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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS 5 Programs of the U.S. Global Health Service This chapter describes six independent programs proposed for the Global Health Service (GHS). Each program would make a unique contribution to the mission of the GHS as discussed in Chapter 4; that is, to be flexible and responsive to target countries’ needs for human resources for health to combat HIV/AIDS; to provide expertise in the form of caregivers, technical advisers, trainers, and mentors; and to sustain enduring relationships after U.S. health professionals work with colleagues on the ground. Taken together, the committee believes this set of programs can significantly augment human resource capacity in seeking to acheive the PEPFAR goals (see Chapter 1). The six programs are as follows: Global Health Service Corps Health Workforce Needs Assessment Fellowship Program Loan Repayment Program Twinning Program Clearinghouse In brief, the committee envisions the Global Health Service Corps as the elite, anchor resource of the GHS, playing a far-reaching role in increasing the effectiveness of current in-country health personnel and expanding the future pool of resident health care assets. Corps members would serve for a minimum of 2 years overseas. The Fellowship and Loan Repayment Programs would provide incentives and reduce barriers to participation by qualified and motivated professionals serving for 1 and 2 years, respec-
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS tively, overseas. The Twinning Program would mobilize health professionals for short- and long-term deployments keyed to specific needs of host countries and/or organizations. In addition, the committee proposes that gaps in human resources for health be evaluated for each PEPFAR focus country through formal needs assessments that could double as a baseline for follow-up evaluation of workforce capacity and distribution. Once these needs assessments had been carried out, uniform data for all countries could be compiled in a central electronic clearinghouse to enable the recruitment of other skilled health professionals. This virtual clearinghouse would thereby utilize information posting and global networking to further support the work of many other organizations and professionals contributing to the fight against global HIV/AIDS. The committee believes that all six programs proposed for the GHS would be helpful in meeting the prevention, treatment, and care goals of PEPFAR. At the same time, some countries might choose to avail themselves of one resource more than another based on their individual needs. The remainder of this chapter is divided into six sections, each describing one of the six proposed GHS programs (for a summary, see Table 5-1). Each section presents in turn background information (often echoing themes and evidence presented earlier in this report), the committee’s recommendation for that program, a fuller description of the program, and the rationale and evidence behind the committee’s recommendation. In some cases, there is also a discussion of deployment, public versus private placement of the program, and program costs. TABLE 5-1 Six Proposed Programs of the U.S. Global Health Service Global Health Service Corps A small group of highly skilled professionals, deployed for a minimum of 2 years Health Workforce Needs Assessment A standardized health personnel needs assessment for all PEPFAR focus countries Fellowship Program A $35,000 award to enable health professionals to work overseas for a minimum of 1 year Loan Repayment Program A $25,000 loan repayment for qualified health professionals for each year of a 2-year service overseas Twinning Program A mechanism for short-, medium-, or long-term mobilization of needed skilled professionals Clearinghouse A resource using information technology for recruitment, information posting, and networking
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS GLOBAL HEALTH SERVICE CORPS If the PEPFAR goals are to be achieved, HIV/AIDS prevention and treatment programs will likely need cadres of health personnel far larger than those currently available in most PEPFAR focus countries (USAID, 2003; USAID Guyana, 2003; WHO, 2003). In addition, the rapid scale-up of antiretroviral therapy (ART) will require expertise and knowledge in a variety of medical and nonmedical areas often unavailable in resource-constrained settings. Indeed, as discussed earlier, there is broad recognition that the limited stock of health workers in many of the PEPFAR focus countries alone could spell failure for the scale-up effort (Kober and Van Damme, 2004). Factors contributing to profound shortages of health workers in these countries are limited baseline educational capacity; the active emigration of many newly trained health personnel; low pay and morale, poor working conditions, and inadequate management, encouraging the departure of health workers; movement of other workers to the private sector; and HIV/AIDS-related attrition of existing staff (WHO, 2004). Additional problems at the health services delivery level include not only shortages and poor distribution of doctors and nurses, but also weak program management, poor technical support, inadequate supplies of drugs, and lack of equipment and infrastructure (HLF, 2004; WHO, 2004). In sum, inadequacies of both health care delivery and infrastructure pose extraordinary challenges to building a sustainable workforce. To address the critical need in all PEPFAR focus countries for key specialized health, management, and technical professionals, the committee proposes the establishment of a Global Health Service Corps. This cadre of specialists would be available to assist with and support the implementation of national strategic HIV/AIDS programs. Its members would work in such areas as medical and nursing education, information technology