National Reporting Instrument 2018

The U.S. Government provides updates on the Code implementation and U.S. support of the voluntary nature of the principles and practices of the Code across relevant government agencies, particularly in preparation for related topics in governance meetings of the WHO and its Regional Offices. In addition, Co-National Authorities (Department of Health and Human Services (HHS), Office of the Secretary, Office of Global Affairs and Health Resources and Services Administration (HRSA), Office of Global Health) meet with stakeholders and provide to the U.S. public opportunities to inform and share comments on implementation of the Code. A Code of Practice Task Force of relevant government agencies has been formed to routinely review and share updates to the implementation of the Code.

In the United States, there is no federal law regulating placement agencies or employment contracts overall. Rather, public authorities regulate certain aspects of private recruitment and employment contracts, as set forth in the requirements for temporary migrant labor programs. Some states have introduced or are developing legislation to expand protections that may apply to health personnel. For example, current California law includes a mandated registration program designed to regulate foreign labor contractors who perform specified recruiting and soliciting activities of foreign workers for employment in the state (http://leginfo.legislature.ca.gov/faces/billCompareClient.xhtml?bill_id=201320140SB477). A proposed rule regulating foreign labor contractors: (https://www.dir.ca.gov/dlse/regulation_detail/FLCR.html) would establish standards for the registration program that further specify who is covered by the permit requirement, set a registration fee, spell out what information must be provided on permit applications, and establish criteria for processing permit applications and permit renewals.

Although the United States does not have a federal law regulating recruitment agencies overall, there are some safeguards in place to help combat fraudulent and unscrupulous recruitment practices. For example, current H2-B regulations generally prohibit the collection of recruitment fees or labor certification expenses and require that employers disclose to workers the terms and conditions of the job, and provide the Department of Labor copies of contracts with their recruiters, and the names and locations of all subsidiary recruiters. The Department of Labor maintains a publicly available list of agents and recruiters. Remedies for violations include reimbursement of unlawfully collected fees to workers, civil money penalties, and debarment from these programs where appropriate. In the permanent labor certification program, current regulations prohibit employers from seeking or receiving payments of any kind for any activity related to obtaining permanent labor certification, whether as an incentive or inducement to filing, or reimbursement for costs incurred in preparing or filing a permanent labor certification application. The kinds of payments that are prohibited include monetary payments, wage concessions, kickbacks, bribes, or tributes, in-kind payments, and free labor. Additionally, U.S. labor and employment laws relating to wages, working conditions, and anti-discrimination generally apply to all workers. Enforcing labor and employment laws for all workers can help decrease their vulnerability to various forms of exploitation, including human trafficking. It can also level the playing field for employers who meet their obligations under the law.

While not focused specifically on recruitment of health personnel, the Department of Labor’s Office of Foreign Labor Certification (OFLC) offers several opportunities for stakeholder consultation in relation to the temporary and permanent labor programs. OFLC conducts quarterly stakeholder meetings, at which stakeholders may raise questions or issues on any of the programs the Office administers. In addition, when promulgating regulations, proposed rules are submitted for public notice and comment and the agency must respond to public comments received during the notice and comment period when issuing the final rule.

No support is required. However, the U.S. Government routinely considers efforts to strengthen data and support the education, training, distribution, retention, and sustainability of the health workforce.

