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                                                       Calendar No. 633
110th Congress                                                   Report
                                 SENATE
 2d Session                                                     110-282

======================================================================



 
         UNITED STATES COMMITMENT TO GLOBAL CHILD SURVIVAL ACT

                                _______
                                

                 April 9, 2008.--Ordered to be printed

          Mr. Biden, from the Committee on Foreign Relations,
                        submitted the following

                                 REPORT

                         [To accompany S. 1418]

    The Committee on Foreign Relations, having had under 
consideration the bill (S. 1418), to provide assistance to 
improve the health of newborns, children, and mothers in 
developing countries, and for other purposes, reports favorably 
thereon with an amendment in the nature of a substitute, and 
recommends that the bill, as amended, do pass.

                                CONTENTS

                                                                   Page

  I. Purpose..........................................................1
 II. Committee Action.................................................1
III. Discussion.......................................................2
 IV. Cost Estimate....................................................2
  V. Evaluation of Regulatory Impact..................................4
 VI. Changes in Existing Law..........................................4

                               I. PURPOSE

    The purpose of S. 1418 is to reduce the mortality rate of 
children and mothers in the developing world through the 
development and implementation of an integrated child and 
maternal health strategy; the creation of an interagency child 
and maternal health task force to achieve health goals; and the 
authorization of increased funding for child and maternal 
health interventions.

                          II. COMMITTEE ACTION

    S. 1418 was introduced by Senators Dodd, Smith, Leahy, and 
Brown on May 15, 2007. An additional 19 members cosponsored the 
legislation. On February 13, 2008, the committee ordered the 
bill, with an amendment in the nature of a substitute, reported 
favorably by voice vote.

                            III. DISCUSSION

    Every year, nearly 10.5 million children under age 5 die 
from highly preventable and treatable causes, while more than 
500,000 mothers die from causes related to pregnancy and 
childbirth. Nearly 40 percent of under-5 childhood deaths occur 
during the first 4 weeks of life. To combat this public health 
crisis, in 2000 the United States joined the international 
community in committing to achieve Millennium Development Goals 
(MGDs) 4 and 5, which aim to reduce the mortality rate of 
children under the age of 5 by two-thirds and the maternal 
mortality rate by three-fourths in the developing world, 
respectively.
    S. 1418 seeks to support these goals and to improve child 
and maternal health in the developing world by increasing 
funding for and delivery of proven low-cost, life saving health 
interventions. The bill requires the President to develop a 
holistic strategy which will include an identification of not 
less than 60 countries with priority needs in maternal and 
child health, a detailed analysis of those needs, and 
prescriptions for interventions designed to improve health 
outcomes in each country. The President will transmit to 
Congress a report on this strategy 180 days after the enactment 
of this bill.
    In implementing this strategy, the President is authorized 
to provide assistance for a wide range of activities including 
immunization interventions; vitamin and micronutrient 
supplementation; oral rehydration therapy; essential newborn 
care; improved sanitation and drinking water; childhood illness 
treatment; promotion of breast-feeding; training of clinicians, 
nurses, technicians, and other persons integral to health care 
delivery; and support health information management systems in 
host countries.
    This legislation creates an interagency task force to 
assess, monitor, and evaluate the progress and contributions of 
relevant U.S. departments and agencies in achieving child and 
maternal health goals. The task force will consult outside 
experts in child and maternal health, including members of 
academic institutions, nongovernmental organizations, and 
international organizations such as the World Bank. The task 
force is required to transmit to the President an annual 
report, for 4 years, on the implementation of this new 
strategy.
    S. 1418 authorizes the appropriation of up to $600 million 
for fiscal year 2008, up to $900 million for fiscal year 2009, 
up to $1.2 billion for fiscal year 2010, and up to $1.6 billion 
for fiscal years 2011 and 2012 to support activities to expand 
child and maternal health interventions.

                           IV. COST ESTIMATE

    Pursuant to Rule XXVI, paragraph 11(a) of the Standing 
Rules of the Senate, the following cost estimate has been 
provided by the Congressional Budget Office.

                                     U.S. Congress,
                               Congressional Budget Office,
                                     Washington, DC, April 3, 2008.
Hon. Joseph R. Biden, Jr.,
Chairman, Committee on Foreign Relations,
U.S. Senate, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 1418, the United 
States Commitment to Global Child Survival Act of 2007.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Michelle S. 
Patterson.
            Sincerely,
                                         Robert A. Sunshine
                                   (For Peter R. Orszag, Director).
    Enclosure.

