4
Envisioning a U.S. Global Health Service

This chapter presents the organizing framework for a new suite of programs and activities designed to respond to the PEPFAR mandate, and to contribute knowledge and expertise on the ground to fight HIV/AIDS, as well as tuberculosis (TB), malaria, and other global scourges. In proposing this group of programs, the committee aims to help address the grave deficiency of human health care resources in countries targeted by PEPFAR, leveraging and multiplying local responses on the ground. The committee’s proposals reflect a recognition of the pivotal contributions that U.S. health workers can make in partnership with overseas colleagues in the common fight against these terrible diseases.

As the overall implementing mechanism for these proposals, the committee envisions a Global Health Service (GHS), as detailed in this chapter. The six specific programs proposed for the GHS—a corps of experts, needs assessment, a competitive 1-year fellowship program, a loan repayment program, organizational twinning, and a clearinghouse—are discussed in Chapter 5.

Recommendation 1: Create a U.S. Global Health Service. The committee discussed the importance of establishing a clear identity for programs designed to mobilize health personnel for service in combating HIV/AIDS in highly impacted countries. A well recognized identity—a brand—was felt to be essential to the creation of mission and the promotion of volunteerism. Therefore the committee recommends the establishment of a U.S. Global Health Service to serve as the umbrella organization for the initiatives and programs to be proposed in this report.



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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS 4 Envisioning a U.S. Global Health Service This chapter presents the organizing framework for a new suite of programs and activities designed to respond to the PEPFAR mandate, and to contribute knowledge and expertise on the ground to fight HIV/AIDS, as well as tuberculosis (TB), malaria, and other global scourges. In proposing this group of programs, the committee aims to help address the grave deficiency of human health care resources in countries targeted by PEPFAR, leveraging and multiplying local responses on the ground. The committee’s proposals reflect a recognition of the pivotal contributions that U.S. health workers can make in partnership with overseas colleagues in the common fight against these terrible diseases. As the overall implementing mechanism for these proposals, the committee envisions a Global Health Service (GHS), as detailed in this chapter. The six specific programs proposed for the GHS—a corps of experts, needs assessment, a competitive 1-year fellowship program, a loan repayment program, organizational twinning, and a clearinghouse—are discussed in Chapter 5. Recommendation 1: Create a U.S. Global Health Service. The committee discussed the importance of establishing a clear identity for programs designed to mobilize health personnel for service in combating HIV/AIDS in highly impacted countries. A well recognized identity—a brand—was felt to be essential to the creation of mission and the promotion of volunteerism. Therefore the committee recommends the establishment of a U.S. Global Health Service to serve as the umbrella organization for the initiatives and programs to be proposed in this report.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Recommendation 1a: Mobilize providers and capacity developers. The committee believes that a wide variety of health professionals and other key technical and management personnel will be essential for achieving the PEPFAR goals of treating 2 million HIV-infected people, preventing 7 million new HIV infections, and caring for 10 million HIV-affected individuals and vulnerable children (the 2-7-10 PEPFAR goals), as well as for building the long-term capacity necessary to control HIV/AIDS, tuberculosis, and malaria. Therefore, the committee recommends that the programs of the U.S. Global Health Service initially focus on the mobilization of clinicians, technicians, and management personnel in direct response to specified in-country needs to achieve PEPFAR goals. In view of the lack of human resources for health in PEPFAR focus countries and many other developing countries, education, training, and development of new, effective configurations of health care delivery in resource-poor settings will take high priority among the U.S. Global Health Service’s activities. VISION AND MISSION The desire to perform volunteer service was first noted as a distinctly American trait by Alexis de Tocqueville in the early nineteenth century. Multiple examples since that time attest to the service and compassion of many Americans toward fellow citizens at home and around the world. Today, an unprecedented medical tragedy offers a new opportunity for Americans to give and give back. The vision behind the committee’s proposal for the GHS springs from a shared conviction that health is a human right, and one that can be attained in a global context only through the coordinated efforts of committed partners. The mission of the GHS is to be flexible and responsive to the needs for human resources for health identified by countries whose citizens are most affected by the HIV/AIDS pandemic and other global scourges; to provide expertise in the form of caregivers, technical advisers, trainers, and mentors; and to sustain enduring relationships after working with colleagues on the ground. Why “Global Health” and Not Just “HIV/AIDS” The committee understood that the participants and programs it envisioned would have, as their primary agenda, a commitment to helping PEPFAR reach its ambitious 5-year goals (i.e., providing antiretroviral therapy [ART] for 2 million people; preventing 7 million new HIV infections; and providing care to 10 million people infected with or affected by