for health systems, health systems design and management, and laboratory and pharmaceutical management. The common purpose of the Corps would be to enhance the effectiveness of current health personnel and support efforts to expand the health workforce of the future. Thus, the Corps would play a key role in the GHS’s overall contribution to the successful realization of PEPFAR goals. Recommendation 3: Establish a U.S. Global Health Service Corps to send key health personnel to PEPFAR countries on a full-time/long-term basis. The committee recommends the establishment of a full-salaried/ long-term U.S. Global Health Service Corps for the recruitment, placement, and support of U.S. health, technical, and management professionals in PEPFAR countries. Because of the critical and highly visible nature of this Corps and the necessity for it to coordinate closely with PEPFAR, the committee further recommends that it be established and
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS administered as a program of the federal government. U.S. Global Health Service Corps professionals should be selected and deployed based on the prioritized needs identified by ministries of health in conjunction with in-country PEPFAR teams. Assignments will be made for a minimum of 2 years with placements in areas and programs where Corps members’ presence would have maximum impact on enhancing the human capacity to prevent and treat HIV/AIDS. The committee proposes an initial deployment of 150 U.S. Global Health Service Corps professionals in the 15 PEPFAR countries based on needs assessment, placement development, and the availability of professionals with the required skills. Program Description Structure The Global Health Service Corps could be established as a program of the federal government. This strategic positioning of the program would allow coordination of the Corps’ mission with the PEPFAR program and U.S. government country teams both abroad and domestically. As the committee envisions the Corps, health professionals, as well as experts in management and technical matters related to health, would be dispatched for extended periods of service to PEPFAR focus countries. The primary purpose of these placements would be to advance the PEPFAR goals by assigning highly qualified personnel to key positions in newly expanding national programs of HIV/AIDS prevention and treatment. The Corps’ specialized professionals would be deployed on a full-time basis for a minimum of 2 years to provide technical assistance for scale-up of these programs. Given the heterogeneous needs of the 15 PEPFAR focus countries, the Corps should encompass a similarly diverse range of expertise, from clinicians and clinician trainers to experts in such nonclinical areas as information technology, health systems management, and laboratory and pharmaceutical management. Deployed U.S. professionals would be expected to work side-by-side with their host country counterparts to maximize the transfer of their skills and to help to develop the next generation of local health leadership. Priority would be given to positions and roles with the greatest potential to have a multiplier effect in promoting indigenous skills and capacity. The Global Health Service Corps would also play a meaningful role in the United States. It would become a dedicated program of the U.S. government supporting the long-term service of personnel in global health. It would provide career options for U.S. health, management, and technical professionals committed to addressing the HIV/AIDS pandemic and other
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS global scourges. As such, the Corps could become an enduring instrument of U.S. foreign aid, foreign policy, and health policy. Eligibility and Selection Process The Global Health Service Corps would work in close coordination with PEPFAR; U.S. government in-country teams; and current governmental efforts to scale up HIV/AIDS prevention and treatment programs abroad, including those of the U.S. Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC), and the Health Resources and Services Administration (HRSA). The Corps could recruit commissioned officers of the U.S. Public Health Service and civil service professionals currently in government service, as well as nongovernmental professionals, into its ranks. It would call on reserved and retired commissioned officers and attract specialists from the private sector, universities, and industry. It would use the Intergovernmental Personnel Act (see Box 5-1) and the GHS Loan Repayment program (described later in this chapter) to assist in its recruitment efforts. The development and prioritization of positions within the Corps would be the responsibility of PEPFAR country teams in conjunction with the respective ministries of health. Using the results of the workforce needs assessments discussed in the next section, these PEPFAR/ministry of health teams would identify key country-level clinical, management, and technical workforce needs associated with the PEPFAR mission. Requests to address these needs with Corps personnel would be made to the Corps, and assignments would be made based on prioritization of needs and identification and availability of appropriate professionals. Priority in making assignments would be given to those supporting the infrastructure development and sustainability of national HIV/AIDS programs. In all cases, the assignments should be relevant to long-term capacity building in the country and should, to the extent possible, involve the transfer of skills to host country professionals. Deployment Individual Corps members would be deployed abroad as government employees with all associated benefits. Following admission into the Corps, members would undergo a country-specific orientation in the United States, followed by a site-specific orientation in the country of assignment. Regardless of previous experience, all Corps members will need to acquire familiarity with cultural and ethical issues specific to their countries of assignment, as well as the particulars of their job. Corps members would generally be supervised by their PEPFAR country team while also being integrated to