S. 1418--United States Commitment to Global Child Survival Act of 2007

    Summary: S. 1418 would require the President to develop a 
comprehensive strategy to improve the health of newborns, 
children, and mothers in developing countries and to furnish 
assistance to accomplish those goals. For those purposes, the 
bill would authorize the appropriation of $5.9 billion over a 
5-year period. CBO estimates that implementing S. 1418 would 
cost about $30 million in 2008 and $4.9 billion over the 2008-
2013 period, assuming appropriation of the authorized amounts. 
Enacting the bill would not affect direct spending or receipts.
    S. 1418 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA) 
and would not affect the budgets of state, local, or tribal 
governments.
    Estimated cost to the Federal Government: The estimated 
budgetary impact of S. 1418 is shown in the following table. 
The costs of this legislation fall within budget function 150 
(international affairs).

----------------------------------------------------------------------------------------------------------------
                                                            By fiscal year, in millions of dollars--
                                               -----------------------------------------------------------------
                                                   2008       2009       2010       2011       2012       2013
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATION

Authorization Level...........................        600        900      1,200      1,600      1,600          0
Estimated Outlays.............................         30        510        787      1,081      1,367      1,171
----------------------------------------------------------------------------------------------------------------

    Basis of estimate: S. 1418 would require the United States 
Agency for International Development (USAID) to expand several 
existing programs focused on improving the health of newborns, 
children, and mothers in developing countries. The bill would 
double to 60 the number of countries in which USAID operates 
those programs and require an interagency task force to assess 
the effectiveness of the aid and activities.
    For those purposes, S. 1418 would authorize the 
appropriation of up to $600 million in 2008, $900 million in 
2009, $1.2 billion in 2010, and $1.6 billion for each of years 
2011 and 2012. To date, the Congress has provided USAID with 
$450 million to fund its current children's and mothers' health 
programs in fiscal year 2008.
    For the estimate CBO assumes that S. 1418 will be enacted 
by early summer, that the maximum authorized amounts are 
appropriated each year, and that outlays will follow historical 
patterns for existing programs. (Funding for 2008 would have to 
be provided in a supplemental appropriation act; most of any 
such 2008 supplemental would be spent in later years.)
    Based on information from USAID, CBO estimates that the 
amount authorized to be appropriated is sufficient to fund the 
expanded requirements and that implementing S. 1418 would cost 
about $4.9 billion over the 2008-2013 period. Most of the 
remaining amount from the authorized funding would be spent by 
2018.
    Intergovernmental and private-sector impact: S. 1418 
contains no intergovernmental or private-sector mandates as 
defined in UMRA and would not affect the budgets of state, 
local, or tribal governments.
    Estimate prepared by: Federal Costs: Michelle S. Patterson; 
Impact on State, Local, and Tribal Governments: Neil Hood; 
Impact on the Private Sector: Jacob Kuipers.
    Estimate approved by: Peter H. Fontaine, Assistant Director 
for Budget Analysis.

                   V. EVALUATION OF REGULATORY IMPACT

    Pursuant to Rule XXVI, paragraph 11(b) of the Standing 
Rules of the Senate, the committee has determined that there is 
no regulatory impact as a result of this legislation.

                      VI. CHANGES IN EXISTING LAW

    Pursuant to Rule XXVI, paragraph 12 of the Standing Rules 
of the Senate, changes in existing law made by the bill, as 
reported, are shown as follows (existing proposed to be omitted 
is enclosed in black brackets, new matter is printed in italic, 
existing law in which no change is proposed is shown in roman).

                   The Foreign Assistance Act of 1961


          Public Law 87-195 [S. 1983], 75 Stat. 424, approved
September 4, 1961, as amended