HHS has been implementing cooperative agreements since 2004 through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) programs. These programs all have specific objectives and program activities in many countries across Africa, the Caribbean, South America and Asia. The overall intent of these programs is to build human resource capacity for health (HRH) and strengthen health systems which in turn will encourage the retention of HRH in their countries, especially in underserved communities. Examples include: • Resilient and Responsive Health Systems (2017 – present) HRSA supports the creation of capacity building plans and the provision of technical assistance focused on the building or enhancing of organizational capacity in a variety of priority areas, including program and financial management, grants management, leadership and governance, personnel management, and evaluation and monitoring. The RRHO Initiative’s purpose is to strengthen the capacity of impact partners supported under the RRHS Initiative. The Initiative’s geographic scope includes Democratic Republic of Congo, Liberia, Sierra Leone, and South Sudan. • International AIDS Education and Training Centers (I-TECH) (2004 – present) HRSA’s I-TECH program works with foreign local partners to develop skilled health care workers and strong national health systems especially in resource limited countries. The I-TECH program provides technical assistance primarily in health workforce development, prevention, treatment and care of HIV/AIDS; operations research and evaluation; and in-country health system strengthening. I-TECH promotes local ownership to sustain effective health systems. • Twinning Programs (2004 – present) HRSA’s Twinning Programs use institution-to-institution partnerships and peer-to-peer relationships for HIV/AIDS-related human resource capacity building in PEPFAR countries. Twinning emphasizes professional exchanges and mentoring for the effective sharing of information, knowledge, and technology. Since the inception of the program, Twinning Programs have provided in-service training for more than 29,300 health and allied care providers and graduated more than 11,000 individuals from preservice programs at partner institutions. This includes training for needed mid-level cadres such as clinical associates, nurses, pharmacy technicians, lab technicians, biomedical technicians, para social workers, and social welfare assistants. • Medical Education Partnership Initiative (MEPI) (2010 – 2015) MEPI was funded by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the HHS/Health Resources and Services Administration (HRSA) and the HHS/ National Institutes of Health (NIH). MEPI supports foreign institutions in Sub-Saharan African countries to develop or expand and enhance models of medical education. These models are intended to support PEPFAR’s goals of increasing the number of new health care workers by 140,000, strengthening medical education systems in the countries in which they exist, and building clinical and research capacity in Africa as part of a retention strategy for faculty of medical schools and clinical professors. From 2010 to 2015, MEPI provided grants to African institutions in 12 countries. Program activities were implemented in South Africa, Tanzania, Mozambique, Nigeria, Ethiopia, Botswana, Kenya, Uganda, Zambia, Zimbabwe, Ghana, and Malawi. MEPI activities have resulted in the development a network of about 30 regional partners, including in-country health and education ministries. • Nursing Educational Partnership Initiative (NEPI) (2010 – 2018) HRSA’s NEPI supports foreign nursing schools and institutions in Sub-Saharan African countries to expand the quantity, quality, and relevance of the nursing and midwifery profession to address the country’s population based health needs. HRSA’s NEPI programmatic objectives include: strengthening the capacity, quality, and effectiveness of nurse and midwifery training and education programs; identifying innovative models to increase the number of qualified health care workers; strengthening research and professional development opportunities; and developing evidence-based strategies to guide future human resources for health investments in the host countries. NEPI activities are implemented in Zambia, Malawi, Lesotho, Ethiopia, and the Democratic Republic of Congo. NEPI supports 3-6 nursing schools in each of these countries. • Health Workforce Global Initiative (HW21) (2017 – 2021) The purpose of this initiative is to provide innovative approaches to increase adequacy, capacity, coordination, employment, complementarity, deployment, and retention of physicians, nurses, midwives, pharmacists, community health workers (CHWs), social service workers, lay health workers, laboratory technicians, and other related cadres that provide primary care and community health services to people living with HIV, tuberculosis (TB), and chronic diseases in sub-Saharan Africa, Central Asia, Eastern Europe, the Caribbean, and/or Latin America. HW21 is a partnership of implementing organizations with demonstrated experience building and strengthening Human Resources for Health (HRH) systems around the world. Strategic dovetailing of efforts will catalyze long-term, sustainable HRH system improvements, address priority HRH challenges at the site level to develop targeted HRH interventions, bring fresh and tested ideas to PEPFAR countries, and accelerate achievement of the 90-90-90 treatment targets. Awarded in September 2017, HW21 is a 5-year cooperative agreement funded by the HRSA with support from PEPFAR. • African Health Professions Regional Collaborate for Nurses and Midwives (ARC) (2011-2017) One of the greatest