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS HIV/AIDS, including orphans and vulnerable children). The committee endorsed the PEPFAR goals and agreed that they should guide its recommendations. At the same time, considering the daily realities of health care in many settings in PEPFAR countries, the committee also concluded that some GHS participants would need to possess knowledge, skills, and experience extending beyond HIV/AIDS. For example, participants might partner with host country colleagues in the direct provision of clinical care and treatment or end-of-life palliative care for HIV/AIDS patients, provide pharmacy or laboratory support, perform training functions, help redesign infrastructure and health systems, or provide other forms of technical assistance within the public or private health sectors of targeted countries. From a purely medical perspective, multiple overlapping diseases associated with poverty (especially TB and malaria; see Chapter 1) and other primary care needs coexist among HIV-infected and vulnerable populations in developing countries. As discussed in Chapter 2, entry points for HIV/ AIDS care include, among others, voluntary counseling and testing sites, primary care clinics, sexual and reproductive health services, and hospitals. At more advanced stages of infection, the comprehensive care of HIV/AIDS patients requires not only mastery of ART and monitoring, but also diagnostic and management expertise pertaining to TB; skin, lung, intestinal, and bloodstream infections; sexually transmitted infections, and other opportunistic infections. In addition, parasitic diseases—most notably malaria—and nutritional issues threaten the health and survival of HIV/AIDS patients and vulnerable populations in developing countries. In short, HIV/AIDS care cannot be isolated from the health context in developing countries, nor should there be parallel programs of HIV/AIDS-related and -nonrelated care in health systems already limited in capacity. In the worst-case scenario, the former could actually detract from the latter, leading to the unintended negative consequence of an even greater disease burden within the general population. For this reason, U.S. health providers sent to work in a particular developing country will need an understanding of its situation with regard to HIV/AIDS-related diseases, as well as HIV/ AIDS itself. Another factor influencing the committee’s thinking was the setting in which U.S. health professionals would work in PEPFAR focus countries. GHS participants will need to understand and accept the challenges and frustrations of delivering health care in resource-poor settings, while at the same time maintaining positive, supportive attitudes toward colleagues and patients, a committed engagement in the tasks they perform, and an overall attitude of service. Simply put, the individuals participating in the GHS as envisioned by the committee will need not only expertise, but also personal attributes qualifying them as outstanding global ambassadors and coworkers on the ground.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Taking all of these factors into account, the committee concluded that the term “Global Health Service” most accurately conveys the master program’s immediate portfolio of activity and expertise, as well as its long-term goal of helping to advance population health in target countries. Another consideration in choosing the name “Global Health Service” was the potential stigma associated with “HIV Corps,” one alternative considered by the committee. Stigma has major negative impacts on health-seeking behavior, especially among patients at risk for HIV/AIDS. Despite the best intentions of its sponsors and participants, a new program with a stigmatizing name could potentially discourage individual patients or whole communities from fully embracing its mission or functions. Linking “Global Health” and “Service” Creating a culture of service was a primary motivation behind the committee’s proposal for a new, federally funded initiative to help to address the human resource crisis in addressing global HIV/AIDS. The needs for service within global health arena are obvious. Despite remarkable advances in health over the last century, the poorest people in the world still suffer heavy burdens of misery and premature death. They should know that others in the world care about their plight. They also need tangible help in the form of global medical aid. Without human health care resources, however, aid—whether in the form of money, drugs, or investments in physical infrastructure—will not achieve its maximum desired impact. Many U.S. health workers identify the desire to help others as a primary motivation in their original choice of profession and currently engage in service activities in their work and personal lives. However, some would like to make an even larger contribution by serving internationally. In a world of growing disparities between the healthy “haves” and “have-nots,” the desires and talents of these Americans deserve a meaningful avenue for expression. Moreover, the next generation of health care workers is increasingly interested in global health. More than 20 percent of students graduating from U.S. medical schools in 2003 participated in an international health experience during their undergraduate medical training, compared with just 6 percent of students graduating in 1984 (AAMC, 1984, 2003). The committee envisions that such individuals—in many health fields—will carry the mission of the GHS forward. Finally, many health workers on the front lines of the battle against the HIV/AIDS pandemic and global diseases associated with poverty are already serving beyond the call of duty. Despite concerns about their own physical safety, economic security, and psychological stress, these individuals continue to display enormous dedication and fortitude in the pursuit of