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS BOX 5-1 The Intergovernmental Personnel Act The Intergovernmental Personnel Act (IPA) Mobility Program provides for the temporary assignment of personnel to facilitate cooperation between the federal government and state and local governments, colleges and universities, Indian tribal governments, federally funded research and development centers, and other eligible organizations. The goal of the program is to facilitate the movement of employees for short periods of time to serve a sound public purpose. Typically, only senior executive–level positions are filled by an IPA agreement. The assignment is for 2 years, extendable for an additional 2 years. The recipient of the appointment continues to be paid by his or her parent organization at full salary and benefits, and the parent organization receives a negotiated reimbursement from the government. At American University for example, Interagency Personnel Agreement (IPA) assignments provide opportunities for faculty members to work for the federal government on special assignment. These assignments require a contract between the university and the employing agency, and must be processed through the Office of Sponsored Programs (OSP). While on an IPA, the faculty member is “on detail” to the agency (or office) while still on active service at the university. Many faculty members have been able to combine an IPA with their sabbaticals and thus arrange a full-year leave at full pay. Most IPAs are for a full-time commitment, although arrangements for a partial IPA may be approved, depending on the nature of the IPA assignment, if the time committed to university service is substantial. The university does not charge indirect costs on IPAs, however, the university does not provide cost share on such agreements either. Sources: http://www.american.edu/academics/provost/dean/faculty/leave_policy.htm. the extent possible into the host country organization to which they are assigned. In addition, coordination and cooperation would be encouraged among Corps personnel in a given country and between these personnel and local public health authorities. Given the complexity and importance of the anticipated assignments and the need for strong collegial relationships to develop, tours of duty should be at least 2 years in length. Assignments might be extended when there is agreement on doing so among Corps leadership, the host organization, and the Corps member. Corps members could serve sequential assignments in different countries depending on skills needed, prioritization, and availability. Evaluation of all assignments would be carried out on an annual basis. The committee believes that the Global Health Service Corps should be launched modestly, but that it should also be large enough to establish its identity, make a contribution, and garner experience. An initial deployment
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS of 150 Corps members (prorated according to need and availability) would achieve these aims while allowing the Corps to remain manageable as a new enterprise. Rationale and Evidence Why a Global Health Service Corps? As discussed throughout this report, a lack of skilled and trained health professionals is one of the principal barriers to the rapid scale-up of HIV/ AIDS prevention and treatment programs in the PEPFAR focus countries (Adano et al., 2004; Wyss, 2004a,b). A range of skills is needed, particularly at the level of key clinical, management, and technical leadership positions essential to building the infrastructure of HIV/AIDS treatment systems (WHO, 2002). Because of the specialized nature of these positions and the long-term requirements of the work, volunteer health professionals and those with short-term availability will be of limited utility in addressing core country-level needs. It will be the role of the Global Health Service Corps, working with public health leaders in the PEPFAR focus countries, to provide specialized health personnel for extended assignments to fill these positions and accelerate program scale-up. The production of new health care workers has not kept pace with the growing demand for greater workforce capacity (RATN, 2003). There is a shortage of trained workers with specific experience in the clinical management of HIV/AIDS treatment programs; there are also severe shortages of well-trained professionals needed to handle other critical functions, such as commodity logistics, pharmaceutical regulation, information management for laboratory support, and operations research (Interim Pharmacy Council of South Africa, 1998; IOM, 2005; Katerere and Matowe, 2003; Ntuli et al., 2003). Uganda illustrates this point. One of the primary constraints on increasing Ugandan ART enrolees from 25,500 to 60,000 by the end of 2005 is the lack of qualified health staff. Most likely, the target will not be reached unless an aggressive intervention is quickly developed and implemented (Adano et al., 2004), yet the country faces an imposing challenge in producing the needed professionals (see below). Kenya also appears to be facing human resource shortage issues. In addition to dealing with the greater numbers of patients due to the upward-spiralling HIV epidemic, Kenyan health workers treating patients with AIDS and AIDS-related illnesses have found that the complexity of the disease poses new demands (Personal communication, Annalisa Trama, UNAIDS Kenya, December 1, 2004). Many such patients require full-time attention and longer hospital stays. As a result, roughly half of the patients in Kenyan medical wards have AIDS-related illnesses.