constraints to scale-up of HIV treatment in sub-Saharan Africa has been the shortage of health care personnel, and the lack of HIV/AIDS training for existing personnel. Physician shortages especially can compromise care. Task sharing is a policy by which other health care cadres (e.g., nurses, midwives, and community health workers) are able to conduct tasks and procedures otherwise set aside for physicians. Task Sharing expands opportunities for persons living with HIV to obtain needed care in a timely manner, and from a competent and compassionate workforce. The ARC project, administered in 16 Sub-Saharan countries, and 3 West African countries, assessed and addressed barriers related to nursing policy and regulations that impeded delivery of quality HIV services, and sought to improve the quality of HIV related nursing practice for pregnant and breastfeeding women and children by convening country teams of nurse and midwifery leaders for cross-collaboration and skills sharing to review nursing practices and policies within their respective countries, and make recommendations to establish task sharing and implement new scope of work for nursing practice. The country teams were assessed using a Capability Maturing Model (CMM) to track their progress on key functions, and to guide technical assistance to the country nurse teams. Results of ARC are published. • Field Epidemiology Training Program (2004 - present) Since 2004, CDC has supported more than 61 countries in the Caribbean, Africa and Asia to train health care personnel on public health principles and practices to identify and respond to communicable threats. FETP fellows learn to identify, investigate and implement solutions on such health threats as Ebola, Zika, Malaria, TB, and HIV/AIDS. Models of the program vary from short intensive 6-9 months programs, to high intensity 24-month programs equivalent to a Master’s in Public Health. FETP highlights the need to develop epidemiological technical expertise among existing health care personnel to provide national public health response, and stem the flow of infectious diseases across country boundaries. • Workforce Allocation Optimization (2013 - present) CDC assists Ministries of Health to make quality improvements to their workforce planning systems and processes by developing local capacity to create and manage registries of their health care workforce, and use of those registries to recruit, allocate and retain trained health care personnel. This effort optimizes placement of health workforce personnel in areas where their skills are most needed. Use of workforce allocation has improved not only the distribution of health care personnel within WHO member countries, but the efficiency of those health care systems to respond to HIV/AIDS. • Human Resources Information Systems (2012 – present) CDC directly assists 8 countries to develop, implement and assess the functionality of their information systems to monitor their HRH investments and share HRH data with the respective Ministries of Health, other multilateral organizations, and local in-country partners, where appropriate. These systems track critical HRH data including funding, and funders, for positions; total number of health care workers by cadre, by district, by facility; performance of facilities by staffing matrix; salary by position and range of salary by cadre; pre-and in-service training; personnel qualifications and skills. CDC provides HRIS technical assistance to other PEPFAR countries by request. In addition: The U.S. Agency for International Development has worked with all cadres of public and private sector health providers in developing countries for more than 35 years. USAID’s investments in HRH are guided by principles that support countries on their journey to self-reliance, including capacity building and enhancing sustainability through health systems strengthening (HSS). Based on these principles, USAID collaborates closely with countries to design and implement programs that will address both the quality and quantity of workers available to serve their population’s health care needs. USAID’s HRH/HSS interventions span the health system, including: data‐driven policy and planning, including human resources management; workforce development (education and training); and performance support systems to improve retention and productivity of the workforce. The interaction of human resources with other areas of the health system, such as finance and governance, is also addressed through, for example, creation of financing schemes such as vouchers, insurance, franchising, contracting out and helping providers access credit to grow health care businesses. More recent work is focused on the public health sector to develop and enhance the policy environment for expanding and fostering the role of the private health sector and its providers. For more than 25 years USAID has also supported public private partnerships in health to expand private sector products and services in developing countries. Central to these efforts is the availability of accurate and complete information on the health workforce. USAID has long supported the development and use of human resource information systems (HRIS), and most recently is collaborating with WHO on the roll-out of National Health Workforce Accounts (NHWAs). Global resources are being developed to support countries as they prepare for implementation of NHWAs, along with direct support for implementation that will allow for efficiency gains to optimize use of the existing workforce, mobilize domestic resources, and promote strategic investments for shared responsibility in HRH and health system improvements for the future.