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS their mission. They need allies. Inspired by their service, the committee embraced the concept of global collaboration in service as the catalyst and central unifying principle for the GHS. Unitary Management and Values As envisioned by the committee, the GHS encompasses a suite of programs under a single banner. Multiple administrative arrangements could be envisioned for the GHS programs. A variety of organizations, whose attributes are listed in Appendix G, could be considered as models. However, the committee members were in agreement that the parent program should be housed within the U.S. government, although certain activities and functions might be contracted to experienced nongovernmental organizations (NGOs). Strategic justifications for housing the individual programs proposed for the GHS within the federal government are presented in Chapter 5. In general, the committee believes that a government-based program will enhance the international credibility, transparency, and clarity of purpose of the GHS; position it closer to the federal appropriations process; and enable certain of its key functions. In addition, a single management structure will serve as a focal point for legislation, budgeting, and administration while allowing the parent office to maximize efficiency and streamline operations. Notwithstanding these conclusions on the importance of the governmental anchor of the GHS, the committee believes that the use of private-sector contracts and public–private partnering will be crucial to foster creative solutions, to supplement financing, and to enhance administrative flexibility. Recommendation 2: Manage the programs of the U.S. Global Health Service in a unitary fashion. The committee recommends that the programs of the U.S. Global Health Service be managed in a unitary fashion to provide maximum synergy, coordination, and clarity of purpose. Fiscal, administrative, and management matters should be handled by the single organizational entity that would be dedicated to the mission of mobilizing U.S. personnel to work in PEPFAR focus countries. Finally, in order for the U.S. Global Health Service to relate closely to PEPFAR and to participate in the annual federal budget process, the committee recommends that the U.S. Global Health Service should be a program of the federal government. In order to be successful, the U.S. Global Health Service needs to collaborate with the private sector, NGOs, and public–private matching programs. Public input to the management of such a high-visibility global program is important for maintaining a balanced view. The committee believes

