6
Looking Ahead

Sustainable solutions to the human resources crisis in addressing global HIV/AIDS will ultimately come from highly affected countries. The Global Health Service (GHS) and component programs proposed in this report could play an important role in catalyzing solutions to the crisis in the PEPFAR focus countries. At the same time, the committee anticipates that GHS personnel and programs—being country-responsive and mission-driven—would adjust to changing conditions over time as the pandemic recedes, and new indigenous workers and configurations of care emerge on the ground. In other words, although an exit timetable cannot be forecast at this stage of the pandemic, the committee endorses the principle of flexible downsizing over time.

This final chapter discusses a long-term view of capacity development, creative partnerships, value-added investments (e-health and global health education), ethical issues in foreign health workforce assistance, and monitoring and evaluation.

A LONG-TERM VIEW OF CAPACITY DEVELOPMENT

The GHS is envisioned as a strategic and humanitarian intervention in settings that currently lack sufficient human health care resources to mount a counterattack on HIV/AIDS. The six programs of the GHS are not intended to produce a permanent workforce or to substitute for the development of health personnel capacity in the PEPFAR focus countries. The long-term sustainability of the program must be a priority for both the PEPFAR countries and the United States. Over time, all the PEPFAR countries will



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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS 6 Looking Ahead Sustainable solutions to the human resources crisis in addressing global HIV/AIDS will ultimately come from highly affected countries. The Global Health Service (GHS) and component programs proposed in this report could play an important role in catalyzing solutions to the crisis in the PEPFAR focus countries. At the same time, the committee anticipates that GHS personnel and programs—being country-responsive and mission-driven—would adjust to changing conditions over time as the pandemic recedes, and new indigenous workers and configurations of care emerge on the ground. In other words, although an exit timetable cannot be forecast at this stage of the pandemic, the committee endorses the principle of flexible downsizing over time. This final chapter discusses a long-term view of capacity development, creative partnerships, value-added investments (e-health and global health education), ethical issues in foreign health workforce assistance, and monitoring and evaluation. A LONG-TERM VIEW OF CAPACITY DEVELOPMENT The GHS is envisioned as a strategic and humanitarian intervention in settings that currently lack sufficient human health care resources to mount a counterattack on HIV/AIDS. The six programs of the GHS are not intended to produce a permanent workforce or to substitute for the development of health personnel capacity in the PEPFAR focus countries. The long-term sustainability of the program must be a priority for both the PEPFAR countries and the United States. Over time, all the PEPFAR countries will

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS have to develop sufficiently capable and sustainable workforces to continue HIV/AIDS prevention and treatment programs into the foreseeable future. There is a strong rationale for U.S. health professionals, as well as other foreign workers, to help through training, skill development, partnership, and other forms of human resource support. The committee believes that national capacity development in each PEPFAR focus country should entail the following steps: Each country should undertake a health workforce needs assessment as part of or a complement to its national plan. National plans are necessary to orient human resource investments and the filling of gaps by foreign personnel. The needs assessment should encompass not only HIV/ AIDS, but also primary prevention and care, because indigenous workers need to pursue their career development within a national system and strategy. National education and training should be accelerated to develop the human resources needed to address the HIV/AIDS pandemic and meet primary health care needs. Those personnel likely to be in highest demand are paraprofessionals such as community health workers. U.S. personnel can contribute to this massive training mission through regionally based activities that maximize the use of available trainers. This contribution is particularly important in sparsely populated areas that lack broad and effective educational and training institutions. The work environment for health professionals should ensure staff retention and promote staff performance. To this end, attention must be paid to financial and nonfinancial incentives, especially social recognition for work performed (Vujicic et al., 2004). Note, however, that special payments to national staff should be viewed with caution; while motivating some, they could discourage others. The “brain drain” should be stemmed by the dampening of demand in richer countries that continue to recruit health workers. Two important measures to this end are developing codes of conduct for the recruitment of health professionals and working toward self-sufficiency in the production of health workers (Buchan et al., 2003; Stilwell et al., 2004). Where necessary, priority programs and health systems should be harmonized to avoid fragmentation, duplication, and waste. With more than half of total health expenditures in some PEPFAR focus countries coming from foreign sources, U.S. personnel can enhance harmonization of funders and funding activities through policy and management support. Although the development of long term-health professional capacity must be a priority for host countries, the United States can take significant actions to assist in the effort. Foremost among these is investing in the