           *       *       *       *       *       *       *


PART I

           *       *       *       *       *       *       *


    Sec. 104. Population and Health.--(a) * * *

           *       *       *       *       *       *       *

    (c) Assistance for Health and Disease Prevention.--(1) In 
order to contribute to improvements in the health of the 
greatest number of poor people in developing countries, the 
President is authorized to furnish assistance, on such terms 
and conditions as he may determine, for health programs. 
Assistance under this subsection shall be used primarily for 
basic integrated health services, safe water and sanitation, 
disease prevention and control, and related health planning and 
research. The assistance shall emphasize self-sustaining 
community-based health programs by means such as training of 
health auxiliary and other appropriate personnel, support for 
the establishment and evaluation of projects that can be 
replicated on a broader scale, measures to improve management 
of health programs, and other services and suppliers to support 
health and disease prevention programs.
    [(2)(A) In carrying out the purposes of this subsection, 
the President shall promote, encourage, and undertake 
activities designed to deal directly with the special health 
needs of children and mothers. Such activities should utilize 
simple, available technologies which can significantly reduce 
childhood mortality, such as improved and expanded immunization 
programs, oral rehydration to combat diarrhoeal diseases, and 
education programs aimed at improving nutrition and sanitation 
and at promoting child spacing. In carrying out this paragraph, 
guidance shall be sought from knowledgeable health 
professionals from outside the agency primarily responsible for 
administering this part. In addition to government-to-
government programs, activities pursuant to this paragraph 
should include support for appropriate activities of the types 
described in this paragraph which are carried out by 
international organizations (which may include international 
organizations receiving funds under chapter 3 of this part) and 
by private and voluntary organizations, and should include 
encouragement to other donors to support such types of 
activities.
    [(B) In addition to amounts otherwise available for such 
purpose, there are authorized to be appropriated to the 
President $25,000,000 for fiscal year 1986 and $75,000,000 for 
fiscal year 1987 for use in carrying out this paragraph. 
Amounts appropriated under this subparagraph are authorized to 
remain available until expended.
    [(C) Appropriations pursuant to subparagraph (B) may be 
referred to as the ``Child Survival Fund.''
    [(3) The Congress recognizes that the promotion of primary 
health care is a major objective of the foreign assistance 
program. The Congress further recognizes that simple, 
relatively low-cost means already exist to reduce incidence of 
communicable diseases among children, mothers, and infants. The 
promotion of vaccines for immunization, and salts for oral 
rehydration, therefore, is an essential feature of the health 
assistance program. To this end, the Congress expects the 
agency primarily responsible for administering this part to set 
as a goal the protection of not less than 80 percent of all 
children, in those countries in which such agency has 
established development programs, from immunizable diseases by 
January 1, 1991. Of the aggregate amounts made available for 
fiscal year 1987 to carry out paragraph (2) of this subsection 
(relating to the Child Survival Fund) and to carry out 
subsection (c) (relating to development assistance for health), 
$50,000,000 shall be used to carry out this paragraph.]
    [(4)] (2) Relationship to other laws.--Assistance made 
available under this subsection and sections 104A, 104B, [and 
104C] 104C, and 104D, and assistance made available under 
chapter 4 of part II to carry out the purposes of this 
subsection and the provisions cited in this paragraph, may be 
made available notwithstanding any other provision of law that 
restricts assistance to foreign countries, except for the 
provisions of this subsection, the provisions of law cited in 
this paragraph, subsection (f), section 634A of this Act, and 
provisions of law that limit assistance to organizations that 
support or participate in a program of coercive abortion or 
involuntary sterilization included under the Child Survival and 
Health Programs Fund heading in the Consolidated Appropriations 
Resolution, 2003 (Public Law 108-7).

           *       *       *       *       *       *       *


SEC. 104A. ASSISTANCE TO COMBAT HIV/AIDS.

           *       *       *       *       *       *       *


    (c) Authorization.--
          (1) In general.--Consistent with section 104(c) and 
        section 104D, the President is authorized to furnish 
        assistance, on such terms and conditions as the 
        President may determine, for HIV/AIDS, including to 
        prevent, treat, and monitor HIV/AIDS, and carry out 
        related activities, in countries in sub-Saharan Africa, 
        the Caribbean, and other countries and areas.

           *       *       *       *       *       *       *

    (f) Funding Limitation.--Of the funds made available to 
carryout this section in any fiscal year, not more than 7 
percent may be used for the administrative expenses of the 
United States Agency for International Development in support 
of activities described in [section 104(c), this section, 
section 104B, and section 104C] section 104(c), this section, 
section 104B, section 104C, and section 104D. Such amount shall 
be in addition to other amounts otherwise available for such 
purposes.

           *       *       *       *       *       *       *


SEC. 104B. ASSISTANCE TO COMBAT TUBERCULOSIS.

           *       *       *       *       *       *       *


    (c) Authorization.--To carry out this section and 
consistent with section 104(c) and section 104D, the President 
is authorized to furnish assistance, on such terms and 
conditions as the President may determine, for the prevention, 
treatment, control, and elimination of tuberculosis.

           *       *       *       *       *       *       *


SEC. 104C. ASSISTANCE TO COMBAT MALARIA.