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS that the best mechanism to this end would be an external advisory committee. Recognizing the fundamental importance of involving partners in the development and ongoing operation of the GHS, the committee believes further that the members of the advisory committee should include colleagues from the PEPFAR focus countries and NGOs, as well as other key collaborators from the United States and abroad. Recommendation 2a: Establish an advisory committee for the Global Health Service that includes international members. The committee recognizes the fundamental importance of involving partners in the development and ongoing operation of the U.S. Global Health Service. These partners would include colleagues from nongovernmental organizations, PEPFAR countries, and other key collaborators from the United States and abroad. The committee recommends the creation of a policy-level advisory committee with international colleagues and a commitment to the strategic engagement of public and private partners in the planning, operation, and evaluation of the U.S. Global Health Service. While a variety of programs to mobilize U.S. health professionals for service abroad are already in existence, none encompasses the scope and values of the proposed GHS, which include the following: A portfolio of human resource capacity-building mechanisms that individually provide unique benefits and together create synergistic benefits otherwise not possible Opportunities for strategic, multifaceted deployment relating to the operating plans of PEPFAR countries Possibilities for strategic public–private partnerships within and among countries that are both federally funded and benefit from funding and resources from other sectors National prominence for volunteering opportunities Reduction of barriers to developing governmental relationships among countries and collaboration among agencies within the United States Coordinated responsibility and accountability for target setting and performance monitoring PRINCIPLES AND MERIT FRAMEWORK The GHS as envisioned by the committee is framed by a set of six guiding principles. These principles are detailed below. Country responsiveness. The programs and members of the GHS will at all times support and be responsive to the host countries in which they

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS operate in both the public and private health sectors. Under the full-time/ long-term program proposed by the committee (the Global Health Service Corps, discussed in Chapter 5), countries will actually trigger deployments (according to the operations plans of PEPFAR countries and/or national internal needs assessments) from among a range of specialists and expertise. Thus the committee endorsed the concept of local ownership (see below), with the support provided being tailored to specific settings, and ongoing monitoring and evaluation being carried out for quality improvement. Interdisciplinary, cross-cutting approach. The effective provision of HIV/AIDS prevention and treatment services, as well as other control efforts targeting major global diseases, requires the talents and expertise of many skilled professionals, including, for example, clinicians (doctors, nurses, and other care providers), public health specialists, laboratory personnel, pharmacists, information technologists, and health systems managers and planners. The committee stresses the need for interdisciplinary and cross-cutting approaches so that the GHS can respond flexibly and creatively to diverse needs on the ground. Training for self-sufficiency. The long-term goal of the GHS is not to provide U.S. health professionals as permanent substitutes for local workers or even to augment local forces, but to empower receiving countries. A key factor in empowerment is training for self-sufficiency. In the long run, self-sufficiency in health care will develop incrementally, nurtured by many investments. With respect to human resources for health, however, the committee envisions self-sufficiency developing on a foundation of professional and institutional relationships. Following overseas service, cross-border personal networks will continue to foster self-sufficiency and collegial exchanges. Nondepletion of the local health care workforce. The committee recognizes that depletion or diversion of the current health workforce in PEPFAR focus countries could inadvertently result from a well-intentioned global health program on the ground. The GHS will engage in ongoing monitoring of its impact on local health care to ensure that it does not drain resources from essential local services or foster the international migration of health workers. Multiplier effect. To the extent possible, participants in programs of the GHS will pursue the goal of cost-effective force multiplication. Given the dire lack of human resources for health in many developing countries, investments in education, training, and new effective approaches to health care delivery will take priority among the activities of the Global Health Service Corps. Such efforts may be further augmented by long-distance learning programs and modern information and network technology, which could eventually encompass a collection of physically dispersed but interlinked nodes.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Sustained involvement and ownership. Just as short-term, albeit compassionate, outpourings of help after a major disaster such as the recent Indian Ocean tsunami do not sustain long-term development (Walker et al., 2005), launching the GHS with the sole purpose of helping to achieve the 5-year goals of PEPFAR will not solve the long-term health needs of PEPFAR countries and populations. However, the investments made by GHS participants and programs will contribute to those larger goals. Although the committee envisions the GHS as an ongoing activity of the U.S. government (thereby winning the trust of local stakeholders and ensuring some sustained involvement), it also envisions the GHS as adjusting to changing conditions over time, thereby allowing indigenous programs and personnel to take ownership of their own HIV/AIDS and other national health objectives. THE GLOBAL HEALTH SERVICE AS STRATEGIC HUMANITARIANISM Humanitarianism marks the recently augmented public health programs of many international organizations, including the United Nations, the World Bank, and the European Union, all of which have placed questions of public health on their agendas and joined in collective efforts against HIV/AIDS, TB, and malaria. Health is a complex concept with many varying historical, cultural, and social associations depending on its geographic and economic context. In western countries, a commitment to international health also has security-related motivations, especially with respect to the control of global epidemics. The recent energized global campaign against severe acute respiratory syndrome (SARS) and the mounting concern over a new global pandemic of avian influenza can certainly be seen in this light. The GHS is proposed as a humanitarian program of the people of the United States at a time when the security of both PEPFAR countries and the United States is jeopardized by disease. In short, the GHS is a program of strategic humanitarianism. The committee believes that such a program will yield benefits in six key areas. Humanitarian benefit. The GHS will enhance health in underserved areas and demonstrate the compassion of the American people. Multicultural understanding. Like the U.S. Peace Corps, the GHS will foster relationships and multicultural understanding while mitigating anti-American sentiment overseas. It should also inspire a greater understanding of and commitment to global health on the part of the American people. Collegial support and capacity building in affected countries. The emergence of HIV/AIDS has desperately worsened Africa’s preexisting crisis in health manpower. Members and programs of the GHS will bring expertise,