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS develoment of indigenous health workforce capacity. Medical and nursing schools need to be built and staffed. Midlevel provider programs that offer continuing education and advanced training need to be promoted and funded. Community and village health workers need to be trained by the thousands and equipped with standardized basic skills for HIV/AIDS work. Training programs at all levels for special competencies associated with HIV/AIDS care need to be supported. PEPFAR, as well as the programs of other agencies of the U.S. government, U.S. philanthropies, corporations, nongovernmental organizations (NGOs), and private donors, should all focus on this crucial and central mission. The United States should collaborate with other governments and those in the global donor community to plan and coordinate a massive health personnel training campaign for countries highly impacted by HIV/AIDS. A second way in which the United States could play a key role in creating stability in the health sector of developing countries is by helping to end the brain drain. Developing nations often experience a chronic and sometimes severe loss of physicians, nurses, and other professionals to developed nations. Among other factors, this migration out of the focus countries is triggered by the failure of the United States and other developed nations to educate sufficient health professionals to meet their domestic needs (Stilwell et al., 2004). The developed countries then must rely on foreign-trained physicians and nurses to close their gaps in service. The resultant exodus of scarce human health care resources is a prominent barrier to building clinical cadres in the PEPFAR focus countries to assume the increased demands of HIV/AIDS, prevention, treatment, and care. In summary, the committee believes that: PEPFAR and other governmental and nongovernmental programs in the United States and elsewhere should invest heavily in programs to build health professional capacity in countries highly impacted by HIV/ AIDS. These investments should include the funding of training programs, instructors, faculty development, and construction where necessary. The U.S. government should work with other governments and international donor organizations in collaboration with the PEPFAR focus countries to mount a strategic campaign for the training of health personnel. The United States and other developed nations should make a formal commitment to self-sufficiency in meeting their health workforce needs and embark promptly on the training programs necessary to meet this commitment. Over the short term, the United States and other developed nations should avoid explicit or implicit recruitment strategies that target the health care workers of low-income countries.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS CREATIVE PARTNERSHIPS Increasingly employed in comprehensive development frameworks, public–private partnerships have featured prominently in international health in recent years. In 2003, the database of the Initiative on Public–Private Partnerships for Health of the Global Forum for Health Research listed 91 international arrangements in the health sector that qualified as public–private partnerships; 76 of these were dedicated to the prevention and control of infectious diseases, notably AIDS, tuberculosis, and malaria (Nishtar, 2004). Large partnerships can also be hosted by an NGO, or can be formed between individual governments and the private sector or NGOs with particular technical or outreach strengths. In principle, as long as one private for-profit organization and at least one not-for-profit organization share efforts and benefits in pursuit of a common objective for the creation of social value, their collaboration can be deemed a public–private partnership. In the United States alone, hundreds of millions of dollars has been invested to promote partnerships creating “thousands of alliances, coalitions, consortia and other health partnerships” (Lasker et al., 2001:179). To support the health workforce mission of PEPFAR, a variety of creative public-private partnerships can be envisioned. One outstanding example currently targeting human capacity gaps with corporate know-how is the Pfizer Global Health Fellows program (described in detail in Chapter 3). Similarly, innovative human resource collaborations are possible with respect to managing laboratory assets, creating reliable drug delivery systems, and redesigning local health care delivery systems. Table 6-1 provides an overview of companies and organizations currently addressing HIV/AIDS in the PEPFAR focus countries. The interventions listed focus on voluntary counseling and testing; prevention, education and awareness; and care, support and treatment. However, these organizations may also be interested in human resource issues and other activities aimed at achieving the PEPFAR goals. Creating a true partnership requires mutual understanding and reciprocity among all parties entering into the relationship. Thus all parties should have something to offer and something to gain, and should avoid the unspoken assumption that the one with the resources wields the power. It may even be necessary to compensate intentionally for the imbalance of power to promote communication and avoid relationships of dependency and paternalism. Those involved in public–private partnerships need to be especially cognizant of cross-cultural differences regarding schedules, efficiency, and structure.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS TABLE 6-1 Potential Partners Addressing HIV/AIDS Company/Organization Intervention Coca-Cola Company http://www2.coca-cola.com/citizenship/africa_program.html Voluntary counseling and testing (VCT); prevention, education, and awareness (PEA); care, support, and treatment (CST) Voxiva http://www.voxiva.net/solutions_hiv_aid.html#desc03 PEA Merck http://www.merck.com/about/cr/policies_performance/social/medicines_developing.html PEA, CST Levi Strauss http://www.levistrauss.com/responsibility/foundation/index.htm PEA, CST IBM http://www.weforum.org/pdf/Initiatives/GHI_HIV_CaseStudy_IBM.pdf VCT, PEA, CST Abbott Laboratories http://www.abbott.com VCT, PEA, CST GlaxoSmithKline http://www.gsk.com/community/index.htm PEA, CST SOURCE : Global Business Coalition on HIV/AIDS (2005). VALUE-ADDED INVESTMENTS In considering how to further the capacity-building mission in global health, the committee discussed two strategies that did not rise to the level of formal recommendations, but would be important value-added investments. E-Health E-health is defined as the use of technology to exchange actionable information to facilitate the delivery of health services (Ladd, 2005). E-health broadly encompasses the following: Telemedicine—the use of technology to support the delivery of clinical services (e.g., telesurgery)

