I 118th CONGRESS 1st Session H. R. 5545 IN THE HOUSE OF REPRESENTATIVES September 18, 2023 Ms. Meng (for herself, Mr. Blumenauer , and Mr. LaHood ) introduced the following bill; which was referred to the Committee on Foreign Affairs A BILL To authorize an Action Plan for United States foreign assistance to developing countries to increase access to sustainable safe water, sanitation, and hygiene in healthcare facilities, promote stronger health systems and sustainable health infrastructure, build capacity of health workers, and promote the safety of health workers and patients, especially women and girls, and for other purposes.

1. Short title This Act may be cited as the Global WASH in Healthcare Facilities Act of 2023 . 2. Findings Congress finds the following: (1) Water, sanitation, and hygiene (WASH) is critical to health security, preparedness and response efforts, including for the prevention of COVID–19 and future pandemics. (2) WASH in healthcare facilities is necessary to ensure health security, including reducing preventable maternal, newborn, and child deaths and reducing the spread of infectious diseases such as cholera, diarrhea, and sepsis. (3) Globally, 1 out of every 5 healthcare facilities have no basic water services, and 1 in 2 do not have adequate facilities to wash hands, leaving 3,850,000,000 people, including health care workers and patients, at greater risk of infections. (4) In least-developed countries, about half of healthcare facilities lack basic water services, 79 percent have no sanitation services, and 68 percent lack basic hygiene services. (5) Healthcare acquired infections arise from poor hygiene, contribute to patient morbidity and mortality, increase the risk of antimicrobial resistance, and contribute to increased costs for patients, their families and healthcare systems. (6) An estimated 15 percent of patients in low- and middle-income countries acquire one or more infections during a typical hospital stay. Infections associated with unclean births account for 26 percent of neonatal deaths and 11 percent of maternal deaths; together they account for more than 1,000,000 deaths each year. 3. Statement of policy; sense of congress (a) Statement of policy objectives It is in the national security interest of the United States to increase access to sustainable and safe water, sanitation, and hygiene in healthcare facilities, through global health, maternal, newborn and child health, and global water programs, activities, and initiatives that— (1) increase access to safe water in healthcare facilities; (2) enable handwashing at all points of care; (3) increase access to toilets in healthcare facilities, including non-sewered sanitation solutions and a variety of technologies for sanitation and healthcare waste treatment; (4) provide for the safe segregation, treatment, and disposal of healthcare waste and increased infection and prevention control measures; (5) promote WASH social and behavior change to ensure the safety of health workers and patients to improve infection prevention and control measures; (6) improve the ability of patients and healthcare workers, including persons with disabilities to access water, sanitation, and hygiene, including for their menstrual health and hygiene needs in primary, secondary, and tertiary healthcare facilities; (7) promote health facility administration management and monitoring of water, sanitation, and hygiene services in healthcare facilities for infection prevention and control and quality of care outcomes, including— (A) ensuring operations and maintenance of water and sanitation infrastructure; and (B) providing support to patients to adopt consistent sanitation, hygiene, and menstrual health behaviors; (8) integrate water, sanitation, and hygiene services into pandemic preparedness and response and global health security initiatives, including preventive measures that help to contain infectious disease outbreaks at their source and support resilient health facilities to ensure continuous primary care during an outbreak; and (9) provide technical support to partner governments, particularly Ministries of Health, to improve wash systems and to incorporate safe water, sanitation, and hygiene into national plans, strategies, and budgets for new and existing healthcare facilities. (b) Sense of congress It is the sense of Congress that the Administrator of the United States Agency for International Development, in implementing the Global WASH in Healthcare Facilities Action Plan described in section 5, should— (1) coordinate in consultation with the USAID Assistant Administrator for Global Health, the Senior Coordinator for Gender Equality and Women’s Empowerment, and the Global Water Coordinator, to expand safe water, sanitation, and hygiene in healthcare facilities; (2) promote assistance to and build the capacity of national governments to include water, sanitation, and hygiene indicators in national health systems monitoring and budgets; (3) coordinate implementation of existing United States Government strategies related to WASH in healthcare facilities, including the United States Global Water Strategy and United States International Activities to Advance Global Health Security and Diplomacy Strategy and Report to achieve the objectives of section 3(a); (4) include policies that promote the privacy, safety, and dignity of women and girls, and disability access in design, implementation, and evaluation, in accordance with existing USAID policies for people with disabilities; (5) promote the development of resilient water, sanitation, and hygiene systems in healthcare facilities; and (6) prioritize high priority countries where the needs are greatest. 