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS A low stock of skilled health workers is not the only impediment to scale-up; fragmentation of the employment process also plays a role (HLF, 2004). Country-level planning and human resource management capacity are often limited in developing countries and inadequately responsive to the changing priorities likely as more people begin ART or receive prevention counselling. An important structural problem in some areas is the undue centralization of government health systems. When all budget and policy decisions are made by the central government, a sense of powerlessness and lack of accountability can result at the district and province levels where the services are delivered (Personal communication, Stephen Moore, CDC-Nairobi, October 24, 2004). The challenge of producing skilled health care workers in the PEPFAR countries is illustrated by Uganda. Although educational institutions (medical schools, nursing schools, schools for health science) produce personnel who then serve as trained professional staff, the country is not generating enough doctors, nurses, pharmacists, or laboratory technologists to run basic health services, let alone HIV/AIDS-specific services (Adano et al., 2004). In addition, many recent graduates of health training institutions cannot find employment because of budget constraints and restrictions on personnel recruitment. Some cadres of trained health workers feel underutilized because they cannot obtain jobs in their areas of professional training that will maximize their potential and create opportunities for professional growth. This lack of career paths and motivation among young professionals has long-term consequences for human resource planning. Costs Salaries, benefits, and travel would account for most of the costs of the Global Health Service Corps. Projecting the exact cost of the Corps is not possible without making a series of assumptions about the personnel system to be used, the disciplines and seniority of the personnel involved, and the details of the approaches to orientation and supervision to be used for the Corps. A reasonable estimate of costs for the Corps can be derived from CDC, which deploys health professionals abroad using government personnel systems; its rough estimate for sending a skilled professional overseas is $250,000 per year per person.1 Using this yardstick, the deployment of an 1 The total can be $300,000 or more depending on certain factors, such as whether the country is more expensive; the base salary is higher (e.g., a medical epidemiologist compared with a junior administrator); how many children the person has (the government pays school fees at $10,000–15,000 per child per year); whether the total tour is shorter (because the costs of the move and set-up [e.g., housing] are amortized over fewer years); or security-related costs are increased (Personal Communication, Michael St. Louis, CDC, February 23, 2005).
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS initial Corps of 150 individuals as recommended by the committee would require a budget of $37.5 million (150 × $250,000). The committee discussed these costs at length, appreciating that the investment required for a fully salaried, full-time/long-term professional would be substantial, and that many other health-related goods and services could be purchased for the same sum. On balance, however, the committee concluded that the investment in a small and specialized Corps that would play a pivotal role in ART scale-up and global health development is an equally important commitment on the part of PEPFAR and the United States. The committee notes further that a $37.5 million aggregate yearly investment represents approximately 1 percent of the current annual PEPFAR budget. Options for Placement Public versus Private Sector Several options exist for the organization and placement of the Global Health Service Corps as the anchor program of the GHS. The first decision to be made is whether to locate the Corps in the public or private sector. The committee decided that all the programs of the GHS should be managed in a unitary fashion within the federal government, while individual programs might be candidates for public–private collaboration or placement in the private sector through contract mechanisms (see Chapter 4). The committee believes strongly that the specialized nature of the Corps, its requirement for long-term service, its visibility, and its potential to be the signature program of the U.S. global health effort argue for its being established as a program of the federal government. Doing so would address important and sensitive issues, including the need for close coordination with PEPFAR and other U.S. global health and foreign policy initiatives. The committee discussed at length the option of placing the Corps in the private sector, managed through a federal government contract. The committee members were aware of many not-for-profit and for-profit organizations under government contract that have been successful in deploying health professionals abroad. These contracts are usually framed in terms of the delivery of specific services and recruitment of health professionals as assets to help to achieve the goals of the contract. Private firms working in this area are generally credited with the ability to locate health professionals and move them into the field quickly. However, working at the government-to-government level is an area in which private firms are less well positioned. For this reason, the committee believes the Corps would better be established as a program of the U.S. government, and that such federal placement would best serve recruitment, placement, mission