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Telehealth—the use of technology to support a wide range of health-related communications and information exchanges (e.g., teleconsultations) Information and communications technologies for health—the use of technology to realize time and cost efficiencies in day-to-day practice (e.g., routine data collection using handheld computers) While this report addresses information management and information technology primarily through the proposed GHS Clearinghouse, the committee also recognizes the great potential for e-health to mitigate the human capacity shortfall by enabling health care workers to increase their efficiency and effectiveness, providing the local health care establishment with immediate access to experts and expert centers in the United States and elsewhere, and offering individual support to deployed professionals to enable and encourage deployments of longer duration. The committee received written and verbal testimony regarding e-health (see Appendixes E and F). Key points regarding the relevance of e-health to the workforce expansion effort are summarized below. E-health allows health professionals to overcome time and distance barriers, bringing expertise, education, and training to remote locations and providing services that poor, isolated communities would otherwise lack. In December 2004, the World Health Organization endorsed the use of e-health (WHO, 2004). A specific e-health application (among many) that could support the scale-up of HIV/AIDS treatment and care in the PEPFAR focus countries is the use of interactive personal digital assistants (PDAs) for management of antiretroviral therapy (ART), patient record keeping, patient tracking, larger-scale data collection, and knowledge building. A pilot evaluation of this technology is currently under way in remote villages of Uganda, allowing health professionals there to share information and data with colleagues in Kampala. One of the main challenges in applying e-health strategies to extend workforce capacity in the PEPFAR focus countries will be to suit the technology and hardware to the context in which care is being delivered. As discussed in Appendix E, sources of connectivity for e-health include satellites, local Internet services, landline phone networks, cellular phone networks, broadcast and two-way radios, WiFi and WiMax networks, and “sneaker networks.”1 Hardware components include desktop computers, laptop computers, handheld computers, satellite ground stations, access points, smart phones, pagers/Blackberries, cell phones, satellite phones, and 1   “Sneaker networks” refers to connectivity via motorbike, bicycle, and foot.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS landline phones. Consequently, many possible configurations may be proposed. A basic principle underlying all e-health interventions is that they should be collaborative and constructive, resulting in clear benefits rather than increasing the workload of already overwhelmed workers. Despite the human and technological challenge of designing e-health interventions to complement different workplaces, the committee strongly believes that e-health can leverage health care resources in the PEPFAR focus countries. The committee therefore endorses the testing of potentially replicable e-health models in the scale-up of HIV/AIDS treatment and care. Global Health Education in the United States International health is more than the study of diseases of the developing world; it is a matrix of many contributing factors—chief among them economic, cultural, historical, political, and environmental—that also influence health and disease worldwide. Students of international health therefore benefit from a multidisciplinary approach. Schools of nursing were early innovators in the area of international health, particularly in their focus on transcultural aspects. These concepts and, in some instances, specific graduate specialty programs have been interwoven throughout undergraduate and graduate curricula in most schools. A few nursing schools have joint graduate degree programs with schools of public health in the area of international health. Current interest in international health among U.S. medical students and postgraduate residents is also running high. 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). In general, students pursue such experiences to fill perceived gaps in their education, to achieve cross-cultural understanding, or to satisfy altruistic ideals (Taylor, 1994). Today, students are also interested in international health research. In 2004, the first 20 highly competitive participants were selected for a new Fogarty/Ellison Fellowship in Global Health and Clinical Research Training, a 1-year mentored clinical research experience at an established National Institutes of Health–funded research center in a developing country. This program is open to any U.S. medical, osteopathic, public health, nursing, or dentistry student.2 The Yale/Johnson and Johnson Physician Scholar 2   Fourteen sites that met stringent criteria for research training were selected for the initial fellowship year: Botswana, Brazil, Haiti, India (2), Kenya, Mali, Peru (2), South Africa (2), Thailand, Uganda, and Zambia. Information about Fogarty/Ellison Fellowships is available at: http://www.aamc.org/students/medstudents/overseasfellowship/2004recipients.htm.