See 6.a above

See 6.a above

No assistance has been received. However, the PEPFAR Twinning Program administered through HRSA provides opportunities for information sharing amongst peers and institutions addressing HIV/AIDS related Human Resources for Health.

The Department of Labor requires employers who are bringing workers to the United States temporarily on an H-1B visa to provide the workers with a copy of the Labor Condition Application (LCA) no later than when the worker reports to work. The LCA informs the foreign worker of the wage to be paid, the job title, period of intended employment, and place of employment. The LCA also informs the worker of how to file a complaint alleging misrepresentation of material facts or failure to comply with the terms listed on the LCA. The Department of Labor also requires employers who are bringing in H-2B temporary workers to provide the workers with a copy of the job order no later than when the worker applies for the visa, in a language understood by the worker, as necessary or reasonable. The H-2B job order informs the foreign worker of the job duties, period of employment, wage to be paid, any training that will be available, deductions that will be made, and how the employer will provide or pay for the cost of the worker’s transportation, among other things. Additionally, the U.S. State Department has several resources available for certain individuals traveling to the United States as temporary workers or students informing them of their legal rights and protections: https://travel.state.gov/content/travel/en/us-visas/visa-information-resources/rights.html There are no specific laws or policies for internationally recruited or trained health personnel. The U.S. federal labor and employment laws generally apply to all workers, and agencies across the federal government, such as the Department of Homeland Security, the Equal Employment Opportunity Commission, the Department of Labor, and the National Labor Relations Board frequently work together to coordinate enforcement of federal law. For example, through the conclusion of a Memoranda of Understanding (MOU), which also recognizes the importance of protecting workers who seek to assert their workplace rights from retaliation by employers, recruiters or other parties, the Departments of Homeland Security and Labor undertook coordination efforts to advance the respective missions of each agency. https://www.dol.gov/sites/default/files/documents/MOU-Addendum.pdf

The H-1B program requires that employers first file a Labor Condition Application (LCA) with the Secretary of Labor attesting that the wage paid to the foreign worker is the higher of the actual wage rate (the rate the employer pays to all other individuals with similar experience and qualifications who are performing the same job), or the prevailing wage (a wage that is predominantly paid to workers in the same occupational classification in the area of intended employment at the time the application is filed). Similarly, H-1B employers must provide foreign workers working conditions based on the same criteria as those the employer offers to its U.S. workers, such as hours, shifts, vacation periods, and benefits. Employers wishing to bring in foreign health personnel on a permanent basis must usually obtain a labor certification from the Department of Labor determining that there are not sufficient U.S. workers who are able, willing, qualified, and available in the area of intended employment and that the employment of a foreign worker will not adversely affect the wages and working conditions of workers in the U.S. similarly employed. One of the methods utilized by the Department of Labor to ensure that the wages and working conditions are not affected is to require the employer to offer at least the prevailing wage to all U.S. workers during its labor market test and then to the foreign worker upon receipt of his or her permanent residency. An employer is not required to file a labor certification application with the Department of Labor for those foreign workers (including professional nurses and physical therapists) who qualify under the Department’s Schedule A. In those cases, an employer must attach its labor certification application to the immigrant worker petition it files directly with the Department of Homeland Security. Employers who are interested in employing H-2B temporary workers must obtain a labor certification from the Department of Labor. Among other requirements, they must offer and pay the H-2B worker no less than the highest of the prevailing wage, the applicable Federal minimum wage, the State minimum wage, or local minimum wage during the entire period of the approved H-2B labor certification.

For more information, please visit the following websites: 1. Wilberforce Trafficking Victims Act: http://travel.state.gov/content/visas/english/general/rights-protections-temporary-workers.html 2. Link to H1B visa protections, 20 CFR Part 655, Subparts H and I: http://www.ecfr.gov/cgi-bin/textidx?SID=96b00af0b6b7ce8e8fda30ea4c512a6f&node=20:3.0.2.1.28&rgn=div5 - 20:3.0.2.1.28.2#sp20.3.655.h 3. The U.S. Department of Labor Occupational Safety & Health Administration: http://www.osha.gov/law-regs.html 4. The U.S. Department of Labor Wage and Hour Division: http://www.dol.gov/whd/ 5. The U.S. Department of Labor Office of Foreign Labor Certification: http://www.foreignlaborcert.doleta.gov/ 6. The U.S. Department of Labor Bureau of Labor Statistics: https://www.bls.gov/