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS coordination, skill banking, retention, and long-term program development. A federally based Corps would also greatly facilitate the program’s integration with PEPFAR and in-country strategies. Multiple agencies and individuals—including the American Medical Student Association, United Methodist Committee on Relief, International Health Medical Education Consortium, and American Society for Tropical Medicine—testified to the committee regarding the growing interest in careers in global health. This interest is seen across the career spectrum—students, established experts, and health professionals wanting to retire early to participate in health programs abroad (Kelly, 2004; Palmer, 2004; Weaver, 2004). The committee believes strongly that this interest should be captured by the range of programs envisioned for the GHS, but that the Corps in particular should provide deployment opportunities and model careers in global health. As the signature program of the GHS initiative, the Corps should be a program of the federal government that will make a statement at home and abroad about the importance of careers in global health and the commitment of the U.S. government to the long-term mission of improving health worldwide. Moreover, a federal Corps would be in a position to recruit from the ranks of the Public Health Service and civil service while also recruiting new professionals into its ranks. Potential Federal Agencies A number of agencies of the U.S. government that currently deploy health professionals should be considered in deciding about the positioning of the Global Health Service Corps. Each is briefly discussed below; a listing of these agencies’ attributes that may be helpful in making this decision is provided in Appendix G. Moreover, the experience of these agencies should inform policy makers designing the Corps. The Peace Corps. The Peace Corps is well established, well recognized, and well regarded with respect to the placement of U.S. citizens abroad. Over the years, public health has been among its areas of focus. The Peace Corps, however, functions with volunteers and does not provide recompense likely to appeal to many senior-level clinical, technical, or management personnel undertaking extended assignments. Rather, the Peace Corps provides volunteers with a living allowance that enables them to live in a manner similar to that of the local people in their community (United States Peace Corps, 2005a). Centers for Disease Control and Prevention. CDC has had extensive experience with foreign assignments. Through its Global AIDS program, it has roughly 40 direct hires in the PEPFAR focus countries, with an average of
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS 2 to 3 per country (CDC, 2005). CDC has a strong epidemiologic tradition (the Epidemic Intelligence Service in particular) and is very well recognized in public health circles worldwide. Its expertise, however, is largely in surveillance and prevention; it has less experience and less of a mandate regarding health systems development or the personnel needed to assist in such efforts. National Health Service Corps. The National Health Service Corps (NHSC) has almost 35 years of experience with the placement of health professionals in underserved areas and with scholarship and loan repayment programs as recruitment strategies (NHSC, 2003). It has an identity that is mission driven and easily equates with a domestic version of the proposed Global Health Service Corps. However, NHSC has no international mandate or experience, and its program is limited to clinicians. Indian Health Service. The Indian Health Service (IHS) is an agency within the Department of Health and Human Services. It provides health services to approximately 1.5 million American Indians and Alaska Natives who belong to more than 557 federally recognized tribes in 35 states. Similar to the proposed GHS, the IHS has a recruitment website, administers scholarship and loan repayment programs, employs a variety of health professionals, and encourages commissioned officers to participate (IHS, 2005). The IHS does not work internationally, however, and has a broad focus on general health care not specific to HIV/AIDS. Other agencies of the federal government also send health professionals abroad. USAID employs multiple contract mechanisms to sponsor health programs that deploy U.S. health personnel; HRSA oversees similar deployments on a smaller scale and targeted to the PEPFAR focus countries. Likewise, the U.S. Armed Forces deploy large numbers of health personnel abroad, both in support of the military mission and in humanitarian relief efforts. The experience of all of the above U.S. government agencies should be taken into account when considering the placement of the Global Health Service Corps. After examining the various options, the committee concluded that the effectiveness, identity, and mission of the Corps to support the PEPFAR goals would best be served by the establishment of a discrete program of the federal government managed by the GHS. Furthermore, the structure of the Corps would then be in place and prepared to mobilize health personnel proactively for emerging global health crises in the future.