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS motivation, and muscle to long-term campaigns that might otherwise exhaust local human resources, despite enhanced access to new treatments. Their presence will also lead to the development of long-term cross-border personal networks. Capacity building in the United States. The GHS will facilitate the development of new knowledge, experience, and public awareness, bolstering the ability of the United States to respond at home and abroad to many infectious/tropical disease threats resulting from globalization. Given the borderless nature of disease and the international and interdisciplinary nature of current scientific research, international collaborations are crucial to addressing global health issues. Epidemics such as SARS and HIV/AIDS, as well as physical disasters such as the recent tsunami in the Indian Ocean and earthquake in Iran, highlight the need for qualified professionals throughout the world to work together. Countering of gender vulnerability. In many affected countries, legal, social, and economic factors have made girls and women especially vulnerable to the HIV/AIDS pandemic. In sub-Saharan Africa, girls and women represent 58 percent of those living with HIV/AIDS. In some of the worst-affected countries in southern Africa, intergenerational sex has led to HIV seroprevalence rates among girls aged 15 to 19 that are four to seven times higher than those among boys of the same age (Fleischman, 2003). In patrilineal African tribes, widows and children of victims of HIV/AIDS may also become destitute because the married couple’s property reverts to the husband’s family upon his death (LaFraniere, 2005). The GHS will combat gender vulnerability, especially through education and other AIDS prevention strategies. Geopolitical security. HIV/AIDS will continue to be a destabilizing force in the world for decades to come. The infection is already eroding state capacity in sub-Saharan Africa (an important front in the war on terror), where 70 percent of currently infected patients reside. By 2010, 20 million children in Africa will have lost one or both parents to AIDS. Orphans and desocialized youth are especially vulnerable to exploitation in civil conflicts. Significant rates of HIV/AIDS in military populations also impact the ability of affected countries to safeguard their national interests and participate in regional peacekeeping. For this and other reasons, HIV/ AIDS is a threat to regional, global, and U.S. security that merits major investments in human capital, as well as in drugs and technology. REFERENCES AAMC (Association of American Medical Colleges). 1984. Medical School Graduation Questionnaire All Schools Report. Washington, DC: AAMC.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS AAMC. 2003. Medical School Graduation Questionnaire All Schools Report. Washington, DC: AAMC. Fleischman J. 2003. Fatal Vulnerabilities: Reducing the Acute Risk of HIV/AIDS Among Women and Girls. Washington, DC: The CSIS Press. LaFraniere S. 2005 (February 18). AIDS and custom leave African families nothing. The New York Times. A. A1. Walker P, Wisner B, Leaning J, Minear L. 2005. Smoke and mirrors: Deficiencies in disaster funding. British Medical Journal 330:247–250.