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Award sends 80 residents and senior physicians abroad on an elective rotation each year. It has been found that overseas experiences during early professional life often lead to career choices in public health and an increased commitment to underserved populations both in the United States and in other countries (Gupta et al., 1999). These examples and others suggest there could be a sizeable pool of U.S. health professionals seeking overseas work opportunities linked to global service in the future. To better serve their educational and employment needs, upgraded global health curricula, supported by appropriate professional consortia, should be encouraged, within both health professional schools and other educational settings. In most U.S. colleges and universities, global health electives, courses, and degree programs are situated within medical schools and schools of public health. Unfortunately, these programs have not received the benefit of support from federal health professions legislation (Titles VII and VIII of the United States Public Health Service Act). Because virtually all of the support provided under this legislation has been targeted at developing the U.S.-based workforce to meet the health needs of this country, little or no attention has been paid to the development of international health expertise. With the exception of certain organizations, such as the International Health and Medical Education Consortium (see Box 6-1), there is little connectivity among students, teachers, course directors, and curricula in the area of international health. The information base on global health study programs outside of graduate schools of health is even sparser. Some universities offer interdepartmental majors in international development or global studies. Standardized, multidisciplinary educational offerings combining, for example, anthropology, economics, environmental sciences, management, and political science, would complement programs aimed at long-term U.S. capacity development in several sectors, including health. As evidence of this growing need, in February 2005 Fogarty International Center invited applications for new programs aimed at fostering global health research and teaching, possibly to include new multidisciplinary global health curricula for undergraduates and graduates in U.S. universities (NIH, 2005). Similar trends overseas have led, for example, to a new bachelor of science degree in global health as one option for completing the bachelor of medicine and bachelor of surgery degree in the United Kingdom (Bateman et al., 2001; Yudkin et al., 2003). The committee supports enhanced investments in such educational offerings and encourages the development of new multidisciplinary curricula in the United States to prepare the next generation of professionals to address HIV/AIDS and other global health challenges likely to arise in the coming decades.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS BOX 6-1 International Health and Medical Education Consortium International Health and Medical Education Consortium (IHMEC), a nonprofit organization, is a consortium of health professionals, faculty, health educators, and institutions dedicated to international health and medical education. Formed in 1991, its mission is to foster medical education in international health in four program areas—curricula, clinical training, career development, and international education policy. IHMEC members represent 82 medical schools, primarily in the United States and Canada, that participate in four general programs areas: global health education policy, curriculum development, clinical electives locally and abroad, and national and international institutional partnerships. Its more than 500 individual members include students, faculty, and other health professionals, and there is also a mailing list of more than 1,000 physicians, nurses, public health officers, physician assistants, and health educators interested in global health. In addition to medical schools, IHMEC partners with schools of nursing and public health; international health institutions worldwide; and professional associations representing public health practitioners, nurse practitioners, and physician assistants. Through its focus on education, IMHEC fosters global health leadership by educating, training, and mentoring students, faculty, professionals, and practitioners to address global health challenges. SOURCES: Stuck et al. (1995) and Velji (1991). ETHICAL CONSIDERATIONS IN DEPLOYING U.S. HEALTH PROFESSIONALS OVERSEAS For many reasons that are discussed throughout this report, addressing the human health care resource crisis in the battle against global HIV/AIDS is a humanitarian and political imperative (see in particular the discussion in Chapter 2). The committee believes that deploying U.S. health professionals to help with training, skill building, and other forms of partnership can greatly contribute to achieving the PEPFAR goals and building primary health care systems in highly affected countries. However, the committee also recognizes the need to consider the ethical aspects of a large-scale deployment of U.S. health professionals. In December 2004, the committee heard testimony on ethical issues involved in foreign health workforce assistance programs (for the full testimony, see Appendix B). This section summarizes key points from this testimony many of which also appear in Chapter 4. Models of emergency humanitarian intervention vary widely. They range from short-term emergency efforts (during civil disorders, for example, when health systems are nonfunctioning), to small-scale assistance