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS role in testing, counseling, access to treatment, care giving, and the nurture of orphans. The devastation brought about by HIV/AIDS to date and the growing social crisis in many of the PEPFAR focus countries calls for a heightened level of cooperation among individuals and organizations battling the pandemic. Marshaling information technology is crucial to these efforts. The Clearinghouse would help meet this need. A virtual network of international sending organizations could offer and receive information and regularly reach thousands of volunteers. It woud be an efficient way to use emerging technology to network people and organizations for the benefit of both. For programs located in various and sometimes remote areas, the Clearinghouse would provide a mechanism for recruitment, information posting, and establishment of a global presence. Networking would also enable organizations to share experiences and to work together on common initiatives while minimizing duplication of services. Recommendation 8: Develop a U.S. Global Health Service Clearinghouse. There are many organizations currently mobilizing health personnel to work in PEPFAR countries. These organizations could be powerful allies in meeting PEPFAR goals. Therefore the committee recommends a multifaceted Clearinghouse for the U.S. Global Health Service that would facilitate information exchange, enhance access to program data, and provide opportunity information for interested health professionals. Program Description The Global Health Service Clearinghouse would be managed by a small professional staff working closely with all of the other programs of the GHS. This team would be responsible for developing the virtual and actual networks that would make up the Clearinghouse. Important aspects of the work would include developing and maintaining an inventory of U.S. organizations that mobilize health personnel for deployment in the PEPFAR focus countries, as well as liaising with those performing the health workforce needs assessments discussed earlier. This database would be available to host country counterparts. A more detailed explanation of the four components of the Clearinghouse is presented below. Program Resource Directory and Networks As part of an overall website, the Program Resource Directory would be a searchable, web-based directory providing volunteers with screened, reliable links to sending organizations’ websites so as to facilitate organiza-
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS tional contacts for recruitment. This function would be especially useful to those applying for a GHS Fellowship or for the Loan Repayment Program, since their applications would be judged in part on their involvement in the program of an established mobilizing organization. Organizations posting links in the Program Resource Directory would be invited to join the network of sending organizations. Being a member would entitle them to participate in a variety of virtual and actual programs, including an annual meeting, an e-newsletter, a Listserv, and other electronic community activities. Organizations involved in twinning partnerships could potentially utilize the networking capabilities established through the Clearinghouse to keep in touch with their sister organization. Groups wishing to be included in this voluntary coordination and communication system of organizations engaged in mobilizing health personnel for the PEPFAR focus counties could self-nominate for inclusion, provided they met basic requirements pertinent to the PEPFAR goals. Criteria for being listed in the directory would be made clear to all organizations. Opportunity Bank A job bank of available host country positions would be a vital tool for identifying vacancies that could be filled by U.S. professionals wishing to work in the PEPFAR focus countries. The data in the Opportunity Bank would come from the health workforce needs assessment performed for each focus country (see above). Uniformity of the assessment data will ensure that information sent from the various focus countries will be compatible and comparable for receiving and posting vacancies. Continuous updating of the information posted will be crucial for tracking open positions. The Opportunity Bank offers the potential to serve as a major facilitator of mobilization by both governmental and nongovernmental programs. Its value, however, would depend to a large extent on the quality of the in-country health workforce needs assessment activity and of the link between host country personnel and the Clearinghouse team. Cultural and Strategic Issues Reference Site The Cultural and Strategic Issues Reference Site would be a virtual warehouse of information pertinent to all health professionals planning to work in the PEPFAR focus countries, including those seeking a GHS Fellowship, loan repayment, or assignment to the Global Health Service Corps. The site would provide primary information on cultural, political, economic, and social issues for all 15 countries. It would offer a range of relevant documents, including the country strategic plans, country profiles from the Office of the U.S. Global AIDS Coordinator, and related epide-