           *       *       *       *       *       *       *


    (c) Authorization.--To carry out this section and 
consistent with section 104(c) and section 104D, the President 
is authorized to furnish assistance, on such terms and 
conditions as the President may determine, for the prevention, 
treatment, control, and elimination of malaria

           *       *       *       *       *       *       *

    (c) Funding Level.--For fiscal year 1987, not less than 
$2,500,000 of the funds available to carry out this part 
(excluding funds made available to carry out [section 
104(c)(2), relating to the Child Survival Fund] section 104D) 
shall be allocated for assistance pursuant to subsection (b) 
for activities which were not funded prior to fiscal year 1987. 
In addition, the Agency for International Development shall, to 
the fullest extent possible, continue and increase assistance 
pursuant to subsection (b) for activities for which assistance 
was provided in fiscal years prior to fiscal year 1987.

SEC. 104D. ASSISTANCE TO REDUCE MORTALITY AND IMPROVE THE HEALTH OF 
                    NEWBORNS, CHILDREN, AND MOTHERS.

    (a) Authorization.--Consistent with section 104(c), the 
President is authorized to furnish assistance, on such terms 
and conditions as the President may determine, to reduce 
mortality and improve the health of newborns, children, and 
mothers in developing countries.
    (b) Activities Supported.--Assistance provided under 
subsection (a) shall, to the maximum extent practicable, 
include
          (1) activities to improve newborn care and treatment;
          (2) activities to treat childhood illness, including 
        increasing access to appropriate treatment for 
        diarrhea, pneumonia, and other life-threatening 
        childhood illnesses;
          (3) activities to improve child and maternal 
        nutrition, including the delivery of iron, zinc, vita-
        min A, iodine, and other key micronutrients and the 
        promotion of breast feeding;
          (4) activities to strengthen the delivery of 
        immunization services, including efforts to eliminate 
        polio;
          (5) activities to improve birth preparedness and 
        maternity services;
          (6) activities to improve the recognition and 
        treatment of obstetric complications and disabilities;
          (7) activities to improve household-level behavior 
        related to safe water, hygiene, exposure to indoor 
        smoke, and environmental toxins such as lead;
          (8) activities to improve capacity for health 
        governance, health finance, and the health work-force, 
        including support for training clinicians, nurses, 
        technicians, sanitation and public health workers, 
        community-based health workers, midwives, birth 
        attendants, peer educators, volunteers, and private 
        sector enterprises;
          (9) activities to address antimicrobial resistance in 
        child and maternal health;
          (10) activities to establish and support the 
        management information systems of host country 
        institutions and the development and use of tools and 
        models to collect, analyze, and disseminate information 
        related to newborn, child, and maternal health;
          (11) activities to develop and conduct needs 
        assessments, baseline studies, targeted evaluations, or 
        other information-gathering efforts for the design, 
        monitoring, and evaluation of newborn, child, and 
        maternal health efforts; and
          (12) activities to integrate and coordinate 
        assistance provided under this section with existing 
        health programs for--
                  (A) the prevention of the transmission of HIV 
                from mother-to-child and other HIV/AIDS 
                counseling, care, and treatment activities;
                  (B) malaria;
                  (C) tuberculosis; and
                  (D) child spacing.
    (c) Guidelines.--To the maximum extent practicable, 
programs, projects, and activities carried out using assistance 
provided under this section shall be--
          (1) carried out through private and voluntary 
        organizations, including faith-based organizations, and 
        relevant international and multilateral organizations, 
        including the GAVI Alliance and UNICEF, that 
        demonstrate effectiveness and commitment to improving 
        the health of newborns, children, and mothers;
          (2) carried out with input by host countries, 
        including civil society and local communities, as well 
        as other donors and multilateral organizations;
          (3) carried out with input by beneficiaries and other 
        directly affected populations, especially women and 
        marginalized communities; and
          (4) designed to build the capacity of host country 
        governments and civil society organizations.
    (d) Annual Report.--Not later than January 31, 2009, and 
annually thereafter for 4 years, the President shall transmit 
to Congress a report on the implementation of this section for 
the prior fiscal year. The report shall include the most recent 
report submitted to the President by the Interagency Task Force 
on Child Survival and Maternal Health in Developing Countries 
under section 5(f) of the United States Commitment to Global 
Child Survival Act of 2007.
    (e) Definitions.--In this section:
          (1) AIDS.--The term ``AIDS'' has the meaning given 
        the term in section 104A(g) (1) of this Act.
          (2) HIV.--The term ``HIV'' has the meaning given the 
        term in section 104A(g) (2) of this Act.
          (3) HIV/AIDS.--The term ``HIV/AIDS'' has the meaning 
        given the term in section 104A(g) (3) of this Act.