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS (the current reality in many PEPFAR focus countries), to large-scale comprehensive assistance with overall strategic coordination. The GHS programs proposed in this report fall into the third of these categories, with training as their paramount mission. The central equity-related question arising from this mission is whether U.S. or other volunteer health personnel focused on a vertical HIV/AIDS program will inadvertently fuel brain drain and/or displace local practitioners from other essential work, including primary health care. To address this issue, the committee supports national human resource planning for health that encompasses not only HIV/AIDS, but also primary prevention and care, as discussed earlier in this chapter. Another relevant equity issue arises from the principle of “primum non nocere” (first do no harm). Without sustainability, short-term assistance could result in even greater disarray in national health systems, as well as feelings of abandonment on the part of host countries. Other ethical issues facing U.S. health personnel overseas includes setting priorities and selecting beneficiaries (volunteers may have different standards than host countries and counterparts regarding men, women, young children, and stigmatized groups as targets for HIV/AIDS treatment and care). Moreover, motivations (for example, political or religious beliefs) may differ between participating U.S. health personnel and the funders of PEPFAR. MONITORING AND EVALUATION The recent rapid increase in international funding to battle the HIV/ AIDS pandemic and other major sources of global disease burden, including malaria and tuberculosis, has made monitoring and evaluation capacity essential to ensure that resources are used effectively at the national and subnational levels. Components of monitoring and evaluation capacity for international initiatives addressing international diseases include overall systems, biologic surveillance, behavioral surveillance, research, program monitoring, and financial monitoring. With respect to the proposed GHS, monitoring and evaluation would clearly be important, and would require flexible systems to assess and track the work of various program participants. These findings, in turn, would guide adjustments in numbers of personnel, professional and personal qualifications, and other skill sets so as to achieve the greatest benefit in augmenting the health workforce in the PEPFAR focus countries. The committee was not in a position to design precise monitoring and evaluation instruments for each proposed program of the GHS, nor would this be a practical exercise at this stage. However, the committee did reflect upon a provocative question posed by a key PEPFAR official: “What would