4. Definitions In this Act: (1) Appropriate congressional committees The term appropriate congressional committees means— (A) the Committee on Foreign Affairs and the Committee on Appropriations of the House of Representatives; and (B) the Committee on Foreign Relations and the Committee on Appropriations of the Senate. (2) Sustainable The term sustainable means the ability of a target country, community, implementing partner, or intended beneficiary to maintain, over time, the programs authorized and outcomes achieved pursuant to this Act. (3) Healthcare facility The term healthcare facility means a hospital, clinic, health center, or other location established for the purpose of providing health care. (4) Healthcare worker The term healthcare worker includes doctors, nurses, lab technicians, pharmacists, janitors, healthcare administrators, and other individuals working at or in partnership with healthcare facilities. (5) High priority country The term high priority country means a country designated pursuant to section 136(h) of the Foreign Assistance Act of 1961 ( 22 U.S.C. 2151h(h) ) and any country identified by USAID as a high priority country for the purposes of this Act. (6) Key stakeholders The term key stakeholders means— (A) communities directly affected by the lack of access to safe water, sanitation or hygiene; (B) other appropriate nongovernmental organizations; and (C) agencies or departments of countries affected by the lack of access to safe water, sanitation, or hygiene. (7) USAID The term USAID means the United States Agency for International Development. (8) WASH The term WASH means water, sanitation, and hygiene. 5. Global wash in healthcare facilities action plan (a) Action plan required The Administrator of the United States Agency for International Development, in coordination with the Director of the Centers for Disease Control and Prevention and the Secretary of State, shall develop and implement an action plan, to be known as the Global WASH in Healthcare Facilities Action Plan , to accomplish the policy objectives listed in section 3(a). Such action plan shall— (1) set specific, timebound, and measurable goals, and identify relevant performance metrics drawing from existing and complementary strategies and plans; (2) describe monitoring and evaluation plans that reflect best practices relating to transparency, accountability, localized sustainability, country capacity, budgetary support and ownership, water, sanitation, and hygiene, including appropriate use of gender disaggregated data; (3) establish clear and transparent criteria for WASH in healthcare facilities in target countries, drawn from existing water, sanitation and hygiene, need for strong health systems, infection prevention and control, pandemic preparedness and response, maternal, newborn and child health, and nutrition programs high priority countries and assessments, and for selecting regions and intended beneficiaries of assistance; (4) describe linkages and coordination with other relevant policies, strategies, plans and initiatives including those related to gender, resilience, global health, and pandemic preparedness and response; (5) describe measures and approaches to address the issues of infection prevention and control, menstrual health and hygiene, safe and equitable access to WASH for health workers, gaps in current data, monitoring and evaluation analysis and capacity, consistent with the policy objectives described in section 3(a); (6) support partner governments to strengthen supply chains and, as appropriate, establish and maintain strategic stockpiles of critical water, sanitation, hygiene and menstrual health products, clean, operational and maintenance inputs, and related hardware for resilient healthcare; (7) address women’s and girls’ specific needs for water, sanitation, and hygiene access in healthcare facilities, in particular, personal safety, privacy, dignity, and menstrual health and hygiene and maternal health; (8) support the long-term sustainability of water, sanitation, and hygiene access in healthcare facilities especially at points of care, through health systems resiliency approaches including capacity building; (9) leverage new and existing water, sanitation, and hygiene technologies, including non-sewered sanitation solutions, and a variety of technologies for sanitation and healthcare waste treatment; (10) in support of sustainably increased WASH access in healthcare facilities and increased local ownership, identify criteria, and methodology for graduating countries from United States assistance provided for the policy objectives listed in section 3(a); and (11) anticipate resource needs to implement the Action Plan, including such amounts to be transferred by the Secretary of State to the Administrator of USAID pursuant to section 6(a). (b) Inclusion in other strategies, policies, plans, and initiatives The Administrator may include the Action Plan required by subsection (a) as a component of the USAID Agency-Specific Plan for the United States International Activities to Advance Global Health Security and Diplomacy Strategy required by the Global Health