The President shall provide for eligible entities to submit applications to the President for grants or contracts under this section in such form and manner as the President may require to carry out the purposes of this section. (2) Selection (A) In general From among the applications submitted under paragraph (1), the President shall select an eligible entity to receive grants or contracts under this section pursuant to a competitive selection process. (B) Criteria The competitive selection process referred to in subparagraph (A) shall be based upon selection criteria, which shall include— (i) the breadth and depth of medical faculty, particularly with experience in obstetrics and reconstructive pelvic surgery; (ii) breadth and depth of public health and international health faculty; (iii) experience in and capacity to conduct training of the global health workforce and to strengthen capacity-building and health systems; (iv) experience in building institutional capacity in sub-Saharan Africa, including through institutional partnerships; (v) willingness to supplement amounts received under grants or contracts under subsection (a) by engaging in community partnerships; and (vi) whether the applicant, for purposes of this Act, has entered into a cooperative agreement with one or more major, university-based medical centers in sub-Saharan Africa. (d) Use of funds (1) International Obstetric Fistula Institute for Sub-Saharan Africa Amounts received under grants or contracts under subsection (a) shall be used to establish and operate at the eligible entity’s medical center in the United States an institute to carry out paragraphs (2) through (7), to be known as the International Obstetric Fistula Institute for Sub-Saharan Africa. The purpose of the Institute shall be to prevent, treat, and monitor obstetric fistula in sub-Saharan African countries. (2) Administration and training The Institute shall— (A) serve as the primary administrative and medical-training hub for the campaign to prevent, treat, and monitor obstetric fistula in sub-Saharan African countries; (B) ensure the campaign described in subparagraph (A) is carried out on both a scientific and humanitarian basis; (C) initiate and oversee the training and clinical activities of physicians, other health professionals, and educators serving at Centers of Clinical Excellence; and (D) ensure a progressive increase in health system and workforce capacity to prevent, treat, and monitor obstetric fistula in each country in which a Center of Clinical Excellence is located. (3) Enforce clinical standards and accountability The Institute shall— (A) promote the utilization of standard clinical protocols, facilitate data collection, coordinate research efforts, and oversee and participate in multi-center randomized surgical trials; and (B) enforce the highest standards of clinical practice and ethical behavior as described in the published code of medical ethics for obstetric fistula surgeons. (4) Develop evidence-based programs for prevention and access to emergency obstetric care The Institute shall— (A) develop and implement comprehensive and culturally appropriate protocols to prevent the formation of obstetric fistula, including the development and implementation of evidence-based systems of care, which identify, track, and evaluate obstetric fistula prevention programs; (B) develop and implement prevention programs that— (i) teach women and family members, in a culturally appropriate manner, how to identify prolonged labor; (ii) inform women and family members of the risks of not seeking appropriate medical care; (iii) refer women and family members to prenatal, perinatal, and postnatal care; (iv) teach women and family members how to mobilize community resources to assist in seeking emergency obstetric care; and (v) teach women and family members to identify symptoms of obstetric fistula and refer women to treatment; (C) assist Centers of Clinical Excellence in developing localized programs for childbirth education, preparation and planning, prolonged-labor detection, labor monitoring, and transportation from villages to local hospitals for obstetric care and to Centers of Clinical Excellence for obstetric fistula care, accounting for factors such as transportation, geography, and scalability of such solutions; and (D) seek to partner with United States medical personnel and volunteers to train and employ local men and women as community-based labor monitors who can educate and assist other women at risk of suffering from obstetric fistula, thereby empowering an entire sector of women in sub-Saharan Africa with information and employment. (5) Centers of Clinical Excellence for Obstetric Fistula Care in Sub-Saharan Africa (A) In general The Institute, in cooperation with each medical center in sub-Saharan African described in subsection (b), shall establish not less than 8 centers in sub-Saharan Africa to treat and prevent obstetric fistula in countries and areas in which obstetric fistula is widespread, as determined by the Institute in consultation with the Advisory Committee. Such centers shall be known as Centers of Clinical Excellence for Obstetric Fistula Care in sub-Saharan Africa. (B) General duties Each Center of Clinical Excellence shall establish programs to treat and prevent obstetric fistula at hospitals and to expand the networks of such hospitals. the Centers of Excellence shall be co-located or located within reasonable proximity to hospitals capable of providing emergency and routine obstetric care, in order to fulfill its duties and to ensure hospitals meet emergency obstetric needs. (C) Specific duties Each Center of Clinical Excellence shall function as localized epicenters of training and clinical excellence for obstetric fistula care, and shall— (i) be a major locus of medical and surgical care for obstetric fistula patients; (ii) be centers for the training of obstetric fistula surgeons, nurses, and other medical personnel; (iii) coordinate and implement community outreach and prevention programs; (iv) partner with the national ministry of health or equivalent government body and medical educators in the country in which the Center of Clinical Excellence is located to develop country-specific training programs for surgeons and other health care personnel involved in obstetric fistula care; (v) be a vehicle for expanding access to emergency obstetric services in affiliated communities; (vi) establish a consulting and referral relationship with a hospital in its geographic vicinity, assist the hospital by completing an initial, comprehensive assessment of what resources the hospital would need to improve delivery of emergency obstetric services, and based on the needs assessments and subject to the approval of the Institute approve funding for each hospital to undergo appropriate physical renovation and reimburse the hospital for emergency obstetric care and cesarean deliveries; and (vii) coordinate a system of village “labor monitors” to help prevent obstetric fistula by identifying pregnant women in their communities, monitoring their labors, and activating an organized emergency-transport system to move high-risk women to local hospitals with adequate obstetric care. (6) United States Obstetric Fistula Treatment and Prevention Corps (A) In general The Institute, in cooperation with each medical center in sub-Saharan African described in subsection (b), shall establish and operate a United States Obstetric Fistula Treatment and Prevention Corps. (B) Duties The Corps shall— (i) provide volunteer medical services at Centers of Clinical Excellence and train local surgeons and other health professionals in techniques of obstetric fistula repair and in other aspects of the care of women with obstetric fistula; (ii) seek to establish an enabling environment in which patient care can be provided effectively, consistently, humanely, and ethically to women with obstetric fistula; and (iii) develop evidence-based systems of care for the prevention of obstetric fistula. (C) Membership The Corps shall consist of— (i) graduates of United States or African residency programs in such fields as obstetrics and gynecology, general surgery, urology, and anesthesiology; and (ii) other doctors, nurses, community-health professionals, public-health professionals, and other expert personnel as needed to further the duties of the Institute to prevent, treat, and monitor obstetric fistula in sub-Saharan African countries. (D) Duration of service Members of the Corps shall commit to a duration of service of not less than 28 months. (E) Compensation, other benefits The Institute may provide compensation, other employment benefits, and loan guarantees to individuals who agree to serve as members of the Corps. (F) Alumni Corps The Institute is authorized to establish an Alumni Corps, comprised of former members of the Corps who have completed successfully at least one period of service described in subparagraph (D) in order to augment medical personnel at Centers for Clinical Excellence. (7) Annual report The Institute shall submit to Congress and make available to the public an annual report on the implementation of this subsection, including a description of— (A) the recruitment for and implementation of the Corps; and (B) the activities of each Center of Clinical Excellence, including— (i) the number of women served at the Center; (ii) the success rate of obstetric fistula-repair surgeries, prevention efforts, and other programs used by the Center and surrounding communities; and (iii) other delivery system and quality measures as appropriate. (e) Personnel The Institute shall be administered by qualified, essential personnel including— (1) a director, who reports directly to the head of the medical center in the United States referred to in subsection (b); (2) expert leadership to oversee key aspects of the duties of the Institute, including— (A) medical and surgical activities; (B) prevention, education, and outreach; (C) partnerships and capacity building; (D) emergency obstetric services; and (E) program management; (3) professional and administrative staff responsible for administration, coordination, and campaign performance; (4) dedicated, full-time, experienced surgeons responsible for the medical supervision and training of United States and sub-Saharan African surgeons assigned to Centers of Clinical Excellence, and for medical research, data collection, and successful implementation of medical programs in sub-Saharan Africa; (5) full-time prevention, education, and outreach coordinators, responsible for the Institute’s outreach, education, prevention, and social reintegration programs as well as for the supervision and training of outreach and education staff assigned to the Centers of Clinical Excellence; (6) an advisory panel for surgical outcomes and quality comprised of no fewer than 15 senior practicing surgeons from the United States and other countries— (A) to ensure a high, uniform level of surgical care; (B) to engage in clinical practice with Centers of Clinical Excellence for Sub-Saharan Africa to share their surgical experience and to provide clinical oversight; and (C) to liaise with Centers of Clinical Excellence for Sub-Saharan Africa and the Institute to ensure the Centers of Clinical Excellence are accountable for providing a consistent and high level of surgical care; and (7) an internal oversight and steering committee comprised of individuals who are medical professionals, public health professionals, international social welfare advisors, economists specializing in international development, or professors of law or political science. (f) Additional personnel The Institute may appoint and fix the pay of additional personnel as the Institute considers appropriate. 