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS success on the ground look like?” Apart from the 5-year numeric targets of PEPFAR, the committee believes the following criteria could be considered a reasonable measure of success: Satisfaction among PEPFAR recipients and GHS participants, and the productivity of U.S. health personnel Skills and knowledge of PEPFAR country counterparts Perceptions of host organizations (public- and private-sector) Perceptions of general stakeholder communities in the PEPFAR focus countries International dissemination of successful models New paradigms of care and configurations of service providers for HIV/AIDS prevention, treatment, and care in all countries heavily impacted by the pandemic With respect to the broader philosophical framework of monitoring and evaluation, two final principles are worth emphasizing. First, to ensure sustainable collaborations, the programs of the GHS must be useful to society, and their value must flow to all core partners. Second, the envisioned partnerships must be viewed as a continual learning process, with the potential for offering unexpected lessons. Strategically strengthening a country’s capacity to monitor and evaluate its workforce is a potentially sustainable effort that would be mutually beneficial to all countries. REFERENCES AAMC (Association of American Medical Colleges). 1984. Medical School Graduation Questionnaire All Schools Report. Washington, DC: AAMC. AAMC. 2003. Medical School Graduation Questionnaire All Schools Report. Washington, DC: AAMC. Bateman C, Baker T, Hoornenborg E, Ericsson U. 2001. Bringing global issues to medical teaching. Lancet 358(9292):1539–1542. Buchan J, Parkin T, Sochalski J. 2003. International Nurse Mobility: Trends and Policy Implications. Geneva, Switzerland: WHO. Global Business Coalition on HIV/AIDS. 2005. Global Business Coalition on HIV/AIDS. [Online]. Available: http://www.businessfightsaids.org/site/pp.asp?c=nmK0LaP6E&b=202243 [accessed March 17, 2005]. Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. 1999. The international health program: The fifteen-year experience with Yale University’s Internal Medicine Residency Program. American Journal of Tropical Medicine & Hygiene 61(6):1019–1023. Ladd H. 2005 (February 14). Telemedicine and Telehealth. Presentation at the February 14, 2005, Workshop of the IOM Committee on Options for the Overseas Placement of U.S. Health Professionals, Washington, DC. Lasker RD, Weiss ES, Miller R. 2001. Partnership synergy: A practical framework for studying and strengthening the collaborative advantage. Milbank Quarterly 79:179–205.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS NIH (National Institute of Health). 2005. Framework Programs for Global Health. [Online]. Available: http://grants.nih.gov/grants/guide/pa-files/PAR-05-050.html [accessed March 1, 2005]. Nishtar S. 2004. Public–private “partnerships” in health: A global call to action. Health Research Policy and Systems 2:5. [Online]. Available: http:www.health-policy-systems.com/contents/2/1/5 [accessed March 1, 2005]. Stilwell B, Diallo K, Zurn P, Vujicic M, Adams O, Dal Poz M. 2004. Migration of health care workers from developing countries: Strategic approaches to its management. Bulletin of the World Health Organization 82(8). Stuck C, Bickley L, Wallace N, Velji AM. 1995. International Health Medical Education Consortium: Its history, philosophy, and role in medical education and health development. Infectious Disease Clinics of North America 9(3):419–423. Taylor CE. 1994. International experience and idealism in medical education. Academic Medicine 69(8):631–634. Velji AM. 1991. International health beyond the year 2000. Infectious Disease Clinics of North America 5(2):417–428. Vujicic M, Zurn P, Diallo K, Dal Poz M. 2004. The role of wages in slowing the migration of health care professionals from developing countries. Human Resources for Health 2:3. WHO (World Health Organization). 2004. eHealth Report by the Secretariat. Geneva, Switzerland: WHO. [Online]. Available: http://www.who.int/gb/ebwha/pdf_files/EB115/B115_39-en.pdf [accessed March 4, 2005]. Yudkin JS, Bayley O, Elnour S, Willott C, Miranda JJ. 2003. Introducing medical students to global health issues: A Bachelor of Science degree in international health. Lancet 362(9386):822–824.

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