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS miologic and regional documents for the orientation and edification of potential volunteers. Crucial information on ethical considerations related to practice abroad would also be provided. A Code for Volunteer Behavior and Conduct could be developed and posted for GHS members to read and sign prior to leaving the United States for work abroad. Statements of policy regarding involvement in local politics and social advocacy activities for GHS-supported personnel might be provided as well. Country Credentials and Travel Guidelines Repository Providing potential recruits with credentialing and travel information for work overseas would simplify an often laborious process. The Country Credentials and Travel Guidelines Repository would assist prospective volunteers for work in the global arena by making this information readily available in one virtual location. This regularly updated compendium of information might include country-specific documents regarding licensure, accreditation, and work permits, as well as other helpful information, such as passport, visa, and driver’s license requirements; travel information and alerts; and details on travel medical insurance policies. Rationale and Evidence The principal rationale for the GHS Clearinghouse is to increase the actual and virtual connectivity of organizations engaged in mobilizing health personnel for service in the PEPFAR focus countries. Many groups in this field have organizational missions and Internet presences that involve promulgating information on volunteer opportunities or country conditions along the lines envisioned for the Clearinghouse. Their activites include the programs of governmental organizations, NGOs, and religious and sectarian organizations listed in Table 5-5. In analyzing the organizations currently engaging in networking with regard to opportunities for health professionals abroad, it became evident to the committee that no single organization or network addresses all aspects of a comprehensive clearinghouse as described above. Moreover, even similar organizations, such as those linked to religious bodies, rarely focus on the networking and sharing of assets in the recruitment and deployment of health professionals needed to build HIV/AIDS human resource capacity in the PEPFAR focus countries. While the multiple origins and sources of support for these critical organizations explain this relative lack of coordination, the committee believes it important to promote harmonized mobilization efforts where possible and the partnering of organizations when appropriate. The committee believes that the sharing of information envi-
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS TABLE 5-5 A Sampling of Organizations Providing Information about HIV/AIDS Work Abroad Organization Activity Virtual Matchmaking Volunteers for Prosperity http://www.volunteersforprosperity.gov/ Potential volunteers can obtain links to organizations that work in the areas of HIV/AIDS, capacity building, and education. International Healthcare Opportunities Clearinghouse http://library.umassmed.edu/ihoc/ Provides a web-based database of available positions for health care professionals that is searchable by region, time commitment, language requirement, and professional skills. International Medical Volunteers Association http://www.imva.org/Pages/volsrchintro.asp Lists health care opportunities and whom to contact for more information. Provides a volunteer registry that contains information about health professionals seeking volunteer medical assignments around the world. Networking InterAction http://www.interaction.org A network of more than 160 nongovernmental organizations (NGOs) that convenes and coordinates to affect public policy and improve the outcomes of their work worldwide. They maintain close ties with NGOs and NGO networks in Europe, Asia, Africa, and Latin America. Uganda Network of AIDS Service Organizations http://www.unaso.or.ug/about.php A nationwide network of NGOs, community-based organizations, faith-based organizations, groups of people living with HIV/AIDS, and local communities involved in the response to HIV/AIDS in Uganda. Kenya AIDS NGOs Consortium http://www.kanco.org/framebody.htm A national membership network of NGOs/community-based organizations and religious organizations involved or with interest in activities related HIV/ AIDS and other sexually transmitted infections in Kenya.
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Organization Activity Africa Religious Health Assets Program A collaboration among the University of Cape Town, University of Kwazulu Natal, and Emory University to fill the gap in strategic mapping of religious structures and networks relevant to HIV/AIDS and other underlying health issues. African Regional Capacity Building Network for HIV/AIDS Prevention, Care, and Treatment (World Bank Group, 2004) A network of subregional “learning sites” designed to expand training of health care practitioners in HIV/AIDS, and to enable harmonization of approaches and facilitate greater knowledge sharing across Ethiopia, Kenya, and Tanzania. Virtual Warehousing InterAction http://www.interaction.org Publishes a newsletter; maintains a website with a virtual library, an events calendar listing meetings and locations, and Private Voluntary Organization Standards. Health Volunteers Overseas http://www.hvousa.org/ Website addresses aspects of volunteering. Peace Corps http://www.peacecorps.gov/ Website addresses aspects of volunteering. International Federation of Red Cross and Red Crescent Societies http://www.ifrc.org/what/health/hivaids/code/ Website with a code of good practice for NGOs responding to HIV/AIDS. U.S. Department of State http://www.state.gov/travel/ Provides extensive information on traveling and living aboard, along with country background notes and key contacts at U.S. embassies and consulates. Fogarty International http://www.fic.nih.gov/services.html Provides links to passport and visa information, foreign travel information, and personal security training, as well as available grants. Development Experience Clearinghouse http://www.dec.org/about.cfm#1 An interactive website of thousands of publications funded by the U.S. Agency for International Development.