6. United States Advisory Committee for the Eradication of Obstetric Fistula (a) Establishment There is established an advisory committee to be known as the United States Advisory Committee for the Eradication of Obstetric Fistula. (b) Membership (1) Selection; qualifications The Advisory Committee shall be composed of 14 members selected by the Secretary (through a competitive process) from among individuals who are distinguished scholars, clinicians, scientists, advocates, and philanthropists and who, collectively— (A) have knowledge and experience in health care and global health policy, including international health, obstetrics, women’s empowerment, human rights, and international law; and (B) have direct experience abroad especially in sub-Saharan Africa. (2) Selection The Advisory Committee shall be composed of 14 members selected by the Secretary through a competitive process. (3) Disqualification An individual shall not be appointed as a member of the Advisory Committee if such individual possesses any personal or financial interest in the discharge of any duties of the Advisory Committee. (4) Terms The term of office of each member of the Advisory Committee shall be 5 years. Members of the Advisory Committee shall be eligible for reappointment for up to 2 terms. (c) Meetings (1) Initial meeting The Advisory Committee shall hold its initial meeting on the date that is no later than 120 days after the date of the enactment of this Act. (2) Meetings The Advisory Committee shall meet at the call of the Chairman or a majority of its members. The Advisory Committee shall meet no less than twice per calendar year. (3) Quorum Six members of the Advisory Committee shall constitute a quorum for purposes of conducting business, except that 2 members of the Advisory Committee shall constitute a quorum for purposes of receiving testimony. (4) Vacancies Any vacancy of the Advisory Committee shall not affect its powers, but shall be filled promptly in the manner in which the original appointment was made. (d) Administration (1) Travel expenses Members of the Advisory Committee shall be allowed travel expenses, including per diem in lieu of subsistence, at rates authorized for employees of agencies under subchapter I of chapter 57 of title 5, United States Code, while away from their homes or regular places of business in performance of services for the Advisory Committee. (2) Administrative support The Secretary shall assist the Advisory Committee by providing to the Advisory Committee such staff and administrative services as may be necessary and appropriate for the Advisory Committee to perform its functions. Upon request of the Advisory Committee, the head of any Federal department or agency may detail any of the personnel of that department or agency to the Advisory Committee without reimbursement to the department or agency of that employee and such detail shall be without interruption or loss of civil service status or privilege. (3) Experts and consultants The Advisory Committee may procure temporary and intermittent services under section 3109(b) of title 5, United States Code. (4) Other resources The Advisory Committee shall have reasonable access to materials, resources, statistical data, and other information the Advisory Committee determines to be necessary to carry out its duties from the Library of Congress, the Department of State, the National Library of Medicine, and other departments and agencies of the executive and legislative branches of the Federal Government. The Chairman of the Advisory Committee shall make requests for such access in writing when necessary. (5) Obtaining official data The Advisory Committee may secure directly from any department or agency of the United States information necessary to enable it to carry out this section. Upon the request of the Chairman of the Advisory Committee, the head of that department or agency shall furnish that information to the Advisory Committee. (e) Duties The primary duties of the Advisory Committee shall include— (1) advising the Institute on an ongoing basis in carrying out the duties of the Institute; (2) evaluating programs and activities to eradicate obstetric fistula and making recommendations regarding the programs of the Institute; (3) advising the Department of State and the United States Agency for International Development on an ongoing basis in carrying out programs and activities to eradicate obstetric fistula; (4) monitoring funds available for programs and activities to eradicate obstetric fistula to ensure such funds are used efficiently and are accounted for properly, including through the conduct of periodic audits; and (5) advising the Administrator of the United States Agency for International Development in an annual written report of the Institute’s performance and success in carrying out its duties. (f) Actions against governments failing To meet minimum standards (1) By Advisory Committee The Advisory Committee— (A) shall advise the Administrator of the United States Agency for International Development, based on information provided to the Advisory Committee by the Institute or based on independent sources of information, of each county that by reason of corruption, indifference, or ineffectiveness, significantly impedes the Institute’s ability to provide services to victims of obstetric fistula and women who are vulnerable to obstetric fistula; and (B) may request the Administrator to recommend suspension of the provision of United States nonhumanitarian, nontrade-related foreign assistance to each country described in subparagraph (A). (2) By USAID Based on the advice of the Advisory Committee under paragraph (1), the Administrator may accept the advice and, in consultation with the Secretary, recommend to the President the suspension of United States nonhumanitarian, nontrade-related foreign assistance to a county described in paragraph (1)(A). 7. Report The President, acting through the Administrator of the United States Agency for International Development, shall submit to Congress on an annual basis a report on the implementation of this Act for the preceding year, including an evaluation of the effectiveness and performance of the Institute, the Centers of Clinical Excellence, the Corps, and all related community outreach and medical programs. 8. Authorization of appropriations (a) In general There are authorized to be appropriated to the President to carry out this Act— (1) $10,000,000 for fiscal year 2015; and (2) $180,000,000 for the period of fiscal years 2016 through 2024. (b) Availability Amounts appropriated pursuant to the authorization of appropriations under subsection (a) are authorized to remain available until expended.