Security and International Pandemic, Preparedness and Response Act (subtitle D of title LV of the National Defense Authorization Act for Fiscal Year 2023), or as a component of other USAID strategies, policies, plans or initiatives, as appropriate. (c) Action plan submission Not later than 1 year after the date of the enactment of this Act, the Administrator of USAID shall submit to the appropriate congressional committees a report consisting of— (1) the Global WASH in Healthcare Facilities Action Plan required under subsection (a); and (2) a description of the manner in which the Administrator intends to advance the policy objectives listed in section 3(a) through such action plan. 6. Assistance to implement the global wash in healthcare facilities action plan (a) Authorization of appropriations Amounts appropriated pursuant to the authorization under section 5564 of the National Defense Authorization Act for Fiscal Year 2023 are also authorized to be made available during fiscal years 2024 through 2027 to carry out the Global WASH in Health Care Facilities Action Plan described in section 5 in support of the United States International Activities to Advance the Global WASH in Healthcare Facilities Action Plan. (b) Authorization of transfers Subject to the availability of funds appropriated pursuant to the authorization under section 5564 of the National Defense Authorization Act for Fiscal Year 2023 and in accordance with subsection (a), the Secretary of State is authorized to transfer to the Administrator of the USAID such sums as may be necessary to implement the Global WASH in Health Care Facilities Action Plan described in section 5 of this Act. (c) Monitoring and evaluation The Administrator shall seek to ensure that assistance to implement the Global WASH in Healthcare Facilities Action Plan is provided under established parameters for a rigorous accountability system to monitor and evaluate progress and impact of the action plan, including by reporting to the appropriate congressional committees and the public on an annual basis, in accordance with section 7. 7. Reports (a) Initial report Not later than 1 year after the date of the submission of the Global WASH in Healthcare Facilities Action Plan required under section 5, the Administrator shall submit to the appropriate congressional committees a report that describes the status of the implementation of the Action Plan. (b) Content The report required under subsection (a) shall— (1) contain a summary of the Global WASH in Healthcare Facilities Action Plan as an appendix; (2) describe the progress made in implementing the Action Plan; (3) identify the indicators and measure results over time, as well as the mechanisms for reporting such results in an open and transparent manner, including disaggregated data on healthcare facilities with basic or safe access to water, sanitation and hygiene defined by the World Health Organization and UNICEF; (4) contain a transparent and detailed accounting of USAID spending to implement the Global WASH in Healthcare Facilities Action Plan and related activities; (5) describe how the Global WASH in Healthcare Facilities Action Plan leverages other United States global health programs including but not limited to maternal and child health, health systems, and global health security; (6) describe the impact of the Global WASH in Healthcare Facilities Action Plan on other global health programs, including progress in the promotion of infection prevention and control, strengthening global health security and pandemic preparedness, prevention and response and reducing preventable maternal and child deaths; (7) assess efforts to coordinate United States global health programs, activities, and initiatives with key stakeholders; (8) assess United States Government-facilitated private investment in related sectors and the impact of private sector investment in target countries and communities; (9) assess the increased access to safe sanitation and hand washing stations in healthcare facilities, including to address menstrual health and hygiene needs; (10) incorporate a plan for regularly sharing lessons learned with a wide range of stakeholders, including local civil society organizations in an open, transparent manner and through biennial stakeholder consultation; and (11) establish mechanisms for receiving feedback from stakeholders and incorporating feedback into updates of relevant congressionally mandated strategies and action plans. (c) Subsequent reports For the five-year period beginning on the date of the submission of the initial report required under subsection (a), the Administrator shall annually submit to the appropriate congressional committees a report on the status of the implementation of the action plan, the progress made in achieving the elements described in section 5, and any changes to the action plan since the date of the submission of the most recent prior report. (d) Inclusion in other reports The Administrator may include the report required by subsection (a) as a component of the United States International Activities to Advance Global Health Security and Diplomacy Strategy report or as a component of other USAID reports, as appropriate. (e) Public availability of information The information referred to in subsections (a) and (b) shall be timely made available on the public website of USAID in a consolidated, downloadable, and machine-searchable format.