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Organization Activity International Healthcare Opportunities Clearinghouse http://library.umassmed.edu/ihoc/ Provides links that offer would-be volunteers travel information, as well as information on health and safety risks and history, culture, and customs. International Clearinghouse on Curriculum for HIV/AIDS Preventive Education http://databases.unesco.org/IBE/AIDBIB/ A bibliographic database of nternational curriculum materials and irelated documentation for HIV/AIDS education at primary and secondary levels of schooling. sioned for the Clearinghouse would help in maintaining a focus on mobilization goals, preventing duplication of services, and placing volunteers in areas where they would have maximal impact. As noted, many organizations use websites to provide information about volunteering and working overseas; these sites also allow e-mail communication with the organization and with others in the field. Some sites include databases for use by potential volunteers in matching their skills with the needs of organizations recruiting in various countries. Others display links to websites that offer positions for professional and nonprofessional volunteers (e.g., Volunteers for Prosperity). Some allow volunteers to search based on their specific skill set (e.g., International Healthcare Opportunities Clearinghouse), while others supply the name of a person in the organization for the individual to contact (e.g., International Medical Volunteers Association). Many include opportunities in some PEPFAR focus countries, while Volunteers for Prosperity provides a searchable database of all the PEPFAR focus countries. The website of the International Federation of Red Cross and Red Crescent Societies posts a code of ethics. The website of Fogarty International Center of the National Institutes of Health provides links to passport and visa information, foreign travel information, and personal security information, as does the website of the U.S. Department of State. However, none of these organizations lists both comprehensive information on mobilizing organizations (the proposed Resource Directory) and extensive placement possibilities in the PEPFAR focus countries (the proposed Opportunities Bank). These two features, as well as the ethical, cultural, credentialing, and travel information that would be offered at the GHS Clearinghouse, would bring a coherence not currently available to the complex issues that surround the mobilization of health professionals.
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS For ease of searching, all four elements of the Clearinghouse should be housed at one website, where those interested could go to be introduced to the various programs of the GHS. The Program Resource Directory and Networks is a likely starting point for sending organizations to become involved with the GHS, and would benefit from a well-designed format such as that of Volunteers for Prosperity or the International Healthcare Opportunities Clearinghouse. CONCLUDING REMARKS There have been few well-conducted studies addressing gaps in human resources for health that could guide the U.S. Department of State in determining how many specialized health, management, and technical professionals will be needed to meet the PEPFAR goals. Collecting this information systematically and storing it in a well-maintained database would provide not only a source of information for job vacancies, but also baseline and follow-up data for tracking how well countries are meeting their human resource requirements and thus how well the PEPFAR initiative is meeting its goals. Opportunities for serving in any of the programs of the GHS could also be stored in the virtual database and made available to interested and qualified professionals. The Global Health Service Corps is likely to be the most expensive of the proposed GHS programs, but is also, the committee believes, the one most likely to have the greatest impact on human resources. The Fellowship and Loan Repayment programs are also expected to increase worker capacity on the ground, as is the Twinning Program, with its unique ability to insert workers into areas or institutions where a partnership has already been developed. Although each program could be implemented independently of the others, the committee believes the greatest impact would come from implementing them collectively, to varying degrees, based on the identified needs of each of the 15 PEPFAR focus countries. REFERENCES Adano U, O’Neil M, Decima E, Kiarie W. 2004. Rapid Assessment of the Human Resource Implications of Scaling up HIV/AIDS Services in Uganda Progress Report 1 & 2. Management and Leadership Development Project/USAID. Boston, MA: Management Sciences for Health. Beran RL, Lawson GE. 1998. Medical student financial assistance, 1996–1997. Journal of the American Medical Association 280: 819–820. Campbell R. 2004 (December 2). Peace Corps. Presentation at the Institute of Medicine Workshop on Options for Overseas Placement of U.S. Health Professionals, Washington, DC. Institute of Medicine Committee on the Options for Overseas Placement of U.S. Health Professionals.
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Representative terms from entire chapter: